Original article
12152
Effect of preoperative two-dimensional animation information
on perioperative anxiety and knowledge retention in patients
undergoing bowel surgery: a randomized pilot study
S. Tou*, W. Tou, D. Mah, A. Karatassas and P. Hewett
*Department of Colorectal Surgery, The Royal Derby Hospital, Derby, UK, Clinical Standards and Governance, Chesterfield Royal Hospital,
Chesterfield, UK and Department of Colorectal Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
Received 3 August 2012; accepted 21 November 2012; Accepted Article online 26 January 2013
Abstract
Aim The use of multimedia information provided
preoperatively can potentially reduce anxiety in patients
and improve the hospital experience. However, the use of
two-dimensional (2D) animation (cartoon) to provide
information to patients undergoing colorectal surgery
has not been investigated. This study investigated the
effect of preoperative 2D information on anxiety and
knowledge retention in patients undergoing bowel
surgery.
Method Patients were randomized to one of two
groups; the video group watched a 13-min cartoon ani-
mation whereas the nonvideo group did not. Anxiety
levels were measured at the preadmission clinic, postvid-
eo, on the day of admission for surgery, within 24-h
after surgery and before discharge using the Spielberger
state-trait anxiety inventory and visual analogue scale.
Both groups completed a knowledge retention ques-
tionnaire and the video group completed a feedback
questionnaire about the animation.
Results Thirty-one patients (16 video, 15 nonvideo)
participated in the study. There was no significant
Introduction
Provision of information using multimedia is suggested
to offer an effective method of managing patient anxi-
ety. Patients can be informed about treatments from a
wide range of information delivery platforms such as
the World Wide Web, in writing or by using other
audio or visual media. Forty to 80% of patients experi-
ence considerable anxiety before and after surgery
[14]. One of the commonest complaints is insufficient
Correspondence to: Mr Samson Tou, Department of Colorectal Surgery, The
Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK.
E-mail: samsontou@aol.com
e256 Colorectal Disease 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e256e265
doi:10.1111/codi.
difference in baseline anxiety score between two groups.
An immediate reduction (P = 0.03) in anxiety score was
observed in the video group after watching the video
compared with baseline. There was a significant reduc-
tion in anxiety score in the video group at discharge
compared with the nonvideo group (P = 0.03). There
was no significant difference in knowledge retention
between two groups. Eighty-eight per cent of patients
who watched the video found it beneficial.
Conclusion 2D animation is an effective medium for
delivering information to patients undergoing bowel
surgery and can potentially reduce anxiety related to
surgery and improve the hospital experience.
Keywords Animation, video, randomized study, bowel
surgery, anxiety
What is new in this paper?
This is the first study to demonstrate that two-dimen-
sional animation can be an effective tool for delivering
information to patients undergoing bowel surgery.
information and limited communication [5]. It is sug-
gested that information to patients could be greatly
enhanced by a two-dimensional (2D) computer-gener-
ated animation video [6,7]. It has been previously
reported that written information is an effective way to
inform patients about surgical interventions [8]. Read-
ing materials and verbal communication with clinicians
can reduce the level of anxiety associated with surgery
[9,10]. However, there is increasing awareness that
other media technologies have the capabilities to
produce graphics and imagery that could enhance
patient well-being and improve the understanding of
treatments [7,10,11].
S. Tou et al.
The goal of this study was to pilot a video (cartoon)
animation. This was to review appropriate ways to
improve knowledge transfer aside from the usual written
information. As such an animation was created to
provide a step-by-step guide to colorectal surgery. The
animation includes details about the diagnostic and
surgical procedures and information on hospital admis-
sion and discharge.
The study aimed to investigate the effect of the
preoperative 2D animation (cartoon) information on
perioperative anxiety and knowledge retention in
patients undergoing bowel resection. This randomized
study aims to highlight any potential benefits.
Method
A 2D video animation and an information sheet were
developed in collaboration with the Colorectal Unit at
the Queen Elizabeth Hospital, Adelaide, Australia. Lit-
erature and Internet reviews were undertaken to assess
the different types of information provided to patients
undergoing bowel surgery [1215]. These searches
included a review of fast-track colorectal surgery and
enhanced recovery programmes. Material content was
also gathered from the existing medical literature
including a patient information sheet describing bowel
surgery created by one of the NHS hospitals, and other
sources of information such as videos on bowel cancer
screening and surgery were also assessed [1618].
Two interventions were prepared for participants
who met the inclusion criteria. Patients aged 18 years
and above, with American Society of Anesthesiologists
grade 13, considered for elective bowel surgery (either
open or laparoscopic approach) and able to read and
understand English sufficiently were eligible to partici-
pate. The fact sheet and computerized cartoon anima-
tion about bowel surgery including pre-, peri- and
postoperative care was written, compiled and designed
by two of the authors (ST, WT). Both the animation
and information sheet depicted the patients complete
in-hospital journey (e.g. information including the role
of the preadmission clinic, bowel preparation, stoma
information, bowel surgery, postoperative recovery,
catheters and pain control etc.; see Appendices A1A4).
The 2D animation was constructed using ANIME
STUDIO DEBUT 7 (Smith Microsoftware, Aliso Viejo,
California, USA), SIBELIUS 6 (2011 Avid Technology,
Inc., Burlington, MA, USA) and I-MOVIE (Apple Inc.,
Cupertino, California, USA) and runs for a total of
13 min. The production features original music compo-
sitions, cartoon characters and audio commentary and
took a total of 4 months to develop. Colorectal sur-
geons, anaesthetists, specialist colorectal and stoma
Colorectal Disease 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e256e265
2D animation and bowel surgery
nurses, nursing staff at the preassessment clinic, theatre,
high-dependency unit and ward, reviewed the anima-
tion. Any feedback and changes were incorporated into
the draft and the revised information sheet and anima-
tion were used for the study.
The study received approval from the Adelaide Health
Service Human Research Ethics Committee. Eligible
participants were approached by telephone prior to
their preoperative assessment. Patients were randomly
assigned to either a video group (watching the video) or
a control group (no video) using computer-generated
random numbers stratified by gender (Fig. 1). Alloca-
tions were sealed in opaque envelopes and hand deliv-
ered to the researcher.
An independent researcher obtained the baseline
anxiety score from both groups on arrival to the pread-
mission clinic by questionnaires using the validated
Spielberger state-trait anxiety inventory (STAI) and a
visual analogue scale (VAS) [19,20]. The researcher and
patients were blinded from the group allocation until
the baseline anxiety score was completed. Other staff
members including nursing staff, anaesthetists, junior
doctors, pharmacists and surgeons (including the princi-
pal investigator) were unaware of the patients group
allocations.
Patients from the video group watched the short
animation film on a desktop computer in a quiet room.
Patients from the video group and control group were
provided with the same information sheet. Postvideo
40 patients underwent open/laparoscopic
colorectal procedures during study period
2 patents excluded due
to language problems
6 patients refused to
participate in the trial
1 patient recruited but
subsequently found unfit
for surgery
31 patients randomized
16 patients in 15 patients in
video group nonvideo group
All data available for analysis for 31 patients
Figure 1 Flow chart of the study.
e257
2D animation and bowel surgery
anxiety score was obtained from the treatment group.
Anxiety score and knowledge retention questionnaires
(nonvalidated; Appendix B) were collated from both
groups of patients on the day of admission before
surgery. Anxiety scores were repeated within 24 h after
operation and just before patients were discharged (i.e.
within 24 h). The video group was also asked to com-
plete a nonvalidated questionnaire (Appendix C) to
allow for direct feedback about the usefulness of the
cartoon animation and on the overall experience.
Primary outcome
The primary outcome measure was the patient anxiety
score using a validated STAI and VAS (score from 0 to
100). The STAI consists of 40 questions to assess peo-
ples anxiety and includes 20 questions designated to
assessing the anxiety state (how the person feels at the
time) and another 20 to assess anxiety trait (how the
person generally feels). Each answer would score
between one and four and the total score range is from
20 to 80. The higher the score the more anxious the
person is in general.
Secondary outcome
Secondary outcome measures were knowledge reten-
tion, feedback questionnaire response (nonvalidated),
clinical outcomes (30-day mortality/morbidity, length
of hospital stay).
Statistical analysis
The primary outcome was patients anxiety score and it
was calculated that 13 patients in each group would
achieve 80% power to detect a significant difference in
anxiety score between two groups of > 10 points, with
group standard deviation of 8.9 [1] and a significance
level of 5%. To allow for nonadherence to the protocol,
we aimed to recruit 15 patients per group in the study.
Collected data were entered into Excel 2007 (Micro-
soft Corporation, Redmond, Washington, USA) and
statistical analyses were performed using the STATISTICAL
Table 1 Baseline characteristics of the video and nonvideo group. Values are given as mean  SD.
Characteristics Total (n = 31)
Age (years) at operation 59 (13)
Age (years) at operation (male) 60 (12)
Age (years) at operation (female) 59 (14)
Trait anxiety score (Y2) 36 (10)
e258 Colorectal Disease 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e256e265
S. Tou et al.
PACKAGE FOR THE SOCIAL SCIENCES SOFTWARE, version 17.0
(SPSS Inc., Chicago, IL, USA). Measurements of cate-
gorical variables were analysed using the chi-square test.
Matched groups were analysed using Wilcoxon signed-
rank test and repeated-measures analysis of variance to
assess anxiety scores of the same participants across dif-
ferent time points.
Results
There were 31 patients included in the study from
August 2011 to January 2012. Data for all patients
were available for analysis (Fig. 1). The male/female
ratio in the two groups was 9/7 and 7/8 and the mean
age was 59 years (Table 1). The average age of patients
in the video group was 62 years compared with
56 years in the nonvideo group. There was no differ-
ence in the trait anxiety score between the video and
nonvideo groups. The operations performed in both
groups are summarized in Table 2. Thirteen patients in
the video group had surgery for cancer (13/16; 81%)
compared with 11 in the non-video group (11/15;
73%).
Anxiety scores were collected from baseline to pre-
discharge. Baseline anxiety scores were similar in both
study groups (Table 3); participants in the video group
were found to be slightly more anxious, but statistically
there was no difference (P = 0.17 STAI; P = 0.09
VAS). The results indicated no significant differences
(both STAI and VAS) between the two study groups at
any stage of hospitalization (Table 3). There was one
patient from the nonvideo group whose response was
markedly different from the other participants. The
STAI and VAS both were much lower than expected
with no fluctuations reported at any stage of testing.
STAI stayed at 2021 and VAS 01 at all stages.
Following discussion amongst the authors an analysis
was also performed after excluding this patient. When
this outlier participant was removed from the nonvideo
group, there was a significant difference in anxiety levels
between two groups at discharge (P = 0.03, STAI only;
Fig. 2), but the difference was not significant in the
VAS (Fig. 3).
Video group (n = 16) Nonvideo group (n = 15) P-value
62 (12) 56 (13) 0.59
63 (12) n = 9 55 (10) n = 7 0.65
60 (13) n = 7 57 (16) n = 8 0.47
36 (10) 36 (11) 0.66
S. Tou et al. 2D animation and bowel surgery

Table 2 Types of operation performed was not significant either (mean 7.4  3.5 days in the
video group vs 9.3  8.8 days in the nonvideo group;
Video group Nonvideo
P = 0.20). There was no significant difference in com-
Operations (n = 16) group (n = 15)
plications between the two groups (results not shown).
To understand further the views of the patients who
Open procedures
Right hemicolectomy 1 0
had watched the video, an additional feedback form was
Ileocolic reanastomosis 0 1 used to evaluate the responses from the video group.
Subtotal colectomy 1* 0 Some of their comments can be seen in Table 4. All
Low anterior resection 0 1 patients indicated that they were in favour of using ani-
Reversal of Hartmanns 1 1 mation to convey medication information and 88%
procedure agreed that the video they watched was helpful. Not
Proctectomy 1 1 everyone opted, or had the opportunity, to watch the
APER 1 1 video at home. The reported reasons given were related
Laparoscopic procedures to fear of increasing anxiety, as expressed by one
Right hemicolectomy 2 1 patient, and on a more practical level reasons regarding
High anterior resection 3 6 the timing of the surgery and not having a video player
Low anterior resection 1 2 available. Of the seven patients who saw the cartoon
Ultra-low anterior resection 2 0 animation at home, four saw it again once only and
Subtotal colectomy 1 0 three watched the video twice. Some patients showed
APER 2 1 the video to family members and the nine patients who
*With ovarian cystectomy and splenectomy. did this expressed the view that their family had found
With hysterectomy, bilateral salpingo-oophorectomy, sleeve the video helpful. The results showed that 63%
bladder resection and small bowel resection. (n = 10) of patients felt that an appropriate level of
One case with cholecystectomy. detail had been provided in the video. Of the remaining
One case converted to open. patients who sought for more information, 50% (n = 3)
One case converted to open. had previously undergone an operation.
APER, abdominoperineal excison of rectum.

Anxiety responses over different time points for the
same participants were also analysed. Patients in the
video group had experienced immediate reductions in
anxiety levels after watching the video, as evidenced by
the STAI test (repeated measures analysis of variance,
P = 0.03; Table 3). The mean anxiety score of the
video group at baseline and on the day of surgery
admission were similar (P = 1.00) and anxiety levels
dropped significantly after surgery, identified in the
scores taken from 24 h after the surgery and before
discharge (P = 0.04; Table 3). Across the various test
periods STAI and VAS scores changed significantly. Some
anxiety changes were found in the control group (VAS
only) and STAI scores from baseline to predischarge were
relatively unchanged (F-test > 0.05; STAI only).
Following analysis of the STAI and VAS data, it was
found that patients in the video group overall were
comparatively less anxious from baseline to predischarge
as indicated by the anxiety levels at each stage of hospi-
talization (Table 3). A knowledge retention question-
naire was administered to patients in the video and the
nonvideo groups. The results between them were not
statistically different (mean 5.8  0.5 for the video
group vs 5.8  0.6 for the nonvideo group; P = 1.00).
The difference between the groups on length of stay
Discussion
There was an emerging pattern in the anxiety scores of
both study groups. The video seems to have had a posi-
tive effect on reducing anxiety. Despite the high anxiety
levels shown at baseline and on the day of surgical
admission, patients in the video group appeared to
cope better with the negative feelings of anxiety and
this had led to quicker and more effective stress
reductions after surgery. The intervention continued to
produce benefits across time and may have played a
significant role in helping to counter the effect of
anxiety at discharge.
Technology has become more affordable, offering
people easier access to patient information. The emer-
gence of multimedia tools can have an impact on and
influence dialogues with medical staff and doctors. Its
use might enable both patients and clinicians to focus
conversations on specific needs and concerns. To date
there has been a small number of published reports sup-
porting the use of 2D cartoon animations to inform
patients about the different aspects of surgery. Hermann
and co-workers developed a three-dimensional (3D)
animation that showed the anatomy of the thyroid and
the step-by-step surgical procedure [14]. User accep-
tance testing around computer-animated surgeries have

Colorectal Disease 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e256e265 e259
2D animation and bowel surgery S. Tou et al.

Table 3 Analysis for differences between the video and nonvideo groups using Wilcoxons signed-rank test. Analysis of anxiety over
time for difference between each time point using repeated-measures analysis of variance.

Anxiety scores Video group Nonvideo group Rank sum P-value

Baseline (preadmission clinic)

STAI 44.1 (12.4)*, 38.5 (12.2) P = 0.17
VAS 51.6 (28.7) 37.5 (26.2) P = 0.09

Postvideo
STAI 34.7 (11.4)*
VAS 41.5 (29.4)

DOSA
STAI 44.3 (13.6)** 41.4 (15.2) P = 0.71
VAS 58.1 (27.7),, 49.5 (30.3) P = 0.29

Postoperation < 24 h
STAI 36.2 (8.2) 36.4 (9.3) P = 1.00
VAS 38.1 (21.2) 29.7 (23.8) P = 0.28

Predischarge
STAI 30.1 (8.3),**, 36.3 (9.4) P = 0.08
VAS 25.6 (20.0), 30.8 (25.5) P = 0.64

F-test
STAI F = 9.83, P < 0.001 F = 2.21, P > 0.05
VAS F = 8.54, P < 0.001 F = 4.98, P < 0.02

*P = 0.03, STAI, baseline vs postvideo.

P = 0.001, STAI, baseline vs predischarge.
P = 0.01, VAS, baseline vs predischarge.
P = 0.03, VAS, postvideo vs DOSA.
P = 0.001, VAS, DOSA vs postoperation.
**P = 0.001, STAI, DOSA vs predischarge.
P = 0.04, STAI, postoperation vs predischarge.
P = 0.001, VAS, DOSA vs predischarge.
DOSA, day of surgical admission; predischarge, within 24 h of discharge; STAI, state-trait anxiety inventory; VAS, visual analogue scale.

50
70
45
40 60
35
50
30
STAI

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VAS

20 30
15 Video group
Nonvideo group 20
10
Video group
5 10 Nonvideo group
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Stages during hospital journey

Figure 2 Adjusted (after excluding the outlier; see text) state-
trait anxiety inventory (STAI) score for patients at different
stages of the hospital journey. *P = 0.03; Wilcoxon-signed-
rank test.
Stages during hospital journey
Figure 3 Adjusted (after excluding the outlier; see text) visual
analogue scale (VAS) score for patients at different stages of
the hospital journey.

e260 Colorectal Disease 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e256e265
S. Tou et al.
Table 4 Some of the participants responses to the 2D animation video.
Explained what to expect. All information was set out well and helped me to put my mind at ease.
Simple and easy to understand. Didnt watch video at home as too anxious. DVD not complicated put me at ease.
Anyone having the operation should watch it.
Helped to understand from beginning to end.
I thought the video was very interesting. I think that most people would take more notice of a video then reading.
Easier to understand than somebody else telling me.
Video was calming. Need more info on feelings after surgery. The recovery period was much tougher than I imagined. Loss of
any control over self for a number of days.
Informative but not enough information.
Helpful, goes through the different stages, but too little information.
shown evidence of effectiveness and one of the benefits
may include reducing pre- and postsurgery anxieties.
The findings of this study on anxiety are consistent
with previous reports [1,14]. There is a plethora of
evidence supporting the use of the new media, and
animation-based information can be employed in hospi-
tal or home care for surgery patients [1,3,10]. Cartoon
animations should be encouraged because they can
reduce anxiety before and after surgery. They is rela-
tively inexpensive to create and are appropriate for a
general audience. Provision of information can contrib-
ute to improvements in length of hospital stay [21],
although the results of this study did not show a signifi-
cant reduction between the two groups. Information
that is restricted to a written form does not minimize
the knowledge transfer and retention process. Both
media are equally effective for this purpose.
Limited hospital resources often preclude the use of
modern technology to develop patient education mate-
rials. For this reason the uptake of modern media and
multimedia information within hospitals has not been
popularized. Health organizations support the provision
of patient information, and there is recognition that a
story told well can appeal to a wider audience. A num-
ber of health authorities and hospitals in different coun-
tries have invested time and resources through media
enterprises to construct and tailor animations using 2D
and 3D techniques. Two videos were found on You-
Tube utilizing animation to inform patients about
bowel cancer screening [17,18]. The NHS in the UK
introduced patients to a video production that filmed
patients and hospital staff during the preoperative and
postoperative periods of bowel surgery [22]. Many
factors may affect how patients respond to information,
but content and simplicity play a major role. Media
have the potential to impact on how and when patients
learn about their health. The optimal medium for
production of patient information remains relatively
unknown. Information if delivered inappropriately can
adversely affect anxiety [23].
Colorectal Disease 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e256e265
2D animation and bowel surgery
Efforts were put into the design and production of a
good-quality animation video. However, it was recog-
nized that there were limitations to the overall design
and implementation given that it was made on an extre-
mely low budget (approximately 500 Australian dollars).
It is unknown whether any other causal effects had
influenced the results. The researcher was also the
patients doctor and there was the possibility of under-
reporting. Anxiety questionnaires and evaluation forms
were self-reported. The recommendation is that the
existing information from the pilot project is used as a
prototype that could be outsourced to 2D/3D anima-
tion professional services. Future projects could include
other procedures, more specialized surgeries and trans-
lations into other languages.
The animation was utilized in a variety of ways,
primarily to help patients understand the hospital treat-
ment, but it could also be used as an educational tool
for training staff. The greatest benefit of the cartoon
animation is having the capacity to change the anxiety
trends commonly associated with surgery.
The present study demonstrated that animation was
an effective way for information to be delivered. Anxiety
levels within the treatment group improved substantially
and there was a significant difference between the two
groups at discharge. Knowledge retention was equally
effective. With this result, there seems to be justification
to make use of animation as a possible medium to
provide information that will certainly benefit patients.
Acknowledgements
The staff from the Department of Colorectal Surgery,
Queen Elizabeth Hospital, Adelaide, Australia.
Author contributions
Conception of idea and production of DVD: ST, WT;
Design and conduct of trial: ST, WT, DM, AK, PH;
Data collection: DM, ST, WT; Analysis and interpreta-
e261
2D animation and bowel surgery
tion of data: ST, WT, PH; Drafting the manuscript: ST,
WT; Critically appraise and revising the draft manu-
script: ST, WT, PH, AK.
Funding
None.
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S. Tou et al. 2D animation and bowel surgery

Appendix A1 Appendix A2

Junior Anaesthetist Pharmacist Specialist

Doctor Nurse

Appendix A3 Appendix A4

Transverse Colon

Ascending Colon
Descending Colon

Small Intestines

Caecum

Sigmoid Colon

Rectum

Colorectal Disease 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e256e265 e263
2D animation and bowel surgery S. Tou et al.

Appendix B

e264 Colorectal Disease 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e256e265
S. Tou et al. 2D animation and bowel surgery

Appendix C

Colorectal Disease 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e256e265 e265
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