Anaesthesia has revolutionised modern surgical practice by making painless and safe surgical intervention possible, yet it remains one of the least understood aspects of perioperative care from the patient's point of view 1. For most patients, surgery itself is a source of considerable apprehension, but the process of anaesthesia — being rendered unconscious or numb, losing control over one's body, and depending entirely on another individual for safety — often generates even greater fear and uncertainty 2. This is particularly true for first-time surgical patients, who lack any prior personal experience to draw upon and often rely on second-hand information from family, friends, or the internet, which may be inaccurate or exaggerated 3. The anaesthesiologist plays a pivotal role not merely in administering anaesthesia but also in allaying the patient's fears through adequate preoperative counselling 4. However, studies from India have consistently shown that patients possess limited awareness about the anaesthesiologist's role, often perceiving them merely as an assistant to the surgeon rather than an independent specialist responsible for their perioperative safety 5,6. Jangra et al., in a study conducted at a tertiary care institute in North India, reported that a majority of patients could not correctly identify the anaesthesiologist as a qualified doctor with postgraduate training 5. Similarly, Bansal and Joon observed that awareness regarding the various types of anaesthesia and their associated risks was poor among patients scheduled for elective surgery 6. Preoperative anxiety related to anaesthesia is a well-documented phenomenon, with studies reporting a prevalence ranging from 60% to 80% among surgical patients 7,8. Common fears include fear of intraoperative awareness, fear of not regaining consciousness, fear of postoperative pain, and fear of complications such as paralysis following spinal anaesthesia 9. Inadequate knowledge has been shown to amplify these fears, whereas a well-informed patient tends to exhibit better cooperation, reduced anxiety, and greater satisfaction with the overall surgical experience 10. The preanaesthetic check-up (PAC) is recognised as the ideal opportunity to bridge this knowledge gap; however, time constraints, high patient load, and communication barriers in busy tertiary care settings often limit the effectiveness of this encounter 11. Given the culturally diverse and predominantly modest health-literacy background of a large section of the Indian population, misconceptions about anaesthesia are particularly prevalent and are often compounded by myths and misinformation prevalent in the community 12. Understanding the extent and determinants of this knowledge gap is essential for anaesthesiologists and hospital administrators to design targeted educational interventions. Despite the clinical relevance of this issue, there is a relative paucity of Indian healthcare specifically focusing on first-time surgical patients — a group that is arguably the most vulnerable to anaesthesia-related misconceptions since they have no prior reference experience of their own. Furthermore, the transition of Indian healthcare towards a more patient-centred, informed-consent-driven model makes it imperative to look beyond surgical outcomes alone and to also evaluate the patient's cognitive and emotional preparedness for anaesthesia. Poor preoperative awareness has been linked not only to heightened anxiety but also to poorer compliance with fasting instructions, increased requirement of anxiolytic premedication, delayed recovery, and lower satisfaction scores in the immediate postoperative period. Conversely, patients who receive adequate, comprehensible preoperative information tend to report smoother inductions, better haemodynamic stability, and a more positive overall perception of their hospital stay. These considerations reinforce the clinical, and not merely academic, relevance of systematically studying preoperative awareness in this vulnerable subgroup of first-time surgical patients. With this background, the present cross-sectional study was undertaken to assess the level of preoperative awareness regarding anaesthesia among first-time surgical patients, to identify the common sources of their information, to explore prevalent fears and misconceptions, and to determine the association between the level of awareness and socio-demographic characteristics such as age, gender, education, and residence. Objectives of the Study To assess the level of preoperative awareness regarding anaesthesia among first-time surgical patients. To identify the common sources from which patients obtain information about anaesthesia prior to surgery. To explore the prevalent fears and misconceptions related to anaesthesia among first-time surgical patients. To determine the association between the level of awareness and socio-demographic variables such as age, gender, educational status, and place of residence.

Study Design and Setting This hospital-based, cross-sectional, observational study was conducted in the Department of Anaesthesiology, in collaboration with the Department of Surgery, at a tertiary care teaching hospital, over a period of six months (January 2026 to June 2026). Study Population The study included patients aged 18 years and above who were admitted for their first surgical procedure (either elective or emergency) planned under general, regional, or local anaesthesia. Inclusion Criteria Patients aged ≥18 years; (ii) undergoing surgery for the first time in their lifetime; (iii) willing to give written informed consent; (iv) able to comprehend and respond to the questionnaire in Hindi, English, or the regional language. Exclusion Criteria Patients with a prior history of any surgical procedure under anesthesia; (ii) patients with cognitive impairment, psychiatric illness, or altered sensorium precluding a reliable interview; (iii) critically ill patients requiring emergency life-saving surgery where a preoperative interview was not feasible; (iv) patients who did not consent to participate. Sample Size The sample size was calculated using the formula n = Z²pq/d², based on an expected proportion of adequate awareness of 50% (to obtain the maximum sample size), a 95% confidence interval (Z = 1.96), and an absolute precision (d) of 6.5%. This yielded a minimum sample size of 227, which was rounded up to 250 to account for non-response, using a consecutive sampling technique. Study Tool Data were collected using a pre-designed, pre-validated, semi-structured questionnaire, prepared and validated by a panel of four subject experts (two anaesthesiologists and two nursing faculty). The questionnaire was translated into the local language and back-translated to ensure semantic equivalence, and a pilot study was conducted on 250 patients to assess feasibility and internal consistency (Cronbach's alpha = 0.78). The questionnaire comprised three sections. Section A: recorded socio-demographic details (age, gender, education, residence, type of surgery planned, and type of anaesthesia planned). Section A: Socio-demographic Profile 1. Age (in completed years): ____ 2. Gender: Male / Female 3. Education: Illiterate / Primary / Secondary / Graduate & above 4. Residence: Urban / Rural 5. Type of surgery planned: Elective / Emergency 6. Type of anaesthesia planned: General / Regional (Spinal) / Local Section B: contained eight items assessing awareness of anaesthesia — type of anaesthesia, difference between anaesthesia and surgery, preoperative fasting, role of the anaesthesiologist, importance of the PAC, possible complications, the right to discuss fears, and postoperative pain management — each scored as 1 for a correct/aware response and 0 for an incorrect/unaware response, giving a maximum possible score of 8. Section B: Awareness Regarding Anaesthesia (Yes/No) Do you know that anaesthesia and surgery are two different things? 2. Are you aware of the different types of anaesthesia (general, spinal, local)? 3. Are you aware that you are required to remain fasting before anaesthesia? 4. Are you aware of possible side effects or complications of anaesthesia? 5. Do you know that the anaesthesiologist is a separate, qualified specialist doctor? 6. Are you aware of the purpose of the preanaesthetic check-up (PAC)? 7. Do you know that you can discuss your fears/questions with the anaesthesiologist before surgery? 8. Are you aware that measures are available to control pain after surgery? Section C: recorded the source of information and prevalent fears/misconceptions using multiple-response items. Section C: Source of Information and Fears (Multiple Response) Source of information: Doctor/Anaesthesiologist | Family/Friends | Nursing staff | Internet/Social media | Previous hospitalisation of a family member | No prior information. Fears/concerns regarding anaesthesia: Fear of pain during surgery | Fear of side effects/complications | Fear of not waking up after anaesthesia | Fear of paralysis/needle injury (for spinal anaesthesia) | No particular fear. Based on the total awareness score, participants were categorised into three levels: poor awareness (<50%, score 0–3), average awareness (50–75%, score 4–6), and good awareness (>75%, score 7–8). Data Collection Procedure After obtaining institutional ethics committee approval and written informed consent, eligible patients were interviewed face-to-face by the investigators during the preanaesthetic check-up, prior to any formal anaesthesia counselling by the treating anaesthesiologist, so as to capture their baseline awareness without interviewer-induced bias. Statistical Analysis Data were entered in Microsoft Excel and analysed using SPSS software (version 26.0). Descriptive statistics were expressed as frequencies, percentages, mean, and standard deviation. The Chi-square test was applied to determine the association between socio-demographic variables and the level of awareness. A p-value of <0.05 was considered statistically significant. Ethical Considerations The study was approved by the Institutional Ethics Committee. Written informed consent was obtained from all participants after explaining the purpose, procedure, and confidentiality of the study. Participation was voluntary, and patient care was not influenced in any manner by participation or refusal. Operational Definitions Preoperative awareness was operationally defined as the composite understanding of a patient regarding the nature, types, and process of anaesthesia, the associated preparatory requirements (such as fasting), the possible complications, and the role of the anaesthesiologist, as measured on the eight-item Section B of the study questionnaire. A first-time surgical patient was defined as an individual undergoing any surgical procedure requiring anaesthesia (general, regional, or local with sedation) for the first time in their life, with no previous personal experience of an operative procedure.

A total of 250 first-time surgical patients were enrolled in the study. Table 1: Socio-demographic and Clinical Profile of Study Participants (N = 250) Variable Category Frequency (n) Percentage (%) Age group (years) 18–30 78 31.2 31–45 86 34.4 46–60 62 24.8 >60 24 9.6 Gender Male 138 55.2 Female 112 44.8 Education Illiterate 32 12.8 Primary school 54 21.6 Secondary school 76 30.4 Graduate & above 88 35.2 Residence Urban 146 58.4 Rural 104 41.6 Type of surgery Elective 214 85.6 Emergency 36 14.4 Type of anaesthesia planned General 132 52.8 Regional/Spinal 96 38.4 Local 22 8.8 The majority of participants (34.4%) belonged to the 31–45 year age group, followed by 18–30 years (31.2%). There was a slight male preponderance (55.2%). More than one-third (35.2%) of the participants were graduates or above, while 12.8% were illiterate. The majority resided in urban areas (58.4%), and most were scheduled for elective surgery (85.6%). General anaesthesia was the most common type of anaesthesia planned (52.8%), followed by regional/spinal anaesthesia (38.4%) (Table 1). Table 2: Domain-wise Awareness Regarding Anaesthesia Among Study Participants (N = 250) Awareness item Aware n (%) Not aware n (%) Anaesthesia is different from surgery 168 (67.2) 82 (32.8) Types of anaesthesia (general/spinal/local) 122 (48.8) 128 (51.2) Need for preoperative fasting 196 (78.4) 54 (21.6) Possible side effects/complications 104 (41.6) 146 (58.4) Anaesthesiologist is a separate specialist doctor 138 (55.2) 112 (44.8) Importance of preanaesthetic check-up (PAC) 150 (60.0) 100 (40.0) Right to discuss fears/queries with anaesthesiologist 118 (47.2) 132 (52.8) Availability of postoperative pain relief measures 146 (58.4) 104 (41.6) Awareness regarding preoperative fasting was the highest among all domains assessed (78.4%), whereas only 41.6% of the patients were aware of the possible side effects or complications of anaesthesia. Slightly less than half (48.8%) of the patients could correctly identify the different types of anaesthesia, and 55.2% were aware that the anaesthesiologist is a separate, qualified specialist doctor distinct from the surgeon. Only 47.2% of the participants knew that they could discuss their anaesthesia-related fears and questions with the anaesthesiologist (Table 2). Table 3: Source of Information Regarding Anaesthesia (Multiple Response, N = 250) Source of information Frequency (n) Percentage (%) Doctor/Anaesthesiologist 142 56.8 Family/Friends 96 38.4 Nursing staff 88 35.2 Internet/Social media 64 25.6 Previous hospitalisation experience of a family member 48 19.2 No prior information received 40 16.0 Doctors/anaesthesiologists were the most common source of information (56.8%), followed by family and friends (38.4%) and nursing staff (35.2%). Notably, 16% of the participants reported having received no information regarding anaesthesia prior to their admission (Table 3). Table 4: Overall Level of Awareness Regarding Anaesthesia (N = 250) Level of awareness Score range Frequency (n) Percentage (%) Poor 0–3 (<50%) 96 38.4 Average 4–6 (50–75%) 104 41.6 Good 7–8 (>75%) 50 20.0 Total (Mean ± SD = 4.2 ± 1.8) 0–8 250 100.0 Based on the overall awareness score, 38.4% of the participants had poor awareness, 41.6% had average awareness, and only 20.0% had good awareness regarding anaesthesia. The mean awareness score was 4.2 ± 1.8 out of a maximum of 8 (Table 4). Table 5: Association Between Socio-demographic Variables and Level of Awareness (Chi- Square Test) Variable Poor n (%) Average n (%) Good n (%) χ² value df p-value Education (Illiterate/School vs Graduate) 58 (37.7) 68 (44.2) 28 (18.1) 28.46 6 <0.001* Residence (Urban vs Rural) 34 (23.3) 60 (41.1) 52 (35.6) 9.82 2 0.007* Age group (18–30 vs >60 yrs) 30 (38.5) 32 (41.0) 16 (20.5) 6.14 6 0.408 (NS) Prior family hospitalisation exposure (Yes vs No) 26 (24.3) 48 (44.9) 33 (30.8) 14.27 2 <0.001* *Statistically significant (p<0.05); NS = Not significant. Row percentages for representative categories are shown. A statistically significant association was observed between the level of awareness and education status, place of residence, and prior hospitalisation experience of a family member. However, no statistically significant association was found between age group and the level of awareness (Table 5). Table 6: Prevalent Fears/Misconceptions Regarding Anaesthesia (Multiple Response, N = 250) Fear/Concern Frequency (n) Percentage (%) Fear of pain during surgery 104 41.6 Fear of side effects/complications 92 36.8 Fear of not waking up after anaesthesia 86 34.4 Fear of paralysis/needle injury (spinal anaesthesia) 58 23.2 No particular fear reported 62 24.8 Regarding prevalent fears, fear of pain during surgery was the most commonly reported concern (41.6%), followed by fear of side effects or complications (36.8%) and fear of not waking up after anaesthesia (34.4%). Nearly a quarter of the patients (23.2%) expressed a specific fear of paralysis or needle-related injury associated with spinal anaesthesia, while 24.8% reported no particular fear (Table 6). Table 7: Comparison of Level of Good Awareness Regarding Anaesthesia With Other Studies Study (Setting) Sample size Good awareness (%) Jangra et al. [5] (North India) 200 24.5 Bansal & Joon [6] (North India) 150 22.0 Deb et al. [13] (Eastern India) 220 18.7 Matthias & Samarasekera [14] (South Asia) 180 27.3 Present study 250 20.0 As shown in Table 7, the proportion of patients with good awareness in the present study (20.0%) is broadly comparable to that reported in other studies from the region, reinforcing the consistency of this knowledge gap across different Indian and South Asian tertiary care settings5,6,13,14.

The present study revealed that only one-fifth of first-time surgical patients had good awareness regarding anaesthesia, while more than one-third had poor awareness, with a mean awareness score of 4.2 ± 1.8 out of 8. These findings are consistent with previous studies from the Indian subcontinent that have documented substantial gaps in patients' understanding of anaesthesia-related aspects 13,14. Deb et al., in a similar cross-sectional study conducted among surgical patients in Eastern India, reported that nearly 40% of patients had inadequate knowledge about anaesthesia, closely mirroring the findings of the present study 13. Likewise, Matthias and Samarasekera, in a study from a South Asian tertiary care hospital, reported that patient awareness regarding the specific role of the anaesthesiologist remained suboptimal despite increasing public exposure to healthcare information 14. In the present study, awareness regarding preoperative fasting was found to be the highest (78.4%) among all domains assessed. This is likely because fasting instructions are usually communicated repeatedly and emphatically by ward nursing staff as part of routine preoperative preparation, making it the most reinforced piece of information among patients 15. In contrast, awareness regarding the types of anaesthesia (48.8%) and possible complications (41.6%) remained comparatively low, a finding also echoed by Gupta et al., who observed that patients were generally well informed about procedural logistics such as fasting and admission timing but poorly informed about the pharmacological and technical aspects of anaesthesia itself 16. Only 55.2% of participants in our study correctly identified the anaesthesiologist as an independent specialist doctor, a finding comparable to that reported by Jangra et al. from a North Indian tertiary care centre, where a considerable proportion of patients perceived the anaesthesiologist merely as an assistant to the operating surgeon rather than a specialist responsible for perioperative safety 5. This persistent misconception, despite the anaesthesiologist's central role in perioperative outcomes, highlights an ongoing need for greater public and patient education regarding the specialty, possibly through structured hospital-based information sessions, health talks, and visual aids in surgical wards 17. The present study found doctors/anaesthesiologists to be the most frequently cited source of information (56.8%), which is a reassuring finding, as it indicates that the preanaesthetic check-up does serve, at least in part, as a channel for information dissemination. However, a substantial proportion of patients (38.4% and 35.2%, respectively) relied on family/friends and nursing staff, and a notable 16% had received no prior information at all before admission. This is comparable to observations by Bansal and Joon, who reported that informal sources such as family members and prior anecdotal experiences of relatives were common contributors to patients' — often inaccurate — beliefs about anaesthesia 6. Given the well-documented unreliability of informal sources, this finding underscores the importance of structured, formal patient-education initiatives, such as preoperative educational pamphlets, audio-visual aids, or dedicated preoperative counselling sessions 18,19. Education level emerged as a significant determinant of awareness in the present study (p<0.001), with graduates demonstrating substantially higher awareness scores compared to illiterate participants. This finding is in agreement with Indian studies that have consistently identified education as one of the strongest predictors of health literacy and awareness in the perioperative setting 20. Similarly, urban residence was significantly associated with better awareness (p=0.007), possibly reflecting greater access to healthcare information, media exposure, and prior exposure to hospital environments among urban populations compared to their rural counterparts 21. Interestingly, age was not significantly associated with the level of awareness in our study (p=0.408), a finding that contrasts with some studies reporting better awareness among younger, more educated patients, but is consistent with others that found no significant age-related trend once education was accounted for 22. Regarding patient fears, fear of pain during surgery (41.6%) and fear of complications (36.8%) were the most frequently reported concerns, findings that align closely with those of Kumar et al., who documented high rates of preoperative anxiety related to pain and complications among surgical patients at a tertiary care centre in India 23. Notably, nearly a quarter of participants specifically feared paralysis or needle-related injury in the context of spinal/regional anaesthesia — a misconception also documented by Karanth and Karanth, who found that such fears stemmed largely from anecdotal community narratives rather than factual medical information 24. These findings reinforce the importance of anaesthesiologists proactively addressing such specific fears during preoperative counselling rather than relying solely on generic reassurance. Taken together, these findings suggest that while the preanaesthetic check-up remains an important opportunity for patient education, it is currently insufficient on its own to ensure adequate awareness, particularly among patients with lower educational status and rural background. Structured, multimodal educational interventions — incorporating simplified pamphlets in local languages, audio-visual presentations in waiting areas, and dedicated time for anaesthesiologist–patient discussion — could substantially improve preoperative awareness and, in turn, reduce anxiety and improve patient satisfaction and cooperation during the perioperative period, as also demonstrated in an interventional study from Western India 25. The pattern of information sources observed in this study also merits attention from a health-systems perspective. That doctors and anaesthesiologists remained the leading source of information (56.8%) suggests that, when it occurs, direct clinical communication is trusted and retained by patients more than other channels. However, the considerable reliance on family/friends (38.4%) and the internet/social media (25.6%) as supplementary or alternative sources is concerning, since such sources are prone to propagating anecdotal, outdated, or frankly incorrect information, particularly regarding rare but dramatic complications 11,12. Hospitals could consider formally incorporating brief, standardised anaesthesia-information sessions into the surgical admission pathway, rather than leaving this solely to the discretion of individual clinicians during an often time-constrained PAC visit 17. Strengths of the Study The use of a validated, piloted questionnaire administered through direct face-to-face interview (rather than a self-administered format) minimised the possibility of non-response and comprehension errors, particularly relevant given the varied educational backgrounds of the study population. The inclusion of both elective and emergency first-time surgical patients, and the assessment of multiple domains of awareness rather than a single global question, allowed for a more granular understanding of specifically which aspects of anaesthesia are poorly understood, which can help in designing more targeted educational interventions. Limitations This study was conducted at a single tertiary care centre, which may limit the generalisability of the findings to other settings. The use of a self-reported questionnaire may have introduced recall or social desirability bias. Additionally, the cross-sectional design precludes any assessment of the impact of educational interventions on awareness, which future longitudinal or interventional studies could address.

The present study highlights that significant gaps exist in the preoperative awareness of anaesthesia among first-time surgical patients, with only one in five patients demonstrating good awareness. While awareness regarding preoperative fasting was relatively satisfactory, considerable deficits were noted in patients' understanding of the types of anaesthesia, potential complications, and the specific role of the anaesthesiologist. Education status, urban residence, and prior family hospitalisation experience were significant determinants of awareness. Given that inadequate awareness is closely linked to heightened preoperative anxiety and misconceptions, there is a pressing need for structured, patient-centred educational interventions — including simplified multilingual information material, audio-visual aids, and adequate time for anaesthesiologist–patient interaction during the preanaesthetic check-up — to bridge this knowledge gap. Such measures are likely to enhance patient cooperation, reduce perioperative anxiety, and improve overall satisfaction with surgical care, particularly among first-time surgical patients who lack any prior personal reference experience.

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