Predictors of Preoperative Anxiety among Surgical Patients in Iran: An Observational Study
Background: Patients undergoing surgery experience significant anxiety in the preoperative period. The aim of the present study was to identify the level of preoperative anxiety among Iranian patients in surgery clinics and its predictive factors.
Methods: In this cross-sectional study, the State-Trait Anxiety Inventory questionnaire was used to assess the patients’ preoperative anxiety. Results were analysed using the Chi-square test and binary logistic regression analysis.
Results: 246 patients were randomly selected, 222 of which were finally included in our analysis. In this study, the state and trait anxiety levels were moderate and low, respectively. Both state and trait anxiety levels were significantly higher among females (p-value 0.03 and 0.009, respectively). Also, patients with higher education had higher state and trait anxiety levels (p-value 0.001 and <0.001, respectively). Patients undergoing aesthetic surgeries had significantly higher state anxiety levels compared to other surgeries (p-value 0.04). Interestingly, the history of surgery was not significantly associated with state anxiety (p-value 0.96). Logistic regression analysis revealed that age, marital status, and education were the most predictive factors for state anxiety. These factors along with the place of residence were also predictive for trait anxiety (p-value <0.05).
Conclusion: Since these predictive factors are not amenable to change before elective surgery, identification of patients with higher anxiety levels is essential. Further studies investigating preoperative anxiety a few days prior to surgery in the Iranian population should be warranted.
 Weissman C. The metabolic response to stress: an overview and update. Anesthesiology. 1990; 73(2):308-27.
 Vileikyte L. Stress and wound healing. Clin Dermatol. 2007; 25(1):49–55.
 Christian LM, Graham JE, Padgett DA, Glaser R, Kiecolt-Glaser JK. Stress and Wound Healing. Neuroimmunomodulation. 2006; 13(5–6):337-46.
 Linn BS, Linn MW, Klimas NG. Effects of psychophysical stress on surgical outcome. Psychosom Med. 1988; 50(3):230-44.
 Boeke S, Jelicic M, Bonke B. Pre-operative anxiety variables as possible predictors of post-operative stay in hospital. Br J Clin Psychol. 1992; 31(3):366–8.
 Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R. Psychological influences on surgical recovery: Perspectives from psychoneuroimmunology. Am Psychol. 1998; 53(11):1209-18.
 Thomas T, Robinson C, Champion D, McKell M, Pell M. Prediction and assessment of the severity of post-operative pain and of satisfaction with management. Pain. 1998; 75(2–3):177–85.
 Williams JGL, Jones JR. Psychophysiological Responses to Anesthesia and Operation. JAMA. 1968; 203(6):415-7.
 Hughes BM, Howard S, James JE, Higgins NM. Individual differences in adaptation of cardiovascular responses to stress. Biol Psychol. 2011; 86(2):129–36.
 Osborn TM, Sandler NA. The effects of preoperative anxiety on intravenous sedation. Anesth Prog. 2004; 51(2):46–51.
 Maranets I, Kain ZN. Preoperative anxiety and intraoperative anesthetic requirements. Anesth Analg. 1999; 89(6):1346-51.
 Goldmann L, Ogg TW, Levey AB. Hypnosis and daycase anaesthesia. Anaesthesia. 1988; 43(6):466-9.
 Kim W-S, Byeon G-J, Song B-J, Lee HJ. Availability of preoperative anxiety scale as a predictive factor for hemodynamic changes during induction of anesthesia. Korean J Anesthesiol. 2010; 58(4):328–33.
 Janis I. Psychological stress: Psychoanalytic and behavioral studies of surgical patients. New York: John Wiley & Sons; 1958.
 Debas H, Laxminarayan R, Straus S. Complementary and alternative medicine. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al., editors. Disease control priorities in developing countries [Internet]. 2nd ed. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006 [cited 2019 May 8]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11796/
 Weiser TG, Haynes AB, Molina G, Lipsitz SR, Esquivel MM, Uribe-Leitz T, et al. Size and distribution of the global volume of surgery in 2012. Bull World Health Organ. 2016; 94(3):201–209F.
 Boker A, Brownell L, Donen N. The Amsterdam preoperative anxiety and information scale provides a simple and reliable measure of preoperative anxiety. Can J Anesth Can. 2002; 49(8):792–8.
 Spielberger CD. Manual for the State-trait anxiety inventory: STAI. Palo Alto, CA: Consulting Psychologists Press; 1983.
 Matthias AT, Samarasekera DN. Preoperative anxiety in surgical patients - experience of a single unit. Acta Anaesthesiol Taiwanica. 2012; 50(1):3-6.
 Jafar MF, Khan FA. Frequency of preoperative anxiety in Pakistani surgical patients. J Pak Med Assoc. 2009; 59(6):359-63.
 Perks A, Chakravarti S, Manninen P. Preoperative anxiety in neurosurgical patients. J Neurosurg Anesthesiol. 2009; 21(2):127-30.
 Göktay F, Altan ZM, Talas A, Akpınar E, Özdemir EÖ, Aytekin S. Anxiety Among Patients Undergoing Nail Surgery and Skin Punch Biopsy. J Cutan Med Surg. 2016; 20(1):35-9.
 Almalki M, Hakami O, Al-Amri A. Assessment of Preoperative Anxiety among Patients Undergoing Elective Surgery. Egypt J Hosp Med. 2017; 69(5):2329–34.
 Erkilic E, Kesimci E, Soykut C, Doger C, Gumus T, Kanbak O. Factors associated with preoperative anxiety levels of Turkish surgical patients: from a single center in Ankara. Patient Prefer Adherence. 2017; 11:291-6.
 Ravangard R, Bastani P, Moradi A, Ahmadzadeh M. Factors affecting the preoperative anxiety from the patients’ perspective. Daneshvar. 2016; 23(124):61–70.
 Nazari-Vanani R, Rahimi-Madiseh M, Drees F. Evaluation of preoperative anxiety and stress, and ways to modify it, the patients in Kashani hospital operating room in 2013. J Clin Nurs Midwifery. 2014; 2:53-60.
 Dehghan-nayeri N, Adib-Hajbaghery M. Effects of progressive relaxation on anxiety and quality of life in female students: A non-randomized controlled trial. Complement Ther Med. 2011; 19(4):194-200.
 Buehrer TW, Rosenthal R, Stierli P, Gurke L. Patients’ Views on Regional Anesthesia for Elective Unilateral Carotid Endarterectomy--A Prospective Cohort Study. Ann Vasc Surg. 2015; 29(7):1392-9.
 Masood Z, Haider J, Jawaid M, Alam SN. Preoperative anxiety in female patients: the issue needs to be addressed. KMUJ KHYBER Med Univ J. 2009; 1(2):38-41.
 Yilmaz M, Sezer H, Gürler H, Bekar M. Predictors of preoperative anxiety in surgical inpatients. J Clin Nurs. 2012; 21(7–8):956-64.
 Forlani M, Morri M, Belvederi Murri M, Bernabei V, Moretti F, Attili T, et al. Anxiety Symptoms in 74+ Community-Dwelling Elderly. PLoS One. 2014; 9(2):e89859.
 Weinstock LS. Gender differences in the presentation and management of social anxiety disorder. J Clin Psychiatry. 1999;60(9):9–13.
 Wang Y, Shen J, Lu J, Yang X. [Preoperative anxiety and depression in patients undergoing cardiac surgery and related influencing factors]. Zhonghua Yi Xue Za Zhi. 2008; 88(39):2759-62.
 Karanci A., Dirik G. Predictors of pre- and postoperative anxiety in emergency surgery patients. J Psychosom Res. 2003; 55(4):363-9.
 Basak F, Hasbahceci M, Guner S, Sisik A, Acar A, Yucel M, et al. Prediction of anxiety and depression in general surgery inpatients: A prospective cohort study of 200 consecutive patients. Int J Surg. 2015; 23:18–22.
 Woldegerima Y, Fitwi G, Yimer H, Hailekiros A. Prevalence and factors associated with preoperative anxiety among elective surgical patients at University of Gondar Hospital. Gondar, Northwest Ethiopia, 2017. A cross-sectional study. Int J Surg Open. 2018; 10:21-9.
 Aykent R, Kocamanoglu IS, Ustun E, Tur A, Sahinoglu H. The reasons and evaluation of preoperative anxiety: a comparison of APAIS and STAI scores. Turkiye Klin J Anesthesiol Reanim. 2007;5(1):7–13.
 Uysal A, Altiparmak, Guner O. The Effect of an Informative Leaflet on Preoperative Anxiety and Patient’s Knowledge of Anesthesia and Anxiety. J Clin Anal Med. 2017; 8(5):370-4.
 Moerman N, van Dam F, Muller M. The Amsterdam preoperative anxiety and information scale (APAIS). Anesth Analg. 1996; 82(3):445–51.
 Williams OA. Patient knowledge of operative care. J R Soc Med. 1993; 86(6):328–31.
 Kiyohara LY, Kayano LK, Oliveira LM, Yamamoto MU, Inagaki MM, Ogawa NY, et al. Surgery information reduces anxiety in the pre-operative period. Rev Hosp Clin Fac Med Sao Paulo. 2004; 59(2):51-6.