Non‐Pharmacological Interventions Before Cataract Surgery for Preoperative Anxiety: A Systematic Review and Meta‐Analysis

ABSTRACT

Aim

The present study was conducted to determine the effect of non‐pharmacological interventions before cataract surgery on preoperative anxiety.

Design

Systematic review and meta‐analysis.

Methods

Five databases were systematically searched until 9 June, 2024. The risk of bias was evaluated using the ROBIN‐I instrument for non‐randomised studies and risk of bias 1 (ROB1) for RCTs. For cases with heterogeneity, random effects, rather than fixed effects, were reported, and subgroup analysis was performed based on the type of intervention. The investigation of publication bias was done in the form of a funnel plot, the Egger regression test and the Trim‐and‐Fill test. Meta‐regression analysis was performed to examine the impact of possible confounding factors on the effect size. Sensitivity analysis evaluated the robustness of our findings by excluding quasi‐experimental studies and applying the Knapp–Hartung method to assess their influence on the overall results.

Results

A random‐effects meta‐analysis of 22 studies and 1998 participants revealed that non‐pharmacological interventions (back massage, hand massage, foot massage, music, educational video, patient education, aromatherapy and relaxation techniques) significantly reduced mean preoperative anxiety compared to the control group. The subgroup analysis indicated that all interventions were effective in reducing preoperative anxiety; however, hand and foot massage did not yield significant effects. Meta‐regression analysis showed a significant correlation between the percentages of women with effect size. The sensitivity analysis confirmed the robustness of non‐pharmacological interventions, while the Knapp–Hartung method maintained the overall effect size but indicated wider confidence intervals. More high‐quality research is needed to validate these interventions and establish clearer guidelines.

Patient or Public Contribution

No Patient or Public Contribution.

Abbreviations

AAS

The Analogue Anxiety Scale

APAIS

The Amsterdam preoperative Anxiety and Information Scale

CI

confidence interval

I ²

Squared I

RCT

randomised controlled trial

ROB

the risk of bias

SE

standard error

SMD

standardised mean difference

STAI

The State–Trait Anxiety Inventory

VAS

Visual Analogue Scale

1. Introduction

Anxiety, characterised by mental, behavioural and physiological changes in response to perceived danger, is common before surgery (Arroll and Kendrick 2018; Blanchard and Blanchard 2008). Preoperative anxiety, affecting 48% of patients globally (Abate, Chekol, and Basu 2020), can lead to haemodynamic instability and increased postoperative analgesic needs (Celik and Edipoglu 2018; Merakou et al. 2015; Navarro‐Gastón and Munuera‐Martínez 2020; Williams and Jones 1968). Factors contributing to this anxiety include social support, pain, fear of surgery outcomes and previous surgical experiences (Abate, Chekol, and Basu 2020; Bedaso and Ayalew 2019; Socea et al. 2020).

Specifically, preoperative anxiety is linked to adverse postoperative effects such as pain, nausea and cognitive impairment (Ni, Zhu, and Ma 2023). Eye surgeries, particularly cataract surgery, often provoke high anxiety levels due to fears of blindness or surgery failure (Kuzmina, Rascheskov, and Kuzmin 2023; Ramirez et al. 2017). Cataracts, the leading cause of visual impairment globally, primarily result from ageing and oxidative stress, with surgery as the preferred treatment (Cicinelli, Buchan, Nicholson, Varadaraj, and Khanna, 2023).

Cataract surgery is among the most performed procedures worldwide, with visual acuity improvement exceeding 70% in high‐income countries and varying in middle‐ and low‐income countries (Ginel et al. 2023; Han et al. 2022). This surgery not only restores vision but also addresses age‐related conditions (Grzybowski and Kanclerz 2020). However, it can also induce physical and psychological effects. A systematic review indicates that phacoemulsification significantly raises preoperative anxiety and depression in visually impaired patients, potentially impacting surgical outcomes (Wang et al. 2022). This anxiety can adversely affect physiological markers like heart rate and blood pressure (Ezepue et al. 2024; Guerrier et al. 2024), posing challenges for patients and resulting in additional healthcare costs (Ginel et al. 2024).

Various pharmacological and non‐pharmacological strategies exist to reduce preoperative anxiety, including midazolam (Obuchowska and Konopinska 2021; Wang et al. 2022) and sublingual melatonin (Sane et al. 2023; Madsen et al. 2020). Non‐pharmacological techniques are associated with fewer side effects and can be applied across different ages and conditions (Wang et al. 2022). Given the growing interest in these interventions (Obuchowska and Konopinska 2021), a comprehensive review of their effectiveness in cataract surgery and preoperative anxiety is needed.

2. Background

Most patients before surgery require non‐pharmacological interventions to receive supportive measures for reducing preoperative anxiety (Salzmann et al. 2023). Non‐pharmacological methods for managing preoperative anxiety, such as music, massage and virtual reality, can serve as alternative or complementary approaches to medication and can be implemented by nurses as short‐term interventions (Agüero‐Millan, Abajas‐Bustillo, and Ortego‐Maté 2023).

Numerous meta‐analyses have investigated the effects of non‐pharmacological interventions on preoperative anxiety in various surgical procedures. One meta‐analysis demonstrated that aromatherapy, particularly when administered for a short duration in clinical settings, can significantly and effectively reduce preoperative anxiety in adults (Guo et al. 2020). Another meta‐analysis indicated that listening to music can have beneficial effects and serve as a suitable alternative to sedatives and anti‐anxiety medications in reducing preoperative anxiety (Bradt, Dileo, and Shim 2013).

However, regarding non‐pharmacological interventions for preoperative anxiety specifically related to cataract surgery, existing studies present conflicting results. Moreover, in the available literature, either cataract surgery has not been included in the studies or the number of studies included has been limited (Kim and Lee 2019). A review study specifically focused on non‐pharmacological interventions for managing anxiety and fear related to cataract surgery. The study examined only three interventions: hand massage, music therapy and patient education. However, it is important to note that no meta‐analysis or assessment of the quality of evidence from the included studies was conducted (Obuchowska and Konopinska 2021). Another meta‐analysis suggested that nursing interventions before and during cataract surgery, such as preoperative videos, back massage and music, may significantly reduce postoperative anxiety and pain, but only five studies were included in their analysis (Zeng et al. 2021).

This research is essential for informing clinical practice and optimising patient care by identifying evidence‐based interventions that can be incorporated into cataract preoperative care protocols. Given the lower cost and fewer complications associated with non‐pharmacological interventions compared to pharmaceutical methods or no intervention, and also considering that no comprehensive meta‐analysis has been conducted in this field to date, this systematic review and meta‐analysis aimed to assess the effectiveness of non‐pharmacological interventions implemented before cataract surgery for reducing preoperative anxiety. The study synthesised findings from relevant studies and examined the available evidence in order to provide a comprehensive overview of these interventions and their potential implications for clinical outcomes.

2.1. Objective

To examine the effects of non‐pharmacological interventions before cataract surgery on preoperative anxiety.

3. Methodology

This study was conducted based on the Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA) guidelines (Page et al. 2021). The protocol of this meta‐analysis was registered at PROSPERO on 17/02/2023 before the start of the study (CRD42023397122).

3.1. Search Methods

Databases of PubMed, Cochrane Library, Scopus, Web of Science and SID were searched, along with Google Scholar as a search engine. The search terms employed in the study's search strategy were as follows: (cataract extraction OR cataract surgery OR phacoemulsification*OR Phacoemulsification) AND (Stress OR Anxiety OR Panic OR surgery OR surgical OR preoperative OR ‘preoperative anxiety’) AND (relaxation technics OR meditation OR Psychotherapy OR Imagery OR aromatherapy OR essential oils OR aroma OR essential oils OR education OR ‘patient education’ OR ‘patient information’ OR ‘education program’ OR ‘Informative Video’ OR Media OR ‘audio video’ OR music OR rhythm OR melody OR singing OR sing OR song OR songs OR ‘hand massage’ OR reflexology foot massage OR ‘hand hold’) AND (‘randomised‐controlled trial’ OR ‘controlled clinical trial’ OR randomised OR randomly OR placebo OR trial OR RCT) until 9 June 2024. A manual search was also done. The references of the entered articles were also examined to obtain more studies. We also searched the European Association for Grey Literature Exploitation (EAGLE) and Health Care Management Information Consortium (HMIC) to find grey literature. The search strategy used to retrieve relevant articles from all databases is provided in Table S1.

3.2. Eligibility Criteria

3.2.1. Types of Studies

Included studies were all controlled and quasi‐experimental clinical trials published in English. The study excluded observational studies, reviews, letters to the editor and seminar and conference articles.

3.2.2. Types of Participants

Adult men and women who underwent age‐related cataract surgery regardless of the type of surgery were included, whereas studies with child participants were excluded.

3.2.3. Types of Interventions

All non‐pharmacological interventions performed preoperatively, such as back massage, hand and foot massage, hand holding, music, video, patient education, aromatherapy and relaxation techniques, were considered. Herbal and pharmaceutical interventions, as well as intraoperative interventions, were excluded from the study.

3.3. Comparison Group

Studies with a placebo, a concurrent treatment, or a waiting list were included in the systematic review. Studies without a comparison or control group were excluded from the study.

3.3.1. Types of Outcome Measures

Included studies were those that assessed post‐intervention anxiety before cataract surgery as a primary or secondary outcome. Studies that reported postoperative anxiety were excluded.

3.4. Selection of Studies

Using a premade form, two authors (MN; MMa) independently reviewed the retrieved articles for eligibility based on their titles, abstracts and, if necessary, full texts. When there was disagreement regarding the inclusion of a particular article, the third author (MMi) was consulted. The agreement between the authors was assessed using Cohen's kappa statistic, which yielded a value of 1, indicating perfect agreement.

3.5. Data Extraction

Two authors (MN; MMa) independently designed the data extraction form based on the guidelines from the Cochrane Handbook for Systematic Reviews of Interventions. Extracted information includes the author's name, year of publication, country, age of participants (years), final sample size, interventions, comparison groups, measurement instruments, outcomes and results. The agreement between the authors during the data extraction process was also assessed using Cohen's kappa statistic, which yielded a value of 1, demonstrating strong inter‐rater reliability.

3.6. Assessment of Risk of Bias in Included Studies

Based on the methods described for risk of bias 1 (ROB1) in the Cochrane Handbook, two authors (MN; MMa) independently assessed the risk of bias of the included randomised controlled trials (RCTs) as low, high, or unclear. The risk of bias in non‐randomised studies was evaluated using the ROBIN‐I instrument. This instrument evaluates biases caused by confounding, selection bias, intervention classification, deviation from the intended intervention, missing data, outcome measurement and selection outcome.

3.7. Data Analysis

Stata version 18 was utilised for the meta‐analysis. The restricted maximum likelihood (REML) method was applied as the random effects model (Tanriver‐Ayder et al. 2021). In light of the fact that different instruments were used to assess preoperative anxiety in the included studies, the standardised mean difference (SMD) was reported along with a 95% confidence interval (CI) (Higgins et al. 2019). Statistical heterogeneity was evaluated based on the I² statistic and the chi‐squared P‐value. Additionally, tau² was used as an absolute measure of heterogeneity between studies. If I² was greater than 30% (Maghalian, Alikamali, Nabighadim, and Mirghafourvand, 2024), the studies were deemed heterogeneous.

Given that the random effects model assumes that the studies were drawn from populations that differ from each other in ways that could impact the treatment effect, the goal of this analysis is typically to generalise to a range of populations. Therefore, in the present systematic review and meta‐analysis, where the interventions in the included studies were varied and could impact the results, the random effects model is more easily justified than the fixed effects model. Thus, we used random effects instead of fixed effects. (Borenstein et al. 2017; Ng et al. 2018). Furthermore, we conducted a subgroup analysis based on the type of intervention to provide additional insights (Iezadi et al. 2021).

The meta‐analysis data was the mean change based on the post‐intervention score minus the baseline and the standard deviation (SD) change according to the SD change equation. (Cumpston et al. 2019).

Sensitivity analysis was conducted using Stata version 18 to assess the robustness of our initial findings through two methods: (1) exclusion of quasi‐experimental studies and (2) application of the Knapp–Hartung method. This approach aimed to evaluate how these factors influenced the overall results.

Publication bias was assessed using Comprehensive Meta‐Analysis V3 through the examination of a funnel plot and the application of the Egger regression test. A significance level of 0.1 was considered for publication bias. Additionally, the Trim‐and‐Fill test, utilising a random‐effects model, was employed to identify potentially missed studies and address publication bias if detected (Iezadi et al. 2021).

A random effects meta‐regression analysis was conducted using Comprehensive Meta‐Analysis V3 with the Knapp–Hartung adjustment to investigate the influence of potential confounding variables on the effect size. These factors included the mean age of participants, the percentage of women, total sample size, year of publication, risk of bias (high risk, low risk, unclear risk), study design (RCT, quasi‐experimental) and intervention type (back massage, hand and foot massage, music, video, patient education, aromatherapy and relaxation techniques) (Thompson and Higgins 2002; Tunç et al. 2023). Certainty of the evidence was done based on the GRADE approach, and judgements were made as high, moderate, low and very low (GRADE Working Group 2004).

4. Results

4.1. Results of the Search

The databases yielded a total of 835 articles, of which 256 were eliminated due to redundancy, 372 were screened by examining their titles, 160 by examining their abstracts, and 47 by reviewing their full texts. Of the 33 articles initially identified, 10 studies were excluded from this analysis for the following reasons: One study (Achar et al. 2021) lacked a control group; two studies (Kekecs et al. 2014; Ezepue et al. 2024) reported solely on baseline preoperative anxiety; one study (Saleh Abadi et al. 2018) focused exclusively on the physiological changes associated with anxiety. Additionally, two studies (Karaman Özlü, Tuğ, and Çay Yayla 2016; Tipotsch‐Maca et al. 2016) reported only postoperative anxiety, and another study (Li et al. 2021) addressed anxiety related to surgeries other than cataract surgery. Studies investigating hand‐holding interventions (Anuja et al. 2014; Mokashi et al. 2004; Moon and Cho 2001) were excluded as they either occurred during the surgical procedure or reported only postoperative anxiety. Consequently, 23 articles remained for qualitative synthesis. Furthermore, the results of one study (Muddana et al. 2021), which were presented as percentages, were excluded from the meta‐analysis (Figure 1 and Table S2).

FIGURE 1.

Flow diagram of the systematic literature search.

4.2. Characteristics of Included Studies

Table 1 shows the characteristics of the included studies.

TABLE 1.

Characteristics of included studies.

Author(s)/country/(year of publication)	Study design	Final sample size	Age of participants (years)	Interventions	Comparison group	Measurement instruments	Outcomes	Results
Ahmed et al./United Kingdom/(2019)	Prospective controlled trial	Informative video group: 100 Control group: 100 (male and female)	Informative video group: 74 ± 10.5 Control group: 73 ± 11 (male and female)	The intervention group watched an informative video preoperatively on the day of their surgery, when they arrived at the ward before their surgery and dilation procedures.	No multimedia training was given and they received only routine care	Preoperative anxiety	VAS	Informative video significantly reduced anxiety in cataract surgery candidates compared to the control group.
Anwaar et al./Lahore/(2021)	RCT	Patient education group: 23 Control group: 23 (male and female)	> 17	Patients listened to a 15‐min and 27‐s audio recording 5 times before surgery, which provided education about the surgical stages, recovery timeline, helpful tips, relaxation techniques and visualisation exercises.	‘Standard clinical therapy, but they didn't do anything to prepare psychologically’	Preoperative anxiety	STAI	Patient education significantly reduced anxiety in cataract surgery candidates compared to the control group.
Barabady et al./Iran/(2020)	RCT	Benson's Relaxation Technique group: 36 Control group: 36 (men and female)	30–60	The intervention group was taught Benson's relaxation technique for 20 min using an audio file, which they then practiced twice before the surgery – once the evening before and once the morning of the surgery – under the supervision of an expert.	‘Control group did not receive any preoperative intervention or relaxation’	Preoperative anxiety	STAI	Benson's relaxation technique significantly reduced anxiety in cataract surgery candidates compared to the control group.
Çavdar et al. /Turkey/(2020)	RCT	Hand massage group: 70 Control group: 70 (male and female)	≤ 18	Immediately before the operation, the patients' palms, hands and fingers were massaged for 10 min with baby oil using techniques like patting, kneading, stretching and circular movements.	The control group did not receive hand massage.	Preoperative anxiety	STAI	Hand massage significantly reduced anxiety in cataract surgery candidates compared to the control group.
Eftekharpour Fatemi et al./Iran (2021)	Non‐blind RCT	Informative video group: 25 Control group: 25 (male and female)	> 60	The 3‐stage informative video shown to patients covered preparation, surgical environment, the operation itself, recovery, post‐surgical care and follow‐up visits with the doctor.	No multimedia training was given and they received only routine care	Preoperative anxiety	STAI	Informative video did not significantly reduce anxiety in cataract surgery candidates compared to the control group.
Farahani et al./Iran/(2019)	Non‐blind RCT	Hand massage group: 30 Foot massage group: 30 Control group: 30 (female)	Hand massage group: 63.66 ± 7.20 Foot massage group: 87.20 ± 12.85 Control group: 63.20 ± 10.52	10 min before surgery, patients received a 5‐min hand massage and a 5‐min foot massage, both using techniques like petrissage, kneading and friction.	Placebo massage: Hand holding was applied, and the patient's hands were rubbed without pressure.	Preoperative anxiety	VAS	Foot and hand massage significantly reduced anxiety in cataract surgery candidates compared to the control group.
Guerrier et al. /France/(2021)	Single‐masked RCT	Music group: 119 Control group: 124 (male and female)	< 18	Patients listened to a 20‐min music session through headphones while wearing a sleeping mask to conceal their eyes, which was removed before the surgical procedure.	Headphones were placed on patient's ears, but no music was played.	Preoperative anxiety	VAS	Music intervention significantly reduced anxiety in cataract surgery candidates compared to the control group.
Gupta et al. /India/(2018)	RCT	Meditation Technique group: 50 Control group: 50 (male and female)	> 40	Patients and their family members received psychoneurotic training, including basic concepts and instructions, before surgery, and patients were advised to practice 30‐min meditation sessions in a dimly‐lit hospital room.	Only received counselling about the surgery and anaesthesia.	Preoperative anxiety	APAIS	Meditation technique significantly reduced anxiety in cataract surgery candidates compared to the control group.
Kim et al./Korea/(2001)	Quasi‐experimental	Hand massage group: 29 Control group: 30 (male and female)	Mean age was 57.42 years (range 20 to 78 years).	5 min before surgery, patients received a 2.5‐min hand massage on the palms and backs of their hands using techniques like effleurage, circular pressure, petrissage and neurostrokes with olive oil.	The control group did not receive hand massage (routine care).	Preoperative anxiety	VAS	Hand massage significantly reduced anxiety in cataract surgery candidates compared to the control group.
Loong et al./Malaysia/(2022)	RCT	Music (binaural beat) group: 31 Control group: 30 (male and female)	Binaural beat group: 67.7 ± 9.0 Control group: 63.9 ± 6.2	10 min before the start of surgery, patients listened to 10 Hz binaural beats designed to induce happiness through headphones.	Headphones were placed on patient's ears, but no music was played.	Preoperative anxiety	STAI	Binaural beats significantly reduced anxiety in cataract surgery candidates compared to the control group.
Mohammadpourhodki et al./Iran/(2019)	Quasi‐experimental	Back massage group: 30 Control group: 30 (male and female)	≤ 18	30 min before surgery, patients received a 15‐min back massage using warm, oily hands with slow, superficial strokes from the occiput to the sacrum while in a semi‐sitting position.	Routine hospital‐based educations, including an information pamphlet.	Preoperative anxiety	STAI	Back massage significantly reduced anxiety in cataract surgery candidates compared to the control group.
Moladoost et al./Iran/(2021)	Quasi‐experimental	Patient education group: 32 Control group: 32 (male and female)	> 18	Patient education involved an in‐person educational session, a hospital visit and telephone contact with the participants.	Routine hospital‐based educations.	Preoperative anxiety	STAI	Patient education significantly reduced anxiety in cataract surgery candidates compared to the control group.
Muddana et al./India/(2021)	Single‐masked RCT	Music group: 165 Control group: 165 (male and female)	53–65	Patients were provided a portable MP3 player to listen to music before and during their first‐time phacoemulsification procedure.	Without music	Preoperative anxiety	Likert scale anxiety rating	Music intervention significantly reduced anxiety in cataract surgery candidates compared to the control group.
Sattar et al./Iran/(2019)	RCT	Informative video group: 80 Control group: 80 (male and female)	20–75	Patients were shown a 10‐min educational video about cataract disease, how cataract surgery is performed and pre‐ and post‐operative care.	No multimedia training was given and they received only routine care	Preoperative anxiety	STAI	Informative video significantly reduced anxiety in cataract surgery candidates compared to the control group.
Shahdadi et al./Iran/(2017)	Quasi‐experimental	Foot massage group: 30 Control group: 30	≤ 18	Patients received 15 min of foot reflexology per foot, including 5 min of warming and 10 min of massaging specific reflection points on the solar network, pituitary, heart and lungs.	The control group did not receive foot massage.	Preoperative anxiety	STAI	Foot massage significantly reduced anxiety in cataract surgery candidates compared to the control group.
Stanley et al./USA/(2019)	RCT	Aromatherapy group: 39 Control group: 36 (male and female)	21–75	In the lounge holding area, a vaporizer with 20 drops of lavender essential oil was placed near the patient's chair to provide lavender aromatherapy.	20 drops of grape seed oil.	Preoperative anxiety	STAI	Aromatherapy significantly reduced anxiety in cataract surgery candidates compared to the control group.
Wibawa et al./Indonesia/(2018)	Quasi‐experimental	Patient Education group: 35 Control group: 34 (male and female)	The majority of participants (84.1%) were over 50 years old.	Patients received 15 min of health education counselling as well as an informational leaflet covering definitions, signs/symptoms of cataracts, importance of surgery and what to do before, during and after the procedure.	Health education was applied using a lecture for 15 min, with a question and answer section and leaflet.	Preoperative anxiety	AAS	Health education using counselling and lecture methods significantly reduced anxiety in patients who were candidates for cataract surgery.
Wiwatwongwana et al./Thailand/(2016)	RCT	Music group: 44 Binaural beat group: 44 Control group: 47 (male and female)	Music group: 67.0 ± 7.8 Binaural beat group: 68.4 ± 8.2 Control group: 69.0 ± 10.0	10 min before surgery, patients listened to music on an iPod shuffle MP3 player through canal‐type stereo earphones.	Headphones were placed on patient's ears, but no music was played.	Preoperative anxiety	STAI‐S	Binaural beats and music interventions significantly reduced anxiety in cataract surgery candidates compared to the control group.
Zhang et al./USA/(2019)	RCT	Informative video group: 39 Control group: 40 (male and female)	≤ 40	Patients were shown a 4‐min informative video explaining phacoemulsification cataract surgery with monofocal lens replacement.	No multimedia training was given and they received only routine care	Preoperative anxiety	STAI	Informative video significantly reduced anxiety in cataract surgery candidates compared to the control group.
Daştan et al./Turkey/(2024)	RCT	Hand massage group: 30 Control group: 30 (male and female)	The majority of participants were over 50 years old in the intervention group and over 60 years old in the control group.	The researcher applied vaseline to their hands and then performed hand massages using techniques like effleurage, petrissage, friction and vibration to distribute the vaseline over the patients' hands.	Routine hospital‐based educations.	Preoperative anxiety	VAS	Hand massage significantly reduced anxiety in cataract surgery candidates compared to the control group.
Ezepue et al./Nigeria/(2023)	RCT	Music group: 49 Control group: 49 (male and female)	Music group: 64.27 ± 7.58 Control group: 66.14 ± 9.27	Participants listened to music on a 2019 portable MP3 player using VectorStock earphones, which they could adjust the volume on to play their preferred music.	Headphones were placed on patient's ears, but no music was played.	Preoperative anxiety	STAI	Music intervention significantly reduced anxiety in cataract surgery patients compared to controls.

Abbreviations: AAS, The Analogue Anxiety Scale; APAIS, the Amsterdam preoperative Anxiety and Information Scale; RCT, randomised controlled trial; STAI, The State–Trait Anxiety Inventory; VAS, Visual Analogue Scale.

4.3. Study Settings

Seven studies were conducted in Iran (Shahdadi, Mansouri, and Bandani 2017; Mohammadpourhodki, Sargolzaei, and Basirinezhad 2019; Barabady et al. 2020; Farmahini Farahani et al. 2020; Eftekharpour Fatemi et al. 2021; Moladoost et al. 2021; Sattar et al. 2021), two studies in the USA (Zhang et al. 2019; Stanley, Wan, and Karim 2020), one study in France (Guerrier et al. 2021), two studies in India (Gupta and Pradhan 2018; Muddana et al. 2021), one study in Thailand (Wiwatwongwana et al. 2016), one study in Malaysia (Loong et al. 2022), one study in Indonesia (Wibawa, Suharjo, and Rahmat 2018), one study in Korea (Kim et al. 2001), one study in Lahore (Anwaar et al. 2022), two studies in Turkey (Çavdar, Yılmaz, and Baydur 2020; Daştan, Efe, and Erkiliç 2024), one study in Nigeria (Ezepue et al. 2023) and one in the United Kingdom (Ahmed et al. 2019).

4.4. Participants

In the majority of the included studies, both men and women participated, with the exception of one study (Farmahini Farahani et al. 2020) that only included women. In each of the included studies, participants were at least 17 years old and free of mental illness. In one study (Zhang et al. 2019), participants with a history of depression or anxiety were included, albeit they were distributed in a homogeneous manner between the study groups. In 10 studies, the use of sedative or anti‐anxiety drugs prior to surgery was among the exclusion criteria, whereas in 9 studies, the use of these drugs was not mentioned (Moon and Cho 2001; Marback, Temporini, and Júnior 2007; Ramirez et al. 2017; Celik and Edipoglu 2018; Saleh Abadi et al. 2018; Guo et al. 2020; Koo et al. 2020; Han et al. 2022; Loong et al. 2022).

4.5. Sample Size

The sample size in the included studies was 1998 participants, which ranged from 46 samples in Anwaar et al. (2022) study to 243 samples in Guerrier et al. (2021) study.

4.6. Outcome Measures

In 13 studies, the STAI measure developed by Speilberger et al. (1983), Wiwatwongwana et al. (2016), Shahdadi, Mansouri, and Bandani (2017), Mohammadpourhodki, Sargolzaei, and Basirinezhad (2019), Zhang et al. (2019), Barabady et al. (2020), Çavdar, Yılmaz, and Baydur (2020), Stanley, Wan, and Karim (2020), Eftekharpour Fatemi et al. (2021), Moladoost et al. (2021), Sattar et al. (2021), Anwaar et al. (2022), Loong et al. (2022), Ezepue et al. (2023) was employed. It is a 40‐item scale that measures state anxiety (STAI‐S) and trait anxiety (STAI‐T) dimensions. Each response is based on a four‐point Likert scale ranging from 20 (minimal anxiety) to 80 (maximal anxiety) (Speilberger et al. 1983).

Five studies (Kim et al. 2001; Ahmed et al. 2019; Farmahini Farahani et al. 2020; Guerrier et al. 2021; Daştan, Efe, and Erkiliç 2024) utilised the visual analogue scale (Abate et al. 2020), a 10 cm horizontal line on which 0 represents the least anxiety and 10 represents the most anxiety (Hornblow and Kidson 1976).

In one study (Gupta and Pradhan 2018), the 6‐item Amsterdam preoperative anxiety and information scale (APAIS) was utilised, which is based on a 5‐point Likert scale and has three subscales: anxiety for anaesthesia, anxiety for surgery and need for information. In the combined anxiety score (anxiety related to anaesthesia and surgery), a score of 11 or above indicates anxiety, and 5 or above indicates a need for additional information regarding anaesthesia and surgery (Moerman et al. 1996).

In one study (Muddana et al. 2021), anxiety was also evaluated using the Likert scale. In one study (Wibawa, Suharjo, and Rahmat 2018), the analogue anxiety scale was used to measure anxiety. If the score is less than 150, there is no anxiety; if it is between 150 and 199, there is mild anxiety; if it is between 200 and 299, there is moderate anxiety; if it is between 300 and 399, there is severe anxiety; and if it is greater than 400, there is panic (Malakcioglu 2022).

4.7. Risk of Bias of Included Studies

Out of the 21 studies included, 15 were RCTs and 6 were quasi‐experimental. Random sequence generation was low risk in 11 studies due to the use of block randomisation (Barabady et al. 2020; Çavdar, Yılmaz, and Baydur 2020; Eftekharpour Fatemi et al. 2021), a computer program (Wiwatwongwana et al. 2016; Zhang et al. 2019; Farmahini Farahani et al. 2020; Guerrier et al. 2021; Daştan, Efe, and Erkiliç 2024), random cards (Sattar et al. 2021; Anwaar et al. 2022; Ezepue et al. 2023) and the envelope technique (Loong et al. 2022). In two studies (Gupta and Pradhan 2018; Stanley, Wan, and Karim 2020), the risk was assessed as unclear because random sequence generation was not mentioned.

Nine studies were considered to have unclear risks because the allocation concealment method was not mentioned. In 6 studies (Wiwatwongwana et al. 2016; Guerrier et al. 2021; Anwaar et al. 2022; Loong et al. 2022; Daştan, Efe, and Erkiliç 2024; Ezepue et al. 2023), the risk was evaluated as low since the researchers and participants were blind until participant allocation to groups was completed.

Blinding of participants and personnel was deemed high risk in seven studies (Gupta and Pradhan 2018; Zhang et al. 2019; Çavdar, Yılmaz, and Baydur 2020; Farmahini Farahani et al. 2020; Stanley, Wan, and Karim 2020; Eftekharpour Fatemi et al. 2021; Anwaar et al. 2022) due to the non‐blindness of the studies or the nature of the intervention, which did not permit participant blinding. The risk was low in 6 studies (Wiwatwongwana et al. 2016; Daştan, Efe, and Erkiliç 2024; Ezepue et al. 2023; Guerrier et al. 2021; Loong et al. 2022) and unclear in two studies (Muddana et al. 2021; Sattar et al. 2021).

The risk of blinding the outcome assessor was high in two studies (Çavdar, Yılmaz, and Baydur 2020; Eftekharpour Fatemi et al. 2021) because the studies were non‐blind and outcome assessor were aware of the type of intervention received, unclear in four studies (Wiwatwongwana et al. 2016; Zhang et al. 2019; Stanley, Wan, and Karim 2020; Sattar et al. 2021) and low in 9 studies (Gupta and Pradhan 2018; Barabady et al. 2020; Farmahini Farahani et al. 2020; Guerrier et al. 2021; Muddana et al. 2021; Anwaar et al. 2022; Loong et al. 2022; Daştan, Efe, and Erkiliç 2024; Ezepue et al. 2023).

All studies were deemed low‐risk in terms of two types of bias. Incomplete outcome data bias posed a low risk because all participants completed the studies, or participant attrition in the study groups was balanced and had no impact on the desired outcome; selection of reporting bias posed a low risk due to the reporting of outcomes and the availability of protocols for the majority of studies. Due to the deficiency of information in these domains, only two studies (Muddana et al. 2021; Ezepue et al. 2023) were labelled as having an unclear risk (Figures 2 and 3).

FIGURE 2.

Risk of bias summary: Review authors' judgements about each risk of bias item for each included study.

FIGURE 3.

Risk of bias graph: Authors' judgements about each risk of bias item presented as percentages across all included studies.

Six studies were quasi‐experimental; the risk of bias assessment using the ROBINS‐1 instrument revealed that the overall risk of bias in these studies (Kim et al. 2001; Shahdadi, Mansouri, and Bandani 2017; Wibawa, Suharjo, and Rahmat 2018; Ahmed et al. 2019; Mohammadpourhodki, Sargolzaei, and Basirinezhad 2019; Moladoost et al. 2021) was high. Consequently, these studies had significant flaws in the examined domains (Table 2).

TABLE 2.

Risk of bias in quasi‐randomised clinical trials according to ROBINS‐I.

Author	Moladoost et al. (2021)	Wibawa, Suharjo, and Rahmat (2018)	Mohammadpourhodki, Sargolzaei, and Basirinezhad (2019)	Kim et al. (2001)	Shahdadi, Mansouri, and Bandani (2017)	Ahmed et al. (2019)
Bias due to confounding	Moderate	Serious	Low	Serious	Serious	Low
Bias in selection of participants	Serious	No information	Serious	No information	Serious	Serious
Bias in the classification of interventions	Serious	No information	Serious	Serious	No information	Serious
Bias due to deviations from intended interventions	Low	Low	No information	No information	Serious	No information
Bias due to missing data	Low	Low	Low	Moderate	Low	Low
Bias in measurement of outcomes	Moderate	Low	Low	Low	Moderate	Low
Bias in selection of reported result	Low	Low	Low	Low	Moderate	Moderate
Overall	Serious	Serious	Serious	Serious	Serious	Serious

Note: Low, low risk of bias (the study is comparable to a well‐performed randomised trial with regard to this domain); No information, no information on which to base a judgement about risk of bias for this domain; Serious, serious risk of bias (the study has some important problems).

4.8. Synthesis of Results

A random‐effects meta‐analysis of 22 studies and 1998 participants revealed that non‐pharmacological interventions (back massage, hand massage, foot massage, music, educational video, patient education, aromatherapy and relaxation techniques) significantly reduced mean preoperative anxiety compared to the control group (SMD: –2.14, 95% CI: −3.48 to −0.79; p < 0.001; low‐certainty evidence). The degree of heterogeneity was high [I ² = 99.4%; p < 0.0001, Tau² = 10.25]. The 95% confidence interval for I ² was 0.00–99.88 (Figure 4). We therefore can only make a weak recommendation for the use of interventions to reduce preoperative anxiety in this population.

FIGURE 4.

The effect of non‐pharmacological interventions before cataract surgery versus control on preoperative anxiety.

Due to the high heterogeneity observed across the included studies (I ² = 99.4%), we conducted a subgroup analysis, a meta‐regression and a sensitivity analysis in order to identify potential sources contributing to this high degree of variability.

Subgroup: variation in type of intervention (music, hand massage, aromatherapy, relaxation techniques, patient education, educational video, back massage and foot massage):

The subgroup analysis is illustrated in Figure 4.

4.8.1. Music

The use of music significantly reduced preoperative anxiety (SMD: –1.26, 95% CI: −1.70 to −0.80; 5 trials, 584 participants; low‐certainty evidence; Tau²: 0.212, I ²: 82.7).

4.8.2. Hand Massage

This intervention led to a significant decrease in anxiety (SMD: –4.79, 95% CI: −12.8 to 3.22; 4 trials, 319 participants; low‐certainty evidence; Tau²: 66.14, I ²: 99.8).

Due to the low certainty of the evidence, we can only suggest the use of hand massage and music but cannot strongly recommend them. Further high‐quality research is needed.

4.8.3. Aromatherapy

The evidence regarding aromatherapy remains uncertain (SMD: –0.52, 95% CI: −0.97 to −0.06; 1 trial, 75 participants; very low‐certainty evidence; Tau²: 0.00, I ²: 0.00).

4.8.4. Relaxation Techniques

These techniques showed a significant reduction in preoperative anxiety (SMD: –1.83, 95% CI: −3.45 to −0.21; 2 trials, 172 participants; very low‐certainty evidence; Tau²: 1.296, I ²: 95.0).

4.8.5. Patient Education

Our findings indicated a significant reduction in anxiety through patient education (SMD: –1.52, 95% CI: −2.77 to −0.28; 3 trials, 179 participants; very low‐certainty evidence; Tau²: 1.111, I ²: 92.6).

4.8.6. Educational Video

The intervention using educational videos also significantly reduced anxiety (SMD: –1.18, 95% CI: −2.00 to −0.35; 4 trials, 489 participants; very low‐certainty evidence; Tau²: 0.659, I ²: 93.7).

4.8.7. Back Massage

The results for back massage were mixed, showing a significant reduction in anxiety (SMD: –0.53, 95% CI: −1.03 to −0.02; 1 trial, 60 participants; very low‐certainty evidence; Tau²: 0.00, I ²: 0.00).

4.8.8. Foot Massage

The results for foot massage were not statistically significant (SMD: –5.12, 95% CI: −11.7 to 1.46; 2 trials, 120 participants; very low‐certainty evidence; Tau²: 22.16, I ²: 98.3).

Given the very low certainty, we can only make weak suggestions for the use of these interventions (aromatherapy, foot massage, back massage, video patient education, relaxation techniques and educational interventions) to reduce preoperative anxiety but cannot confidently recommend them based on the current evidence.

The test for heterogeneity based on subgroup analysis for each intervention is presented in Table S3.

4.8.9. Publication Bias

The funnel plot used to investigate publication bias was asymmetric. The funnel plot used to examine publication bias displayed asymmetry. Furthermore, the Egger regression test (p = 0.006) indicated the presence of bias (Figure 5).

FIGURE 5.

Assessment of the publication bias for preoperative anxiety (Funnel plot).

The results of the Trim‐and‐Fill test suggested that 7 studies were missed. Using Trim and Fill, the imputed point estimate was −2.37 (−2.91, −1.84). The plot of the imputed studies can be found in Figure S1.

4.9. Meta‐Regression Analyses

Table 3 and Figure S2 display the findings from the meta‐regression analyses. The results showed no significant associations between effect sizes and the following variables: total sample size (p = 0.481), year of publication (p = 0.486), risk of bias (p = 0.269), study design (p = 0.109), age of participants (p = 0.197), or type of intervention (p = 0.905). However, a significant correlation was observed between the percentage of women and effect size; specifically, as the percentage of women increased (β = −0.128, p = 0.003), the effect size decreased.

TABLE 3.

Meta‐regression analysis of variables predicting anxiety using Knapp–Hartung adjustment.

Continuous variables	β Regression coefficient (SE)	95% CI	p	R 2
Mean age	−0.215 (0.158)	−0.558 to 0.127	0.197	0.07
Women (%)	−0.128 (0.035)	−0.205 to −0.051	0.003	0.02
Total sample size	0.003 (0.010)	−0.018 to 0.024	0.771	0.11
Year of publication	−0.033 (0.115)	−0.273 to 0.207	0.776	0.04

Categorical variables	Regression coefficient (SE)	95% CI	p	R 2
Study design (reference group: RCT)	0.767 (1.143)	−1.618 to 3.153	0.509	0.07
Risk of bias (reference group: low risk)	—	—	0.77	0.19
High risk	−0.735 (1.576)	−4.035 to 2.564	0.646	—
Unclear risk	0.073 (1.877)	−3.877 to 4.025	0.969	—
Intervention type (reference group: music)	—	—	0.905	0.32
Aromatherapy	0.754 (3.018)	−5.720 to 7.229	0.806	—
Relaxation techniques	−0.565 (2.315)	−5.530 to 4.400	0.810	—
Patient education	−0.263 (2.036)	−4.631 to 4.103	0.898	—
Video informative	0.100 (1.845)	−3.858 to 4.059	0.957	—
Hand massage	−1.081 (1.952)	−5.269 to 3.106	0.588	—
Back massage	0.740 (3.033)	−5.766 to 7.246	0.810	—
Foot massage	−3.291 (2.491)	−8.634 to 2.051	0.207	—

Abbreviations: CI, confidence interval; R ², The R² analogue indicates the extent to which the model accounts for the variance in true effects; SE, standard error.

4.10. Sensitivity Analysis

The sensitivity analysis showed that excluding quasi‐experimental studies did not affect the significance of non‐pharmacological interventions, except for foot massage, which indicated a significant effect on preoperative anxiety after the quasi‐experimental study was removed (Table S4).

According to the Knapp–Hartung method (Figure S3), the overall effect size of preoperative anxiety remained unchanged (SMD –2.14) across analyses. However, the 95% confidence intervals differed, with the Knapp–Hartung method producing a wider confidence interval (−3.68 to −0.59) compared to the initial analysis (−3.48 to −0.79). Furthermore, all interventions retained their significance levels, with only the relaxation technique showing a non‐significant effect on preoperative anxiety as per the Knapp–Hartung method.

4.11. Certainty of Evidence

4.11.1. Preoperative Anxiety

The evidence for preoperative anxiety was rated as very low certainty. The GRADE assessment downgraded the evidence by one level due to risk of bias from detection bias, one level for inconsistency with an I ² of 99.4% and one level for suspected publication bias.

Hand massage and music: The evidence for hand massage and music interventions was rated as low certainty. The GRADE assessment downgraded the evidence by one level due to risk of bias from detection, performance and allocation concealment bias, as well as some inconsistency in the results across studies.

4.11.2. Other Interventions (Aromatherapy, Foot Massage, Back Massage, Educational Video, Relaxation Techniques and Patient Education)

The evidence for these interventions was rated as very low certainty. The GRADE assessment downgraded the evidence by one level for risk of bias and inconsistency and an additional one to two levels for imprecision due to small sample sizes, leading to wide confidence intervals and less precise effect estimates (Table 4).

TABLE 4.

Quality assessment of included studies according to GRADE approach.

No of studies	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Publication bias	Pooled effect size (95% CI)	Final judgement (certainty)
22	RCT and Quasi experimental	Serious	Serious	No serious	No serious	Serious	SMD‐2.14, 95% CI: −3.48 to −0.79	⊕ ⊖ ⊖⊖ Very Low
Aromatherapy
1	RCT	Serious	Undetected	No serious	Very Serious	No serious	SMD: −0.52, 95% CI: −0.98 to −0.06	⊕ ⊖ ⊖⊖ Very Low
Relaxation techniques
2	RCT	Serious	Serious	No serious	Serious	No serious	SMD: −1.83, 95% CI: −3.45 to −0.21	⊕ ⊖ ⊖⊖ Very Low
Patient education
3	RCT and Quasi experimental	Serious	Serious	No serious	Serious	No serious	SMD: −1.52, 95% CI: −2.77 to −0.28	⊕ ⊖ ⊖⊖ Very Low
Video educational
4	RCT	Serious	Serious	No serious	Serious	No serious	SMD: −1.18, 95% CI: −2.00 to −0.35	⊕ ⊖ ⊖⊖ Very Low
Hand massage
4	RCT and Quasi experimental	Serious	Serious	No serious	No serious	No serious	SMD: −4.79, 95% CI: −12.8 to 3.22	Low ⊕ ⊕ ⊖⊖
Music
5	RCT	Serious	Serious	No serious	No serious	No serious	SMD: −1.26, 95% CI: −1.70 to −0.80	Low ⊕ ⊕ ⊖⊖
Back massage
1	Quasi experimental	Serious	Undetected	No serious	Very Serious	No serious	SMD: −0.53, 95% CI: −1.05 to −0.02	⊕ ⊖ ⊖⊖ Very Low
Foot massage
2	RCT and Quasi experimental	Serious	Serious	No serious	Very Serious	No serious	SMD: −5.12, 95% CI: −11.7 to 1.46	⊕ ⊖ ⊖⊖ Very Low

Abbreviations: CI, confidence interval; RCT, randomised controlled trial; SMD, standardised mean difference.

5. Discussion

5.1. Main Finding and Interpretation

The findings of the present study indicate that non‐pharmacological interventions can significantly reduce preoperative anxiety in patients undergoing cataract surgery. The significant reduction in preoperative anxiety through these interventions highlights their potential to enhance patient care. By effectively addressing patients' emotional needs through non‐pharmacological strategies, healthcare providers (particularly nurses) can create a supportive environment that enhances overall patient care (Kwame and Petrucka 2021). This proactive approach not only improves patient comfort but also has the potential to lead to several positive clinical outcomes. Improved preoperative anxiety management can result in better surgical outcomes, as patients who experience less anxiety tend to have lower rates of postoperative complications. Additionally, reduced anxiety is associated with shorter recovery times, which can translate to decreased hospital stays and lower healthcare costs (Baagil, Baagil, and Gerbershagen 2023; Ji et al. 2022; Baek, Kim, and Bissett 2024).

However, the observed high degree of heterogeneity (I ² = 99.4%) raises concerns regarding the reliability and generalisability of these outcomes. Variations in study design, participant characteristics and types of interventions employed contribute to this inconsistency, suggesting that different contexts and methodologies may yield divergent results (Rogers, De Brún, and McAuliffe 2020). To address this substantial heterogeneity, we conducted a comprehensive subgroup analysis, meta‐regression and sensitivity analysis to identify potential sources of variability. The subgroup analysis indicated that all interventions were effective in reducing preoperative anxiety; however, hand and foot massage did not yield significant effects. Music and hand massage showed low‐certainty evidence, necessitating careful interpretation of these results. Other interventions demonstrated very low‐certainty evidence, underscoring the urgent need for more rigorous research in this area.

Several factors may have influenced the results of our study, particularly the diversity in participant demographics, including age, gender and cultural background. This diversity can significantly affect how individuals respond to various interventions. Our meta‐regression analysis revealed a negative correlation between the percentage of women and effect size, suggesting that gender differences in preoperative anxiety responses could impact the effectiveness of the employed interventions (Bedaso, Mekonnen, and Duko 2022). The methodological quality of the included studies is another critical factor affecting our findings. Many studies had small sample sizes, which can lead to an overestimation of effects and reduced reliability. The presence of bias, particularly concerning randomisation and blinding, complicates the interpretation of results. Our sensitivity analysis indicated that excluding quasi‐experimental studies did not significantly alter the effectiveness of most interventions; however, foot massage demonstrated a significant effect when the quasi‐experimental study was removed. This underscores the importance of rigorous study design in evaluating intervention efficacy.

Moreover, participants' educational levels appear to play a significant role in the variability of patient education outcomes. As highlighted in the study by Eftekharpour Fatemi et al. (2021), differences in educational levels among participants may lead to varying levels of preoperative anxiety. This notion is supported by additional literature, including studies by Mulugeta et al. (2018), Gürler, Yılmaz, and Türk (2022), which emphasise the need for tailored educational interventions that consider patients' comprehension levels to effectively mitigate anxiety.

In our study, the interventions with the highest representation were educational videos, hand massage (4 studies) and music (5 studies). Additionally, the effectiveness of educational videos extends beyond cataract surgery; research has indicated similar advantages in other surgical settings, including elective caesarean sections (Maghalian, Mohammad‐Alizadeh‐Charandabi, Ranjbar, Alamdary, and Mirghafourvand, 2024), cardiac surgeries (Ng et al. 2022) and paediatric surgeries (Koo et al. 2020). These results imply a broader applicability of video‐based interventions in reducing preoperative anxiety across various surgical fields. In terms of music interventions, all studies included were RCTs that consistently demonstrated a decrease in preoperative anxiety. Furthermore, research by Guerrier et al. revealed that music not only alleviates anxiety but also reduces postoperative pain, potentially enabling earlier hospital discharge and decreasing healthcare costs (Kühlmann et al. 2018).

Most patients require support, conversation and education before surgery (Salzmann et al. 2023). In the current study, the intervention of patient education was shown to significantly reduce preoperative anxiety across all three included studies before cataract surgery. This underscores the critical role of effective communication and education in the preoperative setting, suggesting that healthcare providers should prioritise these elements to enhance patient preparedness and reduce anxiety (Almutary and Almashi 2024).

A reduction in preoperative anxiety was observed with hand massage; however, this effect was not statistically significant. This reduction may be more pronounced regarding its impact on physiological parameters compared to other interventions, including systolic and diastolic blood pressure and heart rate (Farmahini Farahani et al. 2020; Guerrier et al. 2021; Çavdar, Yılmaz, and Baydur 2020). Furthermore, since hand massage involves physical contact, previous research has indicated that preoperative handholding during cataract surgery results in decreased epinephrine levels and reduced preoperative anxiety, thereby potentially enhancing the effectiveness of hand massage in alleviating anxiety (Moon and Cho 2001; Guerrier et al. 2021; Mokashi et al. 2004).

The mechanisms underlying the reduction of preoperative anxiety through non‐pharmacological methods may be linked to their effects on the hypothalamus‐pituitary–adrenal (HPA) axis and the autonomic nervous system, both of which are crucial in regulating metabolic and cardiovascular responses to environmental stressors (McEwen 1998). Elevated anxiety symptoms are associated with increased cortisol and adrenocorticotropic hormone (ACTH) responses (Fiksdal et al. 2019). Non‐pharmacological interventions likely influence the autonomic nervous system by inhibiting the sympathetic branch and activating the parasympathetic branch, thereby eliciting a relaxation response (Kushki et al. 2013). Research has shown these interventions can decrease heart rate, respiration rates and both systolic and diastolic blood pressure (Kekecs et al. 2014; Merakou et al. 2015; Pourmohammad et al. 2023; Saleh Abadi et al. 2018; Stanley, Wan, and Karim 2020), along with reducing cortisol levels (Moon and Cho 2001).

5.2. Strengths and Limitations

This study represents a comprehensive investigation into the impact of non‐pharmacological interventions on preoperative anxiety before cataract surgery, providing valuable insights. Subgroup analysis was conducted to assess the effects of various interventions, and the certainty of evidence was evaluated using Cochrane's handbook criteria. The study's strengths include the use of meta‐regression and sensitivity analysis to identify potential confounding factors, as well as the inclusion of studies from different countries, enhancing the generalisability of the findings.

It is crucial to acknowledge certain limitations and gaps related to this study. One significant limitation is the language restriction. This limitation may have excluded valuable research published in other languages, potentially affecting the comprehensiveness of our findings. Furthermore, the evidence for some interventions was rated as low to very low, suggesting that results should be interpreted with caution and highlighting a gap in robust research supporting these interventions.

5.3. Implications for Practice

The study emphasises the need for informed decision‐making and policy adjustments in healthcare. It highlights the importance of training nurses in non‐pharmacological interventions. Policymakers should promote these cost‐effective strategies as standard practice in surgical settings. Advocating for such approaches can improve care quality and patient satisfaction.

5.4. Implications for Future Research

Future research should focus on larger, diverse populations to enhance generalisability and standardise non‐pharmacological intervention protocols. Cost‐effectiveness analyses and training programs for healthcare providers will further support the implementation of these interventions in clinical practice. Additionally, exploring technology integration may offer innovative solutions for anxiety management.

6. Conclusion

Non‐pharmacological interventions play a crucial role in alleviating preoperative anxiety, particularly in the context of cataract surgery. Nevertheless, the variability across studies and the low to very low certainty of the evidence suggest that these findings should be interpreted cautiously. While many interventions show promise, further high‐quality research is necessary to confirm their efficacy and develop more definitive guidelines.

Author Contributions

The review was designed by M.N. and M.Mi. M.N. and M.Ma. conducted the searches and independently screened and extracted data, assessed risk of bias and drafted the manuscript. The data were analysed and findings interpreted by M.Mi. All authors were involved with editing the manuscript and approving the final submission.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1. Supplementary Figures and Tables.

Data Availability Statement

All data used with the systematic review and meta‐analyses are available via contact the corresponding author.