Artículos
Euthanasia Attitudes
Questionnaire in Medical Personnel (AHE-PM)
Cuestionario de
actitudes hacia la eutanasia en personal médico (AHE-PM)
Esteban Puente-López epuentel@nebrija.es.
Department of Psychology, Faculty of Natural Science, University
of Nebrija, España
Aurelio Luna Ruiz-Cabello aurelio.luna@um.es.
Department of Sociohealth Sciences, Faculty of Medicine,
University of Murcia, España
David Pina david.pina@um.es
Department of Sociohealth Sciences, Faculty of Medicine,
University of Murcia., España
Aurelio Luna Maldonado aurelio.luna@um.es.
Department of Sociohealth Sciences, Faculty of Medicine,
University of Murcia, España
María José Haro Kay mjharokay@gmail.com.
Department of Sociohealth Sciences, Faculty of Medicine,
University of Murcia, España
Mauricio Lorente Sánchez lorente.mauricio@gmail.com.
Faculty of Medicine, University of Cadiz., España
Joaquín Gamero Lucas joaquin.gamero@uca.es.
Faculty of Medicine, University of Cadiz, España
Euthanasia Attitudes Questionnaire in Medical Personnel (AHE-PM)
Interdisciplinaria,
vol. 40, núm. 1, pp. 350-361,
2023
Centro Interamericano de Investigaciones Psicológicas y Ciencias
Afines
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Recepción:
04
Diciembre 2020
Aprobación:
01
Julio 2022
Abstract:
The right to die is an international
dilemma. Some countries and states already have laws regulating one of the most
common applications of this right, the active voluntary euthanasia. The
evidence from these countries highlights the importance of a bioethical
framework to limit some of its applications. In this regard, the evaluation of
attitudes towards euthanasia in medical personnel will allow to understand the
attitudes of these professionals and how they can deal with such requests,
whether this assisted death is decided by the patients or their surroundings.
Consequently, the aim of this study was to develop a brief scale to evaluate attitudes, as well as to determine their significance according to the gender and seniority of the professionals in this situation.
A double design strategy was followed. On the one hand, a
psychometric design with an exploratory and confirmatory factor analysis and,
on the other, a descriptive analytical design for the comparison of groups.
A six-item scale (AE-PM) and two factors were extracted. The
first focuses on attitudes towards euthanasia to alleviate suffering for
medical reasons and the second one to alleviate the patient’s emotional
suffering.
The scale (AHE-PM) is useful for the rapid exploration of
attitudes towards euthanasia in physicians, a professional group with limited
free time, who may also encounter relatively frequent requests for active
voluntary euthanasia. The two factors obtained allow attitudes to be assessed
from a bioethical perspective, providing information on the application under
apparent medical justification and in situations based on the patient’s
subjective emotional suffering.
Keywords: attitudes,
euthanasia, active voluntary euthanasia, psychometric study, cross-sectional
design.
Resumen: La eutanasia voluntaria activa se define como la petición de un
paciente que quiere morir y la acción que es llevada a cabo por otra persona
para provocar dicha muerte. El derecho a morir es un dilema sobre el que se
debate a nivel internacional. Algunos países y estados ya cuentan con leyes que
regulan una de las aplicaciones más comunes de este derecho. Los datos
aportados por estos países ponen de manifiesto la importancia de un marco
bioético que permita limitar algunas de sus aplicaciones. En este sentido, la
evaluación de las actitudes hacia la eutanasia en personal médico permitirá
conocer las actitudes de estos profesionales y cómo estos pueden enfrentarse a
dichas solicitudes, o no, sea de muerte asistida por parte de los pacientes o
su entorno. Además, se ha reportado en la bibliografía diferentes actitudes
según la experiencia o el sexo de los trabajadores, por lo que es de relevancia
su exploración diferencial.
Por ello, el objetivo del presente trabajo un instrumento de evaluación de actitudes hacia la eutanasia diseñado y validado por y para profesionales médicos en ejercicio. En esta línea, los objetivos de este estudio son obtener una escala corta con propiedades psicométricas adecuadas, que proporcione información relevante sobre las actitudes hacia la eutanasia, así como la posible evaluación de algunas prácticas médicas relacionadas con ésta que pueden ser bioéticamente dudosas.
La muestra estaba compuesta por 419 profesionales de la medicina
procedentes de tres provincias del sur de España. Se siguió una doble
estrategia en el diseño. Por un lado, un diseño psicométrico con un análisis
factorial exploratorio y confirmatorio. Se dividió la muestra en dos
submuestras aleatorias para realizar de forma paralela ambos análisis. Se
utilizaron los estadísticos KMO, Bartlett, RMSEA, RMRS, CFI, NNFI, GFI y AGFI
para explorar el ajuste de modelos. Po otro lado, se utilizó un diseño
asociativo descriptivo para la comparación de grupos mediante la t de Student,
ANOVA, Tukey y la prueba d de Cohen.
Se extrae una escala de seis ítems (AE-PM) y dos factores. El
primero de ellos está centrado en las actitudes hacia la eutanasia para aliviar
el sufrimiento por cuestiones médicas y el segundo para aliviar el sufrimiento
emocional del paciente.
Respecto al estudio de las diferencias, no se observaron
diferencias significativas según el sexo del profesional ni la antigüedad en la
profesión.
La escala (AHE-PM) es útil para la exploración rápida de las
actitudes hacia la eutanasia en médicos, un grupo profesional con limitado
tiempo libre que, además, puede encontrarse con relativa frecuencia ante
solicitudes de eutanasia voluntaria activa. Los dos factores obtenidos permiten
evaluar, por un lado, las actitudes desde una perspectiva bioética. Es de
especial relevancia en estas situaciones el conocimiento de las actitudes del
personal médico hacia la eutanasia, exponiéndolo a un dilema bioético y
personal. La autoconciencia de estos profesionales sobre sus propias actitudes
hacia la eutanasia y su adaptación a los códigos éticos vigentes podría
minimizar el impacto generado por estas situaciones y, por tanto, mejorar la
relación terapéutica y la calidad asistencial. Por otro lado, el instrumento
aporta información sobre la posible recomendación de estas prácticas bajo
aparente justificación médica y/o en situaciones basadas en el sufrimiento
emocional subjetivo del paciente.
Estudios previos indican que los profesionales se ven afectados
emocionalmente cuando se enfrentan a los conceptos de muerte y eutanasia en
pacientes terminales. En este sentido, la escala también podría servir de
evaluación de actitudes y el trabajo en planes de prevención de salud laboral
en los centros sanitarios.
Palabras
clave: actitudes, eutanasia, eutanasia active voluntaria, estudio
psicométrico, estudio transversal.
Introduction
Euthanasia is a term that requires an adequate definition, among
other aspects, due to the different variants of assisted death that exist.
Specifically, the so-called active voluntary euthanasia has been defined as the
request of a patient who wants to die and the action taken by another person to
bring about such death (McCormick, 2011).
This practice has been involved in social and political debate in recent years,
although it is relatively uncommon to find studies addressing this construct in
scientific journals (Barboza-Palomino et
al., 2020). Recently, in Spain, various legalization proposals have been
made, although to date, this situation has not been resolved, and Spain remains
one of the countries in Europe where it is not legal, with the exception of the
Netherlands, Belgium, or Luxembourg (Schotsmans
& Meulenbergs, 2005). In recent months, the debate has intensified
following the case of Carmen in April 2019, who, after decades of illness, was
helped to die by her partner, Angel, who is currently awaiting trial (García-Rada, 2019) and with the recent
regulation of euthanasia in Spain with Organic Law 3/2021, of 24th March.
A recent study shows that 58.4 % of the Spanish population would
support the regulation of euthanasia (del
Rosal & Cerro, 2018). Its application varies among the places where
there are laws governing this practice. For example, in the Netherlands, there
has been an increase of 57 % in just 5 years, going from 4 188 cases of
euthanasia to 6 585 in 2017, in these cases increasing the percentage
associated with psychological problems by up to 300 %. In Belgium, this
increase in cases of euthanasia reaches 982 % from 2003 to 2017, with a total
of 2 309 cases. These data highlight the need and importance of an adequate
bioethical framework for the application of euthanasia (Hrvoje, 2018). A review by Cuman & Gastmans (2017) indicates the
importance of patient decision-making, understood as competence, ability,
discrimination, intellectual capacity, free determination, informed consent,
sensitivity and pressure—even in minors, where the debate remains open. In this
regard, in the places where euthanasia has been legalized, the controversy is
stronger when high percentages of patients who had not completed the proposed
treatments were tired of living or had not even explicitly requested euthanasia
(Hrvoje, 2018). Other issues, such as
a depressed emotional state following sentimental breakups, financial losses,
or other stressful life situations that could momentarily affect mental health
should be considered for a bioethical assessment of its application (Levin et al., 2018). To date, no studies
have been located in Spain that provide these data.
Attitudes are understood as a set of beliefs that individuals
hold about specific objects of reality that are the result of direct experience
or identification with significant others (Ajzen,
1988). Specifically, attitudes towards euthanasia could modulate the
manifestation or non-manifestation of behaviors in favor of euthanasia both in
patients and professionals, either to express a favorable opinion or to address
this option directly with the patient. Various studies show that addressing
these decisions about a patient's life or death affects professionals'
emotional state as well as their degree of job satisfaction (Flannery et al., 2016). In the same vein,
favorable attitudes towards euthanasia related to age and sex were found in
health workers who had worked with patients in terminal stages or who had
diseases with poor prognosis (Francke et
al., 2016; Tamayo-Velázquez et al.,
2012; Zenz et al., 2015).
The complexity of the phenomenon and the heterogeneity of health
services has led to the proliferation of various euthanasia attitude assessment
tools. Specifically, the Frommelt Attitude Toward Care of the Dying (FATCOD; Frommelt, 1991) scale has been widely
used and translated into various languages, including Spanish (Edo-Gual et al., 2018). In its version
for medical staff, it has been validated in medical students (Loera et al., 2018). In addition to the
FATCOD, other instruments have been validated in medical students or samples
with low indicators of internal consistency (Billings
et al., 2009; Rogers, 1996). These
instruments reveal certain psychometric limitations, either because of the
validation with students and non-professionals or, as has been seen in other
cases, because they provide inadequate psychometric properties.
The present study proposes the creation of an euthanasia
attitude assessment instrument designed for and validated by practicing medical
professionals. In this line, the objectives of this study are to obtain a short
scale with appropriate psychometric properties, which provides relevant
information on attitudes towards euthanasia, as well as the possible evaluation
of some medical practices related to this that may be bioethically dubious.
Method
A dual strategy for research design was followed to perform this
work. On the one hand, it is a psychometric study, which aims to explore in
depth the properties of the scale, and on the other hand, it is a
quasi-experimental, cross-sectional study (Ato
et al., 2013).
Participants
The sample was composed of 419 physicians (40.1 % women) aged
between 22 and 72 years old (M = 43.67, SD = 12.21) and mean tenure in the
profession of 15.89 years (SD = 11.38), from 3 Spanish provinces belonging to
the autonomous community of Andalusia (Table 1).
The inclusion criteria of the sample were to answer all the
items related to attitudes towards euthanasia, to be practicing the medical
profession at the time of completing the questionnaire, and to sign the
informed consent. Cases that did not meet all three criteria were excluded.
Table 1
Variables |
N (%) |
Sex |
|
Male |
213 (51.1) |
Female |
205 (48.9) |
Province |
|
Seville |
21 (5) |
Cordoba |
41 (9.8) |
Cadiz |
357 (85.2) |
Years in the
profession |
|
0-9 |
149 (34.8) |
10-19 |
86 (20.5) |
20-29 |
84 (20) |
30-40 |
75 (17.9) |
Missing values |
28 (6.7) |
Instruments
An ad hoc protocol with a total of 46 items was applied. It
included the sociodemographic variables described above, as well as the 39
items that were subject to factor analysis.
Procedure
The works of Barroso et al.
(1992) and Pacheco et al. (1988, 1989) were a precedent for the proposed
questionnaire. This information was complemented by an unpublished qualitative
study following the recommendations of various authors (e.
g. Flores & Medrano, 2019)
with practitioners identifying themes and serving as the basis for item
formulation. For sample collection, a simple random sampling was carried out
among the professionals of the hospitals of the Spanish provinces of Cadiz,
Seville, and Cordoba. Then, a group of interviewers made up of senior
undergraduate medical students personally visited each participant. In the
interview, the professionals were informed about the study, and requested to
sign the informed consent. They were also informed of the anonymous and
voluntary nature of their participation in the study. After acceptance by the
professional, the interviewer provided them with the complete protocol to fill
in. Data collection took place between 2016 and 2018.
The ethical considerations proposed by the American
Psychological Association (APA, 2017)
and the favourable report of the Research Ethics Committee of the University of
Murcia were taken into account.
Data analysis
In this study, the factorial analysis procedure proposed by Brown (2014) was used. Following this
author, it is necessary to apply a double study of the data, first with an
exploratory factor analysis (EFA), from the data group to a structure, and then
with a confirmatory factor analysis (CFA), starting from a theoretical proposal
to confirm it in the set of data. To apply this procedure, one of the two
following conditions is needed: two independent samples, one for each analysis,
or a sample large enough to be able to divide it to 50 %, always seeking to
have sample sizes greater than 300 cases. Given the characteristics of the
present sample (medical professionals in professional practice) it was
impossible to meet these requirements, therefore, the recommendation of Brown (2014) were followed and the program
Factor 10.8 was used (Lorenzo-Seva &
Ferrando, 2007), as it provides fit statistics for EFA and CFA. This
program generates multiple random subsets of the sample, compensating the size
and providing the indicators recommended in the bibliography (Brown, 2014). Polychoric correlations
were applied using the unweighted least squares method. Parallel analysis (PA)
was used for factor selection in a scaling process until obtaining the
parsimonious model with the best fit.
The Kaiser-Meyer-Olkin (KMO) and Bartlett sphericity statistics
were used as criteria for the definition of dimensionality in the EFA.
Statistics based on the root mean square error of approximation (RMSEA) and the
root mean square residual (RMRS) were also calculated, and the structure was
explored with CFA, using the comparative fit index (CFI) and the non-normalized
fit index (NNFI). In addition, the goodness of fit index (GFI) and the adjusted
goodness of fit index (AGFI) were explored. Cronbach's alpha values were also
used.
For item selection, items with factorial loads higher than .40
and items not loading simultaneously higher than .30 on two or more factors
were accepted. The criteria for decision-making of dimensionality were that the
values were within the recommended range for KMO, Bartlett’s sphericity
statistic was significant, the GFI and AGFI values were greater than .95, the
CFI and NNFI values were greater than .90, and the RMSEA and SRMR statistics
were lower than .08.
Student’s t statistics were used to the compare the means
between factors with two levels, and ANOVA for factors of more than two levels.
Tukey’s post hoc test was employed with the ANOVAs to establish differences
between the different groups. In addition, in order to quantify the effect
size, the Cohen’s d was estimated. These analyses were performed with SPSS
(Statistical Package for Social Sciences) version 25.
Results
Structure of the factor analysis
In relation to the first objective, factor analysis was
performed using the unweighted least squares method with normalized Varimax
rotation to individually explore the multidimensionality of the proposed items.
The analysis (Tables 2 and 3) extracted a
scale, called Attitudes towards Euthanasia in Medical Personnel (AHE-PM) with
two dimensions and three items each. Items were grouped by EFA into: Factor I,
Attitudes towards euthanasia to avoid suffering due to poor prognosis, which
explained 58.32 % of the variance (α = .86) and Factor II, Attitudes towards
euthanasia to avoid emotional suffering, which explained 34.91 % of the
variance. (α = .86). The CFA indicators provided by the program also reported
adequate properties for this structure. (KMO = .750, 95 % CI [.725, .779];
Bartlett’s sphericity test 3 = 2 085.0, p < .0001).
Table 2
Item |
Factor I |
Factor II |
|||||
1. To avoid the
suffering of a chronic illness |
.91 |
- |
2.44 (1.99) |
.76 |
.75 |
.48 |
-1.26 |
2. To avoid
suffering from a severe physical disability |
.85 |
- |
2.42 (2.02) |
.79 |
.88 |
.41 |
-1.40 |
3. To prevent the
suffering of a terminal illness |
.75 |
- |
3.29 (2.40) |
.66 |
.78 |
-.45 |
-1.38 |
4. To avoid
suffering for unrequited love |
- |
.99 |
1.12 (0.369 |
.93 |
.91 |
5.66 |
32.00 |
5. To avoid
suffering from insolvency, bankruptcy, and/or eviction |
- |
.96 |
1.15 (.42) |
.92 |
.91 |
4.93 |
24.39 |
6. To avoid
suffering from the loss of a loved one |
- |
.95 |
1.18 (.53) |
.86 |
.96 |
4.38 |
18.58 |
Alpha |
.86 |
.95 |
|||||
Explained variance |
58.32 % |
34.91 % |
M: MeanSD:
Standard deviationR IT-c:
Item-factor correlationAlpha Corrected: Corrected alpha when deleting the item (values above .70 are
considered acceptable)Sk:
Skewness (values close to 0 reflect symmetry in the data)K: Kurtosis (values close to 0 reflect normality
in the distribution)
Table 3
GFI |
AGFI |
KMO |
Bartlett |
CFI |
NNFI |
RMRS |
RMSEA |
|
Scale |
.997 |
.987 |
.750* |
.000* |
.999 |
.999 |
.002 |
.001 |
M: MeanK:
Kurtosis (values close to 0 reflect normality in the distribution)
Descriptive
statistics and internalconsistency
In the analysis of differences as a function of gender and
professional tenure, the relevant comparisons (Tables 4 and 5) revealed no significant differences in either factor or in
the item-by-item analysis.
Table 4
Variable |
||||||||
Factor I |
7.31 (3.85) |
7.22 (4.26) |
.224 |
.823 |
.02 |
|||
Item 1 |
3.27 (1.99) |
3.01 (1.61) |
-.239 |
.811 |
.14 |
|||
Item 2 |
2.49 (1.37) |
2.37 (1.46) |
.903 |
.367 |
.08 |
|||
Item 3 |
2.41 (1.36) |
2.43 (1.46) |
-.130 |
.897 |
.01 |
|||
Factor II |
3.30 (1.51) |
3.61 (2.21) |
-1.685 |
.093 |
.16 |
|||
Item 4 |
1.12 (.58) |
1.25 (.85) |
-1.866 |
.063 |
.18 |
|||
Item 5 |
1.08 (.49) |
1.16 (.70) |
-1.385 |
.167 |
.13 |
|||
Item 6 |
1.10 (.51) |
1.20 (.76) |
-1.537 |
.125 |
0.15 |
|||
M: MeanSD:
Standard deviationt:
Student's t-testp:
significanced:
Cohen's d effect size test.
Table 5
Variable |
Professional tenure
(years) |
gl |
||||
Factor I |
0-9 |
7.29 (3.92) |
.335 |
387 |
.80 |
BCAD |
10-19 |
7.67 (3.88) |
|||||
20-29 |
7.37 (4.22) |
|||||
30-40 |
7.04 (4.44) |
|||||
Item 1 |
0-9 |
3.38 (1.44) |
.235 |
387 |
.87 |
ACBD |
10-19 |
3.23 (1.57) |
|||||
20-29 |
3.32 (1.56) |
|||||
30-40 |
3.23 (1.69) |
|||||
Item 2 |
0-9 |
2.51 (1.38) |
1.075 |
387 |
.359 |
BACD |
10-19 |
2.53 (1.38) |
|||||
20-29 |
2.46 (1.47) |
|||||
30-40 |
2.19 (1.45) |
|||||
Item 3 |
0-9 |
2.39 (1.39) |
.288 |
387 |
.834 |
BCDA |
10-19 |
2.57 (1.37) |
|||||
20-29 |
2.45 (1.50) |
|||||
30-40 |
2.43 (1.54) |
|||||
Factor II |
0-9 |
3.38 (1.61) |
.396 |
387 |
.756 |
BCDA |
10-19 |
3.64 (2.48) |
|||||
20-29 |
3.56 (2.04) |
|||||
30-40 |
3.40 (1.79) |
|||||
Item 4 |
0-9 |
1.17 (.65) |
.104 |
387 |
.958 |
BCDA |
10-19 |
1.22 (.83) |
|||||
20-29 |
1.21 (.79) |
|||||
30-40 |
1.19 (.80) |
|||||
Item 5 |
0-9 |
1.09 (.52) |
.693 |
387 |
.557 |
BCDA |
10-19 |
1.21 (.83) |
|||||
20-29 |
1.13 (.65) |
|||||
30-40 |
1.09 (.50) |
|||||
Item 6 |
0-9 |
1.12 (.54) |
.635 |
387 |
.593 |
CBAD |
10-19 |
1.21 (.83) |
|||||
20-29 |
1.21 (.75) |
|||||
30-40 |
1.12 (.59) |
Initials A, B, C and D represent the 0-9, 10-19, 20-29 and 30-40
years Professional tenure groups respectively. Initials are ordered according
to the mean and differences between groups are represented by a dash.
M: MeanSD:
Standard deviationf:
Snedecor's f-testp:
significanceTukey:
Tukey's post hoc test
Discussion
This study has led to the development of a useful scale (AHE-PM)
to explore attitudes towards euthanasia in medical professionals. Given the
characteristics of the health systems, these professionals often have
difficulties with time availability, so the development of a simple tool, easy
to apply and that requires only a few minutes, is especially useful to
systematically determine individual and group attitudes of the medical staff.
In this sense, a short scale with optimal psychometric properties was obtained,
which provides information on two factors associated with attitudes towards
euthanasia. First, Factor I provides information on attitudes towards the
application of euthanasia in situations where there seems to be some medical
justification. Factor II refers to the application of euthanasia under criteria
based on the patient’s subjective emotional suffering.
In this way, the two factors conform an instrument that allows,
on the one hand, to know medical staff’s attitudes towards euthanasia, exposing
them to a bioethical and personal dilemma. Some studies indicate that
professionals are emotionally affected when faced with the concepts of death
and euthanasia in terminal patients. These professionals’ self-awareness of
their own attitudes towards euthanasia and their adaptation to the current
ethical codes could minimize the impact generated by these situations and, therefore, improve the therapeutic relationship
and the quality of care (Ay & Öz, 2018; Emanuel et al., 2016). The
instrument can also facilitate the detection of professionals who might make
liberal use of euthanasia through its Factor II (Sinclair, 2019).
Specifically, in Factor I, the three items that compose it show
high or very high factor loadings. The same happens in Factor II where the
factor loadings are, in all cases, equal to or greater than .95, indicating
that the structure obtained in this study is likely to remain solid in
subsequent works. With respect to the indicators of symmetry and normality,
acceptable indicators are observed for Factor I while in Factor II these
indicators show atypical values. These results are within expectations since
Factor II is designed to detect atypical attitudes towards euthanasia and,
therefore, shows a significant floor effect (or asymmetry) in the present
sample. Overall, reliability indicators on both factors were very good,
explaining a large percentage of the variance in the sample (Table
2). These results are supported by the fit estimators obtained using the
CFA where all of them showed scores indicating that the model fit the data (Table 3).
In this line, the scale evaluates two aspects of attitudes
towards euthanasia. On the one hand are the aspects that are more closely
related to the current ethical and legal codes, where professionals can face
their own attitudes and become aware of their congruence with the legal
frameworks, and which may even lead to processes in which professionals
question their own attitudes. The other aspect refers to more subjective issues
and can serve as an indicator of controversial attitudes towards euthanasia
that could generate cognitive dissonance in the professionals. Attitudes
towards euthanasia could also be used as a risk indicator for the “liberal”
recommendation of euthanasia in patients who may demand this type of
intervention because of a perception of low self-efficacy, depression or social
isolation, a state of mind that is, for example, common in the elderly (Patrão, Alves, & Neiva, 2019). The
proposed instrument and the study carried out aimed to emphasize the need to
include in the medical faculties sufficient training about the end of life and
the right to die, with the bioethical derivations that this process entails.
As mentioned above, although there are already tools published
that evaluate attitudes towards euthanasia, many of them have been created and
validated using medical students (Loera et
al., 2018). In this sense, this instrument was designed and analyzed
exclusively using practicing professionals. Along these lines, professional
tenure or gender was explored as a differential variable in attitudes towards
euthanasia showing that there appear to be greater attitudes towards euthanasia
in males but years of professional tenure did not appear to be related to these
attitudes (Tables 4 and 5). Although the years of experience do not seem to
determine attitudes towards euthanasia in this study, it is considered that
direct experience can play a key role in modifying previous attitudes. There
may be differences between a student and a professional who has been exposed to
at least one case (Francke et al., 2016;
Tamayo-Velázquez et al., 2012;Zenz et al., 2015). Miltiades (2019) finds these differences
in attitudes towards euthanasia in students who have had close experiences of
serious hospitalizations with students who have not had such experiences. With
regard to gender, the attitudes found in men could be explained by Western
culture, where women have always been perceived as protectors/caretakers,
although this is only a hypothesis and more studies should be carried out in
this area to study these differences in more depth.
It should be noted that this study may have a response tendency.
In this regard, this limitation should be taken into account in its
interpretation. Likewise, the design does not allow inferences beyond
relationships and associations. This information can be supplemented by
applying the questionnaire in other populations, at other moments, or over
time. Finally, it would be advisable to scale other models and study their
psychometric properties in depth from other perspectives, such as the item
response theory or Rasch models.
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