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J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-222
10.4103/jehp.jehp_1344_23
Review Article
Audiovisual technology intervention for reducing preoperative anxiety in children undergoing general anesthesia: A systematic review and meta-analysis
Oktaviani Jacinda R.
Widjaja Vivi 1
Singgih Nicholas A.
Pranowo Sampurno Secodiningrat Raden H.
Department of Urology, Primaya Hospital PGI Cikini, Jakarta, Indonesia
1 Department of Medicine, Mitra Keluarga Waru Hospital, Sidoarjo, Indonesia
Address for correspondence: Dr. Jacinda R. Oktaviani, Jalan Raden Saleh Raya No. 40, Cikini, Kec. Menteng, Central Jakarta City, Special Capital Region of Jakarta, 10330, Indonesia. E-mail: jacindarisha@gmail.com
2024
11 7 2024
13 22225 8 2023
01 11 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Preoperative anxiety (POA) is a concern for children undergoing surgery, especially with general anesthesia. POA can result in many postoperative problems, such as physical, psychological, and financial problems. Nonpharmacological treatments have been investigated for reducing POA as they are more pleasant and have fewer adverse effects compared to pharmacological treatments. Audiovisual technology treatment is one of the nonpharmacological treatments developed lately. This study aims to evaluate the efficacy of an audiovisual technology intervention for reducing POA in children undergoing general anesthesia. This study was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guideline 2020. Google Scholar, PubMed, ProQuest, and Cochrane databases were used for searching English articles published between January 2015 and June 2023. Cochrane Review Manager 5.4 was used for the meta-analysis and the Risk of Bias Tool 2.0 was used to measure the risk of bias. The studies included were randomized controlled trials (RCTs) that compared the audiovisual technology intervention with a control population. The modified Yale Preoperative Anxiety Scale was the outcome of interest. We found 627 articles in four databases using the search term. After screening with the eligibility criteria, three studies from Iran, Denmark, and China were included in the meta-analysis. A random effect model was applied. The meta-analysis resulted in a significant result as a lower modified Yale Preoperative Anxiety Scale score was found in the audiovisual technology intervention group compared with the control group (mean difference -10.75 [-16.48 to -5.03]; 95% confidence interval; P = .0002.) The presence of audiovisual technology interventions such as video games, cartoons or animation videos, and smartphone applications could significantly lower POA in children undergoing general anesthesia.

Anxiety
audiovisual
children
holding room
preoperative
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pmcIntroduction

According to the latest recent data, 3.9 million pediatric procedures are done annually in the United States, involving 4.7% of children in the country.[1] Sixty percent of children and their parents report experiencing anxiety before anesthesia. It is the most frequent emotion felt by children who are candidates for surgery.[2] Preschoolers and school-aged children are too young to grasp the meaning and intent behind surgery.[3] The main causes of anxiety are remaining in an unfamiliar place, being among strangers, being around noisy equipment, fear of physical harm and discomfort, and being apart from one’s parents.[2] According to other reports, up to 65% of children in the holding room and during anesthesia induction experience severe anxiety related to anesthesia and operation.[4]

Preoperative anxiety (POA) in children can be hazardous because it can result in postoperative wound healing delays, bad behaviors, high pain scores, and aberrant hemodynamic responses. From a psychological perspective, POA can cause undesirable behavioral modifications like recurrent enuresis, separation anxiety, agitation, crying, sleep disturbances and nightmares, and malnutrition resulting in insubordination, avoidance of healthy behaviors, and fear of doctors and medical staff. Additionally, these results can lead to longer stays in recovery areas, a greater need for postoperative care, and a family being burdened with an unacceptably high expense of prolonged hospitalization.[2] Moreover, intense feelings of anxiety frequently result in difficult behavior, excruciating pain, the emergence of delirium, and the need for higher sedation or analgesic doses before surgery.[4] Childhood anxiety development might also elevate the risk of anxiety and mood disorders, increase the likelihood of clinical depression, and impair an individual’s social life, schooling, and career in adolescence.[2] Therefore, to ensure perioperative safety and enhance surgical prognosis, it is crucial to reduce children’s anxiety.

Both pharmaceutical and nonpharmacological treatments to lessen POA have been explored. Despite being equally successful, both approaches have their shortcomings. The use of sedative medications is restricted in a busy surgical environment due to the rate at which they can cause nausea and vomiting, the variable onset timings, and prolonged recovery.[5] Additionally, pharmaceutical therapy includes dangers and adverse due to children’s immature physical and psychological state, and young children have limited compliance with taking medicine. Conversely, nonpharmacological therapies are pleasant, safer, and devoid of medication side effects compared to pharmacological therapy.[4] More recent research has looked at the effectiveness of electronic audiovisual treatments to decrease POA.[5] Audiovisual electronics, such as computer games, can have a positive impact on mental health and overall quality of life if done with supervision.[6] Thus, we conducted a systematic review and meta-analysis to determine the effectiveness of audiovisual technology intervention for reducing POA, especially in children undergoing general anesthesia.

Materials and Methods

Search methods

The search was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guideline 2020.[7] Several articles from Google Scholar, PubMed, ProQuest, and Cochrane database were screened. The following terms are used in the advanced search: “gadget” OR “smartphone” OR “handphone” OR “tablet” OR “audiovisual” OR “games” OR “social media” AND “preoperative” OR “holding room” OR “waiting room” AND “anxiety” OR “anxious” AND “pediatric” OR “children” OR “adolescent”. The search was limited to articles published between January 2015 and June 2023 (as the outcome guideline was published in September 2014).[8] We also manually searched the reference lists of chosen papers for relevant publications that matched our inclusion standards to guarantee thoroughness.

Eligibility criteria

This systematic review included all RCT studies that compare the use of audiovisual intervention, especially technology gadgets, for reducing POA. All literature must be in full-text English. The study population was children aged less than 18 years who underwent general anesthesia in the hospital operating room setting. The intervention given must have started in the holding room. The outcome measured must be the Modified Yale Preoperative Anxiety Scale (m-YPAS), which had control and intervention groups compared at the same point in time. This test assesses the children’s anxiety levels in the holding room before surgery and during anesthesia induction. A higher score indicates higher anxiety.[8] Systematic reviews, literature reviews, meta-analyses, case reports, case series, conference abstracts, and experimental self-made applications were excluded. Audiovisual interventions about introducing the operating room and/or operation procedures were also excluded.

Data extraction

Four reviewers extracted the data independently. The data extracted included first author name, year of publication, experimental time, country where the studies were conducted, age of the population, intervention time, sample sizes, audiovisual technology intervention method, surgical procedures, and American Society of Anesthesiologists (ASA) physical status classification.

Risk of bias assessment

All reviewers independently assessed the risk of bias using the Cochrane Risk of Bias 2.0 tool for RCTs. Six areas were evaluated as part of the Risk of Bias 2: randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, selection of the reported result, and overall bias. Each domain’s risk of bias was categorized as low, moderate, or high. A diagrammatic representation was developed to report the risk of bias.

Statistical analysis

Cochrane Review Manager 5.4 software was used to calculate the overall effect. The Inverse Variance method was used to obtain mean differences and standard deviations with a confidence interval of 95%. If the probability (P) were less than 0.05 (5%), it would be described as statistically significant. We calculated the proportion of total variance due to between-study variation using the I2 Index to evaluate between-study heterogeneity. A random-effect model was applied if a value of >50% was obtained (indicates high heterogeneity). A fixed-effect model was applied for a value of <50%.

Results

Literature search

We found 627 study articles using the search terms in four databases. After screening for duplications, the inclusion and exclusion criteria, and other eligibility criteria, three English full-text articles were included in this study. The studies included were from Iran, Denmark, and China. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 diagram flow is presented in Figure 1.

Figure 1 PRISMA flowchart 2020 of the included studies

Study characteristics

All three studies included were published between 2021 and 2023 with a total population of 282 children. The age range in the study population was 3 to 12 years. The audiovisual technology used were video games, tablet computer games, and cartoon videos or animations. Exposure to the intervention was about 15 to 40 minutes. The population was categorized mostly between ASA I and II, and one study included a few ASA III participants. The surgical procedures done in the studies consisted of several fields such as urology (undescended testis, hydrocele, hypospadias, orchidopexy, circumcision, and concealed penile surgery), digestive (herniotomy, umbilical hernia repair, and rectal biopsy), otorhinolaryngology (tonsillectomy and adenoidectomy), and oncology (masses). The characteristics of the included studies are presented in Table 1.

Table 1 Characteristics of included studies

First Author Name (Year)	Experimental Time	Country	Audiovisual Technology Intervention Method	Population Age (year)	Holding Room/Exposure Time (minutes)	Population	Surgical Procedures	ASA	Outcome	
Rostami et al. (2022)	December 2016 to August 2017	Iran	Multiple video games	3-6	15-20	Total: 102 Intervention: 51 Control: 51	herniotomy, undescended testis, hydrocele, hypospadias, tonsillectomy, and extra masses	I-II	Statistically significant lower m-YPAS score	
Clausen et al. (2021)	November 2015 to April 2016	Denmark	Tablet computer games	3-6	not mentioned	Total: 60 Intervention: 30 Control: 30	Orchidopexy, circumcision, inguinal or umbilical hernia repair, and rectal biopsy	I-II	Not statistically significant lower m-YPAS score	
Wang et al. (2023)	June 2019 to October 2019	China	Cartoon videos/animations	3-12	30-40	Total: 120 Intervention: 60 Control: 60	Adenoidectomy, tonsillectomy, and pediatric concealed penile surgery	I-III	Statistically significant lower m-YPAS score	
ASA, American Society of Anesthesiologists; m-YPAS, Modified Yale Preoperative Anxiety Scale

Quality assessment

As determined by the Risk of Bias 2 evaluation, both intention-to-treat and per-protocol showed a low risk of bias in 100% of the included studies. Some concerns were raised from deviations in the outcome measurement and randomization process in the per-protocol evaluation. This concern is likely due to nonblinded interventions in the population (visible audiovisual devices). The comprehensive risk of bias result is presented in Figure 2.

Figure 2 Risk of bias assessment

Meta-analysis

The meta-analysis showed a significant statistical difference in lowering POA between the intervention and control groups, with a mean difference of -10.75 (-16.48 to -5.03; 95% confidence interval; P = .0002). The heterogeneity was 86% among these studies, which means high heterogeneity in the included studies. A random-effect model was then applied. The forest plot of the meta-analysis study is presented in Figure 3. On the funnel plot, both sides have a symmetrical dispersion distribution. The symmetrical scatter plot can be defined as low in bias, but it should be noted that the number of total studies included is small. This study’s funnel plotis presented in Figure 4.

Figure 3 Forrest plot for comparison audiovisual technology intervention and control. AT, Audiovisual Technology; SD, Standard Deviation; CI, Confidence Interval; IV, Inverse-Variance

Figure 4 Funnel plot of the included studies. SE, Standard Error; MD, Mean Difference

Discussion

It is important to anticipate some features of a child’s perception of anesthesia since they frequently have the same worries as adults but are unable to express them.[9] Children must be helped to cope with unpleasant and intrusive therapies by reducing their fear since they are most susceptible to anxiety disorders. Currently, nonpharmacological anxiety management is a top priority.[2] Pharmaceutical therapy carries risks and adverse effects due to children’s immature physical and psychological state, and young children are not always compliant with taking medication.[4] According to a recent study of anesthesiologists, only half of the children having surgery were given sedative premedication.[10] Nonpharmacological therapies offer greater comfort, safety, and lack of medication side effects compared to pharmaceutical therapy. Nonpharmacological modalities include educational efforts, behavioral techniques, parental involvement during anesthesia induction, and alternative medicine methods, each offering a variety of efficient procedures for lowering anxiety. Studies exploring the impacts of technology gadgets, particularly those based on audiovisual interventions, have been a growing area of research. Technology tools, such as smartphones, video glasses, streaming video players, portable computers, iPads, and video games, are frequently used as delivery systems for streaming media content, such as video games, streaming video clips, applications, virtual reality, and cartoons, to distract children from their anxiety before operations.[4]

Electronic games, smartphones, and tablets are already commonplace among kids and teenagers. They are widely used in healthcare settings as diversion tools and as a part of behavior modification therapy.[11] The main causes of anxiety are remaining in a new location, being among strangers, the sound of technology, fear of physical harm and pain, and being separated from parents.[2] Children who use portable media devices stay attentive and unaware of their surroundings while ignoring verbal and tactile cues. Additionally, devices like smartphones are easy to transport and clean.[11]

Video games are a ubiquitous activity in modern culture. Children may get so engrossed in video games that they fail to perceive their own presence or ignore verbal and tactile cues. A study by Rostami E et al.[2] described that video games have a significant mean in decreasing POA compared with the control group. Another study by Ali HM et al.[12] also revealed that video games have a statistical significant effect in lowering POA. Moreover, Patel A et al.[10] described that children are given video games preoperatively had the lowest mean of m-YPAS compared to midazolam and parental presence, they did not give a significant increase before and after the intervention.

Some studies also demonstrated a significant decrease in patients’ anxiety with cartoons or animation videos preoperatively.[34] In a study by Sola C et al.,[13] a combination of watching videos and midazolam did not result in a significant difference compared to using either videos or midazolam alone. A study by Levay MM et al.[14] also demonstrated no significant difference in lowering POA between administrating midazolam and playing tablet games in children. They also summarized several studies comparing audiovisual technology interventions such as video games, video glasses, and cartoons with midazolam. Most studies showed no significant difference between the audiovisual group and midazolam group. However, some studies described the audiovisual group as superior to midazolam.

In a study with children aged three to five years, distraction with tablet devices could reduce the length of stay compared to the midazolam group.[14] Social media, one of the most widely used technologies worldwide, could also reduce POA in children. The ease with which the kids can skip any video they do not like promotes the ideal anxiety-relieving diversion.[15] Nevertheless, children’s use of social media must be monitored because misinformation can influence psychiatric symptoms.[16]

Next, the proper timing for providing the intervention is still debatable, and there are still limited articles about timing. One study by Ryu JH et al.[17] compared the use of a virtual reality tour at the outpatient clinic a few days before anesthesia and 10 minutes before anesthesia. The group given the intervention 10 minutes before anesthesia resulted in lower m-YPAS scores. Further study is needed to determine the best timing and length of audiovisual technology intervention for reducing POA in children.

Rostami E et al.[2] described that after the age of 6 years, a child may communicate their fear and displeasure. However, young children cannot verbalize their concern and frequently exhibit it physiologically. Ghazal EA et al.[9] described age groups and their relation to specific POA types. Ages six months to four years show the greatest level of separation anxiety, inability to comprehend explanations and procedures, significant emotional changes and behavioral regression following surgery, cognitive advancement, and a rise in outbursts. Children between the ages of 4 and 8 years start comprehending how things work and why. Separation anxiety persists, and physical integrity is a matter of concern. Children older than 8 years can tolerate separation well, understand how things work, and sometimes accept things completely. They may also have fears related to waking up during surgery or not waking up at all. Two included studies chose their population to be between 3 to 6 years.[25] Overall, age selection in studies intervening with physiological effects the among pediatric population must be considered in further studies.

An evidence-based review found that parental presence during induction of anesthesia does not reduce children’s anxiety. In the instances where it did, preanesthetic medication and other nonpharmacological interventions, like toys and video games, were more likely to be responsible.[18] Parental presence could also significantly increase POA. A study by Kim H et al.[18] compared POA in children with only video distraction, parental presence, and the combination of both. The video only distraction group did not obtain significant increase in m-YPAS score, but surprisingly, the group given both the video distraction and parental presence had a significant increase in m-YPAS score. Parental presence during induction of anesthesia is debatable, and it is thought that the anxiety from parents makes the children feel more anxious.[1011] Of these included studies, only two allowed parental presence during anesthesia induction,[511] but all studies described a lower m-YPAS mean in the audiovisual group.

Smartphones, tablet computers, and portable video players are just a few examples of portable multimedia equipment that is easily accessible and reasonably priced.[19] Although mostly cost-effective and results in lowering anxiety,[13] some still say audiovisual technology intervention is quite expensive.[10] Music can be an option. A study by Wang X et al.[3] described that music did not have a significant difference compared to animation videos. Additionally, as children typically think precisely and take things literally, the words the anesthesiologist chooses to communicate to the children about what is possible play an important role in the children’s anxiety.[20] A trial of having children and their accompanying parents see and learn about the operating room before surgery failed to reduce their anxiety,[17] but a study showed that a virtual tour of the operation room could reduce POA in children.[21]

This study aimed to describe the effect of audiovisual intervention for reducing POA in children, especially when given before induction in the holding room area. We excluded any videos that display or introduce the operating situation as it would raise bias because of the patients’ different knowledge.

The low number of studies (three) included in this analysis is a limitation because they might not represent all children who are administered general anesthesia. Different ages, exposure times, and audiovisual instruments including various applications used could also be a limitation of this study. Further research is needed to specify the best audiovisual technology devices or applications for lowering POA in children undergoing general anesthesia.

Conclusion

Audiovisual technology interventions such as video games, cartoons or animation videos, and smartphone applications have the efficacy for lowering POA in children undergoing general anesthesia. This intervention can be used as a strategy in the holding room to calm pediatric patients before undergoing surgery with general anesthesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

Authors express wholehearted appreciation to all who accompanied us for fulfilling this project.
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