A multicenter, cross-sectional study was conducted over 4 months, from November 2024 to February 2025, in 4 hospitals with operation theaters in Northern State, Sudan: 2 public hospitals (Dongola Specialized Hospital and Karima Teaching Hospital) and 2 private hospitals (Al-Wifaq Al-Qatari Hospital and Al-Daman Hospital). The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for observational studies [15].

The study included adult patients (≥18 years) undergoing elective surgery who provided written informed consent. Exclusion criteria were emergency or obstetric surgeries, a history of mental illness or cognitive impairment, and incomplete responses to the study questionnaire.

The sample size was calculated using Cochran’s formula: sample size (n) = z2pqe2 [16]. Using a prevalence of 55.7% (from similar LMIC studies), 95% confidence level (z=1.96), and 5% margin of error, the minimum sample size was determined to be 380 [7,16]. In total, 305 of the 380 distributed surveys were completed, yielding a response rate of 80.3%. Patients were recruited using convenience sampling from surgical wards and outpatient clinics 1-2 days before their scheduled operation.

Data were collected through structured face-to-face interviews (within 48 h prior to the scheduled surgery) using a standardized questionnaire comprising 3 sections: a sociodemographic section with 7 items, a medical and surgical history section with 7 items, and the Amsterdam Preoperative Anxiety and Information Scale (APAIS) with 6 items .

The questionnaire was translated into Arabic, and the validated Arabic version of the APAIS was used [17]. A pilot test was conducted among 40 participants to ensure clarity and reliability, yielding a Cronbach α of 0.91, indicating excellent reliability [18]. The English version of the questionnaire is provided as Multimedia Appendix 1.

The APAIS was used to assess preoperative anxiety and desire for information. It is a validated scale with 6 items, each scored on a 5-point Likert scale ranging from 1 (“not at all”) to 5 (“extremely”). Preoperative anxiety was assessed through items 1, 2, 4, and 5, leading to a total score range of 4‐20, with a score ≥11 indicating clinically significant anxiety. Desire for information was assessed using items 3 and 6. The total scores ranged from 2 to 10 and were categorized as low (2-4), average (5-7), or high (8-10) desire for information [19-21].

The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Research Ethical Committee of the Northern State Ministry of Health (REC-MoH-NS-41‐2023) and the research offices of the involved hospitals. Written informed consent was obtained from all participants prior to their inclusion in the study. Participants were assured of the confidentiality of their responses, the anonymity of their data, and their right to withdraw from the study at any time without any impact on their medical care. No compensation was provided to participants for their involvement in the study.

A total of 380 patients undergoing elective surgery were approached, of whom 305 participated in this study (response rate=80.3%). Figure 1 shows the distribution of participants across the 4 participating hospitals. Approximately half of the participants were male (n=173, 56.7%) and aged between 31 and 65 years (n=161, 52.7%), with a median age of 43 (IQR 30‐64) years. Most participants (n=207, 67.9%) were married, and the majority (n=248, 81.3%) had some level of education. Of the 305 participants, 114 (37.4%) were freelancers, and 117 (38.4%) were unemployed. Nearly half of the participants (n=151, 49.5%) had an average monthly income above US $250. Family support was reported by 83.0% of participants (253/305). The sociodemographic characteristics of the participants are summarized in Table 1.

The medical and surgical characteristics of the participants are detailed in Table 1. According to the American Society of Anesthesiologists (ASA) classification system, most patients (268/305, 87.9%) were classified as ASA I and II. Most patients underwent major (n=142, 46.6%) or intermediate (n=136, 44.6%) surgeries. General anesthesia was the most common type of anesthesia used (n=160, 52.5%), and most surgeries (n=169, 55.4%) were performed in public hospitals. Most surgeries (n=264, 86.6%) were not covered by insurance, and most patients (n=221, 72.5%) reported good subjective sleep quality the night before the operation. A significant proportion of patients had had no previous operations (n=186, 61.0%) and no chronic diseases (199, 65.2%).

The prevalence of preoperative anxiety and desire for information among the participants is shown in Tables 2 and 3. Overall, 75 of the 305 participants (24.6%) reported experiencing clinically significant preoperative anxiety. Of the 305 participants, 73 (23.9%) expressed an average desire for information, and 19 (6.2%) reported a high desire for information.

The factors associated with preoperative anxiety (Table 4) included the presence of family support (P=.02), poor subjective sleep quality the night before the operation (P=.01), surgery in a public hospital (P<.001), ASA classification III and IV (P=.02), and a history of chronic diseases (P=.05).

The factors associated with the desire for information (Table 5) included being employed (P=.01), being educated (P=.003), having family support (P=.03), undergoing surgery in a public hospital (P<.001), ASA classification III and IV (P=.001), and having chronic diseases (P=.02).

The results of the logistic regression analysis (Table 6) indicated that patients who had family support were 7 times more likely to develop preoperative anxiety (aOR 7.12, 95% CI 2.64‐19.23; P<.001). Patients treated in public hospitals had more than 4 times the risk of preoperative anxiety compared with those treated in private hospitals (aOR 4.31, 95% CI 2.30-8.07; P<.001). Patients with poor subjective sleep quality the night before the operation and those classified as ASA III and IV had more than 2 times the risk of preoperative anxiety compared with their counterparts (aOR 2.85, 95% CI 1.51‐5.38; P=.001; and aOR 2.36, 95% CI 1.00‐5.54; P=.049, respectively).

Patients with some level of education were more than 2 times more likely to have a desire for information than patients with no education (aOR 2.48, 95% CI 1.00‐6.11; P=.049). Similarly, patients with family support were more than 4 times more likely to have a desire for information than those without family support (aOR 4.10, 95% CI 1.81‐9.30; P=.001). Patients treated in public hospitals had more than 3 times the desire for information compared with those treated in private hospitals (aOR 3.57, 95% CI 1.936.61; P<.001). Furthermore, ASA III and IV patients were more than 3 times more likely to have a desire for information than ASA I and II patients (aOR 3.26, 95% CI 1.39‐7.64; P=.007).

Preoperative anxiety is a common psychological response among patients awaiting surgery, with significant implications for their overall well-being, surgical outcomes, and recovery [22]. This study assessed the prevalence of preoperative anxiety and desire for information among patients scheduled for elective surgery in Northern State, Sudan, and identified the factors associated with these outcomes. A summary of what is known about this topic and what this study adds is shown in Textbox 1.

The study found that 24.6% of participants experienced preoperative anxiety, a rate lower than the global prevalence and that observed in LMICs (48% and 55.7%, respectively) [6,7]. However, studies from Yemen, Nigeria, Palestine, India, Nepal, and France are consistent with our results, reporting rates of 29.8%, 24.4%, 27.1%, 21.0%, 25.8%, and 24.7%, respectively [9,23-27]. These variations may be attributed to diverse factors, such as differences in health care systems, geographical locations, study populations, and assessment tools used.

Our study identified several factors linked to preoperative anxiety, including family support, poor subjective sleep quality, surgery in a public hospital, and ASA classification III and IV. Remarkably, patients with family support were 7 times more likely to experience preoperative anxiety (aOR 7.12, 95% CI 2.64‐19.23; P<.001), which contrasts with the conventional view of family support as a protective factor. The unexpected result may stem from unique family dynamics in Sudan, where extended visits from relatives and community members expressing concerns or sharing negative experiences may inadvertently heighten a patient’s anxiety. This underscores the complex role of social support in preoperative anxiety. Previous studies have reported conflicting results, with some suggesting that family support reduces anxiety and others indicating no significant impact [28,29].

Consistent with previous research, our study found that patients treated in public hospitals had a significantly higher risk of preoperative anxiety compared to those in private hospitals (aOR 4.31, 95% CI 2.30‐8.07; P<.001). A similar trend was observed in a study from Tanzania, which also reported higher preoperative anxiety among patients in public hospitals [30]. This disparity may be due to factors such as differences in resource availability, staffing levels, and the overall patient experience between public and private health care settings.

Poor sleep quality the night before surgery was significantly associated with preoperative anxiety, consistent with previous studies highlighting the strong link between sleep disturbances and anxiety disorders [31-34]. The stress and anticipation of surgery may disrupt sleep, exacerbating anxiety levels. Similarly, patients classified as ASA III and IV had a higher risk of preoperative anxiety, likely due to their increased risk of complications and poorer health status [35]. This finding aligns with several studies demonstrating a significant association between higher ASA classification and elevated anxiety levels [23,36,37].

Notably, 23.9% of the patients expressed an average desire for information, and 6.2% reported a high desire for information. This desire, as part of broader health information–seeking behavior, enhances health literacy. However, surgeons often underestimate the extent of information patients wish to receive preoperatively [38,39]. Similar patterns have been observed in studies from Yemen and Nigeria, where comparable percentages of patients expressed average and high desire for information (16.5% and 16.9% in Yemen, and 14.4% and 5.1% in Nigeria, respectively) [9,23].

Our study reveals that patients with some education are more likely to seek information. One possible explanation is that more educated patients may feel more confident in asking questions and navigating medical discussions, whereas those with less formal education may feel less empowered or perceive themselves as less able to understand complex medical explanations. Patients in public hospitals also showed a higher desire for information, possibly due to perceived communication gaps. Additionally, ASA III and IV patients had a stronger desire for information, likely driven by the need to understand their health risks. To the best of our knowledge, this study is the first to comprehensively explore these factors, addressing a significant gap in the literature and offering insights for enhancing patient-centered care.

This study found that a notable proportion of surgical patients in Northern State, Sudan, experienced preoperative anxiety, a rate lower than the global average but consistent with some local and international findings. Factors associated with increased anxiety included family support, poor sleep quality, public hospital settings, and higher ASA classification. The study also highlighted a significant desire for information among patients, particularly those with some education and those receiving treatment in public hospitals. Addressing these factors through targeted interventions may improve patient outcomes and satisfaction.

Several recommendations can be made on the basis of these study findings to enhance patient care and reduce preoperative anxiety. Health care providers should implement targeted interventions aimed at improving preoperative sleep quality and providing adequate information to patients, as these factors were significantly linked to anxiety levels. Additionally, while family visits may help reduce preoperative anxiety for some patients, they may contribute to increased anxiety in certain situations. Clinical teams should assess the potential risks and benefits of family visits in the preoperative period and act accordingly. Furthermore, public hospitals should prioritize improving patient communication and addressing perceived gaps in information provision, as these factors were associated with a higher desire for information among patients.

This study has several limitations. The small sample size and the use of convenience sampling may limit generalizability, but the multicenter study design enhances representativeness. The cross-sectional design prevents establishing causality; however, it provides a detailed snapshot for future longitudinal studies. The reliance on self-reported data introduces potential biases, but using a validated assessment tool and face-to-face interviews helped minimize these issues.