Educational Comic Book Has Little Effect on Preoperative Anxiety Among Children

An educational comic book was not an effective intervention for decreasing anxiety among pediatric patients undergoing surgery.

An educational comic book was not an effective intervention for decreasing anxiety among pediatric patients undergoing surgery. These findings were published in the Journal of Pediatric Nursing.

Children and adolescents (N=60) undergoing surgery in 2020 at the Botucatu State Hospital in Brazil were recruited for this randomized parallel, 2-group controlled clinical trial. Patients were randomly assigned to receive verbal preoperative guidance alone (n=30) or accompanied by a comic book depicting the surgical experience (n=30). The parents and children were evaluated by the Hamilton Anxiety Rating Scale (HAM-A), Children’s Anxiety Questionnaire (CAQ), modified Yale Preoperative Anxiety Scale (mYPAS), and they rated their anxiety using the Visual Analog Scale (VAS).

The patients were a median age of 8.0 (range, 6.0 to 14.0) years, 63.3% to 73.3% were boys, and the median length of surgery was 60 (range, 20 to 120) minutes. The parents were a median age of 33.5 to 35.0 (range, 23.0 to 59.0) years, 57% to 63% had undergone a previous surgery, 33% to 53% had been a surgical companion before, and they had a median of 11.0 to 12.0 (range, 1.0 to 16.0) years of education.

No significant changes to the CAQ score or any of the subscores were reported after the control and comic book interventions (all P ≥.222). Among the experimental cohort, VAS scores tended to be lower postintervention (median, 3.00 vs 4.00; P =.070).

Among the comic book recipients, HAM-A scores (P =.024), sensory symptoms (P =.009), anxious mood (P =.012), psychic anxiety (P =.015), tension (P =.018), and somatic anxiety (P =.021) were significantly decreased following the intervention. There were significant changes to HAM-A scores (P =.049), interview behavior (P =.011), sensory symptoms (P =.018), nervous system symptoms (P =.026), cardiovascular symptoms (P =.026), depressive mood (P =.042), and somatic anxiety (P =.047) postintervention among the control group.

Compared between groups, no significant differences in mYPAS overall score (P =.751) or the activity (P =.871), vocalization (P =.759), expression (P =.520), status (P =.514), or interaction (P =1.00) components were observed.

This study may have been limited by using the CAQ instrument which was designed to assess anxiety among children aged 5 to 8 years and this study recruited children aged 6 to 14 years.

Study authors concluded, “Preoperative guidance provided by nurses, irrespective of the type of intervention, proved beneficial in reducing parental anxiety after separation from their children outside the operating room. However, both types of interventions, performed on the day of surgery, failed to reduce self-reported preoperative anxiety in children and adolescents upon admission to the operating room. The use of educational materials to minimize children’s anxiety remains controversial, and requires future multicenter studies in high-, middle-, and low-income countries.”


De Avila MAG, Prata RA, Jacob FLDS, De Oliveira Nóbrega FM, De Barros GR, Sugiura BMG. Educational intervention through a comic book for preoperative anxiety in children, adolescents, and their parents: a randomized clinical trial. J Pediatr Nurs. 2022;S0882-5963(22)00171-3. doi:10.1016/j.pedn.2022.07.010