Prevalence and Predictors of Parental Anxiety in Pediatric Surgery: An Observational Study

ABSTRACT

Aims:

Parental anxiety is a common yet often under-addressed component for children undergoing surgery. It is not only distressing for the parents but also affects the perioperative outcomes of the patient. This study aims to determine the prevalence and identify the sociodemographic and clinical predictors of perioperative anxiety among Indian parents whose children were undergoing elective paediatric surgery.

Methods:

A prospective observational study was conducted involving 216 parents at a tertiary care hospital. Parental anxiety status was assessed using the Hamilton Anxiety Rating Scale (HAM-A) at admission and discharge, and the “Amsterdam Pre-Operative Anxiety and Information Scale” (APAIS) immediately before surgery. Associations with demographic, educational, socioeconomic, previous surgical exposure, and surgical variables were analyzed using descriptive statistics, correlation, and regression models.

Results:

Clinically significant preoperative anxiety (HAM-A ≥15 or APAIS ≥11) was observed in 56% of parents, and higher in mothers (67.3% vs. 56.9%, P = 0.002). Lower socioeconomic status and lack of prior surgical experience were associated with higher anxiety. Mothers reported significantly higher anxiety in all APAIS subdomains, including desire for information. Postoperative HAM-A scores showed a significant reduction (P < 0.001).

Conclusion:

Pre-operative anxiety is highly prevalent among Indian parents, particularly mothers and those with lower socioeconomic and educational backgrounds. Structured counseling and information support integrated into perioperative care are essential to reduce anxiety and improve family-centered outcomes.

INTRODUCTION

Hospitalization and surgery are major stressors for both children and their parents. Perioperative anxiety is common, with pre-operative anxiety seen in 60%–80% of pediatric surgical cases.[1] A child’s anxiety is often closely linked to that of their parents. Factors that contribute to anxiety in parents include lack of information, perceived risk to their child’s life, financial implications, and separation anxiety.[2] Literature suggests that low education levels are associated with higher anxiety, and cultural and socioeconomic factors also contribute to anxiety.[3] Effective management of parental anxiety is crucial to improving the overall perioperative experience for both children and their families.

The wide sociocultural and socioeconomic diversity observed in India may shape parental responses to a child’s surgical procedure. Despite this, there is limited evidence from the Indian setting, and few studies have explored differences in anxiety between mothers and fathers or assessed the role of parental education and socioeconomic status (SES).

Therefore, this observational study aimed to assess the prevalence and severity of perioperative anxiety among Indian parents of children undergoing elective surgery. In addition, the study sought to evaluate the association between parental anxiety and selected sociodemographic factors, including parental education, sociodemographic factors like education level, and economic status.

METHODS

This prospective observational study was conducted at a tertiary-level teaching hospital in India, following approval from the Institutional Ethics Committee. The primary objective was to assess the prevalence of perioperative anxiety among parents of children undergoing elective surgery and to identify its association with parental education, SES, and other demographic and clinical variables. The inclusion criteria were parents of pediatric patients scheduled for elective surgical procedures. Exclusion criteria were orphans, parents with psychiatric illness, those on psychiatric medication, uncooperative individuals, and those who declined consent.

After obtaining informed consent, data were collected on parent and child demographics, parental educational status, number of children, and any past surgical experiences and socioeconomic class (based on the Modified Kuppuswamy Scale). Parental anxiety was evaluated using two standardized instruments, the Hamilton Anxiety Rating Scale (HAM-A) and Amsterdam Pre-operative Anxiety and Information Scale (APAIS). The concurrent use of HAM-A and APAIS was carried out to capture complementary information-generalized baseline anxiety and acute, procedure-specific anxiety with information needs. HAM-A was administered at two time points, during pre-anesthesia check-up (T0) and at discharge or by the third postoperative day (T2), whichever came earlier.[4] Scores were categorized as: 0–7 (none/minimal), 8–14 (mild), 15–23 (moderate), and ≥ 24 (severe). The APAIS was used as a self-reported tool assessing the procedure-specific anxiety and desire for information to evaluate pre-operative anxiety and the parents’ desire for information. APAIS was administered just before surgery (T1).[5] A combined APAIS anxiety score of ≥ 11 indicated high pre-operative anxiety.[6] Permission to use both scales was obtained from the original authors. The concurrent use of both scales was done to evaluate both general anxiety levels from the HAM-A and the surgery-specific perioperative anxiety from the APAIS, to provide a more comprehensive assessment. All assessments took place in a private setting to ensure confidentiality and to encourage asking questions.

Statistics

Continuous variables were expressed as mean ± standard deviation, whereas categorical variables were presented as frequencies and percentages. The normality of continuous variables was assessed using the Shapiro–Wilk test and visual inspection of histograms. Variables demonstrating an approximately normal distribution were analyzed using parametric tests, including the independent sample t-test for comparisons between groups. Categorical variables were analyzed using the Chi-square test, and McNemar’s test was used where paired categorical comparisons were required. Regression analysis was performed to identify independent predictors of parental anxiety, including educational status, socioeconomic class, and previous surgical exposure. P <0.05 was considered statistically significant. Data were analyzed using the DATAtab: Online Statistics Calculator (DATAtab e.U. Graz, Austria. https://datatab.net).

Sample size calculation

Due to a lack of Indian data at the time of protocol, we have calculated the sample size, assuming a prevalence of pre-operative anxiety of 50% (to ensure maximum variability). At a 95% confidence level and an absolute margin of error of 7%, the calculated sample size without finite population correction will be 196. Accounting for an anticipated 10% attrition rate (i.e., those who have consented and were assessed during pre-anesthetic checkup (T0) but were lost to follow-up for the subsequent one/two assessments), 216 participants were planned to be recruited in this study.

RESULTS

The calculated minimum sample size for the study was 216 participants. Parents accompanying children scheduled for elective surgery were consecutively invited to participate during the study period. When both parents were present, each parent was approached independently and invited to complete the questionnaire. Consequently, responses were obtained from both mothers and fathers in some cases, resulting in a total of 414 participating parents (215 mothers, 199 fathers). Each parent completed the questionnaire independently, and the unit of analysis for the study was the individual parent. As the study aimed to assess anxiety at the level of individual parents, responses were analyzed separately for each participant [STROBE, Figure 1]. Most children were boys (73.5%), and the mean age was 38.3 ± 46.24 months. Mothers (70%) were more often the accompanying parent. Paternal education was generally higher than maternal. 27% of mothers were illiterate compared to 2.8% of fathers. Most families fell into the middle socioeconomic class (70.9%) [Table 1]. As assessed by the modified Kuppuswamy scale, SES classified 22.6% of the families as lower class, 70.9% as middle class, and 6.5% as upper class [Table 1].

Figure 1.

STrengthening the Reporting of OBservational studies in Epidemiology flow diagram showing recruitment of patients in the study. STROBE: STrengthening the Reporting of OBservational studies in Epidemiology

Table 1.

Demographic and clinical characteristics of participants

Characteristic	Category	Distribution (%)
Child age (months)	Mean±SD	38.29±46.24
Child sex	Male	73.5
	Female	26.5
Father education	Illiterate	2.8
	Primary	29
	High school	30
	College	38.2
Mother education	Illiterate	26.6
	Primary	25.2
	High school	43.8
	College	4.4
SES (modified Kuppuswamy)	Low	22.6
	Middle	70.9
	High	6.5

SES: Socioeconomic status, SD: Standard deviation

At admission (T0), the mean HAM-A score of mothers was significantly higher than that of fathers (21.47 ± 11.67 vs. 17.25 ± 11.05, P = 0.001) with a small effect size (Cohen’s d = 0.31). Based on HAM-A cut-offs (score ≥ 15), 56.9% of fathers and 67.3% of mothers were classified as anxious. These scores reduced significantly to 17.3% and 19.8%, respectively, postoperatively (T2) (P < 0.0001, McNamara’s test) [Figure 2].

Figure 2.

Proportion of parents having anxiety measured with the Hamilton Anxiety Rating Scale over time

The APAIS scale, used pre-surgery (T1), mothers had significantly higher scores (8.8 ± 4.9) than fathers (6.8 ± 4.3, P = 0.002). High anxiety (APAIS ≥ 11) was present in 35.3% of mothers and 16.2% of fathers. Mothers also had a significantly higher desire for information (P < 0.001) [Table 2]. When examined by APAIS subcomponents, mothers scored significantly higher across all domains: anesthesia-related anxiety (P < 0.001), surgery-related anxiety (P = 0.03), combined anxiety (P < 0.001), and information desire (P < 0.001) [Figure 3].

Table 2.

Summary of anxiety scores among fathers and mothers

Scale used	Anxiety measure	Fathers (mean±SD)	Mothers (mean±SD)	P
HAM-A	Admission (T0)	17.1±11.1	21.5±11.7	0.001
	Discharge or day 3, (T2)	6.8±7.7	9.0±8.6	0.009
APAIS	Anesthesia-related anxiety	2.94±1.60	3.77±2.38	<0.001
	Surgery-related anxiety	5.13±2.61	5.69±2.75	0.036
	Combined anxiety score	6.81±4.29	8.80±4.94	<0.001
	Information desire	3.45±2.02	4.04±2.75	<0.001

HAM-A: Hamilton Anxiety Rating Scale, APAIS: Amsterdam Preoperative Anxiety and Information Scale, SD: Standard deviation

Figure 3.

Proportion of parents having Pre-operative anxiety measured with the Amsterdam Pre-Operative Anxiety and Information Scale in the pre-operative area

There was no statistically significant relationship between education level and anxiety on HAM-A, although APAIS showed an inverse association – lower education correlated with higher anxiety (r = −0.21 for fathers; −0.29 for mothers).

SES showed a consistent inverse correlation with anxiety levels. Lower SES was associated with higher pre-operative anxiety on both HAM-A (r = −0.18, P = 0.05) and APAIS (r = −0.21, P < 0.05). Paternal age was negatively correlated with anxiety (r = −0.18, P = 0.019), whereas maternal age had no association. Longer surgery duration was associated with higher postoperative anxiety (HAM-A) in both fathers (r = 0.31) and mothers (r = 0.40, P < 0.001). Prior surgical experience in the child significantly reduced parental anxiety scores on both tools (P < 0.05). No association was found between anxiety and the child’s age, sex, or type of surgery (minor vs. major).

A multiple linear regression analysis was conducted to identify independent predictors of pre-operative anxiety in fathers, incorporating demographic, clinical, and psychosocial variables. The model was not statistically significant, P = 0.84, with an R² = 0.064. None of the included variables, such as education, SES, surgery duration, psychiatric history, or digital information search, emerged as significant independent predictors for mothers. Prior surgical experience and maternal role were more influential than demographic factors.

DISCUSSION

This prospective observational study points out the high prevalence of perioperative anxiety among parents, especially mothers, of children undergoing elective surgery. Nearly two-thirds of mothers reported significant pre-operative anxiety, consistent with earlier studies suggesting a greater emotional burden on female caregivers. Maternal anxiety was higher across all APAIS domains, including desire for information. Cultural norms, emotional bonding, and active participation in caregiving likely contribute to this pattern. The strong information-seeking behavior suggests mothers feel both emotionally and informationally vulnerable.[7] Being a mother was associated with 1.6 times the odds of having severe anxiety, which is in line with Chaurasia et al.’s suggestion of maternal stress dominating perioperative circumstances.[8] Literature reported that multimedia tools significantly increase the comprehension of informed consent and significantly lower parental distress in surgical procedures.[9,10]

The anxiety drops significantly after surgery, at day 3 or discharge, highlighting the anticipatory nature of pre-operative distress. Fear of the unknown, rather than the surgical event itself, appears to be the main driver. This is similar to previous research showing that structured counseling and information delivery can markedly reduce anxiety.[11]

Interestingly, HAM-A scores did not show a strong correlation with education, as APAIS did. This may indicate that parents with lower education struggle more with understanding medical details, which heightens anxiety.[12] These findings emphasize the importance of communication strategies based on health literacy, utilizing visual aids, verbal reinforcements, and video-based counseling.[12]

SES, measured by the modified Kuppuswamy scale, had a weak negative correlation with pre-operative anxiety. Parents from lower SES had higher anxiety levels, consistent with studies suggesting that financial insecurity and limited access to health education may contribute to anxiety during hospitalization.[13] Familiarity with the hospital setting via previous surgery was protective, further supporting the value of surgical orientation or familiarization programs.[8]

Child age, gender, and type of surgery were not significant factors. This suggests parental anxiety may be more psychologically and socially driven than medically determined.[14] While the duration of surgery showed some correlation with anxiety, it likely reflects perceived risk or complexity rather than actual outcomes.

This study has several limitations that should be considered when interpreting the findings. First, the study was conducted at a single tertiary care center, which may limit the generalizability of the results to other healthcare settings with different patient populations and perioperative practices. Second, the study included only parents of children undergoing elective surgery, and therefore, the findings may not be applicable to emergency surgical situations, where anxiety levels may differ due to the urgency and unpredictability of the clinical context. Third, parental anxiety was assessed using self-reported questionnaires, which may be subject to response bias or social desirability bias. In some instances, both parents of the same child participated in the study; therefore, responses may not have been entirely independent. Finally, the study evaluated anxiety during the perioperative period only, and long-term psychological outcomes among parents were not assessed. Future multicenter studies with longitudinal follow-up may help provide a more comprehensive understanding of parental anxiety in pediatric surgical settings.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.