Preoperative anxiety is an emotional response characterized by excessive apprehension, stress, or fear experienced by patients before undergoing surgery
[1]
. It may be related to concerns about the surgery itself, the anesthesia, or potential postoperative consequences. This form of anxiety, which is prevalent among surgical patients, can vary in intensity depending on medical history, personality, and cultural context
[2]
[3]
.
The clinical consequences of preoperative anxiety are numerous and significant. It is associated with an increased physiological stress response, including hyperactivation of the autonomic nervous system, which can lead to tachycardia, hypertension, and impaired hemodynamic stability
[4]
[5]
. It also increases pain sensitivity, reduces patient satisfaction, and prolongs postoperative recovery time
[6]
. Furthermore, it may impact patient prognosis, as it has been linked to increased postoperative complications
[7]
.
Epidemiologically, the prevalence of preoperative anxiety varies depending on the region and economic context. Globally, it affects approximately 11% to 80% of patients, depending on the population studied and the measurement tools used
[8]
. In Africa, this prevalence ranges from 61% to 67%
[9]
[10]
and is often associated with limited access to information, insufficient communication between healthcare professionals and patients, and a lack of psychological resources in hospitals. In Cameroon, preoperative anxiety affects approximately 59% to 68% of patients, although few studies have specifically addressed this issue
[11]
[12]
.
In a resource-limited setting such as Cameroon, where access to quality care and accurate information is often restricted across the country, assessing and preventing preoperative anxiety is of paramount importance for both the patient and their prognosis. These factors could help reduce postoperative complications, save hospital resources, and improve patient outcomes. Identifying the factors associated with this anxiety will guide intervention strategies, particularly by strengthening doctor-patient communication and incorporating psychological support approaches. The objective of this study was therefore to identify the factors associated with preoperative anxiety in patients scheduled for surgical intervention.
2. Materials and Methods2.1. Study Design, Setting, and Period
We conducted a cross-sectional study in the surgical department (including visceral, urological, ophthalmological, ENT, cardiovascular, thoracic, orthopedic, and trauma surgery) of the Douala General Hospital over a three-month period, from October to December 2024.
2.2. Study Population
Our study targeted patients scheduled for elective surgery. From this target population, 370 patients who were hospitalized the day before elective surgery and who consented to participate were included in the study. Unconscious patients and those admitted for emergency surgery were excluded.
2.3. Data Collection Procedure
After approval of our study by the Ethics Committee of the University of Douala (No. 2123/CEI-Udo) and receipt of administrative authorization (No. 161/AR/MINSANTE/HGD/DM), we visited the surgical and gynecology departments every afternoon, the day before surgeries. Upon arrival, we introduced ourselves to the duty nurses, consulted the surgical schedule displayed in the duty room, listed the admitted patients, and located their rooms. We then visited each room, introduced ourselves to the patient, and presented the topic of our study and its relevance. An information note and an informed consent form were provided to the patient before starting the interview, which was based on a pre-tested and standardized data collection form. The information collected from the patients included sociodemographic characteristics (age, sex, occupational sector, education level), as well as their anesthetic and surgical history. In parallel, the quality of information received during pre-anesthesia and surgical consultations was evaluated using the Likert scale
[13]
to assess its influence on the level of anxiety. Potential causes of preoperative anxiety were also assessed and measured using the Amsterdam Preoperative Anxiety and Information Scale (APAIS)
[14]
. The APAIS is a validated self-administered questionnaire specifically designed to assess anxiety related to surgery and anesthesia, as well as the patient’s need for information. This tool has demonstrated good internal consistency, satisfactory reliability, and construct validity in various settings. Several studies have validated its use in both high- and low-resource environments, including sub-Saharan Africa, highlighting its adaptability to local cultural and linguistic contexts. In the Cameroonian context, the APAIS is particularly relevant due to its brevity, ease of administration, and its ability to capture both the emotional and informational dimensions of preoperative stress—an essential feature in a healthcare system where time and resources are often limited (
Table 1
), a six-item tool designed to quantify the intensity of worry before surgery.
<xref ref-type="bibr" rid="scirp.144015-"></xref>Table 1. Amsterdam preoperative anxiety and information scale.
Each Item Is Rated on a Scale from 1 (minimum: strong disagreement) to 5 (maximum: total agreement)
A1
I am concerned about anesthesia.
A2
I keep thinking about anesthesia.
A3
I would like to know as much as possible about anesthesia.
C1
I am concerned about the procedure.
C2
I keep thinking about the procedure.
C3
I would like to know as much as possible about the procedure.
Mean Scores Calculated from the Amsterdam Scale
A1 + A2
Anxiety related to anesthesia.
C1 + C2
Anxiety related to surgery.
A1 + A2 + C1 +C2
Overall anxiety.
A3 + C3
Desire for information score.
2.4. Ethical Considerations
The study was approved by the Ethics Committee of the University of Douala (No. 2123/CEI-Udo), and research authorization was obtained from the administration of the Douala General Hospital (No. 161/AR/MINSANTE/HGD/DM). The purpose of the study, its relevance, the procedures, and the handling of the collected data were read and clearly explained to the patients who met the inclusion criteria in order to obtain their informed consent. Patients were informed that they could withdraw their consent at any time during the study without affecting the quality of care provided in the hospital departments. Data were collected and stored in accordance with current confidentiality and ethical standards.
2.5. Statistical Analysis
Data were recorded in an Excel spreadsheet and analyzed using R software version 4.4.2 and GraphPad version 8.4.3 for Windows. Qualitative variables were presented as frequency (n) and percentage (%), while quantitative variables were expressed as mean ± standard deviation (SD). Pearson’s chi-square test of independence with Fisher’s exact correction, as well as univariate and multivariate logistic regression analyses, were performed to identify factors associated with preoperative anxiety. For these tests, the confidence interval was set at 95%, and the margin of error at 5% (results were considered statistically significant if and only if p < 0.05).
3. Results3.1. Prevalence of Preoperative Anxiety in the Study Population
Figure 1
shows the prevalence of preoperative anxiety in our study population (N = 370 patients). Among them, 174 patients (47%) were classified as anxious, while the remaining 196 patients (53%) were classified as non-anxious. This distribution indicates that nearly half of the patients experienced anxiety prior to surgery, highlighting the importance of considering preoperative anxiety as a common concern in our context.
Figure 1. Prevalence of preoperative anxiety.
3.2. Sociodemographic Factors of the Study Population
Table 2
summarizes the distribution of sociodemographic factors in our study population according to preoperative anxiety status. The mean age was similar between the two groups (42.4 years ± 17 years for anxious patients vs. 41.1 years ± 8 years for non-anxious patients, p = 0.7). Age group distribution did not show any significant differences between the groups (p = 0.2).
Sex was significantly associated with anxiety, with a higher proportion of females in the anxious group (29.7% vs. 27.03%, p = 0.03). Marital status, level of education, and employment sector were not significantly associated with anxiety (p = 0.6, 0.1, and 0.9, respectively).
The majority of participants had a secondary level of education (48.9% in the anxious group vs. 49.0% in the non-anxious group), and the main employment sectors included the private sector and students in both groups.
<xref ref-type="bibr" rid="scirp.144015-"></xref>Table 2. Distribution of sociodemographic factors of the study population based on preoperative anxiety status.
Sociodemographic Factors
Anxious (n = 174)
Non-Anxious (n =196)
p-value
n (%)
n (%)
Mean Age (Years)
42.4 ± 17
41.1 ± 08
0.7
Age Groups (Years)
0.2
15 - 30
47 (27.0%)
53 (27.0%)
31 - 45
56 (32.2%)
64 (32.7%)
46 - 59
35 (20.1%)
39 (19.9%)
≥60
36 (20.7%)
40 (20.4%)
Gender
0.03*
Female
110 (29.7%)
100(27.03%)
Male
76 (20.5%)
84 (22.7%)
Marital Status
0.6
Single
47 (27.0%)
53 (27.0%)
Married
121 (69.5%)
137 (69.9%)
Widowed
6 (3.5%)
6 (3.1%)
Level of Education
0.1
No Schooling
7 (4.0%)
7 (3.6%)
Primary Education
14 (8.0%)
15 (7.7%)
Secondary Education
85 (48.9%)
96 (49.0%)
Higher Education
44 (25.3%)
60 (30.6%)
Employment Sector
0.9
Public Sector
18 (10.3%)
20 (10.2%)
Private Sector
41 (23.6%)
46 (23.5%)
Independent
12 (6.9%)
13 (6.6%)
Student
31 (17.8%)
35 (17.9%)
Trader
19 (10.9%)
21 (10.7%)
Housewife
27 (15.5%)
31 (15.8%)
Farmer
6 (3.5%)
9 (4.6%)
Retired
18 (10.3%)
22 (11.2%)
The data are presented as frequency (N), percentage (%), and mean ± standard deviation (SD). P-value: The Wilcoxon rank-sum test, Pearson’s Chi-squared test, and Fisher’s exact test were performed to compare and identify associations between sociodemographic factors and arterial hypertension. For these tests, the confidence interval was set at 95%, and the margin of error at 5% (a p-value is considered significant if and only if p < 0.05).
3.3. Factors Associated with Preoperative Anxiety (Univariate Analysis Results)
Female sex (OR = 1.2, p = 0.03), absence of previous anesthesia experience (OR = 2.1, p = 0.002), and general anesthesia (OR = 3.9, p < 0.001) were significantly associated with increased preoperative anxiety.
In addition, the absence of explanation regarding the indication for surgery (OR = 9.3, p < 0.001) and lack of information about pain management (OR = 1.0, p = 0.02) significantly increased the risk of anxiety.
Among the fears evaluated, fear of death (OR = 26.5, p < 0.001), fear of waking up during surgery (OR = 11.9, p = 0.02), fear of postoperative pain (OR = 30.6, p < 0.001), and fear of becoming disabled (OR = 5.1, p < 0.001) were strongly associated with anxiety.
Finally, fear of the anesthesiologist’s experience (OR = 7.6, p < 0.001), fear of needles (OR = 4.5, p = 0.001), and fear of feeling pain during surgery (OR = 4.9, p < 0.001) were also significant contributing factors (
Table 3
).
<xref ref-type="bibr" rid="scirp.144015-"></xref>Table 3. Univariate logistic regression analysis of the association between the evaluated factors and preoperative anxiety.
Factors
Modalities
Anxious n (%)
Non-anxious n (%)
COR
95% CI
p-value
Gender
Male
76 (43.7)
84 (42.9)
Female
110 (52.3)
100 (47.6)
1.2
0.68 - 1.56
0.03
Previous Anesthesia
Yes
33 (18.9)
65 (33.2)
No
140 (80.4)
131 (66.8)
2.1
1.3 - 3.4
0.002
Type of Anesthesia
Locoregional
45 (25.9)
113 (57.7)
General
129 (74.1)
82 (41.8)
3.9
2.5 - 6.2
<0.001
I received an explanation about the purpose of the surgery
Sufficiently
71 (40.8)
70 (35.7)
Moderately
70 (40.2)
54 (27.5)
1.3
0.8 - 2.0
>0.9
Slightly
30 (17.2)
43 (21.9)
0.7
0.38 - 1.21
>0.9
Not at all
29 (14.8)
3 (1.7)
9.3
1.3 - 24.4
<0.001
I received details about the pain management plan
Moderately
27 (15.5)
16 (8.1)
Slightly
19 (10.9)
14 (7.1)
0.8
0.31 - 2.0
0.6
Not at all
180 (91.8)
100 (57.4)
1
0.2 - 0.9
0.02
Fear of death
No
163 (93.7)
195 (99.4)
Yes
164 (94.2)
66 (33.7)
26.5
14.9 - 58.3
<0.001
Fear of waking up during surgery
No
163 (93.7)
195 (99.5)
Yes
10 (5.7)
1 (0.5)
11.9
1.51 - 94.4
0.02
Fear of postoperative pain
No
12 (7)
136 (69.4)
Yes
162 (93.1)
60 (30.6)
30.6
12.6 - 48.0
<0.001
Fear of becoming disabled
No
143 (82.2)
188 (95.9)
Yes
31 (17.81)
8 (4.1)
5.1
2.3 - 11.4
<0.001
Fear of the anesthetist’s experience
No
86 (49.4)
172 (87.7)
Yes
88 (50.6)
23 (11.7)
7.6
4.5 - 12.9
<0.001
Fear of needles
No
152 (87.3)
189 (96.4)
Yes
22 (12.64)
6 (3.0)
4.5
1.8 - 11.5
0.001
Fear of feeling pain during surgery
No
144 (82.7)
188 (95.9)
Yes
30 (17.2)
8 (4.1)
4.9
2.2 - 11
<0.001
COR: Crude Odds Ratio; CI: Confidence Interval.
3.4. Factors Associated with Preoperative Anxiety (Multivariate Analysis Results)
Table 4
presents the results of the multivariate analysis aimed at identifying factors associated with preoperative anxiety. The findings show that absence of previous anesthesia experience (AOR = 2.1; 95% CI: 1.3 - 3.4; p = 0.002), use of general anesthesia (AOR = 2.9; 95% CI: 2.8 - 3.1; p = 0.002), complete lack of explanation regarding the indication for surgery (AOR = 9.3; 95% CI: 1.3 - 24.4; p = 0.009), and fear of death (AOR = 3.5; 95% CI: 1.2 - 10.6; p = 0.03) were significantly associated with preoperative anxiety. In contrast, other factors—such as fear of becoming disabled, fear regarding the anesthesiologist’s experience, fear of needles, and fear of feeling pain during surgery—did not show a significant association with preoperative anxiety in this multivariate analysis.
<xref ref-type="bibr" rid="scirp.144015-"></xref>Table 4. Multivariate logistic regression analysis of the association between factors significantly associated during univariate analysis and preoperative anxiety.
Factors
Modalities
AOR
95% CI
p-value
Gender
Male
1
Female
0.9
0.43 - 2.6
0.1
Previous Anesthesia
Yes
1
No
2.1
1.3 - 3.4
0.002
Type of Anesthesia
Locoregional
1
General
2.9
2.8 - 3.1
0.002
I received an explanation about the purpose of the surgery
Sufficiently
1
Moderately
0.87
0.4 - 1.9
0.7
Slightly
0.7
0.19 - 1.23
0.1
Not at all
9.3
1.3 - 24.4
0.009
Fear of death
No
1
Yes
3.5
1.2 - 10.6
0.03
Fear of becoming disabled
No
1
Yes
0.7
0.9 - 8.1
0.1
Fear of the anesthetist’s experience
No
1
Yes
1.6
1.1 - 9.8
>0.9
Fear of needles
No
1
Yes
1.7
0.3 - 4.1
0.8
Fear of feeling pain during surgery
No
1
Yes
1.3
0.5 - 7.2
0.4
AOR: Adjust Odds Ratio; CI: Confidence Interval.
4. Discussion
The results of our study show a high prevalence (47%) of preoperative anxiety among patients scheduled for surgery. This prevalence is comparable to that reported in several recent studies, all of which highlight the multifactorial and frequently underestimated nature of this issue
[15]
. The identification of factors associated with this anxiety—namely the absence of previous anesthesia experience, use of general anesthesia, complete lack of explanation regarding the indication for surgery, and fear of death—allows us to understand several explanatory mechanisms and to consider more targeted prevention and management strategies.
First, the absence of previous anesthesia experience is associated with increased preoperative anxiety. This finding is consistent with recent studies showing that unfamiliarity with the anesthetic process increases fear of the unknown and negative anticipation of complications
[16]
. Patients with no prior exposure to anesthesia often require clear information tailored to their level of understanding, as well as psychological support to help manage their fears.
Second, the use of general anesthesia appears as a factor significantly associated with preoperative anxiety. Patients often fear not waking up, experiencing pain during the procedure, or losing control of their own bodies
[17]
. In this context, it would be relevant to assess the impact of an in-depth pre-anesthetic consultation combined with structured preoperative education to reduce these specific concerns. New approaches, such as audiovisual educational tools or mobile apps, have shown promising effectiveness in reducing such anxiety
[18]
.
Third, the complete absence of explanation regarding the surgical indication is a key factor contributing to anxiety. Poorly informed or uninformed patients tend to overestimate the severity of their condition and surgical risks, leading to heightened emotional stress
[19]
. Clear, empathetic, and patient-centered communication not only enhances therapeutic adherence but also helps reduce anxiety and improve overall patient satisfaction. Developing personalized preoperative information programs with interactive communication strategies appears particularly beneficial
[20]
.
Finally, fear of death remains a major issue in the emotional experience of patients before surgery. This fear exacerbates anxiety and may lead to longer-term psychological consequences
[21]
. Implementing psychological support, including short-term therapy or motivational interviewing in the preoperative phase, may help alleviate this distress and improve the patient experience. Additionally, integrating relaxation techniques, meditation, or medical hypnosis into the care pathway offers promising perspectives for managing this type of stress
[22]
.
5. Conclusion
In summary, our results highlight the need to implement targeted assessment and prevention strategies for preoperative anxiety. Interventions based on personalized information, empathetic communication, and psychological support are essential to address fears related to anesthesia and surgical procedures. In the future, the integration of innovative educational protocols, continuous evaluation of the impact of these initiatives on clinical outcomes, and multidisciplinary collaboration (anesthesiologists, surgeons, psychologists, nurses) could significantly reduce preoperative anxiety and improve patient satisfaction, comfort, and postoperative recovery.
Data Availability
The raw data supporting the conclusions of this study will be made available by the authors without undue restriction and upon reasonable request.
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