The review, led by María Luisa Sosa-López, Sonia J. Romero Martínez, Ana M. Pérez-García, and Mariagiovanna Caprara, followed PRISMA reporting guidelines and was registered in PROSPERO. The team searched Web of Science, Scopus, PubMed, and several EBSCOhost databases between September 1 and October 31, 2025. From 320 records initially identified, plus three found through manual searching of reference lists, 27 peer-reviewed studies met the inclusion criteria. Because some publications contained multiple independent substudies, these 27 papers yielded 36 separate psychometric evaluations covering 12 distinct instruments. All included studies had to involve adult samples not defined by a medical or psychological condition, and each had to report validity, reliability, factor structure, or interpretability data for a scale that explicitly assessed at least one positive dimension of death attitudes.

The instruments identified span a wide conceptual territory. Some are multidimensional classics that fold acceptance into broader profiles alongside fear and avoidance: the original Death Attitude Profile, its revised version (DAP-R), Saunders’ Death Attitude Scale, and the Multidimensional Orientation Toward Dying and Death Inventory (MODDI-F). Others target specific positive facets, such as the Death Reflection Scale, which captures growth-oriented contemplation of mortality across subscales like Motivation to Live and Leaving a Legacy; the Impermanence Awareness and Acceptance Scale, rooted in Buddhist psychology; the Death Attitudes in Relationships Scale, focused on relational and end-of-life communication attitudes; and the Responses to Personal Mortality Measure (RPMM), which examines existential ways of relating to one’s own death. Still others, including the Life Attitude Profile and the Death Perspective Scales, embed death within wider frameworks of meaning, purpose, and religious interpretation.

Methodologically, the review was unusually thorough. Study quality was rated with a version of the Newcastle–Ottawa Scale adapted for cross-sectional research, with two independent evaluators and consensus resolution of discrepancies. Scores ranged from 4.0 to 8.0, with most studies falling in the acceptable-to-good range; the strongest were Kawashima and colleagues’ 2024 study of the DARS and MacDougall and Farreras’ 2016 U.S. validation of the MODDI-F, which benefited from larger, better-described samples and stronger control of confounding variables. Limitations clustered in the selection domain, mainly because few studies reported response rates or compared respondents with non-respondents.

To evaluate the instruments themselves, the authors built an eight-criterion protocol derived from the Standards for Educational and Psychological Testing, the EFPA test review model, the International Test Commission guidelines for test adaptation, and standard scale-development recommendations. The 33 indicators covered construct definition, item development, item analysis, reliability, validity, norms, administration, and ethical and cultural appropriateness, each rated on a five-point ordinal scale. Double coding produced a kappa of 0.551, indicating moderate agreement. The verdict: seven instruments (58.3%) were rated acceptable, four (33.3%) good, and one—the RPMM—was the sole instrument rated excellent.

Reliability evidence varied considerably in strength. The RPMM reported Cronbach’s alpha values between 0.90 and 0.97, while the IMAAS showed alphas from 0.81 to 0.90 alongside high composite reliability and Spearman–Brown coefficients. The original German MODDI-F displayed solid internal consistency across all subscales (α = 0.82–0.92), but older measures were more uneven: alphas ranged from 0.62 to 0.88 for the Death Attitude Scale, and some Life Attitude Profile subscales hovered near 0.55. Cross-cultural versions sometimes dipped, notably the Neutral Acceptance subscale of several DAP-R adaptations (α = 0.60–0.67) and the Chinese MODDI-F’s Fear of Another Person’s Dying subscale (α = 0.68). Temporal stability, assessed through test–retest procedures, was reported far less frequently, appearing in moderate ranges for the DARS, DAP-R, and DRS, with more detailed multi-interval data available for several MODDI-F versions.

Structural validity told a similarly mixed story. Original development studies generally employed extensive exploratory factor analyses to prune large initial item pools—the RPMM began with 120 items, the MMA with 89, and the Death Perspective Scales with 180 revised down to 60—whereas adaptation studies ranged from exhaustive translation-back-translation protocols with expert committees and cognitive pre-testing, as in the Spanish and German DAP-R and the French MODDI-F, to simpler procedures that retained all original items without functional review. Factor structures usually resembled the originals but not always exactly: the Chinese DAP-R split its Neutral and Approach Acceptance factors into a seven-subscale model, while the Serbian DAP-R introduced a culturally specific Purgatory Acceptance dimension. Criterion-related validity, established through relationships with external variables such as well-being, death anxiety, and personality traits, was documented in the original DAP-R, DRS, IMAAS, LAP, MMA, and RPMM, but several linguistic adaptations relied almost exclusively on internal subscale correlations.

The review also exposed structural gaps in the field. Normative data are scarce, with only a few studies, such as the Polish DAP-R and the Austrian DRS, providing even approximate norms from large samples, which means these instruments are currently better suited to research than to interpreting individual scores or clinical decision-making. Ethical reporting was heterogeneous, ranging from full disclosure of committee approval and informed consent to partial or absent documentation, especially in older studies. Geographic coverage was uneven too: Europe produced 40.7% of the publications, North America 29.6%, Asia 25.9%, and Latin America just 3.7%, leaving entire regions without validated versions of any measure. Almost all studies used convenience samples and self-administered questionnaires, limiting generalizability and the assessment of sensitivity to change.

Conceptually, the authors argue that positive and negative attitudes toward death are not simple opposites but partially independent dimensions: the same person can feel death anxiety while also showing reflective openness to finitude, a profile unidimensional scales would miss. Neutral acceptance has been associated with psychological well-being, death reflection with life satisfaction, and impermanence acceptance with adaptive adjustment, though these are associations rather than demonstrated causal effects. The review’s practical guidance is that instrument choice should match the research question: the DAP-R for broad profiles including avoidance, the MODDI-F for differentiating one’s own death from another’s dying, the DRS for growth-oriented reflection, and the RPMM for existential responses to personal mortality—always remembering that evidence remains strongest for research contexts. The authors call for a unified conceptual framework, item response theory methods, systematic invariance testing, longitudinal validation, representative norms, and cross-cultural adaptation in underrepresented regions, so that humanity’s quieter, more accepting relationship with mortality can be measured with the same rigor long devoted to its fears.

Subject of Research: Psychometric instruments for assessing positive attitudes toward death in non-clinical adults

Article Title: Systematic review of instruments for assessing positive attitudes toward death in adults from the general non-clinical population

Article References: Sosa-López, M. L., Martínez, S. J. R., Pérez-García, A. M., & Caprara, M. (2026). Systematic review of instruments for assessing positive attitudes toward death in adults from the general non-clinical population. Current Psychology, 45(21), Article 1644. https://doi.org/10.1007/s12144-026-10173-x

Image Credits: AI Generated

DOI: 10.1007/s12144-026-10173-x

Keywords: thanatology, psychometrics, systematic review, death acceptance, death attitudes, scale validation, DAP-R, MODDI-F, death reflection, existential psychology, positive psychology, cross-cultural adaptation