Attitudes toward death and associated factors among older adults in China: a systematic review and meta-analysis

BACKGROUND: Population aging has intensified global attention to issues surrounding death and dying. Attitudes toward death are associated with older adults' mental health, quality of life, and engagement in end-of-life care planning. However, in China, cultural taboos and limited death education may hinder the development of adaptive and accepting death attitudes. This study systematically reviewed the current status of ​​attitudes toward death​​ and associated factors among older adults in China. METHODS: This review followed PRISMA 2020 guidelines. Seven databases were searched from inception to July 2025, including PubMed, Web of Science, Embase, CINAHL, China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBM), and Wanfang Data. We included cross-sectional studies that used either the Death Attitude Profile-Revised (DAP-R) or the Elderly Death Attitude Scale. The quality was evaluated using Agency for Healthcare Research and Quality (AHRQ) criteria. We used Stata 17.0 to perform a meta-analysis of scores across the scale dimensions, and conducted subgroup, meta-regression, and descriptive analyses to explore sources of heterogeneity and associated factors. RESULTS: > 95%). The scores of each dimension were as follows: neutral acceptance of death (3.606, 95%CI: 3.390-3.822), escape acceptance of death (2.944, 95%CI: 2.703-3.185), death avoidance (2.953, 95%CI: 2.808-3.098), fear of death (2.770, 95%CI: 2.523-3.016), and approach acceptance of death (2.486, 95%CI: 2.157-2.861). Subgroup analysis revealed that clinical populations had lower scores in approach acceptance of death than non-clinical populations, with no significant subgroup differences elsewhere. Univariable meta-regression analyses indicated that predefined covariates did not significantly explain the observed heterogeneity. Descriptive analysis indicated that more positive death attitudes were associated with better health, higher quality of life, and open family discussions about death. Religious belief was linked to higher approach acceptance scores. Subgroup analyses by instrument type and publication-bias assessments suggested no substantial impact on the pooled estimates. CONCLUSIONS: Neutral acceptance may represent a relatively higher-scoring dimension of death attitudes among Chinese older adults. Health-related factors, death-related experiences, and cultural factors appear to be relevant factors associated with death attitudes. Based on these preliminary findings, exploratory interventions, including death education and psychosocial support, could be considered for older adults with poor health. These findings should be interpreted cautiously, given that all included studies were cross-sectional and based on self-reported data, which limits causal inference. TRIAL REGISTRATION: PROSPERO(CRD420251090654).