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. 2023 Jun 29:00302228221144791. doi: 10.1177/00302228221144791

A Systematic Review and Meta-Analysis on Death Anxiety During COVID-19 Pandemic

Indrajit Patra 1, Iskandar Muda 2, Ngakan Ketut Acwin Dwijendra 3, Mazin AA Najm 4, Shadia Hamoud Alshahrani 5, Samah Sajad Kadhim 6, Noora M Hameed 7, Yasir S Alnassar 8, Naseer M Mohammed 9, Yasser Fakri Mustafa 10, Vahid Shojaeimotlagh 11,✉
PMCID: PMC10311374  PMID: 37384902

Abstract

This systematic review was conducted to estimate the pooled score of death anxiety during the COVID-19 pandemic. All eligible articles from January 2020 to May 2022 reporting the death anxiety score were included in the analysis b.y searching the Scopus, PubMed, Embase, and ISI databases. The standard score of death anxiety in the COVID-19 pandemic was 50%. The highest score of death anxiety was related to patients with COVID-19 (59.4%), other chronic patients (58.9%), and the elderly (56.4%). The lowest death anxiety score was related to the general population (42.9%) and health care workers (48.2%). The death anxiety score in the studies whose data was collected in 2020 and 2021 was 51% and 62%, respectively. During the COVID-19 pandemic, people experienced high death anxiety, which had terrible effects on their lives. Therefore, it seems necessary to provide training courses to deal with death anxiety for other possible pandemics.

Keywords: death anxiety, COVID-19 pandemic, systematic review

Introduction

The COVID-19 pandemic has been one of the important and anxiety-provoking global events. Death toll statistics from COVID-19 worldwide reminded the frailty of human existence and aroused thoughts about death in people worldwide (Curșeu et al., 2021). In milder cases, death anxiety can be manageable, but in severe cases, it can be problematic (Özer et al., 2021). Death anxiety refers to a persistent, abnormal, and terrifying fear of dying, leading to adverse health consequences such as reduced physical performance, psychological stress, impaired ego integrity, weakened religious beliefs, dissatisfaction with life, and weakened resilience (Dirik & Gunay, 2009; Bala & Maheshwari, 2019).

The origin of death anxiety is fear of annihilation, the struggle of a living being with nothingness, separation anxiety, attitude towards death as bodily mutilation, or earned or conditioned response of existential origins (Sherman et al., 2010). Fear of death is a fear of something, while dread is a fear of nothing. Humans are afraid of losing themselves and becoming nothing. Therefore, the person tries to turn this anxiety (nothing) into fear (something) so that it can be dealt with (Adelbratt & Strang, 2000). Freud believed that the fear related to death reflected unresolved childhood conflicts rather than the fear of death and stated that “our unconscious does not believe in its own death; it behaves as if immortal” (Furer & Walker, 2008). However, today it is believed that death anxiety is a real and fundamental fear as the basis of many forms of anxiety and phobia. Humans manage this anxiety by living under cultural worldviews and presenting immortality literally (i.e., belief in an afterlife) or symbolically (achievements) (Strachan et al., 2007). In this regard, Terror Management Theory (TMT) was presented to explain the effects of fear of death on human behavior and how people protect themselves against death concerns. The specific way people react to death concerns depends on whether these concerns are conscious or unconscious (Menzies & Menzies, 2020). When thoughts of death are conscious, the individual engages in proximal defenses such as suppression of death thoughts and denying one’s vulnerability (Pyszczynski et al., 1999). People suppress thoughts of death by turning off the news reporting the COVID-19 death tolls and trying to deny their vulnerability because they are not part of the high-risk group and are safe from the disease (Menzies & Menzies, 2020).

These people sometimes try to prevent death by cleaning the house surfaces with disinfectants (Menzies et al., 2020). When thoughts of death leave conscious awareness, people engage in distal defenses and strengthen barriers by endorsing our cultural worldviews or enhancing our self-esteem (Menzies & Menzies, 2020).

A recent systematic review and meta-analysis reviewed nine related studies and reported information on death anxiety (Ozguc et al., 2021). Regarding the presentation of the vaccination program against Covid-19 and the control of this pandemic, the analysis of all published studies and the presentation of the latest results will increase public awareness, and based on these results, countermeasures for potential future pandemics can be designed. Various studies have evaluated death anxiety during the COVID-19 pandemic and reported different results. Therefore, this study aimed to estimate the cumulative standard score of death anxiety related to the COVID-19 pandemic.

Method

This systematic review and meta-analysis was conducted based on PRISMA guidelines (Moher et al., 2009).

Search Strategy

Web of Science/ISI, PubMed, Scopus, and Embase databases was searched between January 1, 2020, and May 30, 2022, with keywords including attitude to anxiety, death anxiety, fear of death, death phobia, scared of death, death depression, COVID-19, coronavirus disease-19, SARS-CoV 2, 2019-nCoV, 2019 NOVEL CORONAVIRUS, Wuhan coronavirus, SARS coronavirus, and Wuhan Seafood Market Pneumonia Virus to access eligible articles. The reference list of all the selected articles was reviewed to access more articles. The search strategy in the PubMed database was as follows:

(“Attitude to Death”[Mesh] OR “Death Anxiety”[tiab] OR “fear of death”[tiab] OR “death Phobia”[tiab] OR “Scared of death”[tiab] OR “Attitude to Death”[tiab] “death depression”[tiab]) AND (“COVID-19”[Mesh] OR “SARS-CoV-2”[Mesh] OR “COVID 19”[tiab] OR “2019-nCoV”[tiab] OR “Coronavirus Disease-19”[tiab] OR “SARS CoV 2”[tiab] OR “2019 Novel Coronavirus”[tiab] OR “Wuhan Coronavirus”[tiab] OR “SARS Coronavirus 2”[tiab] OR “Wuhan Seafood Market Pneumonia Virus”[tiab])

Article Selection and Data Extraction

The inclusion criteria were observational studies, availability of full text of the articles, publishing in the English language, investigating death anxiety during the COVID-19 pandemic, and reporting death anxiety score (mean and standard deviation) in the text of the article. Qualitative studies, clinical trials, review studies, letters to the editor, studies conducted on patients with mental problems, and studies that did not report death anxiety scores were excluded from the analysis. Two authors independently reviewed the titles and abstracts of the articles. Required information such as the first author, publication year, sample size, study location, average age, death anxiety measurement tool and score, target population, and data collection time were entered in a pre-prepared form.

Bias Assessment and Methodological Quality Evaluation

The Newcastle-Ottawa Quality Assessment Scale, with three main criteria of selection (maximum five stars), comparability (maximum two stars), and outcome (maximum three stars), was used to evaluate the methodological quality of articles. The selection criterion has four items, including representativeness of the sample (1 star), sample size (1 star), non-respondents (1 star), and exposure measurement (two stars). The comparability criterion has 1 item (two stars), and the outcome criterion has two items, including outcome evaluation (two stars) and statistical tests (one star). Getting less than five stars means poor quality, five to seven stars means average quality, and getting seven or more means excellent quality (Modesti et al., 2016).

Statistical Analysis

This study conducted all statistical analyzes using STATA Software Version 16. The death anxiety score in the selected studies was reported in mean and standard deviation using different tools based on questions and scoring. The average score (raw score) was converted to a standard score based on the following formula to compare the results.

Transformed Scale=[(Actual raw score)−(lowest possible raw score)possible raw score range]×100

In which, Actual raw score presents the raw values acquired by summation, the lowest possible raw score donates the lowest possible raw value, and the possible raw score range shows the range between the highest and least raw scores that can be calculated (Rezaei et al., 2020).

Binomial distribution was used to combine the selected studies based on calculating the standard score for each study. A forest plot was used to visually display the estimation of death anxiety standard scores with a 95% confidence interval. I2 index and Cochran’s Q test were used to check the heterogeneity between the selected studies. The random effects model was used because the I2 index was more than 75% (the value of I2 > 75% is considered as high heterogeneity), and Cochran’s Q test was also significant (the significance level for this test was considered 0.1). This study was conducted on patients with COVID-19, other chronic patients, students, health professionals, the elderly, and the general population in 2020-21 in Asia, Europe, and America. Subgroup analysis was used to separate the target population, and the one-variable meta-regression test was used to check the relationship between death anxiety scores, average age, publication year, and sample size of selected studies. The Funnel plot based on Egger’s regression test was used to determine the publication error of the studies.

Results

In the initial search, 782 articles were retrieved, of which 347 were duplicates. A total of 283 irrelevant articles were excluded from the analysis after reviewing the title and abstract of the remaining 335 articles. Then, 17 articles were removed due to not reporting the necessary details, and 35 articles (with a sample size of 17,832 people) were included in the analysis after reviewing the full text of the remaining 52 articles (Figure 1). In some studies, the participants were divided into two or three groups, and the information related to death anxiety was reported separately; therefore, each group was analyzed separately (Çağlar & Kaçer, 2022; Dursun et al., 2022; Jazaiery et al., 2022; Khajoei et al., 2022). The target population in the selected articles included patients with COVID-19, other chronic patients, health care workers, the elderly, students, and the general population. The data of 18 studies were collected in 2020 and 5 studies in 2021. Based on the Newcastle-Ottawa tool, five studies were of moderate methodological quality (Gokdemir et al., 2020; Damirchi et al., 2020; Rababa et al., 2021; Ozer et al., 2021; Vazquez et al., 2021), and the rest were excellent (Table 1).

Figure 1.

Figure 1.

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Study selection process.

Table 1.

The Characteristic of the Selected Articles.

Author(s) year Sample size Location Standard score Data collection time Target group Age Scale
Şahan & Yıldız, 2022 384 Turkey 88.2 Aug to Sep 2020 Patients with COVID-19 — VAS
Mohammadi et al. 2022 420 Iran 85.2 Sep to Dec 2021 Nursing students 25.17 ± 2.41 DAS
Korkut, 2022 114 Turkey 45.6 Jul to Oct 2021 Hemodialysis patients 60.6 ± 15.1 DAS
Khajoei et al., 2022 91 Iran 45.7 — Nurses — DAS
139 37.8 — ME personnel —
Jazaiery et al., 2022 300 Iran 40.1 — Dental students 23.9 DAS
60 56.8 — Dental staff 40.1
He & Li, 2022 382 China 44.1 — Medical students 25.5 ± 3.15 DAS
Erbesler & Demir, 2022 344 Turkey 52.3 June to Aug 2021 The elderly 71.55 ± 6.27 DAS
Caglar & Kaçer, 2022 120 Turkey 57.5 — Patients with COVID-19 — DAS
120 56 Patients with MI —
120 51.5 General population —
Pradhan et al., 2022 200 India 35.5 — General population 26.64 ± 4.49 DAQ
Karabag Aydın & Fidan, 2022 383 Turkey 57.3 June to Nov 2020 Nurses 28.11 ± 6.27 RDAS
Shakil et al., 2022 468 Pakistan 25.6 April to May 2020 General population 29.71 ± 11.15 DAQ
Fattah et al., 2021 150 Iran 36.5 May to Aug 2020 Patients with COVID-19 35.3 ± 9.2 DAS
Aguglia et al., 2021 842 Italy 50.6 Mar to May 2020 HCWs 41.8 + 12.5 DAS
Arpacıoğlu et al., 2021 133 Turkey 56 Dec 2020 Elderly — DAS
Unal et al., 2021 1546 Turkey 56.7 Feb 2021 General population — DAS
Vazquez et al., 2021 1951 Spain 33.8 April 2020 General population 45.16 + 12.78 DAI
Xue et al., 2021 917 China 50.6 — General population — DAQ
Yildirim et al., 2021 115 Turkey 53.4 June to Sep 2020 Nursing students 20.6 + 1.90 DAS
Zeng et al., 2021 76 China 43.8 — Patients with COVID-19 41.62 + 15.5 DAS
Ozer et al., 2021 259 Turkey 69.5 May to June 2021 Patients with COVID-19 49.03 + 15.37 DAS
Enea et al., 2021 110 Romania 43.8 Oct 2020 HCWs 43.64 ± 10.1 DAQ
Siegel et al., 2021 849 Israel 53.4 April 2020 General population — DAS
Cheng et al., 2021 870 China 60.1 Feb to April 2020 Nursing students 21.82 ± 2.49 DAS
Rababa et al., 2021 248 UAE 61 April to May 2020 The elderly 63.95 ± 2.9 ASDA
Mirhosseini et al., 2021 1215 Iran 43.1 — General population 33.7 ± 10.7 DAS
Dursun et al., 2021 38 Turkey 77.3 June 2019 to Mar 2020 Patients with GAD — DAS
31 21.5 General population —
Sogutlu & Göktaş, 2021 789 Turkey 48.3 — Students 21.51 ± 3.97 DAS
Chodkiewicz et al., 2021 618 Poland 27.2 Nov to Dec 2020 General population 26 ± 9.7 DAS
Das & Pal, 2021 550 India 45 Nov 2020 General population 37 ± 0.98 Single item
Guner et al., 2021 354 Turkey 56.9 June to Oct 2020 Elderly 68.3 ± 2.90 DAS
Damirchi et al., 2020 354 Iran 64.7 Jan to Mar 2020 General population — DAS
Lee et al., 2020 453 United States 53.25 Jan to Mar 2020 General population — Single item
Kavaklı et al., 2020 562 Turkey 26.5 — General population 33.5 ± 10.9 DAS
Chen et al., 2020 917 India 50.6 — General population 28.6 ± 9.47 DAQ
Gokdemir et al., 2020 240 Turkey 44.3 Mar to April 2020 Family physicians 40.58 ± 8.88 —
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Arabic Scale of Death Anxiety (ASDA) Revised Death Anxiety Scale (RDAS).

The standard score of death anxiety in the COVID-19 pandemic was 50% (Figure 2). Most studies were related to Turkey (17 studies), Iran (8 studies), and China (4 studies). The standard score of death anxiety in these countries was 54.2%, 51.3%, and 50.3%, respectively. The findings related to the continent showed that the standard score of death anxiety was 51% in Asia and 42% in Europe and America. In addition, the death anxiety score in studies related to 2020 and 2021 was 51% and 62%, respectively (Figure 3). The results of subgroup analysis revealed that the highest score of death anxiety was related to patients with COVID-19 (59.4%), other patients (58.9%), and the elderly (56.4%) (Table 2). The lowest score of death anxiety was related to the general population (42.9%) and health care workers (48.2%).

Figure 2.

Figure 2.

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Forest plot related to a standard score of death anxiety. Each study with horizontal lines around the main mean and the red diamond shape represents the result of combining all studies with a 95% confidence interval.

Figure 3.

Figure 3.

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Forest plot related to the death anxiety standard score by year of data collection. Each study with horizontal lines around the main mean and the red diamond shape represents the result of combining all studies with a 95% confidence interval.

Table 2.

Subgroup Analysis by Continent, Collection Time, and Target Population.

Subgroup Number of studies Prevalence rate (95% CI) Between studies
I2 p Q
Continent Asia 35 51 (46–57) 97.73 0.001 1494.75
Europe and America 5 42 (32–52) 97.32 0.001 149.05
Data collection time 2020 18 51 (42–59) 98.85 0.001 1200.30
2021 5 62 (48–76) 98.19 0.001 221.03
Target group Patients with COVID-19 5 59.4 (38.9–79.8) 98.09 0.0001 208.98
Other patients 3 58.9 (42.9–75) 86.48 0.001 14.79
HCWs 7 48.2 (43–53.3) 74.89 0.001 23.90
The elderly 4 56.4 (52.7–60.1) 34.29 0.207 4.57
General population 16 42.9 (36.7–49.1) 97.71 0.0001 611.85
Students 6 55.3 (40.7–69.8) 98.55 0.0001 345.22
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The meta-regression indicated no correlation between the standard score of death anxiety and the average age of the participants in these studies (p = 0.432), and the publication bias was not significant (p = 0.267) (Figure 4).

Figure 4.

Figure 4.

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Publication bias.

Discussion

This study investigated various studies related to death anxiety during COVID-19, which were systematically reviewed, and the overall standard score of death anxiety was 50. The results showed that the participants in these studies obtained half of the overall score of death anxiety, which can be due to uncertainty about the disease process, high prevalence, high mortality rate, and fear of contracting oneself or loved ones (Özer et al., 2021). Menzies and Menzies (2020) stated that death anxiety exists in all humans, but it becomes more evident in situations related to death. Today, the attitude toward death as a natural part of life has undergone radical changes. Quick death has decreased due to medical advances, and people are more afraid of slow death and its different and severe terminal symptoms (Adelbratt & Strang, 2000). COVID-19 posed a particular challenge to people because of the constant reminder of death. People wanted to avoid contracting COVID-19, and online sales of immune boosters and unapproved medicines increased (Garfin et al., 2020).

The highest standard score of death anxiety was related to patients with COVID-19, other chronic diseases, and the elderly. The anxiety level of patients increases with the diagnosis of COVID-19. Helplessness, insecurity, fear, and anxiety experienced during exposure to a fatal event increases death anxiety (Özer Zet al., 2021; Brooks et al., 2020). Patients with chronic severe diseases such as cardiovascular diseases, kidney failure, and cancer are conscious of their death like the general population. However, these patients may face their death earlier than others due to the condition of the disease and experiencing a profound existential crisis in daily life, which ultimately causes death anxiety (Sherman et al., 2010). Şahan and Yıldız (2022) found that chronic diseases are one of the risk factors increasing the death toll during the COVID-19 pandemic. In addition, physical problems, movement limitations, and the elderly’s dependence on others to do daily tasks are the reasons for high death anxiety in the elderly (Bala & Maheshwari, 2019; Assari & Lankarani, 2016; Khademi et al., 2020; Meng et al., 2020). The interruption of social communication during the COVID-19 pandemic exposed the elderly to psychological distress, loneliness, and social isolation, which increased their level of death anxiety (evi-Belz & Aisenberg, 2020; Armitage & Nellums, 2020). The results of other studies also showed that the elderly were admitted to hospitals and intensive care units more than other age groups during the COVID-19 pandemic and had a higher death toll due to having higher rates of comorbid medical conditions (Guan et al., 2020; Garg et al., 2020).

The lowest standard score of death anxiety was related to the general population and healthcare workers. The general population had the most diversity regarding demographic status, education, general health, and cultural and religious characteristics compared to other studies. In addition, healthcare workers had less death anxiety. The reason for this finding can be the high level of knowledge, familiarity with disease prevention methods, experience in dealing with dying patients, and the nature of their jobs. The difference in death anxiety scores in different groups can be attributed to people’s understanding of death, age characteristics, personal experiences, and cultural and religious values.

The standard score of death anxiety in the studies conducted in Asia was higher than in Europe and America. The origin of COVID-19 was Asia, and Asian countries were involved in the pandemic earlier than other countries. Some countries even experienced different waves of the pandemic, which were associated with high death tolls. The standard score of death anxiety in the articles whose data were collected in 2021 was higher than the studies whose data were collected in 2020. People’s fear and anxiety decreased over time due to the introduction of new treatments and different vaccines, which decreased anxiety scores in recent studies.

According to our knowledge, this is the first comprehensive study evaluating the death anxiety score in the COVID-19 pandemic. Ozguc et al. (2021) systematically reviewed nine published studies on death anxiety during the COVID-19 pandemic. Studies were reported separately by type of measurement tool, while raw scores were converted to standard scores, and a pooled score of death anxiety was reported. In addition, they pooled data from interventional and observational studies due to the small number of included studies. If the nature of these studies (sample size, objectives, and methodology) were not the same, and it was necessary, they would be reported separately by study type. One of the strengths of this study is the comprehensiveness and updated results of this study. One of the limitations of this research is the lack of reporting essential findings in some studies, which could not be included in the analysis.

Implications for Practice

According to the results, people experienced high death anxiety during the COVID-19 pandemic, negatively affecting their lives. Therefore, teaching methods to deal with death anxiety (in social networks and even in school and university curricula) seem necessary. Considering the possibility of the start of other waves of covid-19 or other future pandemics, the results of this research can provide a suitable platform for future research and related interventions. The general population shows almost the same reaction to all pandemics. This study (at the end of the COVID-19 pandemic) has reported useful information about death anxiety by separating many variables, so it has provided the possibility of adopting health care plans and evidence-based decisions for health care officials.

Author Biographies

Indrajit Patra holds a PhD, which he obtained from NIT Durgapur, and is currently pursuing research independently, without any present affiliations to institutions. He boasts an impressive publication record with more than 100 research papers that have been featured in international journals with peer review processes. Additionally, he has penned and edited a total of 6 books.

Iskandar Muda is a Professor at the Department of Doctoral Program, Faculty Economic and Business, Universitas Sumatera Utara, Medan, Indonesia, 20222, Jl. Prof TM Hanafiah 12, USU Campus, Padang Bulan, Medan, Indonesia.

Ngakan Ketut Acwin Dwijendra was born on June 3, 1971 in Bangli Bali, and has expertise as an architect, designer, urban planner, researcher, book writer, and is also a yoga teacher. He is a Homebase Architecture Lecturer in the Doctoral Engineering Study Program, Faculty of Engineering at Udayana University.

Mazin A.A.Najm is an Assistant lecturer, Al-Ayen university.

Shadia Hamoud Alshahrani possesses an Extensive knowledge in patient care, Evidence-Based Practice and Clinical Edu, Research currently involving EBP and is employed at Medical Surgical Nursing King Khalid University, Almahala, Khamis Mushate, Saudi Arabia.

Samah Sajad Kadhim is working at present in Medical laboratory techniques department, Al-Mustaqbal University College, Babylon, Iraq.

Noora M. Hameed hails from Iraq and is presently working at Anesthesia techniques, Al–Nisour University College/ Iraq.

Yasir S. Alnassar completed PHD from Iraq and is at present in The University of Mashreq/ Baghdad/ Iraq.

Naseer M. Mohammed has completed phd from Iraq and is currently working at Department of pharmacy/ Mazaya University College/ Dhi Qar, Iraq.

Yasser Fakri Mustafa was born in Mosul, Iraq, in 1976. He received his B.Sc. in Pharmacy from the College of Pharmacy at the University of Mosul in 1999. Also, he acquired the M.Sc. and Ph.D. degrees in Pharmacy/Pharmaceutical Chemistry from the College of Pharmacy/University of Mosul, Mosul, Iraq, in 2005 and 2017, respectively. He had various teaching experiences, such as organic pharmaceutical chemistry, inorganic pharmaceutical chemistry, chemistry of natural products, chemotaxonomy, and heterocyclic compounds. Also, he is an editorial member of several documented journals, such as the Iraqi Journal of Pharmacy, Mosul Journal of Nursing, Journal of Medicinal and Chemical Sciences, Eurasian Chemical Communications, and the International Journal of Pharmacy and Chemistry. The present work of this academic aims to isolate natural coumarins from the seeds of various apple phenotypes and modify their chemical structures for improving biological activities. Also, this project has been extended to another fruit. The other branch of his work is directed toward the chemical modification of curcumin to enhance its physicochemical properties and biological activities to serve better in therapeutics.

Vahid Shojaeimotlagh is an assistant professor with a few years of experience in teaching nursing students. Prior to this position I spent ten years as a nurse and had worked in critical care units of various hospitals. At the moment I am responsible for teaching and conducting a research project such as human resource management, nurse immigration, palliative care, and chronic diseases. In the end, this is my simple religion. There is no need for temples, no need for complicated philosophy, the philosophy is kindness.

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 iDs

Ngakan Ketut Acwin Dwijendra https://orcid.org/0000-0003-0070-4254

Yasser Fakri Mustafa https://orcid.org/0000-0002-0926-7428

Vahid Shojaeimotlagh https://orcid.org/0000-0003-0946-3688

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