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Impact of a novel bundled information, education, & communication video on preoperative anxiety in paediatric patients: A randomised controlled trial
For correspondence: Dr Naveen Paliwal, Department of Emergency Medicine, Dr. S.N. Medical College, Jodhpur 342 003, Rajasthan, India e-mail: drnaveenpaliwal@yahoo.com
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Received: ,
Accepted: ,
Abstract
Background & objectives
Preoperative anxiety affects 40-75 per cent of children undergoing surgery, leading to postoperative complications. While pharmacological methods have limitations, informational videos have shown promise in reducing anxiety. This pilot study aimed to evaluate the impact of a novel Hindi animated Information, Education, and Communication (IEC) video on preoperative anxiety in Indian children undergoing elective surgeries. The study hypothesised that the video would significantly reduce anxiety scores.
Methods
A pilot randomised controlled trial was conducted with 30 children aged 5-10 yr scheduled for elective surgeries under general anaesthesia. Participants were randomly assigned to a video intervention group (VI) or a control group (C). Baseline and preoperative anxiety were measured using the Modified Yale Preoperative Anxiety Scale (m-YPAS), Child Fear Scale (CFS), and State-Trait Anxiety Inventory (STAI) for parents. Postoperative emergence delirium and behavioural changes were assessed using the Paediatric Emergence Delirium (PAED) score and Post-Hospitalisation Behaviour Questionnaire (PHBQ).
Results
Children in the VI group showed significantly lower preoperative anxiety (m-YPAS: 47.9 (10.23) vs. 77.08 (8.38); P<0.001) and heart rates compared to the C group. CFS and STAI-S scores were also significantly lower in the VI group. Although the VI group showed reduced anxiety, there was no significant impact on emergence delirium or postoperative behaviour by day 30.
Interpretation & conclusions
The Hindi animated IEC video effectively reduced preoperative anxiety in children, highlighting the need for culturally and linguistically appropriate interventions. However, its impact on postoperative outcomes requires further investigation with a larger sample size.
Keywords
Anxiety
children
communication
education
emergence delirium
Preoperative anxiety affects 40-75 per cent of children undergoing surgery and is linked to postoperative issues1. These issues include restlessness, enuresis, eating disorders, apathy, social withdrawal, and sleep disturbances, lasting up to six months post-surgery2,3. Anxiety levels vary by age, parental anxiety, socio-economic status, language, fear of surgery, and lack of preparation4,5. Pharmacological pre-medication, though effective, has limitations such as adverse reactions, patient refusal, or issues with timing relative to the procedure. Studies have shown that informational videos and technological distractions are effective in reducing preoperative anxiety in paediatric patients2,3.
The availability of perioperative anaesthesia-related Information, Education, and Communication (IEC) videos in Hindi and other Indian national languages remains significantly limited, despite their crucial role in serving our country’s diverse population. Moreover, cultural and comprehension differences from Western contexts further highlight the need for regionally tailored educational materials for the paediatric population. This pilot study aimed to evaluate the impact of a novel Hindi animated IEC video on reducing preoperative anxiety in Indian children. The video, lasting over four minutes, provides an animated tour of the anaesthesia procedure, addressing common fears and concerns in a clear and comprehensible manner. We hypothesised that this video intervention would significantly reduce anxiety in children. The primary outcome of the study was to assess the impact of a video intervention on a child’s anxiety just before induction on the operating table. Additionally, we compared the parental anxiety scores, child fear scores, the incidence of emergence delirium, and postoperative behavioural changes.
Materials & Methods
Study design and participants
This pilot randomised, controlled, parallel-arm study was ethically approved, registered in the Clinical Trials Registry of India (CTRI/2024/03/064251), and conducted per the Declaration of Helsinki (2013). It was conducted from April 2024 to June 2024 at Dr. S.N. Medical College, Jodhpur, Rajasthan (a tertiary care institute of Western India). Informed consent was obtained from parents or legal guardians, with additional assent from children aged 7 yr and older. Children aged 5-10 yr scheduled for elective surgeries under general anaesthesia, lasting up to two hours, were enrolled. Exclusion criteria included syndromic babies, more than two previous general anaesthesia exposures, significant cognitive impairment or developmental delays, use of psychotropic medications, chronic illness, day-care surgery, and inability to understand Hindi. Children who did not watch the entire video were considered dropouts.
Development and validation of video
The video script was prepared by the authors (RJ, PB, and NP) and validated by four experts before finalisation, and the video was tested for clarity and comprehensibility with a group of children not scheduled for surgery (Supplementary material). This animated video portrayed an anxious child who, through simple and reassuring communication in Hindi, is guided by a doctor on a virtual tour of the operation theatre. The doctor explains perioperative procedures in a child-friendly manner, helping to reduce fear and familiarise the child with the surgical environment. The video covers key stages including preoperative communication, anxiety-free separation from parents, introduction to the OT surroundings, and a smooth, pain-free postoperative recovery.
Randomisation, blinding and outcome assessment
Participants were randomly assigned to either the video intervention (VI) group or the control (C) group using a computer-generated random sequence, with allocation concealed in sealed opaque envelopes. The randomisation process was done by the investigator who was not involved in direct patient care. Observers assessing outcomes were blinded to group allocation. To minimise inter-rater variability, four anaesthesiologists were trained in using the Modified Yale Preoperative Anxiety Scale (m-YPAS)6,7, the Child Fear Scale (CFS)8, the State-Trait Anxiety Inventory (STAI-T and STAI-S)9, and the Post-Hospitalisation Behaviour Questionnaire (PHBQ)10,11.
Study procedure
On the day before surgery, all children underwent a detailed preoperative evaluation. Two of the trained anaesthesiologists met the children in the ward, introduced themselves, and conducted a brief ice-breaking talk. They independently assessed baseline anxiety using the m-YPAS and CFS for children, and baseline STAI-T and STAI-S scores for parents. All children received standard care, including written communication about the perioperative procedure and postoperative care according to institutional protocol, before signing the consent form. Children in the VI group were shown the intervention video on a phone or tablet, and parents were provided with a video link for flexible viewing (Supplementary material). Queries from children and parents regarding the video and anaesthesia procedure were addressed.
On the day of surgery, the two remaining trained anaesthesiologists met with the children and their parents in the preoperative area and independently recorded the children’s m-YPAS and CFS scores immediately after moving the child onto the Operating Table inside the Operating Room. No patients were given anxiolytic medication in the preoperative area. The parents’ STAI-S scores were also recorded immediately after the child was shifted inside the OR. All children underwent surgery with standard ASA monitoring and anaesthesia following the institutional protocol. After surgery, children were moved to the postoperative area only after they had fully regained consciousness and recovered from the effects of neuromuscular blockade. Fifteen minutes post-surgery, the two anaesthesiologists evaluated emergence delirium using the Paediatric Emergence Delirium (PAED) score12.
On the 7th and 30th postoperative days, two anaesthesiologists who were blinded to the group assignment assessed the PHBQ scores via video conferencing. The final analysis used the average scores for m-YPAS, CFS, STAI-T, STAI-S, PAED, and PHBQ, as provided by two anaesthesiologists at each time point.
Statistical analysis
Using the per-protocol approach, we aimed to include 30 participants for the final analysis in this pilot study, with 15 in each group. Data were collected and recorded on a Microsoft Excel spreadsheet. Data normality was tested using the Shapiro-Wilk test. Continuous variables were presented as mean (standard deviation) or median (range) and compared using two-sample t-tests, Wilcoxon rank sum tests as appropriate. Categorical variables were presented as frequencies (%) and compared using the χ2 test. An unpaired t-test was used to compare the data of two groups, and values were presented as P values with confidence intervals. Intra group comparison of changes in m-YPAS, heart rate, CFS, and parental STAI-S from baseline to operating table was done using a paired t-test. A P value of less than 0.05 was considered as significant.
Results & Discussion
A total of 33 children met the inclusion criteria. However, one was excluded because he didn’t understand Hindi, and another was excluded due to having undergone prior experience with anaesthesia as part of a surgical procedure three times previously. Additionally, one child in the VI group was excluded for not watching the entire video. This left 30 children for final analysis, 15 in each group (Figure). The baseline demographic profiles, previous anaesthesia exposure, and duration of surgery were similar across both groups (Table I).
- Consolidated Standards of Reporting Trials (CONSORT) study flow chart.
| Parameter |
Group C (n=15) |
Group VI (n=15) |
P value |
|---|---|---|---|
| Child age* | 6.93 (1.87) | 7.8 (2.96) | 0.34 |
| Parent age* | 32.3 (4.14) | 34.6 (6.2) | 0.24 |
| Gender (M/F); n (%)^ | 10/5 (66.6/33.3) | 11/4 (73.3/ 26.6) | |
| Previous single anaesthesia exposure (yes/no)^ | 1/14 (6.6/93.3) | 2/13 (13.3/86.6) | |
| Duration of surgery* | 65.33 (27.35) | 77.3 (19.2) | 0.17 |
Data are expressed as *mean (SD) or ^number (%). C, control; VI, video intervention; M, male; F, female
The baseline m-YPAS scores were comparable between the groups. However, once on the operating table, group C showed significantly higher anxiety levels compared to group VI [77.08 (8.38) vs. 47.9 (10.23), respectively; P<0.001; 95% confidence interval (CI): -36.17, -22.18]. Group C exhibited an increase in m-YPAS scores (mean difference: 10.68; 95% CI: 4.67, 16.69; P=0.001), while group VI showed a significant decrease (mean difference: -20.6; 95% CI: -28.47, -12.7; P< 0.001).
On the operating table, children in group VI showed minimal change in heart rate (HR) from baseline (mean difference: 0.4; 95% CI: -2.66, 3.46; P=0.7), whereas group C experienced a significant increase in HR (mean difference: 10.2; 95% CI: 5.85, 14.55; P<0.0001). Group C had higher CFS scores on the operating table compared to group VI [3.6 (0.61) vs. 1.5 (0.57); 95% CI: -2.54, -1.65; P<0.001]. The change in CFS scores was significant in both groups, with group C showing an increase (mean difference: 1.14; P<0.001) and Group VI showing a decrease (mean difference: -1.7; P<0.001). Although baseline STAI-Trait scores were slightly higher in group C, this difference was not statistically significant. After shifting the child on the operating table, STAI-S scores were significantly lower in group VI compared to group C [35.4 (4.9) vs. 44.87 (4.59); 95% CI: -13.02, -5.9; P<0.001]. The STAI-S score decreased significantly in both groups compared to baseline. PAED scores were comparable between the groups. On the 7th postoperative day, mildly significant behaviour changes in the C group were observed compared to the VI group (P=0.04), but by the 30th postoperative day, the scores were comparable (Table II and III).
| Parameter | Group C | Group VI |
P value (95% CI) |
|---|---|---|---|
| Heart rate; mean (SD)* | |||
| Baseline | 82.3 (4.9) | 88.13 (3.54) |
<0.001 (2.63, 9.03) |
| On the operating table | 92.5 (6.63) | 88.53 (4.57) |
0.07 (-8.2, 0.29) |
| mYPAS; mean (SD)* | |||
| Baseline | 66.4 (7.67) | 68.5 (10.8) |
0.54 (-4.9, 9.1) |
| On the operating table | 77.08 (8.38) | 47.9 (10.23) |
<0.001 (-36.17, -22.18) |
| STAI-T; mean (SD)* | 48.8 (7.6) | 44.53 (4.44) |
0.07 (-8.92, 0.38) |
| STAI-S; mean (SD)* | |||
| Baseline | 52.3 (7.2) | 54.67 (8.11) |
0.4 (-3.36, 8.1) |
| After shifting the child to the operating table | 44.87 (4.59) | 35.4 (4.9) |
<0.001, (-13.02, -5.9) |
| CFS; mean (SD), median (range)* | |||
| Baseline |
2.46 (0.95) 4 (2,4) |
3.2 (0.55) 3 (2,4) |
0.01 (0.16, 1.3) |
| On operating table |
3.6 (0.61) 4 (2,4) |
1.5 (0.57) 1 (0,2) |
<0.001 (-2.54, -1.65) |
| PEAD score; mean (SD), median (range)* |
8.00 (0.89), 8 (7,10) |
8.06 (0.68) 7 (7,9) |
0.83 (-0.53, -0.65) |
| Behaviour score at 7th day; mean (SD)* | 33.86 (2.82) | 31.6 (2.92) |
0.039 (-4.41, -0.11) |
| Behaviour score at 30th day; mean (SD)* | 36.2 (1.99) | 32.06 (2.51) |
0.052 (-2.23, 1.15) |
Data are expressed as mean (SD) or median (range) as appropriate. Statistical tests include *unpaired t-test and Mann-Whitney U test for analysis of data. CI, confidence interval; CFS, child fear scale; m-YPAS, modified Yale preoperative anxiety scale; STAI-T, State-trait anxiety inventory-trait; STAI-S, State-trait anxiety inventory-state; PAED, paediatric anaesthesia emergence delirium; SD, standard deviation
| Change in parameter from baseline to operating table* |
Group C Change (mean difference); (95% CI); P value |
Group VI Change (mean difference); (95% CI); P value |
|---|---|---|
| Heart rate |
10.2 (2.12); (5.85, 14.55); P<0.0001 |
0.4 (1.5); (-2.66, 3.46); P= 0.7 |
| mYPAS score |
10.68 (2.93); (4.67, 16.69); P=0.001 |
-20.6 (3.8); (-28.47, -12.7); P<0.001 |
| STAI-S score |
-7.43 (2.2); (-11.9, -2.9) P=0.002 |
-19.7 (2.4); (-24.28, -14.2) P<0.001 |
| Child fear score |
1.14 (0.92) (0.54, 1.73) P<0.001 |
-1.7 (0.21) (-2.12, -1.28) P<0.001 |
Children are especially susceptible to preoperative anxiety because of their limited cognitive abilities and greater reliance on others13. Paediatric anaesthetists are often skilled communicators, as anaesthetic induction requires quickly establishing rapport and facilitating the engagement and cooperation of an anxious or distressed child14. A playful introduction to the perioperative environment can alleviate some of the patients’ fears, thereby improving both perceived and actual outcomes. An important consideration is to tailor the information to the specific circumstances that the children will encounter. Using videos that feature the actual hospital or operating theatre setting, rather than relying on generic, commercially available multimedia may be more effective15,16. Sources of children’s preoperative anxiety include venous punctures, the smell of volatile agents delivered through facemasks, and interactions with masked individuals in the OR17. Children experience the greatest anxiety during the induction of anaesthesia and allowing them to hold the mask during this process has been found helpful5,18. This study video, designed as a bundled approach, thoughtfully incorporates all this perioperative information and communicates in the child’s native language, Hindi, with the goal of reducing preoperative anxiety.
The principal findings revealed that the video significantly reduced preoperative anxiety in young Indian children scheduled for elective surgeries under general anaesthesia. The findings of this study are consistent with several other research studies, which have shown that informative video presentations based on OR expectations and anaesthesia techniques lead to lower anxiety scores in children1,19-21. Hou et al22 recently demonstrated that interactive multimedia-based education could effectively reduce preoperative anxiety in both children and their parents. Other studies have also shown that using comic information leaflets and a child’s favourite cartoon videos can successfully reduce preoperative anxiety in children22,23. In this study, parental anxiety significantly decreased in both groups throughout the study, likely because they felt relieved that their children had been transferred to the OR.
Children and their families feel more at ease when they can use smartphone and tablet-based AV interventions as often as needed, to manage stressful situations such as surgery. Before surgery, anaesthesiologists should focus on connecting with patients, respecting what matters most to them24. The content, timing, and delivery method of the perioperative AV intervention must be carefully designed to ensure that children are more likely to engage with the complex information, thereby helping them better manage preoperative anxiety. These interventions help children who feel a loss of control and fear the unknown, such as the hospital environment and procedures, by assisting them in regaining a sense of self-control25,26. Peer-modelling animated preoperative preparation videos facilitate passive distraction by redirecting children’s attention through observation. These videos, if age- and developmentally appropriate to accurately convey complex perioperative information, typically do not require children’s feedback to be effective and allow them to learn new skills by watching a peer perform tasks they will later mimic. A systematic review suggests that AV interventions providing procedural details alone may be sufficient to help a child manage the anticipated threat, and that additional narrative does not contribute to further anxiety coping skills27.
Although our video intervention significantly reduced preoperative anxiety, it did not translate into a reduced incidence of ED or postoperative behaviour changes. This outcome suggests that while anxiety reduction is important, ED is likely influenced by a broader range of factors, including the child’s temperament, the type of surgery, anaesthetic agents, and postoperative pain management28. A study conducted on 400 children under general anaesthesia by Kain et al29 concluded that reducing both preoperative anxiety and the incidence of ED requires a multicomponent behavioural preparation program-comprising anxiety reduction, diversion, video modelling, and parental presence.
This study did have certain limitations. We conducted the study only on children who understood Hindi, so the impact of this video in other languages remains to be evaluated. Furthermore, the impact of reduced anxiety on emergence delirium and postoperative behavioural changes needs to be explored with a larger sample size.
Overall, this study underscores the significance of culturally and linguistically tailored preoperative video interventions in reducing anxiety among children. The positive outcomes of this Information education and communication video intervention demonstrate its potential to bridge communication gaps and enhance patient care, particularly in settings where language and cultural barriers might otherwise impede effective communication.
Acknowledgment
Authors acknowledge Dr(s) Nonglenthung R. Jungio, Chetan Chouhan, Vivek Soni and Arun for assistance in collection of data during the study process.
Financial support & sponsorship
This study received financial assistance from Multi-Disciplinary Research Unit (MDRU) No./MRU/2024/0327 project no. LRAC/2024/01, Indian Council of Medical Research, Department of Health Research, and Institutional funding from Dr. S.N. Medical College, Jodhpur, Rajasthan.
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript, and no images were manipulated using AI.
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