Death anxiety scale (DAS): internal structure and factorial invariance in Peruvian adults

Carlos De La Cruz-Valdiviano; Aldo Bazán-Ramirez; Lincol Olivas-Ugarte; Juan Quijano-Pacheco

doi:10.12688/f1000research.143167.2

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Research Article

Revised

Death anxiety scale (DAS): internal structure and factorial invariance in Peruvian adults

[version 2; peer review: 2 approved]

Carlos De La Cruz-Valdiviano ¹, Aldo Bazán-Ramirez², Lincol Olivas-Ugarte³, Juan Quijano-Pacheco⁴

PUBLISHED 25 Nov 2024

Author details Author details

¹ Piura, Cesar Vallejo University, Piura, Piura 20001, Peru
² Apurímac, Jose María Arguedas National University, Andahuaylas, Andahuaylas CP 03701, Peru
³ Lima, Cesar Vallejo University, Lima Norte, Los Olivos, Lima CP 15314, Peru
⁴ La Libertad, Cesar Vallejo University, Trujillo, Trujillo 13001, Peru

Carlos De La Cruz-Valdiviano
Roles: Conceptualization, Data Curation, Investigation, Validation

Aldo Bazán-Ramirez
Roles: Project Administration, Resources, Writing – Original Draft Preparation

Lincol Olivas-Ugarte
Roles: Formal Analysis, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Juan Quijano-Pacheco
Roles: Funding Acquisition, Resources, Supervision, Visualization, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background

Studies have this reported the presence of death anxiety, ranging from near-death experiences to physically ill people, to a simple thought about death, as well as when it is associated with states of loneliness. The Templer’s Death Anxiety Scale (DAS), based on Eysenk’s incubation theory, has been adapted and validated in different contexts and is still insufficient in countries such as Peru. This study aimed to determine the psychometric properties of the DAS, its internal structure, and factorial invariance.

Methods

An online scale was used in 1248 Peruvians aged between 18 and 70 years (M= 27.37, SD= 11.29) from all regions. DAS was validated using exploratory factor analysis (EFA), confirmatory factor analysis (CFA), convergent validity, measurement invariance, and internal consistency (reliability).

Results

Psychometric properties were found with adequate values in its structure and validity based on the internal structure through exploratory factor analysis, where it was found that the components of the scale are interrelated and the data matrix is factorizable. model of three specific factors and a general factor is presented, which is consistent with the theory and has practical utility, revealing adequate statistical values that reflect acceptable levels of reliability. Finally, there was fairness according to sex and age group of the scale by means of factorial invariance analysis.

Conclusions

Our results indicate adequate psychometric properties and facilitate a better data collection process for future research.

Keywords

death anxiety, validity, reliability, fairness/equity, adults.

Corresponding author: Carlos De La Cruz-Valdiviano

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 De La Cruz-Valdiviano C et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: De La Cruz-Valdiviano C, Bazán-Ramirez A, Olivas-Ugarte L and Quijano-Pacheco J. Death anxiety scale (DAS): internal structure and factorial invariance in Peruvian adults [version 2; peer review: 2 approved]. F1000Research 2024, 13:801 (https://doi.org/10.12688/f1000research.143167.2) First published: 16 Jul 2024, 13:801 (https://doi.org/10.12688/f1000research.143167.1) Latest published: 25 Nov 2024, 13:801 (https://doi.org/10.12688/f1000research.143167.2)

Revised Amendments from Version 1

In response to a reviewer's comment, we have made extensive improvements to our manuscript in terms of argumentation and scientific accuracy. The main changes are listed below:

1.1 Background and Eysenck's theory of incubation: The last paragraph (page 4) was added, which relates to the most recent studies of the Templer Death Anxiety Scale that focus on the general population. These psychometric studies of death anxiety are not exclusive to clinical populations or older adults, but also encompass gender differences, and recent studies have explored the relationship between death anxiety and psychological well-being in the general population.
2.2 Measurement: The last paragraph (page 6) was also added, which supports that the three-factor Death Anxiety Scale is based on a rigorous empirical analysis in line with previous cross-cultural studies that have identified multidimensional structures. This conceptualization allows for a more comprehensive and nuanced assessment of death anxiety in the Peruvian population, capturing specific aspects that may not be evident in a unidimensional structure.
4. Discussion: In Strengths and limitations (page 14), we added, other limitations were that we did not analyze religious practice or the degree of religious involvement and background of chronic disease, which will be options for future studies.

References: The last four references (page 20) were added, which are the sources that support our arguments.

Certainly, these changes have enriched our research, allowing for better argumentation and clarity of our findings.

See the authors' detailed response to the review by Afreen Faiza

1. Introduction

Death is a universal human fact,¹ and people experience death anxiety in different ways, and the way they express it is usually particular according to sociodemographic variables such as age, sex, religion, among others, or psychological variables, such as self-esteem, personality, mood, or coping styles¹^,² In this regard, other authors³ pointed out that there are two main variables: mental health and near-death experiences (accidents or terminal illness) that influence the degree of death anxiety. However, Tomás-Sábado and Gómez-Benito² argued that death anxiety occurs both in people who are physically ill and in those who think about death.

In this context, in 2020, according to the Pan American Health Organization/World Health Organization,⁴ the spread of SARS-Cov-2 was declared a public health emergency, known worldwide as COVID-19. Orús⁵ mentioned that about 6.3 million people died due to this virus as of June 12, 2022. Due to its appearance, several measures have been taken in this regard, and people’s daily lives have been altered in different dimensions, such as work performance, family and social ties, educational activities, economic instability, and health conditions, which are factors that become indicators of anxiety among other psychological repercussions. According to the PAHO/WHO⁶ during the first year of the pandemic, the prevalence of anxiety or fear of death has increased by 25% worldwide, with young people being part of the most affected population. Thus, nowadays, all people live in a very different context to the one they used to know and thus find different reactions to it, as life conditions are altered, which is why many people have suffered from this silent disorder that is anxiety, which is a recurrent topic in research since its features are visible in society.⁷

A study conducted by the University of Bristol found that the number of young people with anxiety increased from 13% to 24%.⁸ Thus, death anxiety is a reaction generated by the sensation of risk, whether real or imaginary, that originates from environmental stimuli.⁹ Taking as a reference what has already been mentioned, it is understandable that when the routine cycle of people’s lives is altered, these have an impact on more internal levels such as ways of thinking, habits that have changed, and the intensity of emotions, which is directly reflected in the behavior that in the end is the manifestation of how each person has internalized this situation. In Metropolitan Lima, where the main districts affected by the pandemic are located because of the high level of contagion and the numerous deaths that have occurred, the general population is taken as a reference for the pandemic reality in order to determine anxiety as a result of this context.¹⁰ It is, therefore, necessary for specialists to have a reliable instrument with which to obtain real results and thus be able to perform an optimal screening in order to analyze the levels of anxiety in the Peruvian population.

The Death Anxiety Scale (DAS) created by Templer¹¹ and authorized by its authors in the Mexican version¹² was used to measure these variables. Therefore, given that an instrument would be very helpful in exploring what has already been explained, the following question was formulated: What is the evidence of validity, reliability, and fairness of the death anxiety scale (DAS-1) in Peruvian adults, 2022? At the methodological level, the study provides rigor in terms of validity, reliability, equity, and psychometric characteristics of an instrument for Peruvian adults. Practically, it encourages professionals who deal with mental health to develop innovative research where standardized, valid, and reliable instruments need to be applied as a screening prior to specialized care. This results in death anxiety assessments relevant to the cultural context in which they are applied. Although Templer’s DAS has resisted the test of time as a commonly used index to capture the conscious experience of death anxiety, a continued evaluation of how the DAS translates in specific countries is required with an assessment in relation to other death construct tools,¹³ such as the population of adults aged 18 to 70 years, which in Peru make up the majority of the population¹⁴ that will lead the way to the country’s development. At the same time, it is relevant because it focuses on one of the most important topics, such as anxiety that the Peruvian adult population may be related to the post-pandemic context. Likewise, it will serve as a background for prospective studies whose objective is to study the same variable, and finally, its purpose is to support early intervention for events that could have serious consequences for this population.

Psychometric tests provide measurable and objective data that provides an overview of the performance of an individual or population. This scale provides a degree of scientific reliability and objective recruitment process. In addition, because it is a standardized test, it reflects accurate information. Therefore, the general objective was to analyze the psychometric properties of the Death Anxiety Scale (DAS) in the Peruvian adult population. Accordingly, following a sequential order, the specific objectives were formulated as follows: 1) to verify the metric quality of the items, and 2) to examine the evidence of validity based on of the internal structure, 3) to examine the evidence of reliability, and finally 4) to examine the evidence of fairness according to sex and age group of the DAS Scale in Peruvian adults.

1.1 Background and Eysenck’s theory of incubation

Rivera and Montero¹² carried out an adaptation in older adults and university students from Mexico; three dimensions were obtained in each group, and internal consistency was.86 and.83, respectively. Lopez-Castedo et al.¹⁵ analyzed patients with ischemic heart disease in Spain, finding positive correlation corrected item-total correlation in all items (0.32 and 0.54). Four factors were identified that together explained 51.85% of the variance in the data, while the reliability values were high (0.77). Resett et al¹⁶ examined 859 adults in Argentina. Factor analyses showed a bifactor structure with higher adequacy than a unifactor structure. These findings allow us to argue that the scale showed evidence of validity and reliability (.80) for that country.

In Peru, few studies have been conducted on death anxiety; in Trujillo, 50 hospitalized patients found that it is negatively related to mental adjustment to cancer; that is, the greater the mental adjustment to cancer, the lower the anxiety about death.¹⁷ Peñaloza¹⁸ analyzed the content validity of health personnel in Lima. AFC explains the three-factor model. The correlation with PIL-TEST was strongly negative (rho = − .630). Reliability by internal consistency through α and ω = .95. Analysis of invariance by sex indicated that the scores differed between men and women. In addition, Graus¹⁹ in older adults in Trujillo by confirmatory factor analysis, and reliability by internal consistency (.93) was very good. Rodriguez,²⁰ in older adults in Chimbote, obtained reliability through ω and gave.81 for fear of agony or illness, .79 for fear of life coming to an end and.90 for fear of death. The results indicated that the scores ranged from acceptable to very good.

Although the first studies covered clinical populations, there are also studies in the general population when considering the influence of sociocultural factors,²¹ where anxiety about death can vary significantly between countries and cultures, depending on elements such as religious beliefs, social norms and exposure to conflict contexts. This aspect is particularly relevant for the Peruvian population, given the cultural diversity and sociocultural values. Likewise, anxiety about death has been investigated in young and middle-aged adults, at the same time, studies such as those by Abdel-Khalek and Neimeyer²² have shown that anxiety about death is not exclusive to clinical populations or older adults. Also, gender differences have been analyzed in the manifestation of anxiety about death in the general population,²² drawing attention to the fact that women tend to report higher levels of anxiety about death than men. Finally, recent studies have explored the relationship between anxiety about death and psychological well-being in the general population. According to Abdel-Khalek and Neimeyer,²² death anxiety is inversely related to subjective well-being, this finding is particularly relevant to emphasize the importance of adequately measuring death anxiety in the general population.

1.2 Anxiety

For RAE,²³ anxiety is a situation of mood agitation, usually a state of fear associated with various diseases. According to Limonero²⁴ fear indicates an expected reaction to the threat posed by anxiety-provoking events. It refers to a target that causes a bisector of discomfort, such as instability, restlessness, and fussiness, in the face of a surprise. Anxiety is a state of unconscious emotion, such as undefined despair.

Hamilton²⁵ notes that fear can be present within normality or illness. Similarly, anxiety presents with a variety of symptoms, including cardiovascular pain, abdominal pain, dyspnea, and mental, cognitive, or subjective symptoms. The present work is based on Eysenck’s incubation theory.²⁶ This, in turn, is based on classical test theory.²⁷

2. Methods

2.1 Participants

The sample consisted of 1248 Peruvian adults between 18 and 70 years of age (Arithmetic Mean [M] = 27.37, Standard Deviation [SD] = 11.29) from all regions of Peru. To select this sample, non-probabilistic convenience sampling was used, taking into account the corresponding inclusion and exclusion criteria.²⁸^–³⁰ According to Comrey and Lee,³¹ a sample size of at least 100 is considered poor, and a sample size greater than or equal to 1000 is considered excellent.

The following inclusion criteria were established for the selection of participants: adults between the aforementioned ages residing in the Peruvian territory; those who would respond favorably to informed consent; those who had completed the responses to the instruments in Google Forms through the online link that was sent to them. Once the responses to the Google Form were obtained, the number of subjects was 1288. However, after careful review, 40 individuals were eliminated (19 said they were retired, widowed, or divorced, all under 20 years of age; 10 were born or lived in another country; 11 did not complete their answers) to avoid possible bias in the information. Those between 18 and 30 years of age stand out (39.9% men and 30% women), and in terms of place of residence, 40.1% of men and 36.5% of women live in the Department of Lima.

2.2 Measurement

Self-administered online surveys were conducted using a written questionnaire and distributed by e-mail.³² The Death Anxiety Scale (DAS -1) was created by Donald I. Templer in the United States in 1970,¹¹ where its application was individual and collective. Later, in 2002, it was adapted and translated into Spanish by Tómas Sábado and Gómez-Benito; in 2010, it was adapted and translated by Rivera y Montero into Mexican Spanish. In Peru, adaptation was given in 2016 in Trujillo by Graus.¹⁹ The time to consider is 10 to 15 min, while its administration is from 18 to 85 years of age. It is composed of 15 items with four Likert-type options.⁷³ The items of this scale consider statements related to concepts related to death and their emotional repercussions on people, considering their impact on them. Initially, there were true and false response options; however, the dichotomous alternatives were modified by alternatives on a Likert scale with the objective of allowing a better variability in the responses that reflects what people feel or think in relation to death, thus improving the internal consistency of the scale itself. Scores were obtained using sums or averages. The participants provided four types of answers on a Likert scale: never or almost never (1), sometimes (2), most of the time (3), and all the time (4), with a minimum score of 15 (low anxiety) and 60 (high anxiety). In dimension I: Fear of agony or pathology, the minimum score was 5, and the highest was 20. In dimension II: Fear of life coming to an end, the minimum score was 7, and the highest was 28. Finally, dimension III: Fear of death, the minimum score is 3, and the highest is 12.

The instrument has psychometric characteristics verified in the United States and Spain, with Cronbach’s alpha fluctuating between .76 and .87 and a fairly good retest security, r = .71 and r = .84.¹² Its construct value has been extensively studied, and its partnership has been defined with many psychological variants, such as depression and anxiety (r = .38 and r = .48, respectively).¹²^,³³ However, studies of its factorial composition are more contradictory in the analysis, sample, and cultural setting in which it is used.

The three-factor Death Anxiety Scale is based on a rigorous empirical analysis that reflects the underlying structure of the data and is in line with previous cross-cultural studies that have identified multidimensional structures. This conceptualization allows for a more comprehensive and nuanced assessment of death anxiety in the Peruvian population, capturing specific aspects that may not be evident in a unidimensional structure. The results of Sharif Nia et al.¹³ and Zuccala et al.³⁴ support the need to adapt the DAS scale according to the cultural and sociodemographic particularities of each sample.

2.3 Procedure

To carry out the study, the necessary permission was requested from the author in order to be able to measure the variable under analysis. Then, the online survey form was disseminated through the Google Forms application in which informed consent, sociodemographic data, and the measurement instrument were included, and the link to the form was sent to individuals who met the requirements of the inclusion criteria for their participation. They were applied through social networks, such as Facebook and WhatsApp. They were also sent by electronic correspondence, prioritizing the authorization of the same for execution, emphasizing anonymity, privacy, and voluntary collaboration. Finally, the responses of individuals who did not meet the sample profile were not considered, and the exploration was carried out correctly using statistical programs.

2.4 Ethical aspects

In accordance with the World Medical Association (WMA) regarding the Declaration of Helsinki,³⁵ specifically related to medical research on human beings, care was taken to consider primarily the health of the subject, precisely this work is oriented to favor conditions that promote their welfare (avoiding damage to their health), while ensuring and promoting satisfaction with the life and rights of those, with the purpose of contributing to screenings that facilitate diagnoses, preventive interventions and quality of treatments. The protocol was submitted for consideration, comment, guidance and approval by the Research Ethics Committee of the Cesar Vallejo University (Dictamen 070-CEI-EPM-UCV-2022)⁷³^,⁷⁴ on September 28, 2022, after which the research could be carried out The participants were previously informed about the nature of the questionnaires, the importance of the study and the guarantee of their anonymity, then, regarding informed consent, the participants responded to their agreement via online.³⁶ Likewise, the study was carried out taking into account the authors cited, so that any type of plagiarism was avoided.

2.5 Statistical analysis

Once the survey application was finished, the participants’ responses were downloaded into a Microsoft Excel spreadsheet to prepare the database. This information was then exported for statistical processing using the free program, RStudio version 4.3. The data were analyzed as follows: First, preliminary statistical analysis of the items was performed using the psych package.³⁷ Statistics such as the mean (M), standard deviation (SD), coefficients of asymmetry (g1 = [-1.5; 1.5]), kurtosis (g2 = [-1.5; 1.5]),³⁸^,³⁹ corrected homogeneity index (CHI ≥ .30),⁴⁰ and communalities (h2 ≥ .40)⁴¹ were examined. Additionally, the polychoric correlation matrix (|r|= [.30; .90]) was extracted.⁴²^,⁴³

Second, exploratory factor analysis (EFA) was performed using the psych and parameter package.⁴⁴ The polychoric correlation matrix was used as input, with the purpose of determining the underlying structure of the DAS Scale. Previously, the assumptions of the EFA were verified: matrix determinant (|A| ≈ 0), Kaiser-Meyer-Olkin sample adequacy test (KMO ≥ .80), and Bartlett’s test of sphericity (p< .001).⁴⁵ The following extraction methods were used: parallel analysis, optimal coordinates, and the Kaiser-Gutman rule. Likewise, the method of minimum residual estimation (Minres) was applied in combination with the oblimin rotation method.⁴⁶ Finally, factor loadings (λ ≥ .30) and interfactorial correlations (φ ≥ .50) were examined.⁴³^,⁴⁷^–⁴⁹

Third, confirmatory factor analysis (CFA) was performed using the Lavaan package.⁵⁰ The polychoric correlation matrix was used as the input because the data did not correspond to continuous variables with a normal distribution.⁵¹ In addition, the Weighted Least Squares with mean and variance adjusted variance (WLSMV) estimator was applied due to the ordinal nature of the items.⁵²^,⁵³ Additionally, different factor structures were tested, as this is a good practice in psychometric studies.⁵⁴ Different fit indices were used for model evaluation, such as chi-square (χ², p < .05), Comparative Fit Index (CFI ≥ .94), Tucker-Lewis indices (TLI ≥ .94), standardized root mean square residual (SRMR ≤ .08), Root Mean Square Error of Approximation (RMSEA ≤ .07)⁵⁵ and RMSEA confidence intervals (Li ≤ .05 and Ls ≤ .10). In addition, because χ² is sensitive to sample size, the chi-square ratio over degrees of freedom (χ²/gl ≤ 5) was evaluated.⁵⁶

In addition, specific indices for the bifactor models were examined. Likewise, the analysis of the indexes of the second-order model was considered, for which a Schmid-Leiman transformation⁵⁷ was performed, allowing the variance of each factor to be estimated,⁵⁸ both of which were processed using the EFA tool package.⁵⁹ The following were considered as indicators of: unidimensionality: The conjunction of the magnitudes of the hierarchical ω coefficient for the overall factor (ωH > .80),⁶⁰ of the hierarchical omega coefficient for the specific factors (ωhs ≥ .30) (Smits et al., 2014),⁶¹ the construct replicability coefficient (H > .90),⁶² common variance explained (ECV >.60), and percentage of uncontaminated correlations (PUC < .80).⁶⁰ Finally, the percentage variance of the factors (ωH2, ωhs2) was calculated as evidence of the instrument’s explanatory power.⁴⁷

Fourth, evidence of reliability was examined using the internal consistency method, quantifying its magnitude with the omega coefficient (ω) for multidimensional scales,⁶³ appropriate for congeneric measures,⁶⁴^,⁶⁵ and values ≥ .80⁶⁶ were taken as the conventional cut-off point. Fifth, evidence of equity was evaluated by means of a factorial equivalence analysis according to sex and age group,⁶⁷ using the semTools package.⁶⁸ Four progressive levels of invariance were considered: 1) configural invariance (unrestricted), 2) metric invariance (factor loadings), 3) strong invariance (loadings and intercepts), and 4) strict invariance (loadings, intercepts, and residuals), taking the changes in CFI (ΔCFI ≤ .010), RMSEA (ΔRMSEA ≤ .015), and SRMR (ΔSRMR ≤ .030)⁶⁹^,⁷⁰ to determine the interpretability of the items by the examinees⁷¹ and the equivalence of the scores obtained in the test, regardless of the participants’ membership.⁷²

3. Results

3.1 Statistical analysis of the items of the DAS Scale

As Table 1 shows, for the most part, the DAS Scale items meet the parameters previously established to claim that the data matrix can be reduced to a smaller set of latent factors: the magnitudes of the correlations|r|= [.30–.90], corrected homogeneity index (CHI ≥ .30), and communalities (h2 ≥ .40). Therefore, the metric quality of the DAS items was verified for inclusion in the AFE.

Table 1. Statistical analysis of the items of the DAS.

Items	M	DE	g¹	g²	CHI	h²	Matrix of polychoric correlations
Items	M	DE	g¹	g²	CHI	h²	A1	A2	A3	A4	A5	A6	A7	A8	A9	A10	A11	A12	A13	A14	A15
A1	1.62	0.66	0.97	1.27	.69	.53	1	−	−	−	−	−	−	−	−	−	−	−	−	−	−
A2	1.71	0.71	0.85	0.80	.54	.33	.50	1	−	−	−	−	−	−	−	−	−	−	−	−	−
A3	1.45	0.65	1.41	1.93	.67	.50	.58	.40	1	−	−	−	−	−	−	−	−	−	−	−	−
A4	1.68	0.72	0.95	0.80	.57	.35	.39	.19	.41	1	−	−	−	−	−	−	−	−	−	−	−
A5	1.68	0.70	0.95	1.08	.74	.61	.79	.48	.66	.47	1	−	−	−	−	−	−	−	−	−	−
A6	1.80	0.76	0.87	0.71	.66	.48	.45	.34	.43	.53	.52	1	−	−	−	−	−	−	−	−	−
A7	1.57	0.64	0.94	0.91	.77	.65	.65	.54	.69	.44	.68	.55	1	−	−	−	−	−	−	−	−
A8	2.17	0.86	0.46	-0.36	.56	.33	.34	.37	.26	.37	.33	.41	.38	1	−	−	−	−	−	−	−
A9	2.00	0.84	0.73	0.16	.72	.56	.54	.45	.47	.48	.59	.57	.54	.47	1	−	−	−	−	−	−
A10	1.57	0.74	1.30	1.45	.58	.37	.37	.38	.40	.34	.42	.35	.51	.42	.47	1	−	−	−	−	−
A11	1.56	0.69	1.25	1.72	.64	.45	.46	.31	.41	.46	.49	.59	.53	.37	.58	.43	1	−	−	−	−
A12	2.00	0.89	0.77	-0.03	.59	.36	.37	.38	.34	.32	.36	.43	.41	.63	.45	.43	.38	1	−	−	−
A13	1.54	0.68	1.23	1.61	.55	.32	.35	.24	.45	.33	.38	.46	.42	.32	.40	.34	.38	.37	1	−	−
A14	1.77	0.88	1.01	0.29	.51	.28	.39	.21	.46	.36	.38	.32	.43	.26	.39	.29	.35	.31	.40	1	−
A15	1.72	0.81	1.08	0.83	.60	.38	.36	.41	.41	.35	.42	.39	.46	.48	.40	.44	.36	.48	.41	.37	1

3.2 Construct validity

As shown in Table 2, the AFE assumptions were previously verified: matrix determinant = .001, KMO test = .92, and Bartlett’s test of sphericity was statistically significant (p < .001), indicating that the variables are interrelated and that the data matrix is factorizable. Therefore, the procedure was repeated. The 15 items were then grouped into three factors with a total cumulative variance of 53.3%. Furthermore, the magnitudes of the interfactorial loadings (ϕ) [.40, .50] were consistent with an oblique three-factor correlated model. However, two items were discarded: item A9 (“I am afraid of dying a painful death”) for presenting very similar factor loadings in more than one factor (F1 = .32, F2 = .25, F3 = .33), and item A14 (“I am horrified to see a corpse”) for presenting low factor loadings (λ <.30). Consequently, we proceeded to run the CFA with only the other 13 remaining items.

Table 2. Exploratory factor analysis of the DAS.

Items	λF1	λF2	λF3
A5	.864	-.074	.081
A1	.837	-.024	-.007
A7	.721	.091	.103
A3	.704	-.055	.143
A2	.590	.340	-.288
A8	-.095	.806	.080
A12	.010	.736	.051
A15	.200	.484	.072
A10	.260	.384	.085
A4	.101	.096	.561
A6	.144	.177	.561
A11	.187	.149	.500
A13	.164	.190	.347
A9	.320	.255	.330
A14	.266	.081	.286
Interfactorial loadings (ϕ)
F1	1	−	−
F2	.543	1	−
F3	576	.457	1
Kaiser-Meyer-Olkin test	.92
Bartlett's test of sphericity	χ²(gl) = 456.31(14), p < .001
Matrix determinant	.001
% Explained variance	25.2	25.2	25.2
% Accumulated variance	25.2	25.2	25.2

Figure 1 shows the three specified models that were tested to determine the best measurement model to fit the data: Model 1 = Correlated factors, Model 2 = Second order, Model 3 = Two-factor. However, the decision on the most plausible structure was made following not only statistical, but also theoretical, methodological, and ultimately practical criteria.

Figure 1. Factorial Models evaluated, three models were tested to determine the measurement model that best fit the data.

Note: Model 1 = Correlated factors; Model 2 = Second order; Model 3 = Two factors; G = General Factor; F1 = Factor 1; F2 = Factor 2; F3 = Factor 3.

Table 3 shows that the three proposed models obtained adequate fit indexes: CFI ≥ .94, TLI ≥ .94, SRMR ≤ .08, RMSEA ≤ .07. Although they present differences, they are not relevant. However, in mathematical terms, it is clear that model 3 shows better relative fit indexes (χ²/gl = 4.95 < 5). Therefore, the specific indexes for a bifactor model were further examined. The conjunction of the values was as follows: the hierarchical omega coefficient for the general factor (ωH > .80), the hierarchical omega coefficient for the specific factors (ωhs ≥ .30), the construct replicability coefficient (H > .90), the common variance explained (ECV > .60), and the percentage of uncontaminated correlations (PUC < .80) allow us to affirm the existence of a general factor that empirically justifies obtaining an overall score for the DAS Scale, with a proportion of explained variance of 69.56%. Finally, it is also noteworthy that the data obtained for the death anxiety variable, considering this bifactor model, is highly reliable for multidimensional scales (ω ≥ .80). Thus, the evidence indicates that the structure of three specific factors and one general factor is the most plausible. Moreover, it is consistent with the theory, is derived from the analysis methodology applied, and has practical utility, in that it would allow in the future to determine the greater weight of any of these three factors in the anxiety responses of the examinees.

Table 3. Confirmatory factor analysis of the DAS.

Models	χ²	gl	χ²/gl	CFI	TLI	RMSEA [IC 90%]	SRMR
Model 1: Correlated factors	473.553	62	7.638	.964	.955	.073 [.067;.079]	.048
Model 2: Second order	429.783	64	5.638	.968	.961	.068 [.062;.074]	.050
Model 3: Bifactorial	257.369	52	4.949	.982	.973	.056 [.050; .063]	.036

Ítems	Second-order model				Bifactor model
	λFG	λF1		λFG	λF1		λFG	λF1
A1	.629	.496	−	−	.632	.596	−	−
A2	.485	.382	−	−	.561	.209	−	−
A3	.599	.472	−	−	.667	.337	−	−
A5	.697	.549	−	−	.691	.58	−	−
A7	.676	.532	−	−	.789	.281	−	−
A8	.629	−	.387	−	.538	−	.610	−
A10	.577	−	.355	−	.609	−	.161	−
A12	.620	−	.381	−	.571	−	.531	−
A15	.591	−	.364	−	.608	−	.253	−
A4	.629	−	−	.202	.587	−	−	.238
A6	.727	−	−	.234	.692	−	−	.513
A11	.689	−	−	.221	.665	−	−	.252
A13	.577	−	−	.185	.58	−	−	.088
ω	.926	.892	.802	.784	.929	.893	.805	.790
ω_H	.817	.342	.220	.073	.834	.236	.249	.124
H	.898	.617	.392	.158	.903	.568	.52	.330
ECV	.726	−	−	−	.717	−	−	−
PUC	.718	−	−	−	.718	−	−	−
% Explained variance	66.75	11.70	4.84	0.53	69.56	5.57	6.20	1.54

3.3 Factorial invariance

As Table 1 shows, for the most part, the DAS items meet the parameters previously established to claim that the data matrix can be reduced to a smaller set of latent factors: magnitudes.

Finally, Table 4 presents the results of the factorial invariance analysis as a function of sex and age. Along these lines, the magnitudes of the variations in CFI (ΔCFI < .010), RMSEA (ΔRMSEA < .015), and SRMR (ΔSRMR ≤ .030) were minimal. Thus, the empirical evidence shows that the study participants interpret the meaning of the DAS items in a very similar way and that the scores obtained in this test are only attributable to the presence of the latent variable death anxiety, without depending on the characteristics of the examinees. Therefore, the new version of the DAS measures death anxiety fairly, without bias, in the Peruvian adult population, regardless of gender or age.

Table 4. Factorial invariance analysis as a function of sex and age group.

Sex (Men = 653, Women = 595)
Levels	χ²	Δχ²	gl	Δgl	CFI	ΔCFI	RMSEA	ΔRMSEA	SRMR	ΔSRMR
Configural	349.744	−	104	−	.979	−	.062	−	.043	−
Metric	32.195	29.549	126	22	.984	.004	.050	.012	.048	.005
Strong	393.091	72.895	148	22	.979	.004	.052	.002	.046	.002
Strict	393.091	.000	148	0	.979	.000	.052	.000	.046	.000

Age group (Young = 863, Adults = 375)
	χ²	Δχ²	gl	Δgl	CFI	ΔCFI	RMSEA	ΔRMSEA	SRMR	ΔSRMR
Configural	317.313	−	104	−	.983	−	.057	−	.040	−
Metric	39.877	73.564	126	22	.979	.004	.058	.001	.050	.010
Strong	395.699	4.822	148	22	.980	.001	.052	.006	.043	.007
Strict	395.699	.000	148	0	.980	.000	.052	.000	.043	.000

4. Discussion

This study is the first to examine the psychometric properties of the Death Anxiety Scale and to provide evidence of its usefulness as a measure of this variable in the general non-clinical population of Peru (n=1248). Studies with a clinical sample were only conducted in Trujillo,¹⁷ health personnel in Lima,¹⁸ Trujillo, older adults¹⁹ and older adults in Chimbote.²⁰ All of them were in zones and had samples of less than 600 subjects. It should be noted that the reliability for internal consistency in health personnel reached .95, followed by older adults in Trujillo¹⁹ with .93. In contrast, in other countries such as Argentina¹⁶ in 859 adult subjects, it only reached a reliability of .80, and in Spain¹⁵ in a clinical sample, the value was .77.

To perform the CFA, three measurement models were tested to perform CFA, which is a good option when validating instruments with confirmatory factor analysis.⁵⁴ Initially, a model of three correlated factors was tested, as proposed by Rivera-Ledesma (2009)¹² in its Mexican version, as it is the version with the largest number of recent studies in Spanish. Subsequently, two hierarchical models were tested: a second-order formative model and another bifactor multidimensional model, in order to find empirical evidence in favor of the existence of a global score on the Death Anxiety Scale.

Consequently, our results support the three-dimensional structure of the DAS, which in turn allows a global score, as reported in previous national¹⁸^–²⁰ and international studies,¹² in Spain, four factors were found in a clinical sample,¹⁵ whereas in Argentina, in non-clinical adults, a better fit to a unifactorial structure was found. This indicates that the DAS, at least in the Peruvian context, can be used as a self-report instrument to measure death anxiety in the general nonclinical adult population.

4.1 Psychometric properties of the DAS

The construct validity of the DAS was tested and found to be satisfactory based on the CFA, and all model fit indices were acceptable. The AFC showed that the model that best fits our data was the three-factor oblique correlated model for all the three dimensions. The three-factor oblique model was better than the one- and two-factor models, indicating that death anxiety has a total score as a variable and, in turn, is composed of three dimensions.

We chose to eliminate two items with poor factor loadings (factor loadings < 0.4) and weaker values than other items in the study sample, such as item 9 (“I am afraid of having a painful death”) of the fear of dying dimension. Likewise, Item 14 (“I am horrified to see a corpse”) of the dimension of fear of life coming to an end. Thus, the adequacy of the model is improved.

The internal consistency reliability results of the DAS showed excellent values for all dimensions, with a Cronbach’s alpha and McDonald’s Omega ≥ .80. These results confirmed previous reports on the reliability of DAS in different studies and populations.¹²^–²⁰

4.2 Measurement invariance

In the present study, the fairness of measurement between sexes and age was also examined using a factorial invariance analysis. It was found that the DAS exhibits complete configurational and metric invariance between sexes and ages. This indicates that DAS can be used to measure death anxiety with the same meaning for women and men or for Peruvian adult subjects of different non-clinical ages. That is, there were no differences in the structure of DAS between the sexes and age groups in the study sample. This result disagrees with the findings of Peñaloza et al.,¹⁹ who reported that scores differed between men and women.

4.3 Strengths and limitations

The main contribution of this study is that it is the first time that DAS validation has been performed in the general Peruvian population, covering most regions of Peru. However, this study had some limitations. First, a cross-sectional and not longitudinal design was used, in which the reliability analysis was based on internal consistency and not on the test-retest stability measure. Second, although death anxiety was universal, Non-probability sampling could pose a limitation in generalizing the sample results to the population. Third, the use of this type of convenience sampling could cause selection bias since only subjects with access to social networks responded to the online questionnaire. Finally, given that the general population was included, other limitations were that we did not analyze religious practice or the degree of religious involvement and background of chronic disease, which will be options for future studies.

5. Conclusions

In summary, our results show that the DAS has good psychometric properties for Peruvian adults. We found that DAS is valid and reliable, with the ability to clearly distinguish death anxiety from other factors. Our data suggest that this instrument is invariant between sexes and non-clinical age groups. Consequently, DAS can be used as a self-report instrument to detect death anxiety in the general adult Peruvian population. This will allow public policies, such as assistance programs, to identify subjects at higher risk and more vulnerable to developing mental health disorders related to quality of life that the state should guarantee.

This study is framed in the field of public and mental health, specifically constituting a methodological contribution that will overcome the lack of a useful, valid, and reliable instrument in the current Peruvian context, involving much more accurate and rigorous measurements of the variable in question, thus serving not only health professionals but also promoters and citizens themselves.

All of these factors contribute to the challenge of preventing and reducing the risk of mental diseases and achieving a biopsychosocial balance. This perspective is in line with the framework of the Global Goals of the 2030 Agenda for Sustainable Development, where Goal 3 aims to ensure healthy lives and promote well-being for all ages worldwide.

Consent statement

The consent of the participants was given in writing before answering the online instruments.

Data availability

Underlying data

Zenodo: De La Cruz-Valdiviano CB: Death anxiety scale (DAS) /database. Zenodo; 2023. doi: https://doi.org/10.5281/zenodo.10689053.⁷³

This project contains the following underlying data:

Database (Statistical results after the application of the Death anxiety scale-DAS).xlsx

Extended data

Zenodo: Death anxiety scale (DAS): internal structure and factorial invariance in Peruvian adults. Zenodo; 2024. https://doi.org/10.5281/zenodo.12191803.⁷⁴

This project contains the following extended data:

• Final results (word).docx
• Ethics Committee Approval.pdf (Etica UCV 70 De La Cruz Valdiviano)
• Permission to use the Death Anxiety Scale_De la Cruz.
• Informed consent
• Death anxiety in Peruvian adults during the COVID-19 pandemic (Open Access).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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Author details Author details

Carlos De La Cruz-Valdiviano
Roles: Conceptualization, Data Curation, Investigation, Validation

Aldo Bazán-Ramirez
Roles: Project Administration, Resources, Writing – Original Draft Preparation

Lincol Olivas-Ugarte
Roles: Formal Analysis, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Juan Quijano-Pacheco
Roles: Funding Acquisition, Resources, Supervision, Visualization, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

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The author(s) declared that no grants were involved in supporting this work.

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De La Cruz-Valdiviano C, Bazán-Ramirez A, Olivas-Ugarte L and Quijano-Pacheco J. Death anxiety scale (DAS): internal structure and factorial invariance in Peruvian adults [version 2; peer review: 2 approved]. F1000Research 2024, 13:801 (https://doi.org/10.12688/f1000research.143167.2)

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Afreen Faiza, Department of Psychology, Fatima College of Health Science, Abu Dhabi, United Arab Emirates

Approved with Reservations

https://doi.org/10.5256/f1000research.156799.r304672

1. Literature Review Section could include recent findings related to death anxiety and its components focused on death anxiety in context of general population as the sample target for scale validation seems general population rather than terminal or physically ill or preoccupation about death.
2. Do Studies cited in : Section 1.1
Rivera and Montero¹² Peñaloza¹⁸used Templar DAs?? if yes please state.
3. do we really need to write separately about anxiety and make another section 1.2 ? better link it with death anxiety or write description about how fear is different from anxiety.
4. what was religious backgrounds/ health status of participants,
5. major concern is that how templer DAS divided into 3 factors ?? what was your rationale to do so as it has one pf major drawback was that TDAs is uni dimensional scale.
how we come up with different names of sub scales : Fear of agony or pathology, Fear of life coming to an end, Fear of death,
( what subscales measures, and how it comply with theory of Templer scale )

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Psychometrics, thanatology, theology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

Report a concern

Author Response 22 Nov 2024

Carlos De La Cruz-Valdiviano, Piura, Cesar Vallejo University, Piura, Piura 20001, Peru

22 Nov 2024

Author Response
1. Literature Review Section could include recent findings related to death anxiety and its components focused on death anxiety in context of general population as the sample target for
... Continue reading
Literature Review Section could include recent findings related to death anxiety and its components focused on death anxiety in context of general population as the sample target for scale validation seems general population rather than terminal or physically ill or preoccupation about death.

Response:
In the literature review, the initial focus was on research concerning death anxiety in clinical populations due to the influence these studies have had on the validation of the Death Anxiety Scale (DAS). However, we understand the importance of providing a more updated and relevant framework for the general population, as the sample in this study consists of Peruvian adults without severe medical conditions. To strengthen the literature review section, we have consulted recent studies addressing death anxiety in the general population, and I include below some relevant findings that will be integrated into the manuscript:

Influence of Sociocultural Factors: Recent research has indicated that death anxiety is strongly influenced by sociocultural and contextual factors⁷². These studies emphasize that death anxiety can vary significantly between countries and cultures, depending on elements such as religious beliefs, social norms, and exposure to conflict contexts. This aspect is particularly relevant for the Peruvian population, given the cultural diversity and sociocultural values that could influence levels of death anxiety.

Death Anxiety in Young and Middle-Aged Adults: Studies such as those by Abdel-Khalek and Neimeyer⁷³ have demonstrated that death anxiety is not exclusive to clinical populations or older adults. High levels of death anxiety have been observed in young and middle-aged adults, who face uncertainties common to this stage of life, such as changes in family and professional roles. These findings are crucial for the context of our Peruvian sample, as most participants fall within a similar age range.

Gender Differences: Some recent studies have suggested that there are significant gender differences in the manifestation of death anxiety in the general population ⁷³. Women tend to report higher levels of death anxiety than men, which could be attributed to a greater predisposition to experiencing emotional concerns. This aspect will be included in the review to provide better contextualization of the study's target population.

Relationship between Death Anxiety and Psychological Well-Being: Lastly, recent studies have explored the relationship between death anxiety and psychological well-being in the general population. According to Abdel-Khalek and Neimeyer ⁷³, death anxiety is inversely related to subjective well-being, indicating that elevated levels of death anxiety are associated with a decrease in quality of life. This finding is particularly relevant to emphasize the importance of adequately measuring death anxiety in the general population and considering its implications for mental well-being.

We once again appreciate your exhaustive review and your suggestions, which will undoubtedly enrich the scope and depth of the analysis of this study. However, we believe that framing the research in the context of the pandemic justifies studying death anxiety in the general population.

2. Do Studies cited in : Section 1.1 Rivera and Montero¹² Peñaloza¹⁸ used Templar DAs?? if yes please state

Response: Yes, both cited studies used Templer's Death Anxiety Scale (DAS) as an instrument to assess death anxiety in their respective samples. Specifically, the study by Rivera and Montero evaluated the psychometric properties of the DAS in a sample of Mexican subjects, while Peñaloza's study also used Templer's DAS to examine its psychometric properties in a sample of healthcare personnel from Lima Metropolitan.

3. Do we really need to write separately about anxiety and make another section 1.2 ? better link it with death anxiety or write description about how fear is different from anxiety.

Response:
We understand the reviewer's concern regarding the separation of the sections related to anxiety and death anxiety. However, we believe that the way these sections were organized has solid theoretical and methodological support, which also reflects a logical and appropriate structure for the reader's understanding.

First, in the section on anxiety (1.2), the intention was to provide a conceptual framework necessary to understand anxiety from a general perspective. Anxiety is a central component in analyzing death anxiety, but each has specific characteristics that needed to be explained independently to avoid confusing the reader. Anxiety is a state of general arousal that can manifest in different contexts and be influenced by various factors, such as existential fear and the perception of the threat of death ⁷⁴. Separating these concepts allowed us to clarify the distinction between anxiety as a broad phenomenon and death-related anxiety, thereby adhering to an academic rigor criterion that facilitates a comprehensive understanding of the construct of death anxiety.

Second, the inclusion of a section discussing general anxiety is also justified from the perspective of Terror Management Theory (TMT), as presented by Zuccala et al.⁷⁵. This theory proposes that death anxiety is a specific form of anxiety underlying various mental disorders, and its correct understanding begins by defining anxiety as a general response to the perception of existential threats. This approach allowed us to develop a solid conceptualization of how fear of death is linked to other fears and anxieties, and laid the foundation for the clear differentiation between fear and anxiety described later.

Third, the structure chosen for the manuscript also responds to methodological coherence, as the factorial solutions found in the exploratory and confirmatory analysis revealed three distinct dimensions in Templer's Death Anxiety Scale (DAS). Each of these dimensions is linked to specific components of anxiety that, according to studies such as those by Sharif Nia et al. ⁷⁴, differ significantly in different cultural and sociodemographic contexts. The presence of multiple factors suggests that death anxiety is not merely a unidimensional fear but can be expressed in different forms, which justifies the proposed structure.

Finally, we consider that the preprint publication of the manuscript already reflects a consensus on the organization of the sections and the methodological decisions made, which have already been reviewed and accepted (100%) by one of the peers. The need to discuss anxiety in general terms before addressing death anxiety is also a response to previous studies that emphasize the importance of contextualizing and clearly defining these concepts to ensure a precise understanding of the construct ⁷⁵.

For these reasons, we believe that it is not necessary to make modifications to the manuscript's structure. The current organization allows for a better understanding of the relationship between anxiety and death anxiety, meeting criteria for clarity and methodological rigor that are essential in this type of study.

4. what was religious backgrounds/ health status of participants?

Response:
Regarding the religious backgrounds of the participants, we acknowledge that this information represents one of the limitations of the present study. Detailed data on religious affiliation or the degree of religious involvement of the participants were not collected. It is important to mention that this aspect may have influenced the interpretation and response of participants to the Death Anxiety Scale (DAS), as religion can act as a modulatory mechanism of the fear of death. Consequently, this limitation is highlighted in the discussion of the study, and we suggest that future research include a thorough analysis of the impact of religious backgrounds to gain a deeper understanding of the phenomenon of death anxiety.
Concerning health status, the study focused on the history of COVID-19, given the relevance of the pandemic to the experience of death anxiety in the general population. Specific data were collected on whether participants had contracted the disease, and the results showed that 45% of respondents reported having had COVID-19. This variable was considered due to the known impact of the pandemic on perceptions of vulnerability and the increase in existential anxiety in many people. However, other aspects of general health, such as the presence of chronic or terminal illnesses, were not addressed, which also constitutes a limitation of this study. This information will be included more clearly in the discussion to indicate how these limitations may have influenced the results obtained and how they should be addressed in future research.
I once again appreciate your careful review and suggestions, which undoubtedly enrich the scope and depth of this study's analysis. Nevertheless, I believe that framing the research within the context of the pandemic justifies studying death anxiety in the general population.

5. Major concern is that how templer DAS divided into 3 factors ?? what was your rationale to do so as it has one pf major drawback was that TDAs is uni dimensional scale. how we come up with different names of sub scales : Fear of agony or pathology, Fear of life coming to an end, Fear of death, ( what subscales measures, and how it comply with theory of Templer scale?)

Response:
Justification of the Factor Structure
In our study, the Death Anxiety Scale (DAS) was subjected to exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), revealing a structure of three interrelated factors, which contradicts the traditionally unidimensional nature attributed to the scale. These three emerging factors were named: Fear of agony or pathology, Fear of life ending, and Fear of death. The results indicated an accumulated variance of 53.3%, which supports the existence of additional components beyond the general factor of death anxiety.

Naming the Subscales
Fear of agony or pathology: This factor includes items that reflect concern about physical suffering or pain associated with death. The naming is derived from the qualitative analysis of the content of the items that make up this factor, which focus on aspects of distress over a painful death or prolonged illness. These findings are consistent with previous findings by Rivera and Montero, as well as Peñaloza, who also found that fear of the process of agony is a crucial component in the structure of death anxiety.

Fear of life ending: This factor represents existential fear related to the perception of the end of life as an inevitable process. The items associated with this component suggest a concern for the finite nature of life and the uncertainty that comes with it, clearly distinguishing it from physical fear or the consequences of death. This type of fear has also been documented in cross-cultural studies where differences are observed in how the end of life is perceived and feared depending on the cultural context and sample evaluated ⁷⁴.

Fear of death: This factor groups items that address the fear of the idea of death itself, including the fear of the unknown that death represents. This component relates to abstract or philosophical anxiety about the act of dying, which is consistent with studies that have evidenced a distinct psychological component in death anxiety ⁷⁵. In the cross-cultural analysis by Sharif Nia et al. ⁷⁴, it was observed that the factor structure of the DAS varied significantly across different cultural contexts, highlighting the need to adapt the scale according to the specific characteristics of each population.

Coherence with Templer's Theory
Although Templer's Scale was initially conceived as unidimensional, recent studies have suggested the existence of multiple dimensions depending on the cultural and population context in which it is applied. For instance, the systematic review conducted by Sharif Nia et al. ⁷⁴ found factor structures ranging from two to five factors, depending on the cultural context and evaluated population. This evidence supports the need to reconsider the unidimensionality of the scale in specific contexts like the Peruvian one, in which we identified three factors that seem to capture particular nuances of death anxiety. Zuccala et al. ⁷⁵ also point out that variability in the DAS factor structure can be attributed to cultural differences and the translation of the instrument's content. Indeed, death anxiety tends to manifest differently according to the cultural context, directly affecting the scale's validity and reliability. Therefore, it has been recommended to conduct continuous evaluations and specific cultural adaptations before applying it in clinical and multicultural settings.

Empirical Evidence
In the confirmatory factor analysis (CFA), the bifactor model best fit the data, with adequate fit indices (CFI ≥ .94, TLI ≥ .94, SRMR ≤ .08, RMSEA ≤ .07) and a proportion of explained variance of 69.56%. This suggests that while a general factor measuring death anxiety exists, the three specific dimensions have sufficient independence to be considered validated subscales, providing greater precision in the evaluation of death anxiety. This is consistent with the results of the exploratory factor analysis previously mentioned.

Conclusion
The division of the Death Anxiety Scale into three factors is based on rigorous empirical analysis that reflects the underlying structure of the data and is in line with previous cross-cultural studies that have identified multidimensional structures. This conceptualization allows for a more comprehensive and nuanced assessment of death anxiety in the Peruvian population, capturing specific aspects that may not be evident in a unidimensional structure. The results of Sharif Nia et al. ⁷⁴ and Zuccala et al. ⁷⁵ support the need to adapt the DAS scale according to the cultural and sociodemographic particularities of each sample, which motivated us to validate a three-dimensional structure in the Peruvian context to provide a more sensitive and accurate assessment tool for our target population.
Literature Review Section could include recent findings related to death anxiety and its components focused on death anxiety in context of general population as the sample target for scale validation seems general population rather than terminal or physically ill or preoccupation about death.

Response:
In the literature review, the initial focus was on research concerning death anxiety in clinical populations due to the influence these studies have had on the validation of the Death Anxiety Scale (DAS). However, we understand the importance of providing a more updated and relevant framework for the general population, as the sample in this study consists of Peruvian adults without severe medical conditions. To strengthen the literature review section, we have consulted recent studies addressing death anxiety in the general population, and I include below some relevant findings that will be integrated into the manuscript:

Influence of Sociocultural Factors: Recent research has indicated that death anxiety is strongly influenced by sociocultural and contextual factors⁷². These studies emphasize that death anxiety can vary significantly between countries and cultures, depending on elements such as religious beliefs, social norms, and exposure to conflict contexts. This aspect is particularly relevant for the Peruvian population, given the cultural diversity and sociocultural values that could influence levels of death anxiety.

Death Anxiety in Young and Middle-Aged Adults: Studies such as those by Abdel-Khalek and Neimeyer⁷³ have demonstrated that death anxiety is not exclusive to clinical populations or older adults. High levels of death anxiety have been observed in young and middle-aged adults, who face uncertainties common to this stage of life, such as changes in family and professional roles. These findings are crucial for the context of our Peruvian sample, as most participants fall within a similar age range.

Gender Differences: Some recent studies have suggested that there are significant gender differences in the manifestation of death anxiety in the general population ⁷³. Women tend to report higher levels of death anxiety than men, which could be attributed to a greater predisposition to experiencing emotional concerns. This aspect will be included in the review to provide better contextualization of the study's target population.

Relationship between Death Anxiety and Psychological Well-Being: Lastly, recent studies have explored the relationship between death anxiety and psychological well-being in the general population. According to Abdel-Khalek and Neimeyer ⁷³, death anxiety is inversely related to subjective well-being, indicating that elevated levels of death anxiety are associated with a decrease in quality of life. This finding is particularly relevant to emphasize the importance of adequately measuring death anxiety in the general population and considering its implications for mental well-being.

We once again appreciate your exhaustive review and your suggestions, which will undoubtedly enrich the scope and depth of the analysis of this study. However, we believe that framing the research in the context of the pandemic justifies studying death anxiety in the general population.

2. Do Studies cited in : Section 1.1 Rivera and Montero¹² Peñaloza¹⁸ used Templar DAs?? if yes please state

Response: Yes, both cited studies used Templer's Death Anxiety Scale (DAS) as an instrument to assess death anxiety in their respective samples. Specifically, the study by Rivera and Montero evaluated the psychometric properties of the DAS in a sample of Mexican subjects, while Peñaloza's study also used Templer's DAS to examine its psychometric properties in a sample of healthcare personnel from Lima Metropolitan.

3. Do we really need to write separately about anxiety and make another section 1.2 ? better link it with death anxiety or write description about how fear is different from anxiety.

Response:
We understand the reviewer's concern regarding the separation of the sections related to anxiety and death anxiety. However, we believe that the way these sections were organized has solid theoretical and methodological support, which also reflects a logical and appropriate structure for the reader's understanding.

First, in the section on anxiety (1.2), the intention was to provide a conceptual framework necessary to understand anxiety from a general perspective. Anxiety is a central component in analyzing death anxiety, but each has specific characteristics that needed to be explained independently to avoid confusing the reader. Anxiety is a state of general arousal that can manifest in different contexts and be influenced by various factors, such as existential fear and the perception of the threat of death ⁷⁴. Separating these concepts allowed us to clarify the distinction between anxiety as a broad phenomenon and death-related anxiety, thereby adhering to an academic rigor criterion that facilitates a comprehensive understanding of the construct of death anxiety.

Second, the inclusion of a section discussing general anxiety is also justified from the perspective of Terror Management Theory (TMT), as presented by Zuccala et al.⁷⁵. This theory proposes that death anxiety is a specific form of anxiety underlying various mental disorders, and its correct understanding begins by defining anxiety as a general response to the perception of existential threats. This approach allowed us to develop a solid conceptualization of how fear of death is linked to other fears and anxieties, and laid the foundation for the clear differentiation between fear and anxiety described later.

Third, the structure chosen for the manuscript also responds to methodological coherence, as the factorial solutions found in the exploratory and confirmatory analysis revealed three distinct dimensions in Templer's Death Anxiety Scale (DAS). Each of these dimensions is linked to specific components of anxiety that, according to studies such as those by Sharif Nia et al. ⁷⁴, differ significantly in different cultural and sociodemographic contexts. The presence of multiple factors suggests that death anxiety is not merely a unidimensional fear but can be expressed in different forms, which justifies the proposed structure.

Finally, we consider that the preprint publication of the manuscript already reflects a consensus on the organization of the sections and the methodological decisions made, which have already been reviewed and accepted (100%) by one of the peers. The need to discuss anxiety in general terms before addressing death anxiety is also a response to previous studies that emphasize the importance of contextualizing and clearly defining these concepts to ensure a precise understanding of the construct ⁷⁵.

For these reasons, we believe that it is not necessary to make modifications to the manuscript's structure. The current organization allows for a better understanding of the relationship between anxiety and death anxiety, meeting criteria for clarity and methodological rigor that are essential in this type of study.

4. what was religious backgrounds/ health status of participants?

Response:
Regarding the religious backgrounds of the participants, we acknowledge that this information represents one of the limitations of the present study. Detailed data on religious affiliation or the degree of religious involvement of the participants were not collected. It is important to mention that this aspect may have influenced the interpretation and response of participants to the Death Anxiety Scale (DAS), as religion can act as a modulatory mechanism of the fear of death. Consequently, this limitation is highlighted in the discussion of the study, and we suggest that future research include a thorough analysis of the impact of religious backgrounds to gain a deeper understanding of the phenomenon of death anxiety.
Concerning health status, the study focused on the history of COVID-19, given the relevance of the pandemic to the experience of death anxiety in the general population. Specific data were collected on whether participants had contracted the disease, and the results showed that 45% of respondents reported having had COVID-19. This variable was considered due to the known impact of the pandemic on perceptions of vulnerability and the increase in existential anxiety in many people. However, other aspects of general health, such as the presence of chronic or terminal illnesses, were not addressed, which also constitutes a limitation of this study. This information will be included more clearly in the discussion to indicate how these limitations may have influenced the results obtained and how they should be addressed in future research.
I once again appreciate your careful review and suggestions, which undoubtedly enrich the scope and depth of this study's analysis. Nevertheless, I believe that framing the research within the context of the pandemic justifies studying death anxiety in the general population.

5. Major concern is that how templer DAS divided into 3 factors ?? what was your rationale to do so as it has one pf major drawback was that TDAs is uni dimensional scale. how we come up with different names of sub scales : Fear of agony or pathology, Fear of life coming to an end, Fear of death, ( what subscales measures, and how it comply with theory of Templer scale?)

Response:
Justification of the Factor Structure
In our study, the Death Anxiety Scale (DAS) was subjected to exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), revealing a structure of three interrelated factors, which contradicts the traditionally unidimensional nature attributed to the scale. These three emerging factors were named: Fear of agony or pathology, Fear of life ending, and Fear of death. The results indicated an accumulated variance of 53.3%, which supports the existence of additional components beyond the general factor of death anxiety.

Naming the Subscales
Fear of agony or pathology: This factor includes items that reflect concern about physical suffering or pain associated with death. The naming is derived from the qualitative analysis of the content of the items that make up this factor, which focus on aspects of distress over a painful death or prolonged illness. These findings are consistent with previous findings by Rivera and Montero, as well as Peñaloza, who also found that fear of the process of agony is a crucial component in the structure of death anxiety.

Fear of life ending: This factor represents existential fear related to the perception of the end of life as an inevitable process. The items associated with this component suggest a concern for the finite nature of life and the uncertainty that comes with it, clearly distinguishing it from physical fear or the consequences of death. This type of fear has also been documented in cross-cultural studies where differences are observed in how the end of life is perceived and feared depending on the cultural context and sample evaluated ⁷⁴.

Fear of death: This factor groups items that address the fear of the idea of death itself, including the fear of the unknown that death represents. This component relates to abstract or philosophical anxiety about the act of dying, which is consistent with studies that have evidenced a distinct psychological component in death anxiety ⁷⁵. In the cross-cultural analysis by Sharif Nia et al. ⁷⁴, it was observed that the factor structure of the DAS varied significantly across different cultural contexts, highlighting the need to adapt the scale according to the specific characteristics of each population.

Coherence with Templer's Theory
Although Templer's Scale was initially conceived as unidimensional, recent studies have suggested the existence of multiple dimensions depending on the cultural and population context in which it is applied. For instance, the systematic review conducted by Sharif Nia et al. ⁷⁴ found factor structures ranging from two to five factors, depending on the cultural context and evaluated population. This evidence supports the need to reconsider the unidimensionality of the scale in specific contexts like the Peruvian one, in which we identified three factors that seem to capture particular nuances of death anxiety. Zuccala et al. ⁷⁵ also point out that variability in the DAS factor structure can be attributed to cultural differences and the translation of the instrument's content. Indeed, death anxiety tends to manifest differently according to the cultural context, directly affecting the scale's validity and reliability. Therefore, it has been recommended to conduct continuous evaluations and specific cultural adaptations before applying it in clinical and multicultural settings.

Empirical Evidence
In the confirmatory factor analysis (CFA), the bifactor model best fit the data, with adequate fit indices (CFI ≥ .94, TLI ≥ .94, SRMR ≤ .08, RMSEA ≤ .07) and a proportion of explained variance of 69.56%. This suggests that while a general factor measuring death anxiety exists, the three specific dimensions have sufficient independence to be considered validated subscales, providing greater precision in the evaluation of death anxiety. This is consistent with the results of the exploratory factor analysis previously mentioned.

Conclusion
The division of the Death Anxiety Scale into three factors is based on rigorous empirical analysis that reflects the underlying structure of the data and is in line with previous cross-cultural studies that have identified multidimensional structures. This conceptualization allows for a more comprehensive and nuanced assessment of death anxiety in the Peruvian population, capturing specific aspects that may not be evident in a unidimensional structure. The results of Sharif Nia et al. ⁷⁴ and Zuccala et al. ⁷⁵ support the need to adapt the DAS scale according to the cultural and sociodemographic particularities of each sample, which motivated us to validate a three-dimensional structure in the Peruvian context to provide a more sensitive and accurate assessment tool for our target population.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 22 Nov 2024

Carlos De La Cruz-Valdiviano, Piura, Cesar Vallejo University, Piura, Piura 20001, Peru

22 Nov 2024

Author Response
1. Literature Review Section could include recent findings related to death anxiety and its components focused on death anxiety in context of general population as the sample target for
... Continue reading
Literature Review Section could include recent findings related to death anxiety and its components focused on death anxiety in context of general population as the sample target for scale validation seems general population rather than terminal or physically ill or preoccupation about death.

Response:
In the literature review, the initial focus was on research concerning death anxiety in clinical populations due to the influence these studies have had on the validation of the Death Anxiety Scale (DAS). However, we understand the importance of providing a more updated and relevant framework for the general population, as the sample in this study consists of Peruvian adults without severe medical conditions. To strengthen the literature review section, we have consulted recent studies addressing death anxiety in the general population, and I include below some relevant findings that will be integrated into the manuscript:

Influence of Sociocultural Factors: Recent research has indicated that death anxiety is strongly influenced by sociocultural and contextual factors⁷². These studies emphasize that death anxiety can vary significantly between countries and cultures, depending on elements such as religious beliefs, social norms, and exposure to conflict contexts. This aspect is particularly relevant for the Peruvian population, given the cultural diversity and sociocultural values that could influence levels of death anxiety.

Death Anxiety in Young and Middle-Aged Adults: Studies such as those by Abdel-Khalek and Neimeyer⁷³ have demonstrated that death anxiety is not exclusive to clinical populations or older adults. High levels of death anxiety have been observed in young and middle-aged adults, who face uncertainties common to this stage of life, such as changes in family and professional roles. These findings are crucial for the context of our Peruvian sample, as most participants fall within a similar age range.

Gender Differences: Some recent studies have suggested that there are significant gender differences in the manifestation of death anxiety in the general population ⁷³. Women tend to report higher levels of death anxiety than men, which could be attributed to a greater predisposition to experiencing emotional concerns. This aspect will be included in the review to provide better contextualization of the study's target population.

Relationship between Death Anxiety and Psychological Well-Being: Lastly, recent studies have explored the relationship between death anxiety and psychological well-being in the general population. According to Abdel-Khalek and Neimeyer ⁷³, death anxiety is inversely related to subjective well-being, indicating that elevated levels of death anxiety are associated with a decrease in quality of life. This finding is particularly relevant to emphasize the importance of adequately measuring death anxiety in the general population and considering its implications for mental well-being.

We once again appreciate your exhaustive review and your suggestions, which will undoubtedly enrich the scope and depth of the analysis of this study. However, we believe that framing the research in the context of the pandemic justifies studying death anxiety in the general population.

2. Do Studies cited in : Section 1.1 Rivera and Montero¹² Peñaloza¹⁸ used Templar DAs?? if yes please state

Response: Yes, both cited studies used Templer's Death Anxiety Scale (DAS) as an instrument to assess death anxiety in their respective samples. Specifically, the study by Rivera and Montero evaluated the psychometric properties of the DAS in a sample of Mexican subjects, while Peñaloza's study also used Templer's DAS to examine its psychometric properties in a sample of healthcare personnel from Lima Metropolitan.

3. Do we really need to write separately about anxiety and make another section 1.2 ? better link it with death anxiety or write description about how fear is different from anxiety.

Response:
We understand the reviewer's concern regarding the separation of the sections related to anxiety and death anxiety. However, we believe that the way these sections were organized has solid theoretical and methodological support, which also reflects a logical and appropriate structure for the reader's understanding.

First, in the section on anxiety (1.2), the intention was to provide a conceptual framework necessary to understand anxiety from a general perspective. Anxiety is a central component in analyzing death anxiety, but each has specific characteristics that needed to be explained independently to avoid confusing the reader. Anxiety is a state of general arousal that can manifest in different contexts and be influenced by various factors, such as existential fear and the perception of the threat of death ⁷⁴. Separating these concepts allowed us to clarify the distinction between anxiety as a broad phenomenon and death-related anxiety, thereby adhering to an academic rigor criterion that facilitates a comprehensive understanding of the construct of death anxiety.

Second, the inclusion of a section discussing general anxiety is also justified from the perspective of Terror Management Theory (TMT), as presented by Zuccala et al.⁷⁵. This theory proposes that death anxiety is a specific form of anxiety underlying various mental disorders, and its correct understanding begins by defining anxiety as a general response to the perception of existential threats. This approach allowed us to develop a solid conceptualization of how fear of death is linked to other fears and anxieties, and laid the foundation for the clear differentiation between fear and anxiety described later.

Third, the structure chosen for the manuscript also responds to methodological coherence, as the factorial solutions found in the exploratory and confirmatory analysis revealed three distinct dimensions in Templer's Death Anxiety Scale (DAS). Each of these dimensions is linked to specific components of anxiety that, according to studies such as those by Sharif Nia et al. ⁷⁴, differ significantly in different cultural and sociodemographic contexts. The presence of multiple factors suggests that death anxiety is not merely a unidimensional fear but can be expressed in different forms, which justifies the proposed structure.

Finally, we consider that the preprint publication of the manuscript already reflects a consensus on the organization of the sections and the methodological decisions made, which have already been reviewed and accepted (100%) by one of the peers. The need to discuss anxiety in general terms before addressing death anxiety is also a response to previous studies that emphasize the importance of contextualizing and clearly defining these concepts to ensure a precise understanding of the construct ⁷⁵.

For these reasons, we believe that it is not necessary to make modifications to the manuscript's structure. The current organization allows for a better understanding of the relationship between anxiety and death anxiety, meeting criteria for clarity and methodological rigor that are essential in this type of study.

4. what was religious backgrounds/ health status of participants?

Response:
Regarding the religious backgrounds of the participants, we acknowledge that this information represents one of the limitations of the present study. Detailed data on religious affiliation or the degree of religious involvement of the participants were not collected. It is important to mention that this aspect may have influenced the interpretation and response of participants to the Death Anxiety Scale (DAS), as religion can act as a modulatory mechanism of the fear of death. Consequently, this limitation is highlighted in the discussion of the study, and we suggest that future research include a thorough analysis of the impact of religious backgrounds to gain a deeper understanding of the phenomenon of death anxiety.
Concerning health status, the study focused on the history of COVID-19, given the relevance of the pandemic to the experience of death anxiety in the general population. Specific data were collected on whether participants had contracted the disease, and the results showed that 45% of respondents reported having had COVID-19. This variable was considered due to the known impact of the pandemic on perceptions of vulnerability and the increase in existential anxiety in many people. However, other aspects of general health, such as the presence of chronic or terminal illnesses, were not addressed, which also constitutes a limitation of this study. This information will be included more clearly in the discussion to indicate how these limitations may have influenced the results obtained and how they should be addressed in future research.
I once again appreciate your careful review and suggestions, which undoubtedly enrich the scope and depth of this study's analysis. Nevertheless, I believe that framing the research within the context of the pandemic justifies studying death anxiety in the general population.

5. Major concern is that how templer DAS divided into 3 factors ?? what was your rationale to do so as it has one pf major drawback was that TDAs is uni dimensional scale. how we come up with different names of sub scales : Fear of agony or pathology, Fear of life coming to an end, Fear of death, ( what subscales measures, and how it comply with theory of Templer scale?)

Response:
Justification of the Factor Structure
In our study, the Death Anxiety Scale (DAS) was subjected to exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), revealing a structure of three interrelated factors, which contradicts the traditionally unidimensional nature attributed to the scale. These three emerging factors were named: Fear of agony or pathology, Fear of life ending, and Fear of death. The results indicated an accumulated variance of 53.3%, which supports the existence of additional components beyond the general factor of death anxiety.

Naming the Subscales
Fear of agony or pathology: This factor includes items that reflect concern about physical suffering or pain associated with death. The naming is derived from the qualitative analysis of the content of the items that make up this factor, which focus on aspects of distress over a painful death or prolonged illness. These findings are consistent with previous findings by Rivera and Montero, as well as Peñaloza, who also found that fear of the process of agony is a crucial component in the structure of death anxiety.

Fear of life ending: This factor represents existential fear related to the perception of the end of life as an inevitable process. The items associated with this component suggest a concern for the finite nature of life and the uncertainty that comes with it, clearly distinguishing it from physical fear or the consequences of death. This type of fear has also been documented in cross-cultural studies where differences are observed in how the end of life is perceived and feared depending on the cultural context and sample evaluated ⁷⁴.

Fear of death: This factor groups items that address the fear of the idea of death itself, including the fear of the unknown that death represents. This component relates to abstract or philosophical anxiety about the act of dying, which is consistent with studies that have evidenced a distinct psychological component in death anxiety ⁷⁵. In the cross-cultural analysis by Sharif Nia et al. ⁷⁴, it was observed that the factor structure of the DAS varied significantly across different cultural contexts, highlighting the need to adapt the scale according to the specific characteristics of each population.

Coherence with Templer's Theory
Although Templer's Scale was initially conceived as unidimensional, recent studies have suggested the existence of multiple dimensions depending on the cultural and population context in which it is applied. For instance, the systematic review conducted by Sharif Nia et al. ⁷⁴ found factor structures ranging from two to five factors, depending on the cultural context and evaluated population. This evidence supports the need to reconsider the unidimensionality of the scale in specific contexts like the Peruvian one, in which we identified three factors that seem to capture particular nuances of death anxiety. Zuccala et al. ⁷⁵ also point out that variability in the DAS factor structure can be attributed to cultural differences and the translation of the instrument's content. Indeed, death anxiety tends to manifest differently according to the cultural context, directly affecting the scale's validity and reliability. Therefore, it has been recommended to conduct continuous evaluations and specific cultural adaptations before applying it in clinical and multicultural settings.

Empirical Evidence
In the confirmatory factor analysis (CFA), the bifactor model best fit the data, with adequate fit indices (CFI ≥ .94, TLI ≥ .94, SRMR ≤ .08, RMSEA ≤ .07) and a proportion of explained variance of 69.56%. This suggests that while a general factor measuring death anxiety exists, the three specific dimensions have sufficient independence to be considered validated subscales, providing greater precision in the evaluation of death anxiety. This is consistent with the results of the exploratory factor analysis previously mentioned.

Conclusion
The division of the Death Anxiety Scale into three factors is based on rigorous empirical analysis that reflects the underlying structure of the data and is in line with previous cross-cultural studies that have identified multidimensional structures. This conceptualization allows for a more comprehensive and nuanced assessment of death anxiety in the Peruvian population, capturing specific aspects that may not be evident in a unidimensional structure. The results of Sharif Nia et al. ⁷⁴ and Zuccala et al. ⁷⁵ support the need to adapt the DAS scale according to the cultural and sociodemographic particularities of each sample, which motivated us to validate a three-dimensional structure in the Peruvian context to provide a more sensitive and accurate assessment tool for our target population.
Literature Review Section could include recent findings related to death anxiety and its components focused on death anxiety in context of general population as the sample target for scale validation seems general population rather than terminal or physically ill or preoccupation about death.

Response:
In the literature review, the initial focus was on research concerning death anxiety in clinical populations due to the influence these studies have had on the validation of the Death Anxiety Scale (DAS). However, we understand the importance of providing a more updated and relevant framework for the general population, as the sample in this study consists of Peruvian adults without severe medical conditions. To strengthen the literature review section, we have consulted recent studies addressing death anxiety in the general population, and I include below some relevant findings that will be integrated into the manuscript:

Influence of Sociocultural Factors: Recent research has indicated that death anxiety is strongly influenced by sociocultural and contextual factors⁷². These studies emphasize that death anxiety can vary significantly between countries and cultures, depending on elements such as religious beliefs, social norms, and exposure to conflict contexts. This aspect is particularly relevant for the Peruvian population, given the cultural diversity and sociocultural values that could influence levels of death anxiety.

Death Anxiety in Young and Middle-Aged Adults: Studies such as those by Abdel-Khalek and Neimeyer⁷³ have demonstrated that death anxiety is not exclusive to clinical populations or older adults. High levels of death anxiety have been observed in young and middle-aged adults, who face uncertainties common to this stage of life, such as changes in family and professional roles. These findings are crucial for the context of our Peruvian sample, as most participants fall within a similar age range.

Gender Differences: Some recent studies have suggested that there are significant gender differences in the manifestation of death anxiety in the general population ⁷³. Women tend to report higher levels of death anxiety than men, which could be attributed to a greater predisposition to experiencing emotional concerns. This aspect will be included in the review to provide better contextualization of the study's target population.

Relationship between Death Anxiety and Psychological Well-Being: Lastly, recent studies have explored the relationship between death anxiety and psychological well-being in the general population. According to Abdel-Khalek and Neimeyer ⁷³, death anxiety is inversely related to subjective well-being, indicating that elevated levels of death anxiety are associated with a decrease in quality of life. This finding is particularly relevant to emphasize the importance of adequately measuring death anxiety in the general population and considering its implications for mental well-being.

We once again appreciate your exhaustive review and your suggestions, which will undoubtedly enrich the scope and depth of the analysis of this study. However, we believe that framing the research in the context of the pandemic justifies studying death anxiety in the general population.

2. Do Studies cited in : Section 1.1 Rivera and Montero¹² Peñaloza¹⁸ used Templar DAs?? if yes please state

Response: Yes, both cited studies used Templer's Death Anxiety Scale (DAS) as an instrument to assess death anxiety in their respective samples. Specifically, the study by Rivera and Montero evaluated the psychometric properties of the DAS in a sample of Mexican subjects, while Peñaloza's study also used Templer's DAS to examine its psychometric properties in a sample of healthcare personnel from Lima Metropolitan.

3. Do we really need to write separately about anxiety and make another section 1.2 ? better link it with death anxiety or write description about how fear is different from anxiety.

Response:
We understand the reviewer's concern regarding the separation of the sections related to anxiety and death anxiety. However, we believe that the way these sections were organized has solid theoretical and methodological support, which also reflects a logical and appropriate structure for the reader's understanding.

First, in the section on anxiety (1.2), the intention was to provide a conceptual framework necessary to understand anxiety from a general perspective. Anxiety is a central component in analyzing death anxiety, but each has specific characteristics that needed to be explained independently to avoid confusing the reader. Anxiety is a state of general arousal that can manifest in different contexts and be influenced by various factors, such as existential fear and the perception of the threat of death ⁷⁴. Separating these concepts allowed us to clarify the distinction between anxiety as a broad phenomenon and death-related anxiety, thereby adhering to an academic rigor criterion that facilitates a comprehensive understanding of the construct of death anxiety.

Second, the inclusion of a section discussing general anxiety is also justified from the perspective of Terror Management Theory (TMT), as presented by Zuccala et al.⁷⁵. This theory proposes that death anxiety is a specific form of anxiety underlying various mental disorders, and its correct understanding begins by defining anxiety as a general response to the perception of existential threats. This approach allowed us to develop a solid conceptualization of how fear of death is linked to other fears and anxieties, and laid the foundation for the clear differentiation between fear and anxiety described later.

Third, the structure chosen for the manuscript also responds to methodological coherence, as the factorial solutions found in the exploratory and confirmatory analysis revealed three distinct dimensions in Templer's Death Anxiety Scale (DAS). Each of these dimensions is linked to specific components of anxiety that, according to studies such as those by Sharif Nia et al. ⁷⁴, differ significantly in different cultural and sociodemographic contexts. The presence of multiple factors suggests that death anxiety is not merely a unidimensional fear but can be expressed in different forms, which justifies the proposed structure.

Finally, we consider that the preprint publication of the manuscript already reflects a consensus on the organization of the sections and the methodological decisions made, which have already been reviewed and accepted (100%) by one of the peers. The need to discuss anxiety in general terms before addressing death anxiety is also a response to previous studies that emphasize the importance of contextualizing and clearly defining these concepts to ensure a precise understanding of the construct ⁷⁵.

For these reasons, we believe that it is not necessary to make modifications to the manuscript's structure. The current organization allows for a better understanding of the relationship between anxiety and death anxiety, meeting criteria for clarity and methodological rigor that are essential in this type of study.

4. what was religious backgrounds/ health status of participants?

Response:
Regarding the religious backgrounds of the participants, we acknowledge that this information represents one of the limitations of the present study. Detailed data on religious affiliation or the degree of religious involvement of the participants were not collected. It is important to mention that this aspect may have influenced the interpretation and response of participants to the Death Anxiety Scale (DAS), as religion can act as a modulatory mechanism of the fear of death. Consequently, this limitation is highlighted in the discussion of the study, and we suggest that future research include a thorough analysis of the impact of religious backgrounds to gain a deeper understanding of the phenomenon of death anxiety.
Concerning health status, the study focused on the history of COVID-19, given the relevance of the pandemic to the experience of death anxiety in the general population. Specific data were collected on whether participants had contracted the disease, and the results showed that 45% of respondents reported having had COVID-19. This variable was considered due to the known impact of the pandemic on perceptions of vulnerability and the increase in existential anxiety in many people. However, other aspects of general health, such as the presence of chronic or terminal illnesses, were not addressed, which also constitutes a limitation of this study. This information will be included more clearly in the discussion to indicate how these limitations may have influenced the results obtained and how they should be addressed in future research.
I once again appreciate your careful review and suggestions, which undoubtedly enrich the scope and depth of this study's analysis. Nevertheless, I believe that framing the research within the context of the pandemic justifies studying death anxiety in the general population.

5. Major concern is that how templer DAS divided into 3 factors ?? what was your rationale to do so as it has one pf major drawback was that TDAs is uni dimensional scale. how we come up with different names of sub scales : Fear of agony or pathology, Fear of life coming to an end, Fear of death, ( what subscales measures, and how it comply with theory of Templer scale?)

Response:
Justification of the Factor Structure
In our study, the Death Anxiety Scale (DAS) was subjected to exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), revealing a structure of three interrelated factors, which contradicts the traditionally unidimensional nature attributed to the scale. These three emerging factors were named: Fear of agony or pathology, Fear of life ending, and Fear of death. The results indicated an accumulated variance of 53.3%, which supports the existence of additional components beyond the general factor of death anxiety.

Naming the Subscales
Fear of agony or pathology: This factor includes items that reflect concern about physical suffering or pain associated with death. The naming is derived from the qualitative analysis of the content of the items that make up this factor, which focus on aspects of distress over a painful death or prolonged illness. These findings are consistent with previous findings by Rivera and Montero, as well as Peñaloza, who also found that fear of the process of agony is a crucial component in the structure of death anxiety.

Fear of life ending: This factor represents existential fear related to the perception of the end of life as an inevitable process. The items associated with this component suggest a concern for the finite nature of life and the uncertainty that comes with it, clearly distinguishing it from physical fear or the consequences of death. This type of fear has also been documented in cross-cultural studies where differences are observed in how the end of life is perceived and feared depending on the cultural context and sample evaluated ⁷⁴.

Fear of death: This factor groups items that address the fear of the idea of death itself, including the fear of the unknown that death represents. This component relates to abstract or philosophical anxiety about the act of dying, which is consistent with studies that have evidenced a distinct psychological component in death anxiety ⁷⁵. In the cross-cultural analysis by Sharif Nia et al. ⁷⁴, it was observed that the factor structure of the DAS varied significantly across different cultural contexts, highlighting the need to adapt the scale according to the specific characteristics of each population.

Coherence with Templer's Theory
Although Templer's Scale was initially conceived as unidimensional, recent studies have suggested the existence of multiple dimensions depending on the cultural and population context in which it is applied. For instance, the systematic review conducted by Sharif Nia et al. ⁷⁴ found factor structures ranging from two to five factors, depending on the cultural context and evaluated population. This evidence supports the need to reconsider the unidimensionality of the scale in specific contexts like the Peruvian one, in which we identified three factors that seem to capture particular nuances of death anxiety. Zuccala et al. ⁷⁵ also point out that variability in the DAS factor structure can be attributed to cultural differences and the translation of the instrument's content. Indeed, death anxiety tends to manifest differently according to the cultural context, directly affecting the scale's validity and reliability. Therefore, it has been recommended to conduct continuous evaluations and specific cultural adaptations before applying it in clinical and multicultural settings.

Empirical Evidence
In the confirmatory factor analysis (CFA), the bifactor model best fit the data, with adequate fit indices (CFI ≥ .94, TLI ≥ .94, SRMR ≤ .08, RMSEA ≤ .07) and a proportion of explained variance of 69.56%. This suggests that while a general factor measuring death anxiety exists, the three specific dimensions have sufficient independence to be considered validated subscales, providing greater precision in the evaluation of death anxiety. This is consistent with the results of the exploratory factor analysis previously mentioned.

Conclusion
The division of the Death Anxiety Scale into three factors is based on rigorous empirical analysis that reflects the underlying structure of the data and is in line with previous cross-cultural studies that have identified multidimensional structures. This conceptualization allows for a more comprehensive and nuanced assessment of death anxiety in the Peruvian population, capturing specific aspects that may not be evident in a unidimensional structure. The results of Sharif Nia et al. ⁷⁴ and Zuccala et al. ⁷⁵ support the need to adapt the DAS scale according to the cultural and sociodemographic particularities of each sample, which motivated us to validate a three-dimensional structure in the Peruvian context to provide a more sensitive and accurate assessment tool for our target population.
Competing Interests: No competing interests were disclosed. Close
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Afreen Faiza, Fatima College of Health Science, Abu Dhabi, United Arab Emirates
Hanaa Shuwiekh, Fayoum University, Faiyum, Egypt

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Afreen Faiza, Department of Psychology, Fatima College of Health Science, Abu Dhabi, United Arab Emirates

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Article addressed all suggestions.

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Psychometrics, thanatology, theology

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Hanaa Shuwiekh, Fayoum University, Faiyum, Faiyum Governorate, Egypt

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Good research in its methodological treatment, although the concept, which is death anxiety, has been studied a lot. Good luck.

Is the work clearly and accurately presented and does it cite the current literature?

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Yes
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Afreen Faiza, Department of Psychology, Fatima College of Health Science, Abu Dhabi, United Arab Emirates

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Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

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No competing interests were disclosed.

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Psychometrics, thanatology, theology

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22 Nov 2024

Carlos De La Cruz-Valdiviano, Piura, Cesar Vallejo University, Piura, Piura 20001, Peru

Literature Review Section could include recent findings related to death anxiety and its components focused on death anxiety in context of general population as the sample target for scale validation seems general population rather than terminal or physically ill or preoccupation about death.

Response:
In the literature review, the initial focus was on research concerning death anxiety in clinical populations due to the influence these studies have had on the validation of the Death Anxiety Scale (DAS). However, we understand the importance of providing a more updated and relevant framework for the general population, as the sample in this study consists of Peruvian adults without severe medical conditions. To strengthen the literature review section, we have consulted recent studies addressing death anxiety in the general population, and I include below some relevant findings that will be integrated into the manuscript:

Influence of Sociocultural Factors: Recent research has indicated that death anxiety is strongly influenced by sociocultural and contextual factors⁷². These studies emphasize that death anxiety can vary significantly between countries and cultures, depending on elements such as religious beliefs, social norms, and exposure to conflict contexts. This aspect is particularly relevant for the Peruvian population, given the cultural diversity and sociocultural values that could influence levels of death anxiety.

Death Anxiety in Young and Middle-Aged Adults: Studies such as those by Abdel-Khalek and Neimeyer⁷³ have demonstrated that death anxiety is not exclusive to clinical populations or older adults. High levels of death anxiety have been observed in young and middle-aged adults, who face uncertainties common to this stage of life, such as changes in family and professional roles. These findings are crucial for the context of our Peruvian sample, as most participants fall within a similar age range.

Gender Differences: Some recent studies have suggested that there are significant gender differences in the manifestation of death anxiety in the general population ⁷³. Women tend to report higher levels of death anxiety than men, which could be attributed to a greater predisposition to experiencing emotional concerns. This aspect will be included in the review to provide better contextualization of the study's target population.

Relationship between Death Anxiety and Psychological Well-Being: Lastly, recent studies have explored the relationship between death anxiety and psychological well-being in the general population. According to Abdel-Khalek and Neimeyer ⁷³, death anxiety is inversely related to subjective well-being, indicating that elevated levels of death anxiety are associated with a decrease in quality of life. This finding is particularly relevant to emphasize the importance of adequately measuring death anxiety in the general population and considering its implications for mental well-being.

We once again appreciate your exhaustive review and your suggestions, which will undoubtedly enrich the scope and depth of the analysis of this study. However, we believe that framing the research in the context of the pandemic justifies studying death anxiety in the general population.

2. Do Studies cited in : Section 1.1 Rivera and Montero¹² Peñaloza¹⁸ used Templar DAs?? if yes please state

Response: Yes, both cited studies used Templer's Death Anxiety Scale (DAS) as an instrument to assess death anxiety in their respective samples. Specifically, the study by Rivera and Montero evaluated the psychometric properties of the DAS in a sample of Mexican subjects, while Peñaloza's study also used Templer's DAS to examine its psychometric properties in a sample of healthcare personnel from Lima Metropolitan.

3. Do we really need to write separately about anxiety and make another section 1.2 ? better link it with death anxiety or write description about how fear is different from anxiety.

Response:
We understand the reviewer's concern regarding the separation of the sections related to anxiety and death anxiety. However, we believe that the way these sections were organized has solid theoretical and methodological support, which also reflects a logical and appropriate structure for the reader's understanding.

First, in the section on anxiety (1.2), the intention was to provide a conceptual framework necessary to understand anxiety from a general perspective. Anxiety is a central component in analyzing death anxiety, but each has specific characteristics that needed to be explained independently to avoid confusing the reader. Anxiety is a state of general arousal that can manifest in different contexts and be influenced by various factors, such as existential fear and the perception of the threat of death ⁷⁴. Separating these concepts allowed us to clarify the distinction between anxiety as a broad phenomenon and death-related anxiety, thereby adhering to an academic rigor criterion that facilitates a comprehensive understanding of the construct of death anxiety.

Second, the inclusion of a section discussing general anxiety is also justified from the perspective of Terror Management Theory (TMT), as presented by Zuccala et al.⁷⁵. This theory proposes that death anxiety is a specific form of anxiety underlying various mental disorders, and its correct understanding begins by defining anxiety as a general response to the perception of existential threats. This approach allowed us to develop a solid conceptualization of how fear of death is linked to other fears and anxieties, and laid the foundation for the clear differentiation between fear and anxiety described later.

Third, the structure chosen for the manuscript also responds to methodological coherence, as the factorial solutions found in the exploratory and confirmatory analysis revealed three distinct dimensions in Templer's Death Anxiety Scale (DAS). Each of these dimensions is linked to specific components of anxiety that, according to studies such as those by Sharif Nia et al. ⁷⁴, differ significantly in different cultural and sociodemographic contexts. The presence of multiple factors suggests that death anxiety is not merely a unidimensional fear but can be expressed in different forms, which justifies the proposed structure.

Finally, we consider that the preprint publication of the manuscript already reflects a consensus on the organization of the sections and the methodological decisions made, which have already been reviewed and accepted (100%) by one of the peers. The need to discuss anxiety in general terms before addressing death anxiety is also a response to previous studies that emphasize the importance of contextualizing and clearly defining these concepts to ensure a precise understanding of the construct ⁷⁵.

For these reasons, we believe that it is not necessary to make modifications to the manuscript's structure. The current organization allows for a better understanding of the relationship between anxiety and death anxiety, meeting criteria for clarity and methodological rigor that are essential in this type of study.

4. what was religious backgrounds/ health status of participants?

Response:
Regarding the religious backgrounds of the participants, we acknowledge that this information represents one of the limitations of the present study. Detailed data on religious affiliation or the degree of religious involvement of the participants were not collected. It is important to mention that this aspect may have influenced the interpretation and response of participants to the Death Anxiety Scale (DAS), as religion can act as a modulatory mechanism of the fear of death. Consequently, this limitation is highlighted in the discussion of the study, and we suggest that future research include a thorough analysis of the impact of religious backgrounds to gain a deeper understanding of the phenomenon of death anxiety.
Concerning health status, the study focused on the history of COVID-19, given the relevance of the pandemic to the experience of death anxiety in the general population. Specific data were collected on whether participants had contracted the disease, and the results showed that 45% of respondents reported having had COVID-19. This variable was considered due to the known impact of the pandemic on perceptions of vulnerability and the increase in existential anxiety in many people. However, other aspects of general health, such as the presence of chronic or terminal illnesses, were not addressed, which also constitutes a limitation of this study. This information will be included more clearly in the discussion to indicate how these limitations may have influenced the results obtained and how they should be addressed in future research.
I once again appreciate your careful review and suggestions, which undoubtedly enrich the scope and depth of this study's analysis. Nevertheless, I believe that framing the research within the context of the pandemic justifies studying death anxiety in the general population.

5. Major concern is that how templer DAS divided into 3 factors ?? what was your rationale to do so as it has one pf major drawback was that TDAs is uni dimensional scale. how we come up with different names of sub scales : Fear of agony or pathology, Fear of life coming to an end, Fear of death, ( what subscales measures, and how it comply with theory of Templer scale?)

Response:
Justification of the Factor Structure
In our study, the Death Anxiety Scale (DAS) was subjected to exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), revealing a structure of three interrelated factors, which contradicts the traditionally unidimensional nature attributed to the scale. These three emerging factors were named: Fear of agony or pathology, Fear of life ending, and Fear of death. The results indicated an accumulated variance of 53.3%, which supports the existence of additional components beyond the general factor of death anxiety.

Naming the Subscales
Fear of agony or pathology: This factor includes items that reflect concern about physical suffering or pain associated with death. The naming is derived from the qualitative analysis of the content of the items that make up this factor, which focus on aspects of distress over a painful death or prolonged illness. These findings are consistent with previous findings by Rivera and Montero, as well as Peñaloza, who also found that fear of the process of agony is a crucial component in the structure of death anxiety.

Fear of life ending: This factor represents existential fear related to the perception of the end of life as an inevitable process. The items associated with this component suggest a concern for the finite nature of life and the uncertainty that comes with it, clearly distinguishing it from physical fear or the consequences of death. This type of fear has also been documented in cross-cultural studies where differences are observed in how the end of life is perceived and feared depending on the cultural context and sample evaluated ⁷⁴.

Fear of death: This factor groups items that address the fear of the idea of death itself, including the fear of the unknown that death represents. This component relates to abstract or philosophical anxiety about the act of dying, which is consistent with studies that have evidenced a distinct psychological component in death anxiety ⁷⁵. In the cross-cultural analysis by Sharif Nia et al. ⁷⁴, it was observed that the factor structure of the DAS varied significantly across different cultural contexts, highlighting the need to adapt the scale according to the specific characteristics of each population.

Coherence with Templer's Theory
Although Templer's Scale was initially conceived as unidimensional, recent studies have suggested the existence of multiple dimensions depending on the cultural and population context in which it is applied. For instance, the systematic review conducted by Sharif Nia et al. ⁷⁴ found factor structures ranging from two to five factors, depending on the cultural context and evaluated population. This evidence supports the need to reconsider the unidimensionality of the scale in specific contexts like the Peruvian one, in which we identified three factors that seem to capture particular nuances of death anxiety. Zuccala et al. ⁷⁵ also point out that variability in the DAS factor structure can be attributed to cultural differences and the translation of the instrument's content. Indeed, death anxiety tends to manifest differently according to the cultural context, directly affecting the scale's validity and reliability. Therefore, it has been recommended to conduct continuous evaluations and specific cultural adaptations before applying it in clinical and multicultural settings.

Empirical Evidence
In the confirmatory factor analysis (CFA), the bifactor model best fit the data, with adequate fit indices (CFI ≥ .94, TLI ≥ .94, SRMR ≤ .08, RMSEA ≤ .07) and a proportion of explained variance of 69.56%. This suggests that while a general factor measuring death anxiety exists, the three specific dimensions have sufficient independence to be considered validated subscales, providing greater precision in the evaluation of death anxiety. This is consistent with the results of the exploratory factor analysis previously mentioned.

Conclusion
The division of the Death Anxiety Scale into three factors is based on rigorous empirical analysis that reflects the underlying structure of the data and is in line with previous cross-cultural studies that have identified multidimensional structures. This conceptualization allows for a more comprehensive and nuanced assessment of death anxiety in the Peruvian population, capturing specific aspects that may not be evident in a unidimensional structure. The results of Sharif Nia et al. ⁷⁴ and Zuccala et al. ⁷⁵ support the need to adapt the DAS scale according to the cultural and sociodemographic particularities of each sample, which motivated us to validate a three-dimensional structure in the Peruvian context to provide a more sensitive and accurate assessment tool for our target population.

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Death anxiety scale (DAS): internal structure and factorial invariance in Peruvian adults

Abstract

Background

Methods

Results

Conclusions

Keywords

Revised Amendments from Version 1

1. Introduction

1.1 Background and Eysenck’s theory of incubation

1.2 Anxiety

2. Methods

2.1 Participants

2.2 Measurement

2.3 Procedure

2.4 Ethical aspects

2.5 Statistical analysis

3. Results

3.1 Statistical analysis of the items of the DAS Scale

Table 1. Statistical analysis of the items of the DAS.

3.2 Construct validity

Table 2. Exploratory factor analysis of the DAS.

Figure 1. Factorial Models evaluated, three models were tested to determine the measurement model that best fit the data.

Table 3. Confirmatory factor analysis of the DAS.

3.3 Factorial invariance

Table 4. Factorial invariance analysis as a function of sex and age group.

4. Discussion

4.1 Psychometric properties of the DAS

4.2 Measurement invariance

4.3 Strengths and limitations

5. Conclusions

Consent statement

Data availability

Underlying data

Extended data

References

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