Parent Behaviors and Child’s Anxiety during Anesthesia Induction: Examining Relevant Cultural Factors

Significance and Specific Aims

It is estimated that 2.3 million children under 15 years of age undergo surgery in the United States each year, and up to 65% experience significant anxiety before surgery1. High preoperative anxiety in children is associated with increased postoperative pain, delayed hospital discharge as well as maladaptive postoperative behavioral changes and emergence delirium2,3. Previous studies have indicated that induction of anesthesia is the most stressful period for children throughout the entire preoperative process4. Parental presence has been found beneficial in reducing children’s anxiety5\”It’s OK\”, however, results have been mixed.

Health disparities literature has focused on cultural variations in health outcomes including anxiety, pain expression, and pain management. Cultural values may be associated with these variations. For example, simpatia (i.e., agreeableness, pleasantness, and respect even in the context of stressful situations) is a commonly held value among Latino populations, and is thought to impact Latino patients’ interactions with healthcare providers6,7. However, few studies have systematically examined cultural factors in the context of healthcare procedures, and none to date on anesthesia induction. The present study aimed to identify relevant cultural factors for Latino families in the context of outpatient surgery and to examine how these factors may be associated with surgical anxiety and coping in Latino children.


An interdisciplinary group of investigators with expertise in areas such as pain, perioperative management and Latino/a health partnered with a community task force of Latina mothers (n = 10) whose children underwent surgery at a local children’s hospital. Using a community based participatory research approach, collaborators engaged in a six-month process to identify factors from multiple systems (e.g., family and hospital-wide) that youth and mothers believed impact children’s perioperative health and wellbeing. Grounded theory qualitative methods were used to collect and analyze data.

The second part of the study is ongoing and involved the development of a behavioral observation measure for the cultural value of simpatia, as part of a larger observational measure of perioperative procedures and behaviors. The new scale has been used to begin coding 30 videos of anesthesia induction from two children’s hospitals, Lucile Packard Children’s Hospital Stanford (n = 15) and Children’s Hospital Colorado (n = 15).


Results from the first phase of the study indicated that simpatia was among the cultural variables identified as important in the perioperative process. Youth reports indicated that patients indirectly benefit from parents’ simpatia-congruent behaviors. That is, when parents appeared content and happy during the preoperative process, youth felt more at ease. Development of the Simpatia Scale for Anesthesia Induction was guided using existing literature and previously used measures of simpatia. 8 Reliability (>85%) among two coders was established and maintained via consensus meetings. Kappa values ranged from fair to perfect interrater agreement (0.27-1.00).

Preliminary results from the second phase of the study indicate parents engaged in simpatia-consistent behaviors between 43-87% of anesthesia induction time intervals (30 seconds each). Parents smiled or laughed during 88% of time intervals, maintained eye contact toward child 89% of the time, engaged in appeasing behaviors t (e.g., caressing hand) 71% of the time, and assisted health care providers 43% of the time. Children’s acute distress levels (i.e., crying, screaming and physically resisting) were low, at 9% of the time, while children appropriately engaged with adults approximately 74% of the time.


Current results suggest that simpatia-congruent behaviors may be common during anesthesia induction in a sample of Latino parents, most of whom are first generation immigrants. Although preliminary, these findings may have important implications for health care providers interacting with parents. Providers should consider the importance of communication that reinforces simpatia-congruent behaviors during induction with Latino families. Overall, greater understanding of unique social and cultural factors that may create disparities in quality of managing perioperative care is needed.