JMIR Publications

ABSTRACT

Background:

Preoperative anxiety affects an estimated 50–70% of children undergoing surgery and is associated with poorer perioperative cooperation, increased postoperative distress, and delayed recovery. Digital storytelling and immersive technologies, including virtual reality (VR) and augmented reality (AR), have emerged as child-centered preparation tools to improve the preoperative experience. This systematic review and meta-analysis aimed to synthesize and critically appraise the available evidence on the effects of these interventions in reducing preoperative anxiety among pediatric patients undergoing elective surgery.

Objective:

Despite increasing research interest, the available evidence remains heterogeneous in intervention type, delivery mode, timing of exposure, surgical populations, and anxiety measurement tools. In addition, the overall certainty of evidence is influenced by variability in study quality and reporting. Therefore, this systematic review and meta-analysis aimed to synthesize and critically appraise the available evidence on the effects of digital storytelling and immersive technology-based interventions (including VR, AR, and app-based storytelling tools) in reducing preoperative anxiety among pediatric patients undergoing elective surgery, compared with standard care or conventional preparation methods.

Methods:

A systematic search was conducted in PubMed, Scopus, Web of Science, and the Cochrane Library for studies published between January 2015 and June 2025. Randomized controlled trials and quasi-experimental studies evaluating digital storytelling (e.g., narrative-based apps/videos) or immersive technologies (e.g., VR/AR) were included. Preoperative anxiety was assessed using validated measures such as the Modified Yale Preoperative Anxiety Scale (mYPAS), State-Trait Anxiety Inventory (STAI), or Visual Analog Scale (VAS). Two reviewers independently screened studies and extracted data. Risk of bias was assessed using the Cochrane Risk of Bias tool version 2 (RoB 2). A random-effects meta-analysis was performed in R using standardized mean differences (SMDs).

Results:

A total of 379 records were identified, and 13 studies met the inclusion criteria. Most studies reported lower preoperative anxiety in intervention groups compared with standard care or conventional preparation. Five studies provided sufficient comparable data for meta-analysis, showing a significant pooled reduction in anxiety favoring digital interventions (SMD = –0.99; 95% CI: –1.44 to –0.54), with substantial heterogeneity (I² = 78.1%; Q = 19.74, df = 4, p = 0.0006). Overall risk of bias was high in most trials, primarily due to deviations from intended interventions and limitations in blinding.

Conclusions:

This review suggests a trend toward reduced preoperative anxiety among pediatric patients receiving digital storytelling and immersive technology-based interventions. However, the certainty of evidence is limited by substantial heterogeneity, the small number of studies included in the meta-analysis, variability in outcome measures, and overall study quality. Therefore, the pooled estimate should be interpreted with caution. Further high-quality studies using standardized outcomes and robust methodology are needed, including evaluation of parental anxiety and longer-term postoperative effects. Clinical Trial: CRD420251111293