Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral factors. It is defined as an unpleasant feeling of fear and concern and is commonly found among patients in need of or about to undergo surgical procedures. Deepening the surgical correlations, anxiety may provoke several hindrances to all surgical processes: during the perioperative period, it can disrupt anesthetic induction or hinder patient recovery; during the postoperative period, it can increase pain, increase demand for analgesic consumption, prolong hospital recovery stay, decrease overall patient satisfaction, and increase readmission rates. Perioperative anxiety has been reported to be affected by various factors, including socio-demographic characteristics (age, gender, socioeconomic status, education level, marital status, mental diseases, past anesthesia exposure) and clinical factors (type and complexity of surgery, chronicity of disease, and nature of procedure).[3–5] Also, it was shown that perioperative anxiety can be ameliorated by providing preoperative education to the patients, adequate provision of information before the procedure, and anxiolytic medicines.
In terms of preoperative anxiety, it was found that it differs with type and nature of surgeries, and cardiac surgery is one of the most important domains in the realm of preoperative anxiety studies as cardiovascular disease alone is reported to be an independent risk factor for the development of anxiety. As an example, it may provoke detrimental effects during the perioperative period of a cardiac surgery such as hemodynamic fluctuations, high morbidity, and high-readmission rates. The preoperative anxiety prevalence rates in cardiac surgery patients in developing countries can go as high as 84%. However, its prevalence is not uniform among different population groups around the world.[10–14] Moreover, little information is available regarding preoperative anxiety in cardiac surgeries within many developing countries.[9,11–13] For this reason, the study of preoperative anxiety in cardiac patients – which can alter the perioperative outcomes of such patients – is required in developing countries like Nepal; and, as far as our knowledge goes, this type of study has yet to be conducted within this country.
Globally, the history of cardiac surgeries started back in the 1960s, but in Nepal open heart surgeries were started to be performed regularly in the 1990s, and the majority of such surgeries are still performed in its capital city (Kathmandu). Particularly, the Manmohan Cardiothoracic Vascular and Transplant Center (MCVTC), a university hospital dedicated to cardiothoracic and vascular patients located in Kathmandu, Nepal, is one of the largest cardiac centers in the city, where around 600 cardiac surgeries are carried out annually. People from all over the country come to the center to get services for their heart problems. Thus, the patients in the hospital may represent the demographic and clinical characteristics of all Nepalese patients with heart diseases.
The geopolitical situation, cultural diversity, needs, available resources, educational level, socioeconomic status, availability of healthcare facilities, and beliefs towards the healthcare system of Nepalese people are quite different from those of people around the world. Particularly, cardiac surgery poses significant challenges to Nepalese patients, given that this may become a financial burden to patients’ families and a social stigma related to cardiac diseases may affect patients negatively. Thus, this study hypothesized that the anxiety prevalence among Nepalese people during the preoperative cardiac surgery period would be high, and that the factors associated with anxiety would be different from those reported in the existing literature.
Based on this information, this study had three objectives:
- (1) to clarify the levels of preoperative anxiety in Nepalese adult cardiac patients waiting for open heart surgery (expected to be high);
- (2) to identify factors associated with preoperative anxiety; and
- (3) to evaluate any possible association between preoperative anxiety and patients’ desire to obtain information related to their heart surgery.
2 Material and methods
2.1 Setting and patients
This was a prospective observational study conducted at the preoperative holding area on the surgery ward of the MCVTC. This study was carried out between April 2016 and March 2017 (1 year). All the adult cardiac patients, who were scheduled for the cardiac surgery during the study period, were approached to participate in the study (non-probability sampling). In total, 140 patients enrolled, and the inclusion criteria were being 16 years or older, scheduled for cardiac surgery, and able to independently answer the Amsterdam Preoperative Anxiety and Information Scale (APAIS) questionnaire written in Nepalese.
First, the principal investigator separately explained the overview and aims of the study to each patient, and then written consent was obtained from each patient who voluntarily agreed to take part in this research. Patients who did not wish to take part in the study, who were incapable of providing written consent, or who could not respond to investigators’ queries due to any reason, were excluded. One day prior to the surgery (as patients were already electively scheduled to undergo surgery), within the patient's room, the principal investigator provided patients with explanations related to the questionnaire and its application, so as to avoid any confusion or doubts related to the questionnaire. On the next day, before being taken to the operating room, patients responded to the questionnaire independently. Patients who were incapable of reading and writing received assistance from the principal investigator to fill in the questionnaire. As per the hospital guidelines, all patients received a tablet of diazepam 5 mg at 10 pm on the day before the surgery.
With regard to the response rate, 12 patients did not understand the questionnaire in Nepalese, three patients had an intellectual disability and two patients were aphasic. These 17 patients were excluded from the study. In total, 123 patients (87.9%) were included in the statistical analyses.
2.2 Data collection
According to the previous literature,[3–5,12,17] we considered various factors that may influence anxiety during the perioperative period. The questionnaire consisted of socio-demographic characteristics (sex, age, socioeconomic status, educational level, marital status), past medical conditions (past mental/nervous disease, past anesthesia exposure), and type of surgery (valvular, coronary artery bypass grafting [CABG], congenital, combined [valvular surgery and CABG]). We extracted these factors from the medical chart. Socioeconomic status was stratified using the revised Kuppuswamy scale. Then, we asked the participants to respond to the questionnaire with regard to their anxiety levels based on the APAIS independently. The APAIS (Table 1) was developed to measure anxiety levels (Cronbach alpha 0.86) and to provide information about anesthesia and surgery (Cronbach alpha 0.72) in preoperative patients, and is a validated tool available in different languages, like Tamil, Sri Lankan, and Nepali (Table 1).[20,3]
2.3 Data analysis
We conducted a descriptive analysis of the socio-demographic characteristics and the APAIS score. We calculated the proportion for categorical variables and median for continuous variables. With regard to the APAIS score, we calculated the median and interquartile range for each item and its subscales, as follows: anesthesia-related anxiety (Sum A = items 1 + 2, range 2–10; surgery-related anxiety (Sum S) = items 4 + 5, range 2–10; combined anxiety (Sum C) = 1 + 2 + 4 + 5, range 4–20; information desire (Sum I) = items 3 + 6, range 2–10. Analysis of the relationship between the APAIS scales with the State-Trait Anxiety Inventory (STAI) showed a correlation of 0.74 between the APAIS and the STAI.
To clarify the characteristics of patients with anxiety, we conducted an exploratory analysis. We constructed a logistic regression model for the variable “combined anxiety.” We used a Combined anxiety score of 10 as a cut-off value for the presence of anxiety, following a methodological approach from a previous studies.[3,19] As covariates, we considered all socio-demographic characteristics, using the backward stepwise variable selection method (P < .1). The covariates with a small number of participants were re-grouped when necessary.
To clarify the characteristics of patients who desired to obtain information related to their heart surgery, we conducted exploratory analysis once again. We constructed a Poisson regression model for the variable “information desire,” using this variable as a count data. We chose this model given the score distribution of this subscale. As covariates, we considered all socio-demographic factors and the combined anxiety score, using the backward stepwise variable selection method (P < .1). All analyses were performed using Stata/IC version 15.0 and Excel.
2.4 Ethics statement
This study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the Institution Review Board of the Institute of Medicine, Tribhuvan University (279(6-11-E)/079/070).
Participants’ socio-demographic characteristics are presented in Table 2. There were 62 (50.4%) female and 61 (49.6%) male participants. The participants’ median age was 44 years (IQR 33–56). There were 39 (31.7%) participants in the very low and low socioeconomic status groups, 43 (35%) were in the middle and 41 (33.3%) were in high or very high socioeconomic status group. There were 37 (30.1%) respondents who did not complete high school and 85 (69.1%) had a high school diploma or higher level of education and a data was missing for one patient. Approximately one-half of participants (n = 65; 52.9%) underwent valvular heart surgery, while remaining underwent other type of cardiac surgeries. There were 88 (71.5%) participants without past anesthesia exposure, and 109 (88.6%) without past mental/nervous disease.
Table 3 presents participants’ median scores on the APAIS and its subscales. The median of participants’ total anxiety score was 11 (IQR 8–13), and the median of the information desire score was 3 (IQR 2–4). According to the APAIS scale score, 72 (58.5%) participants were categorized as having preoperative anxiety (combined anxiety scale on APAIS > 10) (Supplementary Material 1, https://links.lww.com/MD/D885).
Table 4 shows the results of the univariate and multivariate logistic regression analyses for participants’ combined anxiety score. The univariate analyses showed that male participants had a lower risk of having anxiety compared to females (OR 0.31, 95% CI 0.15–0.65, P < .05); that middle socioeconomic status participants had a lower risk of having anxiety compared to those with very low and low socioeconomic status (OR 0.34, 95% CI 0.14–0.83, P < .05); and those with past mental/nervous diseases had a higher risk of having anxiety compared to those without past mental/nervous diseases (OR 4.49, 95% CI 1.19–17.00, P < .05).
After the adjustment of covariates, it was found that male participants had a lower risk of having anxiety compared to females (OR 0.25, 95% CI 0.11–0.57, P < .001), and those with past anesthesia exposure had a higher risk of having anxiety compared to those without past anesthesia exposure (OR 2.38, 95% CI 1.01–5.62, P < .05).
Univariate analysis of the Poisson regression model (Table 5) showed that the incidence rate ratio (IRR) on the information desire score was lower in male participants compared to females (IRR 0.74, 95% CI 0.62–0.88, P < .05), and higher in participants with past mental/nervous diseases compared to those without past mental/nervous diseases (IRR 1.31, 95% CI 1.04–1.66, P < .05). Further, it was higher among participants with higher combined anxiety scores compared to those with lower scores (IRR 1.53, 95% CI 1.29–1.82, P < .001).
After the adjustment of covariates, it was found that male participants had lower IRR on the information desire score compared to females (IRR 0.80, 95% CI 0.67–0.94, P < .001), and the IRR was higher in educated participants than in patients who had not completed high school (IRR 1.18, 95% CI 1.01–1.40, P < .05). Further, participants with higher combined anxiety scores had higher IRR on the information desire scores compared to those with lower scores (IRR 1.44, 95% CI 1.21–1.73, P < .001).
In the present study, more than half of the participants experienced preoperative anxiety. Anxiety was more prevalent in females and participants with a past history of anesthesia exposure and mental/nervous disease. Participants with higher anxiety levels had a greater desire for information related to their heart surgery. Information desire was also higher in more educated participants.
In this study, the overall preoperative anxiety prevalence rate was 58.5%. The proportions of patients with anxiety reported in previous studies are diverse, but are generally higher than those in our study. For example, studies conducted in Ethiopia (61%) and Pakistan (for non-cardiac patients) (62%) reported slightly higher proportions of patients with preoperative anxiety, though they used similar measures to assess preoperative anxiety. However, other three studies reported much higher preoperative anxiety: one conducted with cardiac patients in India (84%), and two studies with non-cardiac patients in Sri Lanka (76.6%) and Nigeria (90%). The possible reasons for the relatively low prevalence of anxiety in our study are: first, all patients in our study had taken anxiolytics (Diazepam tablets) before completing the questionnaire; and second, the existence of strong family and community support within the Nepalese population, which lead to decreased anxiety levels among participants. In contrast, however, the results of this study indicated that preoperative anxiety prevalence rates were higher than that of two studies using different measurement tools: one with cardiac patients in Poland (48%), and the other with non-cardiac patients in Austria (45.3%).[10,25] The anxiety measurement tool we used was a subjective one, while the study done in Austria used both subjective (questionnaire) and objective tools (biofeedback measurement and cortisol levels). The sensitivity and specificity of objective tools are supposed to be higher than that of subjective tools. The methodical difference in the measurement of anxiety could be one of the reasons for high-anxiety level observed in our participants.
Further, we believe the discrepancy in the preoperative anxiety prevalence rates between affluent and less affluent countries might be due to differences in participants’ socioeconomic status, educational level and level of understanding, healthcare systems, and healthcare information. In our study, 83 (66.7%) participants had middle or low-socioeconomic status, and 70 (56.9%) had a high school education or less. These factors were associated with higher preoperative anxiety in both univariate and multivariate analyses. In Nepal, 81% of the population live in rural areas, where basic healthcare standards are still under development. In that regard, the majority of the participants in this study belonged to that group and, unsurprisingly, it was the first time that many patients may have come to Kathmandu, and they came only to receive their surgery. Thus, we believe that the unfamiliar environment of the capital city and the atmosphere of the hospital – to which they were not accustomed – might have played a role in increasing their anxiety levels. In addition, it has been found that the intensity of anxiety is further increased in patients with unexpected prolonged hospital stays because of deteriorating health conditions or complications of surgery.
In this study, female participants were more likely to experience higher anxiety levels than males. In corroboration of this finding, studies performed with cardiac patients in the USA, Iran, and Taiwan also reported higher anxiety levels in female patients. We believe that this may be due to physiological reasons: female patients usually show hormonal fluctuations (in estrogen and progesterone) during stressful situations, and that may make female patients more susceptible to developing higher levels of anxiety. Additionally, it has been shown that women usually develop anxiety more easily than men, and also experience a higher fear of separation from their family.
With regard to other patient characteristics, past anesthesia exposure and past mental/nervous disease were found to be positively correlated with anxiety levels. We believe that participants’ fear of experiencing negative situations – much like what they have already experienced in their past – like surgical pain, postoperative nausea and vomiting, and surgery postponement, may have made them more anxious. Furthermore, previous studies have shown that fear of surgery complications, separation from their families, financial loss, and fear of death can lead to high-anxiety levels. However, prior studies have not found associations between the specific characteristics assessed in our study (past mental/nervous disease and past anesthesia exposure) and anxiety.[22,23] Thus, the results of our study suggest that further research is required to confirm the accuracy of these findings within Nepalese cardiac surgery patients.
Our study did not find an association between age and the presence of anxiety. Previous studies, however, have reported mixed findings regarding an association between anxiety and age. A single center study done with Turkish preoperative patients showed that younger patients tended to have more anxiety while, on the other hand, one study found that older people are more likely to experience anxiety and depression. As we did not find a relationship between age and anxiety, further studies with larger samples are needed to clarify this relationship in Nepalese preoperative patients.
Our results also indicated that participants with higher anxiety levels also had a greater interest in receiving information related to their surgical procedure. In that regard, one previous study classified people according to how they cope with stress, and two groups were proposed: the monitors, who want to know as much information as possible; and the bunters, who want to avoid as much information as possible. Further, inadequate information provided to monitors has been shown to increase their anxiety levels, and detailed information provided to bunters also had the same effect. Based on this classification, we believe that participants who had past mental/nervous disease, past anesthesia exposure, and were educated might have behaved as monitors. Thus, it may be inferred that detailed and precise information regarding the procedure must be provided to anxious patients with these characteristics before the surgery, so as to prevent the development of compensatory mechanisms such as preoperative anxiety.
This study had several limitations. First, the participants with less education required help from the investigator to complete the questionnaire, which was supposed to be filled out by the patients themselves, and this might have been a source of bias to their responses. Future studies should try different methodological approaches that avoid these situations. Second, this was a study performed within a single center in Nepal. Future studies should utilize sample groups from different locations and hospitals within Nepal. Third, in the present study anxiety levels were measured at a single instance, but during the course of study we felt that if we had measured anxiety at multiple instances preoperatively and also extended the measurement to the postoperative period, it would have increased the clinical relevance of the study. Further, anxiety is also prevalent in the pediatrics population equally or even more so than adults. We did not include pediatric patients in the study due to the nature of the measurement tool. We suggest that further study should target a pediatric population using an appropriate measurement tool.
This study demonstrated that more than a half of the participant presents preoperative anxiety and, like most countries around the world, female patients are prone to have preoperative anxiety. Similarly, history of past anesthesia exposure is identified as a risk factor for preoperative anxiety. However, adequate information is required to anxious patients with specific sociodemographic characteristics – female gender as well as educated participants – before the procedure, which may decrease preoperative anxiety. The preoperative evaluation of anxiety and its proper management in high-risk groups should be incorporated in the management protocol, so as to improve the quality care of cardiac surgery patients.
We would like to acknowledge Dr Bibhush Shrestha, Dr Priska Baskota, Dr Arjun Gurung, Dr Bidur Dhungel, and Dr Pramee Bajracharya for their assistance in making this study as pleasant and fluid as possible. Also, we would like to extend our acknowledgement to Dr Bibhushal Thapa for the constructive comments on the study.
Conceptualization: Shailendra Sigdel, Madindra Basnet, Bishwas Pradhan.
Data curation: Shailendra Sigdel, Madindra Basnet.
Formal analysis: Yurie Kobashi, Akihiko Ozaki.
Funding acquisition: All Authors.
Investigation: All Authors.
Methodology: Shailendra Sigdel, Madindra Basnet.
Project administration: Shailendra Sigdel, Akihiko Ozaki, Madindra Basnet, Bishwas Pradhan.
Resources: All Authors.
Software: Shailendra Sigdel, Yurie Kobashi, Akihiko Ozaki.
Supervision: All Authors.
Validation: All Authors.
Visualization: All Authors.
Writing – original draft: Shailendra Sigdel.
Writing – review & editing: All Authors.
Shailendra Sigdel orcid: 0000-0001-5357-1083.
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