Nawel Zammit, Department of Family and Community Medicine. Faculty of Medicine of Sousse, Tunisia. Tel: (+216) 97 226 340; E-mail:-
Aims: To determine the prevalence of preoperative anxiety and its predictors among elective surgery patients in Sousse, Tunisia.
Methods: Cross sectional study was conducted in the 2 tertiary care hospitals of the region of Sousse, Tunisia during March 2016. All patients scheduled for elective surgery in 5 randomly selected surgery departments were included. Data were collected on the hospitals wards within 24 hours before surgery using the Amsterdam Preoperative Anxiety Information Scale.
Results: Participants accounted for 332. Their mean age was 47.5 (±15.5) years. Females represented 53%. Preoperative anxiety was identified among 67.5% of them while 42.2% had important need for information, High grade of surgery and high level of information requirement were the main predictors of preoperative anxiety with adjusted odds ratios of 9 (CI95% : 3.4-23.8) and 1.5 (CI95% : 1.3-1.7) respectively.
Conclusion: High prevalence of preoperative anxiety and important need for information were identified among elective surgery patients of Sousse. Doctors should enhance their communication skills and attribute much more time for communication with their patients before surgery.
Key words: Anxiety; Preoperative Period; Prevention And Control
Several factors were identified to be associated with preoperative anxiety such as: the gender, the age, the education level, the surgery type, the anesthesia type, previous experiences of hospital stay…etc. However, there is contradictory results about some of these factors [4,10-19].
In Tunisia, several studies focused on the surgery outcomes but few authors focused on the psychological well being of surgery patients. Thus, the aims of this study were to determine the prevalence of preoperative anxiety among patients in the tertiary care hospitals of Sousse and to identify its related factors.
Characteristics |
N (%) |
Sociodemographic characteristics |
|
Female |
176 (53) |
Urban origin |
176 (53) |
Illiterate or have primary educational level |
181 (54.5) |
Married |
314 (94.6) |
Medical characteristics |
|
Previously operated |
135 (40.7) |
Hospital ward |
|
General surgery |
165 (49.7) |
Urology |
48 (14.5) |
Gynecology |
74 (22.3) |
Orthopedics |
45 (13.6) |
Grade of surgery |
|
Major |
78 (23.5) |
Intermediate |
254 (76.5) |
Anesthesia type |
|
General |
217 (65.4) |
Regional |
115 (34.6) |
APAIS scale components |
Mean (±SD) |
n(%) |
Global anxiety score |
13.1 (3.5) |
|
Global anxiety score > 10 |
|
224 (67.5) |
Surgery anxiety score |
8.2 (1.9) |
|
Anesthesia anxiety score |
4.9 (2.1) |
|
Information score |
6.7 (2.2) |
|
2-4 |
|
59 (17.7) |
5-7 |
|
133 (40.1%) |
8-10 |
|
140 (42.2%) |
Binary logistic regression showed that the most influential factors on preoperative anxiety among participants were: the major grade of surgery and the high level of information requirement with adjusted odds ratios of respectively: 9 (CI95% : 3.4-23.8) and 1.5 (CI95% : 1.3-1.7) [Table 4].
Characteristics |
Preoperative anxiety |
p-value |
||
|
Yes |
No |
|
|
Age (years) mean (SD) |
|
46.6 (15.4) |
49.3 (15.4) |
0.1 |
Gender |
Men n (%) |
111 (49.6) |
45 (41.7) |
0.2 |
|
Women n (%) |
113 (50.4) |
63 (58.3) |
|
Origin |
Urban n (%) |
122 (54.5) |
54 (50) |
0.4 |
|
Rural n (%) |
102 (45.5) |
54 (50) |
|
Study level |
Analphabete n (%) |
53 (23.7) |
35 (32.4) |
0.09 |
|
Primary n (%) |
63 (28.1) |
30 (27.8) |
0.9 |
|
Secondary n (%) |
80 (35.7) |
30 (27.8) |
0.15 |
|
University n (%) |
28 (12.5) |
13 (12) |
0.9 |
Marital status |
Married n (%) |
171 (77) |
89 (82.4) |
0.3 |
|
Not married n (%) |
51 (23) |
19 (17.6) |
|
Medical History |
Have surgical history n (%) |
85 (37.9) |
50 (46.3) |
0.1 |
|
Don’t have surgical history n (%) |
139 (62.1) |
58 (53.7) |
|
|
Duration of surgical history (years) mean(SD) |
7.3 (8.7) |
4.4 (4.9) |
0.01 |
Waiting time before surgery (days) mean(SD) |
|
48.1 (68.1) |
29.5 (30) |
0.001 |
Information score mean(SD) |
|
7.3 (2) |
5.4 (2) |
<0.001 |
Anesthesia type |
General anesthesia n (%) |
162 (72.3) |
55 (50.9) |
<0.001 |
|
Regional anesthesia n (%) |
62 (27.7) |
53 (49.1) |
|
Surgery grade |
Major grade |
73 (32.6) |
5 (4.6) |
<0.001 |
|
Intermediate grade |
151 (67.4) |
103 (95.4) |
|
Hospital ward |
General surgery n(%) |
109 (48.7) |
56 (51.9) |
0.3 |
|
Urology n (%) |
38 (17) |
10 (9.3) |
|
|
Gynecology n (%) |
48 (21.4) |
26 (24.1) |
|
|
Orthopedics n (%) |
29 (12.9) |
16 (14.8) |
|
Characteristics |
Crude OR (CI 95%) |
p-value |
Adjusted OR (CI 95%) |
p-value |
Major grade surgery |
10 (3.9-25.5) |
<0.001 |
9(3.4-23.8) |
<0.001 |
Intermediate grade surgery |
1 |
- |
1 |
- |
Information score |
1.5 (1.4-1.7) |
<0.001 |
1.5 (1.3-1.7) |
<0.001 |
The prevalence of preoperative anxiety among participants is almost similar to some previous studies in other countries [25,26]. While, other studies reported different rates of anxiety among surgery patients ranging from 32% to 94% [4,19]. This wide range could be explained by the use of different scales to assess preoperative anxiety and by different groups of patients [4].
Concerning the socio-demographic characteristics, the univariable analysis showed no significant difference between males and females within anxiety prevalence which was in conformity with the results of previous studies [1,10]. Whereas, other studies showed that females were more anxious than males [4,11]. In addition, age did not influence the anxiety level among participants. This was in line with the finding of a previous study [4]. However, other authors found that younger patients were more anxious than elder patients [12,27]. While, other authors reported a positive association between age and anxiety [13]. Furthermore, no significant association was found between educational level, marital status, previous surgery and preoperative anxiety; in opposition to other studies [4,14,15]. These findings substantiate that further studies with larger sample size are required to clarify the socio-demographic predictors of preoperative anxiety. The univariable analysis showed also that an extended waiting time of surgery was associated with higher anxiety score among participants. This finding is consistent with several previous studies which suggested that preoperative waiting represents a trigger for anxiety [28,29]. Besides, compared to local anesthesia, general anesthesia was significantly associated to preoperative anxiety. A previous study among patients selecting either general or regional anesthesia showed higher anxiety level in patients selecting general anesthesia compared to those opting for regional anesthesia [18]. It seems that the use of needles and mask during anesthesia induction as well as fear of waking up during the surgery or not waking afterwards are the most sources of anxiety [30].
The multivariable analysis showed that major grade surgery was the main predictor of preoperative anxiety. Earlier studies showed that the highest scores of anxiety were recorded during complex surgeries such in oncology, cardiac surgery and neurosurgery [5,16,17,31,32].
Nevertheless, other studies highlighted a higher level of anxiety in patients undergoing intermediate surgery [4,17]. These findings might be explained by different conceptions of both: the disease and the operation risks [17].
The multivariable analysis highlighted that high information requirement is another predictor of preoperative anxiety among participants which join previous studies findings showing that receiving information about their surgery method, its risks and the recovery delay reduces preoperative anxiety [5,15].
In Tunisia, most studies conducted in surgical patients focused on the surgical outcomes. The current study is one of the rare studies focusing on the psychological well being of surgical patients. In addition, unlike several other studies, the current study has the advantage of measuring preoperative anxiety in 5 different surgery departments. However, the present study has some limitations that should be mentioned. Firstly, because of the cross-sectional nature of the study, it was not possible to report causal relationships but only simple associations. Another limitation is that preoperative anxiety was measured within 24 hours before surgery which could not reflect the anxiety level just before surgery and may lead to underestimate the real anxiety level. While measuring anxiety just before surgery could interfere with operation preparation and may be disconcerting for the care givers. Finally, cutoff values used to identify significant anxiety and the level of information requirement were based on previous studies in other countries and may not be the adapted cutoff for the Tunisian population. This could be an area of further research.
Surgery patients, especially those undergoing high grade surgery or general anesthesia, should get more attention from both the surgeon and the anesthesiologist in order to redress erroneous beliefs and give the adequate explanations about the operation. Maximizing surgical capacity, better management of waitlists, improving teamwork and optimizing operating room might contribute to reduce waiting time before surgery and provide much more time for communication with patient. Improvement of the communication skills among doctors may contribute to decrease anxiety levels and increase confidence in the healthcare system. Further research on the impact of behavioral preparation, humorous distraction, music therapy and social support before surgery is recommended.
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