Preoperative Health Belief Model-Based Nursing Intervention on Anxiety and Pain-Related Stress in Lung Cancer Patients

Summary

This protocol details a Health Belief Model-based preoperative visit designed to alleviate anxiety and pain-related stress in lung cancer surgery patients, aiming to improve postoperative outcomes.

Abstract

To explore the intervention effect of preoperative visit nursing based on the Health Belief Model (HBM) on the perception of preoperative anxiety and pain-related stress in patients with lung cancer (LC).

This retrospective study included 110 LC patients who underwent surgery at our hospital from June 2022 to June 2024. Based on the preoperative nursing protocol received, patients were assigned to a control group (routine preoperative care, n = 55) or a study group (HBM-based preoperative visit nursing, n = 55). Primary outcomes were preoperative anxiety (Amsterdam Anxiety and Information Scale [APAIS]; higher scores indicate greater anxiety), pain sensitivity (Pain Sensitivity Questionnaire [PSQ]; higher scores indicate greater sensitivity), perceived stress (Perceived Stress Scale [PSS]; higher scores indicate greater stress), and postoperative pain (Visual Analogue Scale [VAS]; higher scores indicate greater pain). Secondary outcomes included preoperative physiological parameters (systolic/diastolic blood pressure, heart rate), sleep quality (Pittsburgh Sleep Quality Index [PSQI]; higher scores indicate poorer sleep), and postoperative complications.No significant baseline differences existed between groups (P > 0.05). Between-group comparisons used independent t-tests or chi-square tests; repeated-measures ANOVA was used for longitudinal data. After intervention, APAIS, PSQ, and PSS scores decreased in both groups, with significantly lower scores in the study group (P < 0.05). Except at 6 h postoperatively, VAS scores at 12 h, 24 h, and 48 h were significantly lower in the study group (P < 0.05). Preoperative physiological parameters increased less in the study group (P < 0.05); PSQI scores decreased more in the study group (P < 0.05). The study group had a lower postoperative complication rate (3.64% vs. 16.36%, P < 0.05). HBM-based preoperative visit nursing may alleviate preoperative anxiety, pain sensitivity, and stress perception, reduce postoperative pain and physiological stress, improve sleep quality, and lower postoperative complications in LC patients.

Introduction

Lung cancer (LC) is one of the most common malignancies and occurs when abnormal cells in the lungs grow uncontrollably to form masses or tumors¹. In recent decades, factors such as population aging, industrial pollution, widespread tobacco use, and dietary carcinogen exposure have contributed to the rising incidence of LC². Patients with LC typically present with cough, dyspnea, and shortness of breath. Without timely treatment, disease progression may lead to comorbidities including cardiovascular disease, chronic obstructive pulmonary disease, and diabetes, exacerbating the condition and imposing a substantial burden on individuals, families, and society³. Currently, surgery offers the best evidence-based chance of cure for eligible LC patients. However, as a significant physiological stressor, surgery can activate the sympathetic nervous system, endocrine, and cardiovascular responses, precipitating preoperative anxiety and fear, accompanied by increased pain-related stress perception⁴. Stress perception refers to an individual's appraisal of stressors and their coping resources; when resources are perceived as insufficient, internal homeostasis is disrupted, resulting in anxiety and pain⁵. Pain is a common postoperative symptom that substantially impacts quality of life, often triggering anxiety and depression and creating a vicious cycle⁶. Preoperative anxiety may reduce treatment compliance, exacerbate postoperative pain, prolong recovery, and diminish quality of life. Therefore, effective interventions to alleviate preoperative anxiety and pain-related stress are essential. Traditional preoperative interventions, such as brief verbal education and routine vital sign monitoring, are often unstructured and lack systematic psychological support, limiting their effectiveness in addressing patients' emotional needs⁷.

The Health Belief Model (HBM) serves as a crucial theoretical framework employing social psychology techniques to elucidate behaviors pertaining to health. It is a well-established theoretical framework that explains and predicts health-related behaviors based on six key constructs: perceived susceptibility (belief about the risk of developing a health problem), perceived severity (belief about the seriousness of the condition), perceived benefits (belief in the effectiveness of recommended actions), perceived barriers (belief about the costs or obstacles of taking action), self-efficacy (confidence in one's ability to take action), and cues to action (triggers that prompt action)⁸. Currently, this model is used in health education for a variety of chronic diseases, including diabetes management, breast cancer patient education, and stroke patient rehabilitation, among others.

Preoperative visit nursing is to understand the psychological state and needs of patients through communication and consultation of medical and nursing records, so as to provide patients with personalized preoperative psychological support and nursing guidance⁹. Lately, with the continuous advancement of medical technology and the ongoing evolution of medical service concepts, the preoperative visit, a form of humanized medical service, has been widely recognized and adopted. In the context of preoperative care, HBM provides a useful lens to understand patients' psychological responses to surgery. For example, patients who perceive lung cancer as a severe threat (high perceived severity) and believe that surgery is effective (high perceived benefits) may be more motivated to engage in preoperative preparation. Conversely, those who fear pain or have misconceptions about surgery (high perceived barriers) may experience heightened anxiety. By systematically addressing these beliefs, nursing interventions can promote adaptive behaviors (e.g., relaxation, adherence to preoperative instructions) and reduce maladaptive responses (e.g., anxiety, pain-related stress)¹⁰. However, there are few studies on the application of this preoperative nursing mode in the treatment of LC patients. In this study, we applied the HBM as a guiding framework to develop a structured preoperative visit nursing intervention. Rather than using HBM as the intervention itself, we used its constructs to design and organize the intervention components. This theory-driven approach ensures that each element of the intervention targets specific psychological determinants of preoperative anxiety and pain perception, thereby enhancing the intervention's coherence, transparency, and replicability.

So this study explores the intervention effect of preoperative visit based on the Health Belief Model on preoperative anxiety and pain-related stress perception in LC patients, aiming to further improve nursing quality, reduce preoperative anxiety and stress perception in patients, create more favorable conditions for their surgery and postoperative rehabilitation, and provide a scientific basis for clinical application.

Protocol

This study was conducted in accordance with the guidelines of the Ethics Committee of Affiliated Hospital of Panzhihua University (Approval No: 2020-039). Due to the retrospective nature of the study, which involved only the analysis of de-identified data from existing medical records, the requirement for informed consent was waived by the ethics committee. Patient data were anonymized prior to analysis to ensure confidentiality. This study was designed as a retrospective cohort study. Data were collected by reviewing the electronic medical records of patients who underwent lung cancer surgery at our institution between June 2022 and June 2024. During this period, two different preoperative nursing protocols were sequentially implemented as part of standard clinical practice: routine preoperative care and HBM-based preoperative visit nursing. The assignment of patients to either protocol was determined solely by the date of admission, and no active intervention was performed by the researchers for the purpose of this study (Figure 1).

1. Study design and participants

1. Conduct this retrospective study based on any specific timeline.
   NOTE: This study included 110 LC patients who had surgery in our hospital from June 2022 to June 2024.
2. Enroll 110 patients diagnosed with lung cancer (LC) who will undergo surgical treatment.
3. Organize multidisciplinary consultations involving oncology surgery, respiratory medicine, thoracic surgery, and radiotherapy departments.
4. Perform comprehensive diagnosis and preoperative evaluation via chest CT, X-ray, and tissue/cytology examinations to confirm diagnostic accuracy and surgical treatment plans.
5. Inclusion criteria:
   1. Confirm that the patient meets the diagnostic criteria for LC¹¹, based on chest CT and X-ray findings, and has surgical indications.
   2. Include patients aged between 18 and 75 years, with intact cognitive function and no history of mental disorders.
   3. Ensure the patient can communicate fluently in Mandarin, understand questionnaire content, and complete all survey evaluations.
   4. Confirm the patient can tolerate the study-related treatment regimen.
6. Exclusion criteria:
   1. Exclude patients who have other severe chronic diseases (e.g., cerebrovascular disease, liver/kidney disease) with unstable conditions.
   2.  Exclude patients who are allergic to anesthetics or surgery-related drugs and are unable to tolerate surgery.
   3. Exclude patients who have experienced recent significant life changes or psychological trauma.
   4. Exclude patients who have a clear diagnosis of psychological disorders (e.g., anxiety, depression).
      ​NOTE: This exclusion was applied to avoid confounding in anxiety outcome assessment, as pre-existing anxiety may not reflect surgical experience. Although this population may benefit from psychological support, future studies should target this subgroup.
   5. Exclude patients who show poor compliance, have immune system disorders or mental illnesses, or have cognitive/speech disorders.
      NOTE: Poor compliance was defined based on medical records as repeated missed appointments, non-adherence to prior treatments, or inability to follow instructions. These patients were excluded to ensure intervention fidelity and accurate outcome assessment. We recognize that this exclusion may limit generalizability; future research should explore strategies to engage patients with compliance challenges.
   6. Exclude patients who have received systematic psychological intervention or therapy before surgery.
   7. Exclude patients who are pregnant or lactating, refuse preoperative visit, nursing or study-related assessments, or have uncontrolled severe preoperative pain.
7. Drop-out criteria:
   1. Drop out patients who fail to meet the inclusion criteria or have incomplete data after enrollment.
   2.  Drop out patients who show poor compliance, drop out midway, or develop other diseases during the study period.
   3. Drop out patients who develop severe psychological or emotional problems and cannot continue participation.
   4. Drop out patients who change or add new surgical methods during the study period.
      ​NOTE: A total of 20 patients were excluded from the analysis: 10 patients did not meet the inclusion criteria, 4 patients were excluded due to incomplete medical records or inability to verify eligibility, and 6 patients were excluded for other reasons (e.g., transfer to another hospital, cancellation of surgery).
8. Sample size estimation
   1. Estimate the sample size a priori based on the primary outcome of preoperative anxiety, as measured by the Amsterdam Preoperative Anxiety and Information Scale (APAIS) anxiety subscale.
   2. Base the calculation on preliminary data, anticipating a mean reduction of approximately 4.0 points for the intervention group and 2.2 points for the control group, with an estimated common standard deviation of 3.3 points for the score change. This corresponds to a standardized effect size (Cohen’s d) of 0.55.
   3. Set the significance level (α) to 0.05 (two-tailed) and the desired statistical power (1-β) to 80%.
   4. Using sample size calculation software, calculate that a minimum of 52 patients per group is required to detect the specified effect.
   5. To account for potential data unavailability common in retrospective reviews, increase the target sample size by approximately 5% to 55 patients per group.
   6. Ensure the final analyzed cohort meets this pre-specified requirement, which was achieved with 110 patients (55 per group).

2. Description of preoperative care pathways

NOTE: During the study period, two distinct preoperative nursing protocols were sequentially implemented as standard care at our institution, with patients assigned to a protocol based solely on their admission date. The following sections detail the components of each protocol. For the study group, the HBM-based preoperative visit nursing was designed to operationalize the six HBM constructs through a series of structured components. Supplementary Table 1 maps each intervention component to the corresponding HBM construct, illustrating how the theoretical framework guided the intervention design.

1. Control group (Routine preoperative care)
   1. Review the patient’s medical records 1 day before surgery.
   2. Inform the patient of preoperative precautions via oral education.
   3. Monitor the patient’s vital signs.
   4. Inform the patient of key points for surgical cooperation, and provide medication care, diet care, disease observation, and complication care.
2. Study group (HBM-based preoperative visit nursing)
   NOTE: The HBM-based preoperative visit was delivered as a single bedside session on the day before surgery, lasting approximately 45–60 min. The intervention integrated preoperative evaluation, health education, emotional counseling, preoperative guidance, pain management, and family support (detailed below). All components were completed within this single visit.
   1. Conduct preoperative visits in the Ward 1 day before surgery (per operation notice) using the following steps:
      1. Establish a preoperative visit team comprising two nurses, one attending doctor, one psychological counselor, one nutritionist, one pharmacist, and one rehabilitation therapist.
      2. Provide professional HBM preoperative visit nursing training to the team. This training included: (1) an overview of the six HBM constructs and their application in preoperative care; (2) communication techniques for assessing patients' health beliefs and addressing misconceptions; (3) standardized procedures for delivering each intervention component; and (4) role-playing scenarios to practice counseling and education skills. The training was delivered in a single 2-hour session prior to the study period.
      3. Explain visit workflows and common preoperative visit communication methods (e.g., interpersonal communication, professional knowledge, health education) to team members.
      4. Require team members to pass an assessment before participating in visits.
   2. Perform preoperative evaluation:
      1. Review the patient’s medical records to understand their condition, examination results, surgical diagnosis, and drug allergy history.
      2. Conduct targeted preoperative conversations with the patient based on their specific condition.
   3. Provide preoperative health education:
      1. Adjust the ward environment according to the patient’s needs to create a relaxed, home-like space.
      2. Explain LC pathogenesis, surgical principles, and related knowledge to the patient and their family via scenario simulation and multimedia assistance.
      3. Listen to the patient’s concerns, understand their disease/surgery cognition, and correct misunderstandings.
      4. Introduce the operating room (location, facilities, equipment, staff) and highlight the surgical/anesthesia team’s expertise to build trust and reduce anxiety.
   4. Provide preoperative emotional counseling:
      1. Arrange for psychological counselors to guide nurses in providing one-on-one psychological counseling to the patient. Deliver this counseling during the single preoperative visit, lasting approximately 15–20 min per patient.
      2. Encourage the patient to express their thoughts, answer questions patiently, and relieve negative emotions.
      3. Share successful cases with patients with severe anxiety to improve their confidence.
      4. Guide the patient to distract themselves (e.g., listening to music, watching TV dramas, or reading) before surgery.
   5. Provide preoperative guidance:
      1. Describe the basic surgical process, explain the surgery’s purpose, and inform the patient of preoperative preparation details (e.g., clothing, skin preparation, diet, bowel movements).
      2. Guide the patient in preoperative respiratory training as described in steps 2.2.5.3–2.2.5.5:
      3. Perform pursed-lip breathing: Instruct the patient to stand/sit, relax, inhale deeply through the nose for 2 s, exhale slowly through “fish-mouth”/“whistle-shaped” lips (inspiration:expiration ratio = 2:1 or 3:1); conduct 2 sessions preoperatively, 10 min/session.
      4. Perform abdominal breathing: Instruct the patient to lie supine/sit, place hands on the abdomen/chest (keep chest still), inhale deeply through the nose (expand abdomen), exhale slowly (contract abdomen); each breath lasts 3–5 s, with 1–2 s pauses before/after breathing; conduct 5–6 breaths/min, 2 sessions preoperatively, 10 min/session.
      5. Guide the patient in position training (e.g., lateral, prone) to adapt to the surgical position (per surgical needs).
      6. Advise the patient on preoperative diet and sleep management, inform them of fasting/water-deprivation times, and remind them to remove accessories/dentures (Dietary and sleep advice was provided at this time because most patients were admitted only 1–2 days before surgery, precluding earlier intervention. The guidance served as an initial introduction, with the expectation that patients would apply it in the short preoperative window).
   6. Conduct pain management:
      1. Provide pain management training to the patient to help them master pain management knowledge/skills.
      2. Analyze the patient’s preoperative psychological state and pain experience, and evaluate their pain adaptation ability.
      3. Distract the patient via music or games; use an analgesic pump if necessary.
   7. Facilitate family emotional support:
      1. Inform the patient’s family of the importance of companionship.
      2. Encourage family members to participate in preoperative visits and health education.
      3. Help family members understand the patient’s psychological state and pain management needs to support postoperative family care.

3. Study indicators and assessment tools

1. Main indicators and assessment tools
   1. Use the Amsterdam Preoperative Anxiety and Information Scale (APAIS)¹² to assess the preoperative anxiety level of patients on admission and the day before surgery:
      1. Use the 6-item APAIS (4-item preoperative anxiety subscale, 2-item information needs subscale).
      2. Apply a 5-point Likert scale (total score: 20 for anxiety subscale, 10 for information needs subscale; higher scores = higher anxiety/information needs).
   2. Assess preoperative pain sensitivity using the Pain Sensitivity Questionnaire (PSQ) on admission¹³:
      1. Use the 17-item PSQ; ask patients to rate expected pain responses (0 = no pain, 10 = most pain).
      2. Use 3 items to depict painless states (as a reference); calculate the average of 14 items (higher averages = higher pain sensitivity).
   3. Use the perceived stress scale (PSS)¹⁴ to evaluate the preoperative perceived stress on admission and the day before surgery:
      1. Use the 10-item PSS (6 items for crisis perception factors, scored positively; 4 items for coping ability factors, scored in reverse).
      2. Apply a 5-point scoring system (total score = 40; higher scores = higher perceived stress).
   4. Evaluate postoperative pain using the Visual Analogue Scale (VAS)¹⁵:
      1. Use the 10-point VAS (total score = 10; lower scores = lower pain level).
      2. Measure VAS scores at 6 h, 12 h, 24 h, and 48 h after surgery.
2. Secondary indicators and assessment tools
   1. Measure preoperative physiological parameters at admission and 2 h before surgery:
      1. Measure heart rate (HR) using an electrocardiogram machine.
      2. Measure systolic blood pressure (SBP) and diastolic blood pressure (DBP) using an electronic sphygmometer.
   2. Assess sleep quality using the Pittsburgh Sleep Quality Index (PSQI)¹⁶ on admission and the day before surgery:
      1. Use the PSQI to score 7 dimensions (e.g., sleep quality, sleep latency, sleep duration) before and after intervention.
      2. Apply a 4-point scoring system (total score = 21; higher scores = poorer sleep quality).
   3. Record the incidence of postoperative complications in both groups.

4. Statistical analysis

1. Use statistical software to analyze data.
2. Present categorical data as [n (%)] and analyze using the chi-square test.
3. Present continuous data as mean ± standard deviation (x̄ ± s) and analyze using the t-test.
4. Baseline demographic and clinical characteristics were compared between groups to assess comparability. As no significant differences were observed, no further adjustment for these variables was performed in the primary analysis.
5. For all longitudinal data involving repeated measures (e.g., VAS scores at four time points; APAIS, PSQ, PSS, physiological indices, and PSQI scores before and after intervention), analyze them using repeated-measures analysis of variance (RM-ANOVA) to examine the effects of Time, Group, and the Time × Group interaction. If a significant interaction is found, conduct post-hoc tests with appropriate correction (e.g., Bonferroni).
6. Define statistical significance as P < 0.05.

Results

In the study group, there were 36 males and 19 females, with an average age of 55.11 ± 9.36 years and body mass index (BMI) of 23.38 ± 1.80 kg/m². TNM stages I, II, and III were documented in 19, 26, and 10 patients, respectively. Adenocarcinoma was the dominant histology (n = 31), followed by squamous-cell carcinoma (n = 21), small-cell carcinoma (n = 2), and other subtypes (n = 1). Tumour location was right-sided in 41 cases and left-sided in 14. Twenty-six participants had completed junior high...

Discussion

With changes in dietary habits, physical activity patterns, work-related stress, and environmental exposures among Chinese residents, the incidence of LC has shown a trend toward younger age, seriously threatening human health and life safety¹⁷. For eligible patients, surgery offers the best evidence-based chance of cure for LC¹⁸. However, before surgery, most patients have anxiety and pain-related pressure perception, and this pressure will increase with the progress of th...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Electrocardiogram machine	Hubei Cardiogenic Technology Co., LTD.	CBox-0001
Electronic sphygmometer	Hunan Deda Medical Co., LTD.	DE-X10
Sample Size Calculation Software	G*Power	Version 3.1	Used for a priori power analysis
Statistical Analysis Software	IBM SPSS Statistics	Version 27.0	Used for all data analysis