\n
Abstract
\n<\/span><\/strong>Background.<\/span> Preoperative anxiety is common among patients scheduled for surgery and can have affect clinical outcomes. The Amsterdam Preoperative Anxiety and Information Scale (APAIS) is a scale used to assess preoperative anxiety and the need for information among surgical patients. The aim of this study was to translate the original version of APAIS into Danish. Furthermore, to evaluate the Danish version of the APAIS by following the guidelines provided by the International Society for Pharmacoeconomics and Outcome Research (ISPOR).
\n<\/span>Methods
\n<\/strong><\/span>The translation process followed the ISPOR guidelines and involved forward and back trans-lations, reconciliation, cognitive debriefing, and proofreading. The results were evaluated through statistical analysis.
\n<\/span>Results
\n<\/strong><\/span>A total of 14 total knee arthroplasty patients participated in the cognitive debriefing process and provided feedback on the comprehensibility and feasibility of the Danish version of APAIS. Based on the feedback from the cognitive debriefing, the Danish version of APAIS demonstrated comprehensibility and feasibility. The difference in comprehensibility and feasibility between middle-aged and elderly individuals was statistically non-significant.
\n<\/span>Conclusion
\n<\/strong><\/span>The Danish version of APAIS is comprehensible and feasible for assessing preoperative anxiety and the need for information among Danish-speaking patients who were scheduled for total knee arthroplasty surgery.
\n<\/span>Clinical Relevance
\n<\/strong><\/span>The Danish APAIS provides a time-efficient, culturally appropriate alternative to existing scales, supporting early identification of anxiety and enhancing patient-centered care. By addressing preoperative concerns, the scale has the potential to improve surgical outcomes, streamline recovery processes, and foster better communication between patients and clinical teams.<\/span><\/p>\nKeywords<\/span><\/strong>:<\/strong> Amsterdam Preoperative Anxiety and Information Scale, APAIS, translation, anxiety, information, preoperative<\/span><\/p>\n<\/div>\nBackground
\n<\/strong><\/span>Preoperative anxiety is prevalent among patients scheduled for surgery. A systematic review (1). examined the prevalence of preoperative anxiety among surgical patients worldwide and found that 48% of the patients experienced anxiety. Anxiety may cause different symptoms of mental and physiological distress and is, therefore, essential to assess(2). <\/span>Preoperative anxiety is likely to increase the consumption of sedatives during surgical procedures(3), potentially prolonging patients’ recovery time in the Post-Anesthesia Care Unit (PACU) and increasing the risk of side effects(2). Additionally, preoperative anxiety can negatively impact the patient’s mental state postoperatively, leading to feelings of anxiety, sadness, and depression(4).<\/span><\/p>\nMoerman et al. developed the validated Amsterdam Preoperative Anxiety and Information Scale (APAIS) in 1996(5). The APAIS is based on a reflective model; this is evidenced by the use of factor analysis in the original article, which demonstrates that the items on the scale are intended to reflect the underlying constructs of preoperative anxiety and the need for information. The APAIS has demonstrated strong psychometric properties, including validity and reliability. Integrating the APAIS into clinical practice can facilitate the identification of patients experiencing high levels of anxiety and need for information. By addressing these needs, the APAIS has the potential to enhance clinical outcomes(5).<\/span><\/p>\nThe APAIS is a 6-item scale and is developed to be more concise and less time-consuming compared to other anxiety scales used in a clinical setting e.g. STAI(6) and HADS(7)<\/span> assesses general state and trait anxiety, not specific to any particular situation. Additionally, the HADS scale assesses generalized symptoms of anxiety, fear, and depression according to patients in a hospital setting(6,8). Both the STAI and HADS are considered golden standards when measuring anxiety, but they are both time-consuming and not explicitly developed for a surgial setting. Therefore, translating the APAIS into Danish is pertinent, as this scale is highly specific to the preoperative setting and is time-efficient.<\/span><\/p>\nThe scale has been translated into many different languages such as French(9), Turkish(10), Chinese(11), Serbia(12), Amharic(13), Arabic (14), Malay(15), Italian(16), Portugese(17), Spanish(18), Japanese(19), and Urdu(20), and is highly used worldwide(6,21). The APAIS is most commonly used for elective surgery patients such as orthopedic, vascular, cancer, gynecological, and urological procedures. The aim of this study is to translate the APAIS into Danish according to the International Society for Pharmacoeconomics and Outcome Research (ISPOR)(22) and to ensure that the questionnaire is understandable and easy to complete for individuals of all ages. Therefore, the included participants in this study are divided into seniors (\u226565) and middle-aged (<65).<\/span><\/p>\nMethods
\n<\/span><\/strong>Setting, procedure, and participants
\n<\/span><\/strong>The translation was conducted at the Department of Anesthesiology at Zealand University Hospital (ZUH), Koege, Denmark. Patients scheduled for total knee arthroplasty (TKA) surgery were selected to participate in the cognitive debriefing session. The cognitive debriefing was performed to assess the level of comprehensibility and cognitive equivalence of the translation among patients from the target population(23). To recruit patients for the cognitive debriefing, we provided a detailed explanation of the study’s purpose and asked if they would like to participate. After obtaining oral and written informed consent, the patients completed the Danish APAIS and an evaluation form, a few weeks prior to their TKA procedure. The translation process was executed following the guidelines by ISPOR(22) and a summary of the steps are outlined in <\/span>Table 1<\/span>.<\/span><\/p>\nThe scale
\n<\/span><\/strong>The APAIS assess the patient\u2019s anxiety and need for information (5). The scale consists of six concise items where the participants provided their responses using a 5-point Likert scale. One corresponds to ‘Not at all’ and 5 corresponds to ‘Extremely’. The total score of anxiety ranges from 4 (not anxious) to 20 (highly anxious), and the total score of the requirement of information ranges from 2 (no need for information) to 10 (high need for information)(5).<\/span><\/p>\n![\"\"](\"https:\/\/i0.wp.com\/sygeplejevidenskab.dk\/wp-content\/uploads\/2025\/05\/TABLE-1.png?resize=700%2C469&quality=80&ssl=1\")
<\/p>\n
Statistical Analysis
\n<\/span><\/strong>A quantitative methodology was employed to evaluate the translation of the APAIS, using an evaluation form. The evaluation form consisted of different questions that examined the participants\u2019 understanding and the ease with which the questions could be comprehended. Questions such as \u201cthe scale was applicable and easy to understand\u201d, \u201cthe question is comprehensible\u201d for each question, \u201cthe question was quick to understand\u201d for each question and \u201cThe entire questionnaire was quick to complete\u201d. <\/span>The participants subsequently rated their agreement on a 6-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’. This approach allowed for the derivation of general conclusions. The cognitive debriefing data were analyzed using statistical methods, including means, interquartile ranges, Standard Deviations, percentages, tests for normal distribution, and the Mann-Whitney U test. <\/span>Analysis was conducted to compare comprehensibility and feasibility between middle-aged and seniors. The statistical analyses were performed using both Excel and R Studio (version 2023.12.0). <\/span>For inter-group comparisons, the Mann-Whitney U test was applied. The cut-off limit for defining an individual as senior was established as \u226565 years old, aligning with guidelines from the Danish Health Authority(24). Since no personal or identifiable information about the participants was required, Human Participants Protection was not deemed necessary.<\/span><\/p>\nResults
\n<\/span><\/strong>Step 1 \u2013 Preparation
\n<\/span><\/strong>During the preparation, efforts were made to obtain approval from the original authors of the APAIS to translate the scale into Danish. Consequently, various attempts were made to establish contact with the original authors. Unfortunately, obtaining their approval was not feasible. Despite this challenge, the team of translators decided to proceed with the translation process.
\n<\/span>Step 2 – Forward translation
\n<\/span><\/strong>One associate professor, who is also an intensive care unit nurse, one nurse anesthetist, and one healthcare technology engineer each performed an independent forward translation from English to Danish. These translations were carried out independently and without mutual influence. All three translators were native Danish speakers.
\n<\/span>Step 3 \u2013 Reconciliation
\n<\/span><\/strong>After evaluating the various translations, they were merged into a final draft, which was discussed and agreed upon by all three translators. The translators tried to retain the original items\u2019 meaning, ensuring that the APAIS assesses the same parameters even in a different language. A minor challenge was encountered concerning the term “anesthetic.” However, after a thorough discussion, consensus was reached on the most appropriate terminology. All other aspects were consistently translated.
\n<\/span>Step 4 – Back translation
\n<\/span><\/strong>The Danish version of the APAIS was back-translated into English by a contract surveyor who is a native speaker of the source language, English, and also possesses a professional level of proficiency in Danish. He did not know how the original items were phrased in the English version of APAIS.
\n<\/span>Step 5 – Back translation review
\n<\/span><\/strong>The three translators then reviewed the back translation and compared it to the original phrasing regarding making necessary adjustments. There were minor deviations in the concept of terms of the APAIS original and the back translation, but the significance of every item remained the same.
\n<\/span>Step 6 – Harmonization
\n<\/span><\/strong>Contacting the original authors to assess the English back translation proved unfeasible. A thorough search on PubMed yielded no studies publishing their back translations(9,10,19,11-18), precluding comparison of the back translation of the Danish APAIS with other translations in different languages. Consequently, the team of translators decided to continue with the next step in the process.
\n<\/span>Step 7 – Cognitive debriefing
\n<\/span><\/strong>In this step, the translation underwent evaluation by the participants. The evaluation form assesses comprehensibility and feasibility. The Danish version of the APAIS (<\/span>Figure 1<\/span><\/strong>) underwent an evaluation process by the included patients. <\/span>A total of 14 patients participated in the evaluation, including eight males and six females, varying in age from 48 to 86 years old whereas nine are seniors \u226565 and the other five are middle-aged <65 years old. <\/span>A total of 12 out of the 14 patients participating had previously undergone surgical procedures. All patients were scheduled to undergo TKA. Each patient evaluating the APAIS received a printed copy of the Danish version and an evaluation form to assess the comprehensibility and feasibility of the translated version (<\/span>Table 2<\/span><\/strong>).<\/span><\/p>\n![\"\"](\"https:\/\/i0.wp.com\/sygeplejevidenskab.dk\/wp-content\/uploads\/2025\/05\/FIGURE-1.png?resize=700%2C389&quality=80&ssl=1\")
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![\"\"](\"https:\/\/i0.wp.com\/sygeplejevidenskab.dk\/wp-content\/uploads\/2025\/05\/Table-2.png?resize=332%2C186&quality=80&ssl=1\")
<\/p>\n
Step 8 – Review of cognitive debriefing results and finalization
\n<\/span><\/strong>In this step, the results from the cognitive debriefing underwent statistical analysis, followed by final adjustments to the translation. Each item in the Danish APAIS was evaluated regarding language, content, time, and usability. Each item was rated on a Likert scale ranging from 1-6 (strongly disagree, disagree, slightly disagree, slightly agree, agree, strongly agree). The results from the cognitive debriefing can be seen in<\/span> Table 3<\/strong>. <\/span>The results show that 100% of patients agree, at some level, according to comprehensibility, that the items in the Danish APAIS are understandable. A total of 92.9% did agree, at some level, according to the feasibility, that every item was quick to understand. In general, 100% of the patients agreed that the Danish APAIS was quick to answer. <\/span>The data from the cognitive debriefing have been analyzed in R studio (version 2023.12.0), and calculations in Excel have been made to calculate averages and other, percentages. <\/span>Furthermore, a Mann-Whitney U test was conducted to assess whether there is any significant difference in comprehensibility and feasibility between patients younger than 65 years and elderly patients. The statistical significance level was set to p < 0.05. No statistically significant differences were observed between the groups in terms of comprehen-sibility and feasibility of the Danish APAIS,<\/span> (<\/span>Table 4<\/span>). The results from evaluating the Danish APAIS indicate that the scale is highly comprehensible, and its feasibility is reasonably good, as the majority of patients showed strong agreement with the scale’s items.
\n<\/span>Step 9 – Proofreading
\n<\/span><\/strong>The three translators proofread the final version.
\n<\/span>Step 10 – Final report
\n<\/span><\/strong>The team of translators approved the Danish version of the APAIS based on the forward and backward translation, cognitive debriefing, and a thorough review of the cognitive debriefing process.<\/span><\/p>\n![\"\"](\"https:\/\/i0.wp.com\/sygeplejevidenskab.dk\/wp-content\/uploads\/2025\/05\/TABLE-3.png?resize=711%2C393&quality=80&ssl=1\")
<\/p>\n
![\"\"](\"https:\/\/i0.wp.com\/sygeplejevidenskab.dk\/wp-content\/uploads\/2025\/05\/Table-4.png?resize=711%2C395&quality=80&ssl=1\")
<\/p>\n
<\/p>\n
Discussion
\n<\/span><\/strong>This study aimed to translate the original APAIS into Danish while maintaining the comprehension of each item. The evaluation showed that the Danish version of APAIS is comprehensible and feasible since the evaluation through the cognitive debriefing indicated that the items are comprehensible for patients regardless of whether they were middle-aged or elderly. The majority of the patients strongly agreed with the comprehensibility of the items. Based on an average calculation for the entire sample and across all items, it took patients a short amount of time to understand the APAIS. <\/span>One patient rated \u201cslightly disagree\u201d on the evaluation form in response to the statement that “it took a short amount of time to understand the question,” according to items one, three, and six on the Danish APAIS. <\/span>A cognitive debriefing session of the original APAIS could not be found, which would have been relevant for comparing evaluations of the original and the Danish version. Some patients may find specific items somewhat time-consuming to understand. This could imply a general sentiment that some items are indeed somewhat time-consuming.<\/span><\/p>\nFurthermore, ‘time-consuming’ is not defined within a specific timeframe, making it highly subjective in determining how much time qualifies as time-consuming. <\/span>Some limitations emerged and should be acknowledged. Firstly, it was not possible to comprehensively follow all steps outlined by ISPOR, as repeated efforts to establish contact with the original authors of the APAIS were unsuccessful. ISPOR does not provide alternative means of contacting original authors when direct communication is not feasible. <\/span>Therefore, the inability to obtain consent from the original author represents a limitation. Secondly, a small sample size of n = 14 was utilized due to the constrained time frame. <\/span>Despite this limitation, efforts were made to ensure the reliability of the responses by conducting the assessment under controlled conditions, and the participants were representative as they were elective surgery patients. However, it is worth noting that according to ISPOR guidelines, a sample size of 5-8 respondents is typically deemed sufficient for testing comprehensibility and cognitive equivalence.<\/span><\/p>\nConsequently, the reliability of findings from a small sample size may warrant further discussion. Another limitation relates to the age distribution of the sample, with the majority of participants being 60 years or older. Consequently, the response patterns of younger participants during the cognitive debriefing remain unknown. <\/span>As recommended in step six of the ISPOR guidelines(22), a comparison to the back-translation to other studies was desired, but that step could not be performed since it was impos-sible to detect any published studies in PubMed that mention their back-translation(6-17). <\/span>Validation through exploratory factor analysis and confirmatory factor analysis has not been performed in this translation, and a re-test of the Danish APAIS according to the cognitive debriefing has not been conducted. Test-retest reliability assesses whether an individual’s responses to a questionnaire remain consistent across repeated testing of the same questionnaire, indicating reproducibility(23). <\/span>The reason for not retesting the Danish version is twofold. Firstly, it was not possible to have patients complete the Danish APAIS and the evaluation form twice, with a two-week gap between the first and second completion, because it was paper-based and required their physical presence at the hospital site. Secondly, the authors did not intend to validate the Danish version of APAIS.<\/span><\/p>\nConclusion
\n<\/span><\/strong>The Danish version of APAIS provides a publicly accessible screening scale for evaluating preoperative anxiety and the need for information among Danish-speaking surgical patients. It is important to note that this translation has not undergone formal validation. However, based on the data obtained from the cognitive debriefing, it can be inferred that the majority of patients, irrespective of their age, expressed a high level of agreement with the items in the scale being comprehensible and feasible.<\/span><\/p>\nReferences
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