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. 2023 Mar 13:00302228231157446. doi: 10.1177/00302228231157446

Death Anxiety During COVID-19 and its Related Factors among Chinese Elderly People

Dengle Yang 1,✉, Yiyun Xia 2, Wenyuan Wu 3, Yuanming Feng 4, Jingyu Liang 5, Jin Zhang 6
PMCID: PMC10014449  PMID: 36913726

Abstract

This study aimed at investigating death anxiety and its related factors in Chinese elderly people during COVID-19. This study totally interviewed 264 participants from four cities in different regions of China. Death anxiety scale (DAS), NEO-Five-Factor Inventory (Neo-FFI) and Brief COPE were scored on the basis of one-on-one interviews. Quarantine experience didn’t make significant difference in death anxiety among the elderly; Elderly people with high death anxiety had higher scores of neuroticism, and were more likely to use a Behavior Disengagement coping strategy; Multiple linear regression analysis showed that neuroticism, openness and COVID impact predicted 44.6% of the variance in the death anxiety among elderly people. The results support both theories of vulnerability-stress model and terror management theory (TMT). In the post-epidemic era, we suggest to pay attention to the mental health status of elderly people with personality susceptibility to handling the stress of infection badly.

Keywords: Death anxiety, Chinese elderly people, Personality traits, Coping strategies, Quarantine, COVID-19

Introduction

The coronavirus and its variants (Delta, Omicron, etc.) continue to threaten many people’s physical and mental health, and this is especially true of elder people who contract COVID-19. Both the rate and the severity of infection by the coronavirus is directly related to the age of the person. Among the people who contract COVID-19, the mortality rate is highest in people over 65. The high mortality rate among the elderly is only one of many accompanying uncertainties that sustain greater anxiety among the elderly who are at especial risk (Weiss & Murdoch, 2020). Following the criteria for risk regions designated by The Joint Prevention and Control Mechanism of the State Council of China (2020), it has become possible in China to identify three levels of risk among regions where Covid has taken a foothold: low, medium and high-risk. The medium and high-risk regions have both been designated by the lockdown zones, with close and secondary contacts placed under stricter centralized quarantine, while the rest of the high-risk residents are placed under strictly implemented home quarantine. Residents in low-risk regions are only asked to implement standard prevention and control measures, after which they are allowed to move about freely within the region.

According to the data of China’s seventh Census (2021), the Chinese population over 60 years old accounts for 18.7% of the total population, which reflects the deepening aging degree of Chinese society. During the present pandemic, the elderly have always been the focus of COVID-19 prevention. During a period of frequent outbreak and infection, the elderly will experience higher death anxiety (Yao et al., 2020), Meng et al. investigated the basic mental health status of this population during the pandemic, and it was found that 37.1% of the elderly showed anxiety and depression (Meng et al., 2020). Furthermore, COVID-19 patients with anxiety and depressive disorders may have higher death anxiety (Khademi et al., 2020). A study of demographic factors influencing death anxiety in the elderly found that gender and marital status were both related to the degree of death anxiety, and that the level of death anxiety in elderly Chinese women was lower than that in elderly Chinese men (Cicirelli, 2002). Compared with the widowed, married elderly have higher levels of death anxiety.

Soon after the outbreak of the epidemic, China resolutely adopted quarantine measures and effectively controlled the spread of the epidemic. However, being in quarantine for long periods may lead to psychological problems such as depression and anxiety (Brooks et al., 2020). In addition, due to the requirements of epidemic prevention measures, many elderly people are forced to accept home quarantine or even centralized quarantine, which adds to their isolation from usual sources of social support such as parks and restaurants. Researchers have paid much attention to the psychological impact of quarantine measures. Individuals who experienced quarantine usually report that they are experiencing psychological stress (Mihashi et al., 2009). Studies of hospital caregivers working in quarantine have also found that traumatic incidents emerge from the quarantine experience, and that these are predictive of post-traumatic stress disorder (PTSD) even 3 years later (Bai et al., 2004; Shih et al., 2009). Several qualitative studies of the psychological impact of quarantine measures (Caleo et al., 2018; Cava et al., 2005; Liu et al., 2012; Pellecchia et al., 2015; Wang et al., 2011) have also documented the negative psychological experiences that can be directed related to quarantine, these include fear, anger, numbness, anxiety and depression. A previous study on the degree of death anxiety in elderly people over 65 years old who were quarantined at home confirmed that those with negative nucleic acid tests but with a history of close contact with people who had caught Coved had significantly higher death anxiety than people the same age who are negative for Covid and without contact with people who have caught Covid. (Aslaner et al., 2022). It is not difficult to speculate that in China, most of the elderly undergoing quarantine who were nucleic acid negative did have close contacts with people who had caught Covid, and so are at risk of experiencing higher than normal death anxiety for people their age. Unfortunately, at present little is known about death anxiety among the elderly population in China, especially among those who have experienced quarantine, despite the large number of people now who have had that experience.

Research on factors related to death anxiety has long been a concern of researchers, who have divided these into internal factors and external factors. Among the external factors related to death anxiety researchers have recovered are poor baseline health status, psychological stress, religious belief, and degree of satisfaction with their lives (Semenova & Stadtlander, 2016). An external factor that is life-threatening would be something like the COVID-19 pandemic, which it is easy to demonstrate would significantly enhance death anxiety in the elderly (Rababa et al., 2021). Meanwhile, female gender and being a widow are also noteworthy external factors related to death anxiety among the elderly. Being a widower increases the death anxiety among men. From the perspective of cultural value, some researchers have found that under the traditional patriarchal social structure of China, elderly women have a lower sense of cultural value, and so will have higher death anxiety than men (Pei et al., 2022). The influence of having lost a marriage partner on death anxiety is consistent, that is, the elderly widowed have more death anxiety than the elderly with living spouse, which may be partly related to the influence of culture and belief (Majid & Ennis, 2022; Pei et al., 2022). Among the internal related factors of death anxiety that researchers have paid much attention to are personality traits. A study of residents in Turkey and Denmark found a positive association between neuroticism and death anxiety (Özdemir et al., 2021). Beyond neuroticism, extraversion is also an important factor affecting death anxiety (Frazier & Foss-Goodman, 1989). However, there are no studies on personality traits and death anxiety among the elderly in China that we were able to find. Another internal related factor is coping strategy, and coping research focuses on the internal and external resources that individuals have when choosing coping strategies. According to the theory of Terror Management Theory (TMT), when people are facing a crisis event, such as COVID-19 outbreak or being quarantined due to contact with infected people, they will activate basic defense mechanisms such as self-esteem and cultural worldview, to alleviate their fear. Studies have found that during the pandemic, the presence of religious coping behaviors in the elderly correlated with lower levels of death anxiety (Rababa et al., 2021). As we all know, China has a unique cultural and religious background, with three basically Chinese religions—Buddhism, Taoism, and Confucianism, and several imported religions, including Christianity, Judaism, Islam, and Bahai, that have attracted a following among contemporary Chinese people. Further studies of the effect of the effect of having such a strong multicultural religious base may be able to answer the question as to whether the coping strategies of Chinese elderly people are also especially various.

The present study, whose findings we will report here, was undertaken to explore the death anxiety of the elderly during the outbreak in China of a new round of the Delta variant of COVID-19 from July to November 2021. We chose to study its relationship to personality traits, coping strategy, gender, religious beliefs, COVID-19 impact, and living alone or not, as well as other factors related to this background. Based on questions that emerged from a survey of the previous studies on death anxiety reported here, we carried out our research with the following questions in mind: (1) Does experiencing quarantine have an effect on death anxiety of the elderly? (2) Are there differences, between the elderly with high death anxiety and those with low death anxiety, in personality traits, coping styles, gender, religious beliefs, COVID-19 impact, and living alone? (3) What might be considered likely predictors of death anxiety among the elderly in China when forced to confront COVID-19.

Method

Survey

For this study, we chose specific regions in four different cities during an outbreak of COVID-19 between July 2021 and November 2022. The following regions that were both medium and high-risk for infection were selected as the experimental group (EG): Zhongnan Street, Liwan District, Guangzhou city; Lukou Street, Nanjing city; Guihua Street, Hetang District, Zhuzhou city. Randomly conducted interviews took place in identified lockdown regions, 2–3 weeks after the lockdown was lifted by social workers of the local social work station or the staff of the neighborhood committee.

The “elderly” population interviewed for the study were age of 60 and above. Each interview was conducted one-to-one, utilizing a semi-structured interview. Each interview duration was from 1–1.5 hours. The location of the interview was based on the convenience of the people being interviewed, so sites we used to conduct our interviews included the interviewee’s home, a community social work station or a community street.

The single Control group (CG) we chose was in the Mudan District of Heze City, which had no epidemic outbreak in the past year. In each of the three EGs, all of which were in cities that had a Covid outbreak, we chose a community of a size similar to that of the CG, and everyone in the EGs received the same interview as the CG.

The interviewers who conducted these structured interviews included five experienced senior clinicians with significant psychological counseling and psychotherapy experience. Prior to conducting any interviews, all members of the research group completed a 1-week on-site psychological interview training.

Participants

A total of 264 elderly people (60–96 years old, Mean age = 74.5 ± 8.4; male = 167, female = 97) were interviewed in this study. There were 169 subjects in the EG and 95 subjects in the CG, the elderly in the EG and the CG were both not infected with the coronavirus. Inclusion criteria: (1) Elderly people who voluntarily participated in this survey; (2) No language communication barriers and ability to accurately understand the content of the questionnaire; (3) Age ≥60, no gender limitation; (4) Good physical condition. Exclusion criteria: (1) Patients with intellectual disability, history of mental illness or suffering from Alzheimer’s disease and severe organic diseases; (2) Those for whom the subject of death is particularly taboo or who were individually unwilling to discuss death.

Measures

Demographic Characteristics Collected

Sociodemographic information was routinely collected from all interviewees, such as age, gender, education years, marital status, whether living alone, religious belief and other information. Then various instruments were administered to each interviewee, as follows:

Death Anxiety Scale

This scale was compiled and published by Professor Templer of the University of California in 1970. In China, the Chinese version was introduced by Yang Hong through cross-cultural adjustment. The scale is a multi-dimensional scale with 15 items, including four dimensions: emotion, pressure and pain, time awareness and cognition. The test-retest reliability of the Chinese version of the scale was 0.831, and the internal consistency Cronbach’s ɑ coefficient was 0.731 (Yang et al., 2016). The scale adopts Likert 5-level scoring method, in which 9 items are scored positively and six items are scored negatively (items 2, 3, 5, 6, 7, 15), with a total score of 75 points. The higher the score, the more serious the death anxiety was. According to the original five-level scale, 35 was defined as high death anxiety.

NEO Five-Factor Inventory

The NEO Five-Factor Inventory (NEO-FFI) contains 60 items, including five key personality dimensions abstracted from several decades of earlier research on the variables most frequently observed when personality is scrutinized, including neuroticism, extraversion, openness, agreeableness and conscientiousness. For each these factors, normally present to some degree in everyone, it adopts a 5-level scale (1–5). The internal consistency coefficient of each subscale was between 0.67 and 0.83, indicating high reliability. (McCrae & Costa, 2004).

The Brief Coping Orientation to Problems Experienced (Brief COPE)

A simplified version of the COPE Experience with 28 items measuring 14 different coping strategies: Positive coping, planning, positive reframing, acceptance, humor, religion, emotional support, instrumental support, self-distraction, denial, venting, substance use, Behavior Disengagement self-blame. A 4-point scale was used: (1) rarely, (2) occasionally, (3) often, and (4) fairly frequently. The reliability of each subscale is between 0.50 and 0.90 (Carver, 1997).

Covid-19 Impact

Asking about the impact of COVID-19 on their life, survey time of occurrence, frequency of occurrence, degree of mental impact (0–4 five dimensions, 0 no impact, 4 great impact), duration (1 = less than 3 months, 2 = 3–6 months, 3 = 7–12 months, 4 = more than 12 months). We used the following formula developed on the basis of the Life event scale (LES) that postulates that “The event stimulation = the impact of the event × the duration of the event × the number of times the event occurs.

Statistical Analysis

The Statistical Package for the Social Sciences (SPSS) version 26.0 (Armonk, NY: IBM Corp) was used for all statistical analyses. Descriptive statistics were used to identify the elderly people’s demographic characteristics and personality traits, coping strategies, and death anxiety. An independent sample t-test was used to compare the death anxiety between the EG and the CG, as well as differences in personality traits, coping strategies, and the COVID-19 impact between the high and low death anxiety groups. Finally, multiple regression analysis was used to obtain the predictors of death anxiety, taking the death anxiety scores as the dependent variable and personality traits, coping strategies, COVID-19 impact degree, gender, education years, marital status, living alone or not, and religious belief as the independent variables.

Ethical Consideration

Ethical approval for this study was obtained from the Research Review Committee (21QN15). During the interview, the interviewers were instructed to introduce the purpose and content of the research to the interviewees in detail and submit the informed consent form to the interviewees. Written or oral informed consent was routinely obtained from the respondents before the interviews.

Results

Demographic Characteristics of the Elderly and its Comparison of DAS Scores

A total of 264 elderly people ranging from 60–96 years old, with a Mean Age = 74.5 ± 8.4; the number of males = 167 and the number of females = 97) were interviewed in this study. Comparing the scores of death anxiety in the different groups, we found significant differences in death anxiety on the basis of marital status (F = 2.684, p < .05), and the post-hoc test showed that the death anxiety of the widowed was significantly higher than divorced elderly (p < .05), that those married but separated for more than 1 month had significantly higher death anxiety than divorced elderly (p < .05); and that subjects married but separated for more than 1 month had significantly higher death anxiety than the unmarried elderly (p < .05). Socio-demographic characteristics of the elderly are given in Table 1.

Table 1.

Demographic Characteristics and its Comparison of DAS Scores of the Elderly.

Items N % DAS t(F)
Gender
 Male 167 63.3 t = 0.005
 Female 97 36.7
Highest diploma
 Elementary 130 49.2 F = 0.914
 Middle school 72 27.3
 High school 50 18.9
 College 12 4.5
Marital status
 Unmarried 7 2.7 F = 2.684*
 Married and living together 188 71.2
 Married but separate over 1 month 3 1.1
 Divorced 6 2.3
 Widowed 60 22.7
Religion
 No 228 86.4 F = 0.589
 Buddhism 29 11.0
 Christian 5 1.9
 Catholic 2 0.8
 Taoism 0 0
Smoking or not
 Yes, still smoke 23 8.7 F = 0.583
 Yes, just before 29 11.0
 Never 212 80.3
Alcoholism
 No 220 83.3 t = 0.847
 Yes 44 16.7
Live alone
 Alone 77 29.2 t = 1.192
 With partner, children or relatives 187 70.8
Age (years) Mean SD
74.58 8.44
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*p < .05.

Comparison of Death Anxiety between EG and CG

A t test was used to compare the elderly in the EG and the CG, and it was found that there was no significant difference in death anxiety between the two groups (t = −0.847, p > .05 (see Table 2).

Table 2.

Comparison of Death Anxiety between EG and CG.

Item EG CG T
DAS 40.50 ± 8.84 41.46 ± 8.82 −0.847
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Comparison of Personality, Coping and COVID-19 Impact between the Elderly with High and Low Death Anxiety

The total Death Anxiety Scale (DAS) score higher than 35 were considered as high death anxiety. According to this, 264 elderly people were divided into high death anxiety group and low death anxiety group. Independent sample t-test was performed on the two groups, and significant differences were found between the two groups (t = −24.350, p < .001) see Table 3. Independent sample t-test was used to compare the personality traits, coping strategies and COVID-19 impact of elderly people between high and low death anxiety group, significant differences were found at Conscientiousness, Extraversion, Agreeableness, Neuroticism, Active coping, Positive Reframe, Self-distraction, Behavior Disengagement (the above eight, p < .001). Plan, Humor and Instrumental support (the above three, p < .05); There were also significant differences in the impact of COVID-19 between the two groups (p < .001). At last, Pearson correlation analysis was used to test the correlation between DAS score and each variable. These results are presented in Table 4.

Table 3.

Independent Sample t-Test between High Death Anxiety Group and Low Death Anxiety Group.

Item High DAS (n = 194) Low DAS (n = 70) t
DAS 44.79 ± 6.59 29.91 ± 3.22 −24.350***
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***p < .001.

Table 4.

Comparison of Personality, Coping and COVID-19 Impact between the Elderly with Two Groups and Correlations with DAS Scores.

Items High DA (n = 194) Low DA (n = 70) t R
M ± SD M ± SD
NEO-FFI variables
 Openness 34.87 ± 4.76 35.75 ± 4.41 1.359 −0.165**
 Conscientiousness 40.61 ± 5.56 44.68 ± 4.75 5.438*** −0.305**
 Extraversion 34.55 ± 5.91 39.25 ± 6.23 5.626*** −0.342**
 Agreeableness 38.78 ± 5.16 42.65 ± 4.88 5.454*** −0.307**
 Neuroticism 34.62 ± 6.23 26.44 ± 6.96 −8.000*** 0.511**
BCOPE
 Active coping 4.39 ± 1.27 5.35 ± 1.40 5.264*** −0.251**
 Planning 4.59 ± 1.61 5.10 ± 1.55 2.491* −0.183**
 Positive reframing 4.28 ± 1.15 5.54 ± 1.61 5.978*** −0.350**
 Acceptance 5.11 ± 0.99 5.05 ± 1.31 −0.370 0.033
 Use of humor 4.02 ± 1.32 4.60 ± 1.73 2.531* −0.185**
 Religion 2.58 ± 1.06 2.81 ± 1.20 1.476 −0.137*
 Emotional support 4.70 ± 1.12 4.97 ± 1.39 1.558 −0.080
 Instrumental support 4.49 ± 1.03 4.88 ± 1.24 2.554* −0.151*
 Capacity for self-distraction 5.04 ± 1.03 5.75 ± 1.42 3.845*** −0.239**
 Denial 3.40 ± 1.34 3.41 ± 1.25 0.066 0.082
 Venting 4.40 ± 1.18 4.67 ± 1.29 1.561 −0.092
 Substance use 2.72 ± 1.26 2.51 ± 1.01 −1.367 0.054
 Behavior disengagement 4.39 ± 1.38 3.32 ± 1.16 −5.746*** 0.266**
 Self-blame 3.70 ± 1.39 3.68 ± 1.28 −0.107 0.011
 COVID-19 impact 2.26 ± 1.07 0.93 ± 0.71 −9.347*** 0.569**
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*p < .05, **p < .01, ***p < .001.

Predictors of Death Anxiety in the Elderly in China during COVID-19

Multiple stepwise linear regression model statistically significantly predicted death anxiety scores (F = 45.845, p < .001, adj. R2 = 0.446). Neuroticism (p < .001), openness (p < .05) and COVID impact (p < .001) entered the regression model. These results are shown in Table 5.

Table 5.

Multiple Regression Analysis with the Death Anxiety Scores (N = 264).

Predictor Variables β t R2 Adj. R2 F
Model 0.456 0.446 45.845
Constant 32.042 6.533***
Neuroticism 0.386 5.433***
COVID impact 2.804 5.488***
Openness −0.279 −2.359*
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*p < .05, ***p < .001, R2 = coefficient of determination, Model = “stepwise” method in SPSS Statistics.

Discussion

This paper is the first to study death anxiety among the elderly in China during the COVID-19 pandemic. We investigated the degree of death anxiety in part to explore whether experiencing quarantine would reduce or increase the death anxiety of the elderly, and to determine which other factors can be reasonably assumed to be predictors of death anxiety among this population of older Chinese people.

Demographic Factors and Death Anxiety among the Elderly

Eight demographic variables including age, gender, marital status, highest education level, living alone, religion, smoking, and drinking were recorded for all the subjects in this study. The results showed that except for a significant difference of death anxiety in the elderly on the basis of marital status, the other demographic factors were not at all significant in predicting the degree of death anxiety. That the relationship between age, education, living alone, religion and smoking and death anxiety was not supported by our study was consistent with previous studies in other elderly populations (Donald, 1972; Pei et al., 2022; Scovel, 2004; Thorson & Powell, 1993). The difference we found in death anxiety among the elderly with different marital status is consistent with the findings of New Zealand researchers (MacLeod et al., 2016). Unlike these researchers, however, we did not find any difference in death anxiety between the widowed and the married elderly. That this variable was not significant as has been found in other countries may be related to China’s “care for the elderly” culture of supporting the elderly, which assures that aged widow or widower can still get child and family care and help. Furthermore, the elderly mostly receives the influence of traditional culture which values the “continuity of the family line”, so that once their children grow up, the elderly can feel that a family-continuing task has been completed and that they themselves are entitled to face death with more safety in the form of family interest and support. On the other hand, this study further found that both the widowed and married elderly who had been separated from their spouses for more than 1 month had significantly higher death anxiety than the divorced elderly. It also found that elder who were married but separated for more than 1 month had significantly higher death anxiety than the unmarried elderly. We postulate that the separation from a spouse, whether from death or divorce results in a loss of intimacy, and that this loss leads to an elderly individual feeling they are hovering between life and death. When this feeling is associated with the permanent loss of a spouse, it may be much more likely to cause death anxiety. In addition, the significant loss faced by a widowed spouse can increase the prevalence of physical diseases such as heart failure and rheumatoid arthritis (Majid & Ennis, 2022), and this may be another of the factors that leads to the rise in death anxiety. Finally, that the death anxiety of the elderly who are married but separated for more than 1 month is higher than that of the divorced elderly suggests that the separated elderly are still living in the stage of intensification of intimate relationship conflicts, including the despair that results from stalemate with an intimate partner. The latter has to be an added psychological stress leading to many kinds of anxiety in the separated elderly.

Quarantine and Death Anxiety of the Elderly

This study found, importantly, that experiencing quarantine had no significant effect on death anxiety in the elderly. The absence of effect of quarantine on death anxiety may be connected to the dissemination of definitive information concerning the epidemic in China, which has led to greater public awareness of the virus, to widespread vaccination, and to understanding of the value of a defined period of quarantine. In addition, the availability of various forms of daily life support is also an important part of the quarantine period. Community personnel and social workers in China routinely deliver food and water to the quarantined elderly, so that basic life support for the elderly is guaranteed. Finally, because of the publicity given to preventive measures during the epidemic, and the dissemination of information about Covid by the media, the elderly can acquire knowledge that they can individually use for self-protection. When authoritative information is given by the media, it can prevent the spread of rumors and suspicions, which definite stabilizes the mood of elderly people.

Nevertheless, death anxiety remains a problem for elderly Chinese people, as our study makes clear. The average values for death anxiety that we collected were more than the critical value of 35. It can be seen that in the second round of the outbreak, even the elderly in the lower-risk regions of China had high death anxiety. This was a different from previous research that had shown higher death anxiety in the elderly mostly among those in this group who had close contact with other elderly who were infected (Aslaner et al., 2022). The higher death anxiety in both groups, those without much contact with the infected, and those with much contact with infected people may be influenced by the amount of media information about the danger of infection. This has been especially obvious when new media source of information is relied upon. Studies have confirmed that the increased use of new media for information makes people more likely to feel depression, anxiety and stress during the pandemic (Chao et al., 2020). A great deal of information, including the COVID-19 outbreak period of information, the elderly deaths and hospital scenes reported from multiple sources and discussed by family, friends often reached the elderly, stimulating worry about the fragility of life and death, and putting each older individual under considerable stress. This paper only discusses the impact of so much frightening information on the elderly population, so the impact on other populations of Chinese people needs to be researched in future studies like this one using similar methodology.

Personality Traits, Coping Strategies, COVID-19 Impact, and Death Anxiety

We found significant differences in personality traits between the high and low death anxiety groups of the elderly, which is consistent with previous studies on personality and death anxiety. For instance, there are many studies supporting the relationship between neuroticism and death anxiety (Donald, 1972; Pérez-Mengual et al., 2021; Pradhan et al., 2020). Individuals with higher neuroticism scores on the NEO Five-Factor Inventory respond more strongly to external stimuli than ordinary people, and they have poor emotional regulation ability, so that, they are easily put in a bad emotional state. The other three personality traits: agreeableness, extraversion, and conscientiousness, all scored higher in the low-death anxiety group. This is also consistent with the conclusions of previous studies (Doroudian et al., 2018; Pérez-Mengual et al., 2021). Extraversion, agreeableness and conscientiousness are all protective factors for mental health (Grevenstein et al., 2016), and some studies have confirmed that conscientiousness is a protective factor for individuals to maintain psychological health during COVID-19 (Liu et al., 2022). According to the vulnerability-stress model, when individuals face the outbreak of a stressful event, the individual who has different personality susceptibility will have a different response. This finding reminds us to pay attention to the mental health status of the elderly susceptible to personality traits during the COVID-19 outbreak (Major Figures on 2021 Population Census of China, 2021).

On the basis of Fear Management theory (TMT), individuals will spontaneously activate corresponding coping mechanisms when encountering fearful events, such a pandemic. This paper compared the coping strategies of the elderly with high and the elderly with low death anxiety. We found that except for behavior disengagement, the coping strategies of the elderly with high death anxiety were significantly less developed than they were in those with low death anxiety. The other six dimensions of Active Coping, Positive Reframing, Self-distraction, Planning, Ability to Use Humor and Instrumental Support are all higher in the elderly with low death anxiety. Different from previous studies that paid more attention to religious coping, the conclusion of this study did not confirm the relationship between death anxiety and religious coping. Ours is similar to the conclusion of another study on death anxiety in the elderly in Hong Kong, China (Wu et al., 2002). Although the enthusiasm for religion has soared in China since 2018, the percentage of Chinese people who has religious belief is still very low compared to the Western countries (Blanchard et al., 2008). This means that Western studies on religious coping and death anxiety are not necessarily appropriate to explain the Chinese population. Secondly, we found that elderly people with high death anxiety are more likely to use Behavior Disengagement coping strategy. According to the study of Burker et al., behavioral disengagement is positively associated with depression (Burker et al., 2005). We can speculate that the elderly with higher death anxiety may experience more negative emotions such as depression, and for them behavioral disengagement could be the coping method of choice. Culturally speaking, behavioral disengagement is often a way of giving up and developing a completely passive response. The absence of anxiety is thus not always a good thing. This negative attitude is not inconsistent with the Wu-Wei of Taoism culture, but it has more of a resigned to fate, pessimistic attitude of a “Given Up-Giving Up Complex” (Engel, 1968). Finally, the elderly people with low death anxiety were more likely to use more active coping strategies, which complemented Judith’s finding that individuals with high death anxiety were more likely to use avoidance coping strategies during the pandemic (Partouche-Sebban et al., 2021). In general, the conclusion of this study are also in line with the theory of Fear Management theory. Positive coping strategies can help individuals reduce death anxiety and better cope with challenges at present.

We concluded, consistent with previous studies, that neuroticism and the influence of COVID-19 produced a predictable increase of death anxiety in the elderly (Ozdemir et al., 2019; Pérez-Mengual et al., 2021). According to a vulnerability-stress model, individuals with high neuroticism are far more likely to produce great and more sustained responses when compared to people with low neuroticism facing the very same event. Generally, neuroticism is associated with poor ability to cope effectively with stress or regulate negative emotional states (Gunthert et al., 1999). Neuroticism is thought to be an important regulator of physiological stress, and individuals with high levels of neuroticism use potentially maladaptive coping strategies, such as self-blame, tend to over reinforce threat-related stimuli, and more often interpret neutral situations as threats. However, when such individuals need to regulate this negative emotion, it is difficult for them to isolate and reduce the negative emotion. In conclusion, the death anxiety and stress response of the elderly with neurotic traits under the influence of the pandemic need more attention and psychological assistance (Health Commission Website, 2020).

The presence of another personality trait, openness, on the other hand, was predictive of a lower death anxiety in older adults. Openness has been considered as a protective factor for depression, and individuals with high openness tend to use cognitive reconstruction, acceptance, distraction and other strategies that require new perspectives (Connor-Smith & Flachsbart, 2007; Takahashi et al., 2017). In addition, although the concept of “hate death, avoid death, and taboo death” of Confucian culture has taken root in Chinese people’s hearts for 25 hundred years to encourage the elderly to avoid the topic of death, openness is exactly the trait to neutralize of this conservative attitude towards death. More studies on death from a psycho-cultural perspective are needed to explore this potential.

If personality traits link to individual susceptibility, the outbreak of COVID-19 is irritant factor that comes from the external environment. This study confirmed that just the usual stress associated with a COVID-19 outbreak can positively predict an increase in the death anxiety of the elderly. This finding suggests that the death anxiety of the elderly may continue to maintain a high level in the post-pandemic era as long infection with the COVID virus is still occurring frequently enough to be disruptive. Therefore, we need to pay attention to the anxiety, depression, PTSD and chronic disease comorbidities that may result from high death anxiety in the elderly people who know they are at risk for this infection. The elderly, it must be emphasized, are in a stage of life that fosters the self-integration of the experience of a lifetime. Elderly people like to integrate their life stories to gain a sense of meaning. According to researchers who have studied meaning-making, however, though people do have the need to construct meaning, the imminence of death can destroy the meaning of human existence. Therefore, in the post-epidemic era, it is necessary to carry out death education for the elderly, which can build a sense of significance not only to survival but also to the inevitable surrender to death and in both ways help people threatened by COVID to achieve self-integration in the midst of their stress.

Conclusions

This study investigated the relationship in elder Chinese people between death anxiety and sociodemographic factors, personality traits, coping styles, experiences of quarantine, and the impact of COVID-19 as a threat to their existence. First, it noted differences in the degree of death anxiety between subjects that had different marital statuses. The conclusion suggests that we should pay more attention to the death anxiety of the divorced, widowed and separated elderly. Secondly, there were differences in conscientiousness, agreeableness, neuroticism, extraversion and openness between the high and low death anxiety groups. The elderly with low death anxiety scored higher on all of these traits except neuroticism, which correlated with high death anxiety. Behavior Disengagement, when we turn to coping styles, also correlated with high anxiety about death among the elderly. But six other coping styles, which we named Active Coping, Positive Reframing, Self-distraction, Planning, Use of Humor, and Instrumental support, when present in our elderly subjects, correlated with lower death anxiety. In addition, this study found that the experience of quarantine did not significantly affect the death anxiety of the elderly. The average score of death anxiety of the elderly was higher than 35, regardless of whether there had been an experience of quarantine. Finally, we identified the personality trait of neuroticism and the environmental presence of heightened COVID-19 risk as positive predictors of greater death anxiety in the elderly, and we discovered that the presence of significant openness in the personality of a subject was a negative predictor.

Limitations

Our study was based on face-to-face interviews, and unfortunately, we found that it was not easy to communicate with the elderly due to dialects and accents. We learned that more time and patience would be needed in a future study. Without preparation for the limitations we encountered, the number of potential interviewees was greatly limited, especially in large-scale communities. Ironically, because of the repeated outbreaks of epidemic, the investigation into the anxiety this was likely causing could not continue and will have to be carried out by other investigators who have can maintain access to the very subjects they need to hear from when environmental stress increases.

Acknowledgments

We want to extend our thanks to every elderly person who accepted the interview. Their patience and wisdom inspired and enlightened each of us. We also owe a debt of gratitude to the social workers of Guangzhou Datong Social Work Service Center, Zhongnan street station and Hailong street station; Zhuzhou Datong Social Work Service Center, Department of Psychology of Heze University, and Social Work Station of Nanjing Lukou Town for their great help in this research. In addition, we would like to acknowledge the help of the team of the professional interviewers we assembled from the able students and faculty of the City University of Macau, Heze University and Guangdong Open University. At last but not least, we would like to express a special thanks to Dr John Beebe for his meticulous editing of this paper.

Author Biographies

Dengle Yang, PhD in Applied psychology. Post-doctoral researcher at Guangdong University of foreign studies. His research centers on Analytical Psychology, dream, and death studies and suicide. Currently undergoing training in Jungian psychology in IAAP (International Association for Analytical Psychology). He is a licensed clinical psychologist of CPS (Chinese Psychological Society). Guangdong University of foreign studies, 2 Baiyun Avenue, Baiyun District, Guangzhou 510420, China. Email: yangdengle@hotmail.com

Wenyuan Wu, PhD in Applied psychology. Lecturer of Heze University, China. Email: 478906857@qq.com

Yiyun Xia, PhD in Applied psychology. Lecturer of Nanjing normal university of special education, China. Email: sharon-xiayiyun@foxmail.com

Yuanming Feng, Doctoral student of applied psychology of City university of Macau, China. Email: 936290335@qq.com

Jingyu Liang, PhD in Applied Psychology. She is a post-doctoral researcher in the School of Humanities, Tongji University, China. Email: ljyolive@163.com

Jin Zhang, professor of literature and cultural study of Lan Zhou university, China. Email: 1192700435@qq.com

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Dengle Yang https://orcid.org/0000-0003-1022-924X

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