Preoperative anxiety in Ethiopia: a systematic review and meta-analysis



Background: Anxiety is a vague and uneasy feeling of the individual. It is one of the commonest events that can happen to surgical patients. The prevalence is higher in low-income countries. In Ethiopia, the prevalence of preoperative anxiety reported is variable. This meta-analysis aimed to find the pooled prevalence of preoperative anxiety.

Methods: The databases for the search were PubMed, Web of Science, and Google Scholar by the date 02/03/2020. To assess publication bias Egger's test regression analysis was applied.

Results: This meta-analysis included a total of 6 studies with 1832 study subjects. The pooled prevalence of preoperative anxiety was 55.54 %( 95% CI, 46.30 to 64.78%). Based on the subgroup analysis, the Oromia region ranked first (63.27%).

Conclusions: The national prevalence of preoperative anxiety was high. Oromia region ranked first followed by Amhara, SNNP, and Addis Ababa. Patients need to assess often for anxiety during the preoperative visit.


Perioperative anxiety is a vague, and uneasy feeling of the individual[1]. It is one of the global health problems and a prevalent concern with negative effects but ignored[2]. It is worrying events for most surgical patients[3]. Preoperative anxiety is a challenging problem in the preoperative care of patients[4]. In certain types of surgery, anxiety increases postoperative morbidity and mortality[5]. Most patients in the preoperative phase experience anxiety[6]. A low level of anxiety is an expected reaction to especially for a patient’s first surgical experience[7]. Yet, Preoperative anxiety has a great influence on surgery outcomes[8]. Higher levels of preoperative anxiety result in delay wound healing[7].

In the preoperative period anxiety can lead to an unstable hemodynamic status[9]. Studies have shown that preoperative anxiety causes suppression of the immune system[10]. Due to the reasons mentioned above, it considered major morbidity after surgery [11]. Preoperative anxiety is also known to increase the patient's release of catecholamines[3]. This increases blood pressure, heart rate, blood glucose levels. , and arrhythmia of infection [12]. It also increases the anesthetic need and hospital stay [13]. Besides, it surges the economic burden and impaired quality of life of the patients[14, 15]. The main sources of pre-operative anxiety are lack of knowledge, risk of death, pain, and body image [16].

Effective perioperative nursing care activities have implemented in national and international settings. These are because of providing better environments and quality of life [17]. Notable, Preoperative education,  psychological support, better social support and answer questions [18, 19]. Yet, waiting for surgery, anesthesia, concerns about surgical intervention, and postoperative pain[15]. Despite the growing advancements of surgical and anesthetic techniques, surgery remains stressful[9].

A first global report claimed that preoperative anxiety is the most major problems. This has shown that it occurred in every type of surgical procedure[20]. Its burden reported both in developed and developing countries. In China, preoperative anxiety reported as 20%[21], 21% in Saudi Arabia[22], 36.5 in Iran[9], 31% in India[13], and 62.8% in Pakistan[23]. In Africa it reported as  51.0% in Nigeria[24], 67.5% in Tunisia[25], 57% in Kenya[26] and 72.8% in Rwanda[27].

In Ethiopia, different studies had conducted to find the prevalence of preoperative anxiety. The prevalence found in the range between 39.8% to 70.3% [28-33] in the Ethiopian setting. Hence, discrepancies between studies make difficult to represent the national prevalence. Having national representative data is real to underpin effective prevention strategies. Thus, need to have a pooled estimation of preoperative anxiety at the country level. This analysis aimed to find the pooled prevalence of preoperative anxiety in the Ethiopian setting. The review question was what is the prevalence for preoperative anxiety in Ethiopia?



The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline[34] used to report this meta-analysis(Additional file 1 research checklist).

Literature search

The databases for the search were Medline (PubMed), Web of Science, and Google Scholar. The terms for the search were pre-defined for a comprehensive search strategy. These included all fields within records and Medical Subject Headings (MeSH terms). In the Boolean operator, within each axis, we combined keywords with the “OR” operator. Then we linked the search strategies for the two axes with the “AND” operator. The search terms used for the search were “Preoperative anxiety” OR “anxiety” OR “surgical anxiety” OR “pre-surgical anxiety” OR “preoperative worry” OR “concerns” OR “nervousness” AND “prevalence” OR “magnitude” OR “burden” AND “Ethiopia”. The specific  searching detail in PubMed with MeSH terms was (“Preoperative anxiety” [MeSH Terms] OR “anxiety”[MeSH Terms] OR “surgical anxiety”[MeSH Terms] OR “pre-surgical anxiety”[MeSH Terms] OR “preoperative worry”[MeSH Terms] OR “concerns”[MeSH Terms] OR “nervousness”[MeSH Terms] AND “prevalence” [All Fields]) OR “magnitude”[MeSH Terms]OR “burden”[MeSH Terms] AND (“Ethiopia” [MeSH Terms] by the date 02/03/2020.

The publication year of the studies was not limited during the search.

Study selection

All retrieved studies were exported to Endnote version 7 reference manager. It is the study selection method that we used to remove duplicated studies.

The retrieved articles were screened according to pre-defined inclusion and exclusion criteria. Discussion and/or involvement of the third reviewer resolved any disagreements.

Eligibility criteria

Inclusion criteria

Included studies were articles that reported the prevalence of preoperative anxiety. It also included studies published in English and studies conducted only in Ethiopia.

Exclusion criteria

Excluded criteria were articles without full-text available and qualitative studies. Other excluded criteria were any reviews, commentaries, consultants’ corners, letters, and conference abstracts.

Quality assessment

We used Joanna Brigg’s Institute (JBI) quality appraisal criteria[35]. It is the assessment tool used to check the quality of each article. The tool consists of nine major items. The first item is appropriate to the sample frame. The second is the appropriate sampling technique. The third is the adequacy of the sample size. The fourth is a description of the study subjects and settings. The fifth is enough coverage of data analysis. The sixth is the validity of the method for identification of the condition. The seventh item is a standard and reliable measurement for all participants. The eighth is the appropriateness of statistical analysis. And the last item is adequacy and management of response rate. Studies considered low-risk when it would fit 5 or above quality assessment checklists.

Data extraction

A standardized form used to extract data by two authors. The following information from each article was extracted. Such as first author, and publication year, the study design, and study population. The locations of the study were also extracted.

Outcome measurement

The major outcome is to determine the prevalence of preoperative anxiety in Ethiopia. It calculated as dividing the numbers of patients who develop anxiety to the total number of patients multiply by 100. A total number of patients refer to all adult elective patients during the study period. Preoperative anxiety is an event, a person presents with signs and symptoms of the anxiety[36]

Data analysis

The required data were collected using a Microsoft Excel 2010 workbook form. Then, the STATA Version11 software was used to analyze the data. The original articles presented using tables and forest plots. A weighted inverse variance random-effects model[37] used to estimate the pooled prevalence. I2 statistics used to assess the percentage of total variation across studies [38]. I2 ≤ 25% suggested more homogeneity. 25% < I2 ≤ 75% suggested moderate heterogeneity, and I2 > 75% suggested high heterogeneity[38]. Egger’s regression test was also used to assess publication bias [39]. Furthermore, the sub-group analysis carried out based on the region of studies. This reduces the random discrepancies between the point estimates of the primary study.


Literature search result

A comprehensive literature search of the database yielded a total of 75 publications.  Among these, 69 disregarded due to qualitative study, abstracts, and titles. Finally, this meta-analysis includes a total of 6 studies with 1832 subjects [28-33](Figure 1).

Characteristics of included studies

The range of publication year for included studies was from 2014 to 2019. Three regions and Addis Ababa was the settings studies found. Two in Oromia region[30, 33], two in Amhara region[31, 32], one in Addis Ababa[28], and one in Southern Nation, Nationalities, and People (SNNP)[29]. All included studies done by using the cross-sectional study design (Table 1).

Table 1:  Characteristics of included studies in the meta-analysis of preoperative anxiety. 



Study year


Study design

Sample size


Surgery type

Srahbzu M[ 28]

May to 

June, 2017

Addis Ababa

Cross- sectional



Orthopedic trauma  patients scheduled for elective surgery

Mulugeta H et al/2018[ 32]

February to April, 2017


Cross- sectional



All adults scheduled for elective surgery

Takele G/2019[ 30]

March to May, 2018


Cross- sectional



All adults scheduled for elective surgery

Nigussie S     et al/2014[ 33]

February     to April, 2012


Cross- sectional



All adults scheduled for elective surgery

Woldegerima Y.B et al/2018[ 31]

March to June, 2017


Cross- sectional



All adults scheduled for elective surgery

Bedaso A et al/2019[ 29]

November to Dec, 2018


Cross- sectional



All adults scheduled for elective surgery

We did an assessment of studies with JBI quality appraisal checklists. Based on this, none of the included studies was poor quality status.


The absence of publication bias was assessed with Egger’s regression test (p = 0.201), which showed that no publication bias.

The pooled prevalence of preoperative anxiety estimated from 6 studies [28-33] was 55.54 %( 95% CI, 46.30 to 64.78%)(Figure 2).

Subgroup analysis

Based on the subgroup analysis, the Oromia region ranked first (63.27%). Followed by Amhara (60.53%),  and SNNP (47.00%). The report of the lowest prevalence was from the Addid Ababa (39.80%)(Figure3).


Preoperative anxiety continues a global burden of perioperative care. It is a common problem that affects surgical patients and results in adverse outcomes[40].

According to this meta-analysis, preoperative anxiety found was 55.54% (46.30, 64.78) in Ethiopia. This is comparable with the study conducted in Nigeria[24] and Kenya[26]. Factors of preoperative anxiety like financial loss, poor behavioral adherence during Factors of preoperative anxiety almost similar in developing countries including Ethiopia[33, 41]. This includes financial loss, prolonged hospital stay and adverse postoperative outcomes.

This finding is lower than a study conducted in Tunisia[25], Pakistan[23] and Rwanda[27]. This discrepancy might be due to the difference in the study setting and population. In the current study, the prevalence estimated from all elective waiting surgical patients. In later, the prevalence of preoperative anxiety estimated from specific cases. Involved cases are hernia, thyroid and cardiac surgeries.

The current finding is higher than the study from China[21], Saudi Arabia[22], India[13] and Iran[9]. This difference might be due to the lack of preoperative anxiety control guidelines. Evidence shows that, anxiety evaluation should be incorporated in preoperative assessment of the patients[12, 42]. Moreover, clinical negligence[43] might  increases preoperative anxiety. But not reiterate instructions, use relaxation techniques like slow and deep breathing [44].

Based on the subgroup analysis, the regional prevalence was also determined. The highest prevalence of preoperative anxiety noted in the Oromia region (63.27%). This is almost two times higher than a result of Addis Ababa (39.80%). This might be the study population in the Oromia was all elective surgery patients. But, the studies done in Addis Ababa were orthopedic trauma patients.

Due to the lack of studies in some locations of Ethiopia, the result may not represent a national figure. Although I2 is not an absolute measure of heterogeneity, high heterogeneity was observed.


In this finding, prevalence of preoperative anxiety was higher compared to the STAI[45]. Oromia region ranked first followed by Amhara, SNNP, and Addis Ababa. Thus, efforts should make to ensure the prevention of preoperative anxiety. Furthermore, nurses must spend a considerable amount of time working with preoperative patients. It is imperative, thus, nurses take training about the most effective strategies. Finally, due to its implications on postoperative outcomes, anxiety evaluation should incorporate.


CI: Confidence Interval; SNNPR: Southern Nations and Nationalities of People Region; STAI: Stata-Trait Anxiety Inventory


Ethical approval and consent to participate: Not applicable.

Consent for publication: Not applicable

Availability of data and materials: All datasets analyzed during this study are presented within the manuscript and/or additional supporting file.

Competing interests: The author declares that, they have no competing interests

Funding: There is no fund received from any fund agency.

Authors’ contributions: YB design and planning of the study, review of the literature. More to the point YB contributes data analysis and drafting manuscript. KG contributes literature review, data collection and took part to realize statistical analysis. Both authors have read and approved the manuscript.

Acknowledgments: Not applicable


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