The prevalence and risk factors of death anxiety and fear of COVID‐19 in an Iranian community: A cross‐sectional study

Abstract Background and Aims COVID‐19 has adversely impacted the public's mental health. One of the causes of psychopathology during the present pandemic is death anxiety and fear of COVID‐19. The present study aimed to determine the prevalence and risk factors of death anxiety and fear of COVID‐19 in Shiraz city, south of Iran. Methods This cross‐sectional study was conducted among 982 participants in Shiraz from October to November 2021. Data were collected using Templer's Death Anxiety Scale and the Fear of COVID‐19 Scale. Trained interviewers collected data throughout different city districts. A data‐driven approach (latent class analysis) was applied to categorize the participants and determine the risk factors. Results Among the participants, 507 (51.6%) were female, and 475 (48.4%) were male. The participants’ mean age was 38.26 ± 15.16 years. Based on the analysis, 259 (26.4%), 512 (52.1%), and 211 (21.5%) participants had low, moderate, and severe levels of death anxiety. Also, 393 (40.06%) and 588 (59.94%) of the participants had low and high levels of fear, respectively. Higher death anxiety was significantly associated with being female, having an associate degree, being retired, share of medical expenditure from total expenditure of more than 10%, having a history of hospital admission due to COVID‐19, history of COVID‐19 in relatives, and having fear of COVID‐19. Also, being female, expenses equal to income, history of hospital admission due to COVID‐19, death in relatives, and higher death anxiety were linked to higher levels of fear of COVID‐19. Conclusions Death anxiety and fear of COVID‐19 are closely associated with each other and affected by various sociodemographic and economic factors. Given this pandemic's unpredictable nature and chronicity, interventions at the community level to support high‐risk groups are crucial.


| INTRODUCTION
Death anxiety is as old as humanity. It is defined as a psychological state arising from one's fear of death or being harmed. 1,2 Encountering situations that lead to anticipation or awareness of dying is known as death anxiety. 3 Higher death anxiety is shown to be able to predict both the existence and severity of mental diseases. 4,5 Death anxiety has been a subject of research among different population groups. In studies among cancer patients and older adults, death anxiety was reported to be moderate to high, and higher death anxiety was associated with lower quality of life. 6,7 Determinants of death anxiety are also varied among different groups since individuals' ideas about death are influenced by a variety of demographic, social, cultural, psychological, and health aspects. 8 With the emergence of the coronavirus disease 2019 (COVID- 19) pandemic, encountering death either in relatives or acquaintances, misleading information, and uncertain reports about the disease lead to numerous psychological consequences, such as fear and death anxiety. 9,10 Previous studies assessed the overall impact of the pandemics on mental health, while fear of death has yet to be understood entirely. 11 Vindegaard and Benrose, in a systematic review, indicated that various sociodemographic factors, current or past medical history, psychological and social factors, and job-related factors were correlated with symptoms of psychiatric diseases at the time of the pandemic. 12 Lee et al. stated that much of the psychological distress, such as death anxiety during the pandemic, could be attributed to COVID-19-related factors. 13 A previous study showed that death anxiety in the time of pandemic is relatively high and associated with the death of a family member from COVID-19, religiosity and cultural norms, perceived level of stress, attitude toward COVID-19, subjective proximity to death, coping strategies, history of close contact with COVID-19 patients, mental illness, alcohol consumption, loneliness, perceived risk, and strategies for coping with stress. 14 It has been almost 2 years since the beginning of the COVID-19 pandemic, but our knowledge of death anxiety and fear of COVID-19 goes back mainly to the early days of the pandemic. The current study varies from previous ones in that the interviews were performed in-person, more sophisticated methods of analysis were utilized, and up-to-date data is provided because the public perception of COVID-19 has evolved dramatically since the early days of the pandemic. This study aims to determine the prevalence and risk factors of death anxiety and fear of COVID-19 in the era of the COVID-19 pandemic.

| METHODS
This cross-sectional study was conducted among 982 participants in Shiraz, Iran, from October to November 2021. Shiraz, the capital of Fars Province, is located in the south of Iran and has a population of 1.87 million. The trend of COVID-19 new cases and deaths in Iran during the study period can be seen in Supporting Information: Figure S1. Preventive policies adopted by the government to prevent COVID-19 at the time of the study included mandatory face masks in public places, a night traffic ban, and closure of schools, restaurants, and cinemas.

| Study design
Considering each of the 10 urban districts of Shiraz as a separate cluster, we applied a convenience sampling method. Participants were selected at main streets, parks, and malls in different districts and at different times. After acquiring verbal informed consent, questionnaires were completed by four trained interviewers. The interviewers used a predefined protocol to invite people to participate, including self-introduction, asking if they lived in the current district, explaining the study, and obtaining informed consent.
To minimize any selection bias, each interviewer approached each city district at least three times (morning, noon, and evening) during the study period. The inclusion criteria were individuals over the age of 18, the ability to communicate, and a desire to participate in the study. Individuals who were not residents of the district where the interview took place were excluded. The study flowchart can be seen in Supporting Information: Figure S2.

| Data collection and instruments of measurement
First, a questionnaire consisting of demographic features, economic status, history of COVID-19 in respondents or relatives, death from COVID-19 in the relatives, psychiatric disorders, and suicide attempts were filled. Then, data were collected from participants using two data collection tools.
A validated Persian version of Templer's (1970) Death Anxiety Scale (DAS) was used as the psychometric tool. 15,16 It is a dichotomous questionnaire consisting of 15 statements. In the original version, six items were keyed "false," and nine were keyed "true." Answers conforming to the key equal a score of one. 15 However, in the Persian version, validated by Rajabi and Bahrani in 2006, each "true" equals a score of one, and each "false" equals a score of zero. 16 Hence, a higher DAS score indicates higher death anxiety.
To assess fear of the COVID-19, we used the Fear of COVID-19 Scale (FCV-19S), developed by Ahorsu et al. in Iran. 17 This Likert scale consists of seven items, with the score for each item ranging from one to five, and a higher score indicating greater the fear of COVID-19.

| DISCUSSION
The effects of public health emergencies on mental status are well understood and reported during previous similar outbreaks, namely Ebola and severe acute respiratory syndrome (SARS). 18,19 Although previous studies mainly focused on describing the effects of the COVID-19 pandemic on mental health, this study is one of few that scrutinize one of the contributing factors to psychopathology during the present pandemic, namely death anxiety and fear of COVID-19, and evaluates its associated risk factors.
According to our findings, females were shown to have more death anxiety and fear of the COVID-19. In line with our results, previous studies indicated that females are more prone to various types of psychopathology during the COVID-19 pandemic. [20][21][22] Therefore, death anxiety and fear of COVID-19 may be responsible for a part of the current burden of mental disorders among women.
Also, there was a significant association between the history of COVID-19 in participants or their relatives and death anxiety.
T A B L E 1 Association between demographic features, economic status, COVID-19 infection, psychiatric disorder, and fear of COVID-19 with death anxiety based on multinomial logistic regression. When an individual or their relatives get infected with the disease, they feel more threatened as their concern changes from fear of getting the disease to fear of the outcome of the disease (death or recovery). 23 Additionally, as an infected individual seeks more information about the disease, they may encounter uncertain or inaccurate information that makes them incorrectly estimate the disease's risks. 24 Our results showed that having an associate degree was associated with higher death anxiety. In contrast, having a master's or higher degree had a protective effect. In line with our findings, previous studies indicated that lower levels of education were associated with psychiatric symptoms. 22,25 On the other hand, some studies suggested the protective role of receiving information on COVID-19 from scientific sources rather than social media on mental issues. 25,26 Furthermore, uncertain reports, rumors, and conspiracy theories mainly affect people with lower levels of health literacy. 27,28 Therefore, it can be hypothesized that while educated individuals seek reliable information, low educated people fail to conceptualize the disease correctly, which may predispose them to both over and underestimate the risk of the disease, sometimes resulting in exaggerated fear and anxiety.
Another way the pandemic has affected society is through its effects on employment status and the economy. 29

| Strengths and limitations
As a strength, we utilized in-person interviews to fill out questionnaires that do not have the limitations of online surveys. Also, we took the sample from different city districts, which are representative of people with different socioeconomic statuses, educational levels, and neighborhood conditions. However, our study is not free of limitations, and the cross-sectional design of this study prevents us from drawing firm conclusions on the causality between risk factors and variables. Also, our sample did not contain people with disabilities who cannot commute in the city. Furthermore, we acknowledge the differences in fear and death anxiety between urban and rural areas.
Self-reported nature of the study's instruments may lead to recall or social desirability bias. Also, we acknowledge potential selections bias because of the people who refused to participate in the study. Finally, our results are based on a survey in an urban area in the south of Iran; hence, the results should be interpreted with caution in terms of generalizability.

| Implications
As fear and death anxiety are affected by a wide range of social, economic, cultural, and regional factors, further research in different parts of the world is essential to portray a clearer picture of this topic.

CONFLICT OF INTEREST
The authors declare no conflict of interest.

TRANSPARENCY STATEMENT
The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.