Knowledge, perceptions, and concerns regarding anesthesia and their association with consent hesitancy among preoperative patients in Saudi Arabia: a bicentric cross-sectional study

1 Introduction

General anesthesia is a pharmacologically induced, reversible state characterized by unconsciousness, amnesia, analgesia, and immobility, achieved while maintaining physiological stability (1). Beyond enabling surgery, anesthesia care influences patients’ perioperative experience, including their sense of control, trust in the clinical team, and willingness to proceed with an operation (2, 3). Despite major advances in monitoring and safety, fear of anesthesia remains common, and for some patients the prospect of anesthesia is more distressing than the surgical procedure itself (4).

Preoperative anxiety is highly prevalent, with systematic reviews reporting that up to half of surgical patients experience clinically meaningful anxiety before anesthesia and surgery (5). These concerns are multifactorial and may relate to perceived anesthetic complications, loss of awareness or control, postoperative pain or disability, and catastrophic outcomes such as death or permanent neurologic injury (6). Such fears are not merely subjective: preoperative anxiety has been associated with poorer perioperative experience and lower patient satisfaction (7). Several studies also suggest that fear is not evenly distributed across patient groups; for example, female sex, lower educational attainment, and socioeconomic disadvantage have been linked to higher rates of preoperative fear (8).

Importantly, anxiety may be amplified by misconceptions and incomplete understanding of the anesthesiologist's role, training, and responsibilities. Even when an adverse event is rare—such as explicit intraoperative awareness, reported in < 0.3% of cases—patients may overestimate its likelihood; in one study, nearly 40% of patients reported concern about awareness during surgery (9, 10). This mismatch between perceived and actual risk highlights the potential value of anesthesia literacy and effective preoperative communication. Patient education and structured counseling have been associated with reduced preoperative anxiety and improved recovery-related outcomes, including shorter length of stay (11). Building a clear anesthesiologist–patient relationship and providing understandable, trustworthy information may therefore reduce fear, strengthen trust, and support informed consent (4, 6, 12, 13).

However, data on how anesthesia literacy and anesthesia-related fears specifically contribute to consent hesitancy in Saudi Arabia remain limited. Therefore, the primary objective of this bicentric cross-sectional study was to identify the key factors associated with anesthesia-related consent hesitancy among adults attending preoperative clinics at two secondary-care hospitals in Riyadh, Saudi Arabia. To achieve this, we investigated multiple potential predictors, including patients’ anesthesia knowledge and information sources, satisfaction with anesthesia-related communication, trust in anesthesiologists, and perceived anesthesia risks and fears.

2 Methods

2.1 Study design and population

This cross-sectional study was conducted in the preoperative assessment clinics of two secondary-care hospitals in Riyadh between June 2024 and March 2025. Consecutive eligible patients were approached in clinic waiting areas and invited to complete an electronic self-administered survey. Participation was voluntary, and refusal had no effect on clinical care. Eligible participants included adults aged ≥ 18 years attending preoperative assessment clinics during the study period. Participants were required to be able to understand and complete the questionnaire independently. Exclusion criteria included individuals who declined participation, were unable to provide informed consent, or had incomplete questionnaire responses that precluded analysis. A convenience sampling approach was used, whereby consecutive patients present in clinic waiting areas during the study period were invited to participate.

Due to the use of a convenience sampling approach in a busy clinical setting, the exact number of patients approached was not systematically recorded; therefore, a response rate could not be calculated. Non-participation was primarily due to patient refusal or incomplete questionnaire responses.

Eligible patients were approached consecutively in clinic waiting areas and invited to participate. Participation was voluntary, and no incentives were provided. Due to the nature of the clinical setting and convenience sampling approach, the exact number of patients approached and those who declined participation were not systematically recorded. Participants who declined or did not complete the questionnaire were not included in the final analysis.

2.2 Ethics statement & informed consent

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board at King Abdullah bin Abdulaziz University Hospital (KAAUH) (IRB log number: 23-0193) and Security Forces Hospital (SFH) (IRB log number: H-01-R-069). All participants were provided with informed consent prior to the commencement of the study. The research objectives were explained to all participants, and it was clarified that they could withdraw from the study without any consequences.

2.3 Outcome measures

2.3.1 Primary outcome: consent hesitancy

The primary outcome of this study was consent hesitancy. This was defined as a patient's level of reluctance to proceed with anesthesia, quantified through their expressed concerns about specific anesthesia-related risks. We measured this using a composite “Consent Hesitancy Score.” This score was calculated by summing the participants’ Likert-scale ratings for each potential anesthesia-related complication listed in the survey. The score was derived from the 10 questions in Section 6 of the survey, where each concern was rated on a 4-point Likert scale from 1 (Not concerned) to 4 (Very concerned), resulting in a total possible score ranging from 10 to 40. For the analysis, the Consent Hesitancy Score was treated as a continuous variable, with higher scores indicating greater hesitancy.

2.3.2 Secondary outcomes

Secondary outcomes included: For clarity, key terms were defined a priori. “Awareness” was used to describe participants’ self-reported recognition of anesthesia-related postoperative complications (primary outcome). “Knowledge” or “anesthesia literacy” was used more broadly to reflect participants’ understanding of anesthesia concepts, roles of anesthesiologists, and related information. These terms were applied consistently throughout the manuscript.

• Self-reported awareness of anesthesia-related postoperative complications (assessed as a binary variable: aware vs. not aware/unsure).
• Patient attitudes toward anesthesia and anesthesiologists, including trust, perceived importance of experience, and views on separate anesthesia consent.
• Sources of anesthesia-related information and patient satisfaction with that information.
• Anesthesia knowledge and literacy, assessed through various domains including understanding of the anesthesiologist's role.

This study did not employ a validated multidomain instrument to measure anesthesia literacy as a unified construct. Instead, it assessed several related domains, including self-reported awareness of anesthesia-related complications, prior exposure to anesthesia, information sources, attitudes toward anesthesiologists, and anesthesia-related concerns. Accordingly, the findings should be interpreted as reflecting patients’ knowledge, perceptions, and concerns rather than a comprehensive measure of anesthesia literacy.

2.4 Study survey and data collection

Data were collected using a self-administered questionnaire distributed electronically via Google Forms. The survey instrument underwent content validation through expert review by a consultant surgeon and two consultant anesthesiologists to ensure clinical relevance, clarity, and appropriateness of the included items. A pilot test was conducted among non-medical individuals to evaluate comprehension and feasibility, with minor wording adjustments made accordingly.

The study instrument comprises six sections: (1) Sociodemographic data including age, gender, residence, nationality, comorbidities, psychiatric history, level of education, current career/study major, and history of surgery or anesthesia. (2) Surgical history comprised questions about the number of previous surgeries, surgical specialties involved, types of anesthesia received, prior information about anesthesia, and satisfaction with the anesthesiologist's communication. (3) Information sources included participants’ sources of information regarding anesthesia and their satisfaction if the source was a healthcare provider. (4) Decision-making process involved various questions related to the importance of anesthesia-related information in surgical decision-making, participants’ evaluation of the risks and benefits of anesthesia, and perceptions regarding the necessity of separate anesthesia consent. (5) Perceptions of Anesthesiologists and training included questions related to participants’ awareness of the educational and training pathway of anesthesiologists, preferences regarding the anesthesiologist's gender, perceived importance of the anesthesiologist's experience, their influence on surgical outcomes, trust in their clinical judgment, confidence in their ability to manage complications, and the impact of learning about the anesthesiologist's qualifications. (6) Anesthesia complications included awareness of potential postoperative anesthesia complications and those most concerning to participants.

2.5 Sample size calculation

Because no prior Saudi data exist on anesthesia literacy prevalence, a conservative prevalence (p = 0.5) was assumed to maximize sample size. Using the single-proportion formula:with Z = 1.96 and absolute precision d = 0.05 generated a minimum of 384 participants. To offset an anticipated 10% non-response rate, the target sample was inflated to 422 patients. This size provides 80% power to detect small-to-moderate effect sizes in multivariable models (odds ratio ≈ 1.6) at α = 0.05.

n=Z0.952p(1−p)d2

2.6 Statistical analysis and data management

A comprehensive statistical analysis was conducted using IBM SPSS version 29.0. Descriptive statistics were used to summarize participant characteristics and survey responses, presented as frequencies, percentages, means, and standard deviations as appropriate. Bivariate analyses were performed to assess associations between participant characteristics and key outcomes. Chi-square tests were used for categorical variables, and independent samples t-tests were used to compare mean concern scores between groups. The primary outcome, the Consent Hesitancy Score, was analyzed as a continuous variable using multivariable linear regression, with model assumptions inspected via residual diagnostics. Multivariable binary logistic regression was used for the secondary binary outcome of self-reported awareness of anesthesia-related complications (aware vs. not aware/unsure). Variables included in the multivariable model were selected based on clinical relevance and statistical significance in bivariate analyses (p < 0.10). Missing data were handled using a complete-case analysis approach, whereby participants with missing responses for a given variable were excluded from the corresponding analysis. As a result, denominators varied across analyses. For example, the analysis of information sources included 447 participants due to incomplete responses in that section. Statistical significance was set at a two-sided p-value < 0.05 with 95% confidence intervals reported where applicable. Denominators varied across analyses due to missing responses, and the number of participants included in each analysis is reported accordingly.

3 Results

A total of 477 participants who completed the questionnaire were included in the final analysis. Participants with incomplete responses were excluded. The number of patients who declined participation was not recorded (Table 1). The internal consistency of the anesthesia-related concern (hesitancy) items was assessed using Cronbach's alpha. The hesitancy scale demonstrated good internal consistency, with a Cronbach's alpha coefficient of 0.88, indicating a high level of reliability among the included items. As shown in Table 1, the sample was predominantly young (53.2% aged 18–25 years) and female (57.4%), with most residing in the central region (80.1%). Students and employed individuals together accounted for nearly 80% of the sample, and only 11.9% had a healthcare-related background.

Table 1. Demographic factors of the participants, N = 477.

Regarding comorbidities, most participants reported none. Among mental health conditions (reported by 21.6% of the sample), anxiety was the most common (15.1%), followed by depression (10.1%) and panic attacks (5.9%). Obsessive-compulsive disorder (4%) and other conditions were less frequent. For physical health conditions (reported by 19.9%), asthma was the most prevalent (6.7%), with smaller proportions reporting hypertension (6.1%), diabetes mellitus (5.9%), and cardiovascular disease (2.9%). Other chronic illnesses (e.g., hypothyroidism, ulcerative colitis, sleep apnea) were rare, each affecting less than 1% of the sample.

This demographic and comorbidity profile reflects the population typically seen in preoperative clinics at secondary-care hospitals in Riyadh but limits generalizability to older adults, patients from other regions, or those with more complex medical histories.

Among the 477 participants, 238 (49.9%) reported previous surgery with anesthesia (Table 2). Of these, 125 (52.5%) had undergone one procedure, 60 (25.2%) two procedures, and 53 (22.3%) three or more procedures. General anesthesia was the most commonly reported anesthesia type (n = 175, 73.5%), followed by spinal anesthesia (n = 32, 13.4%) and regional anesthesia (n = 5, 2.1%); 26 participants (10.9%) were unsure of the anesthesia type received. The nearly even split between participants with and without prior surgical experience provides a useful comparison, as those with previous exposure represent a subgroup whose attitudes and awareness may be shaped by direct personal experience, whereas those without such experience rely solely on external information sources.

Table 2. Surgical and anesthesia experience among participants.

Regarding awareness of anesthesia options, 121 participants (50.8%) reported feeling somewhat or very informed, whereas 87 (36.6%) reported feeling somewhat or very uninformed. That roughly one-third of patients with prior surgical experience still felt uninformed about their anesthesia options suggests that the preoperative informed consent process may not consistently achieve its educational aims, even among those who have already undergone the process at least once. Satisfaction with the interaction with the anesthesiologist was high, with 191 participants (80.3%) reporting being satisfied or very satisfied and 11 (4.6%) reporting dissatisfaction.

Otorhinolaryngology (ENT) procedures were the most common (see Figure 1), reported by 50 individuals (21.4%). This was followed by orthopedic surgery (n = 34, 14.5%), gastrointestinal (GI) surgery (n = 32, 13.7%), and gynecology and obstetrics (n = 28, 12.0%). Other notable categories included oral and maxillofacial surgery (8.6%), bariatric surgery (7.7%), and ophthalmic surgery (5.1%).This distribution, spanning multiple surgical disciplines, suggests that the sample captured a reasonably broad range of perioperative experiences rather than being concentrated within a single specialty, which supports the generalizability of the anesthesia-related perceptions observed.

Participants could select multiple sources from which they typically obtain information about anesthesia (see Figure 2). The most frequently reported source was healthcare providers (HCPs) (n = 383, 80.3%), followed by friends or family (n = 308, 64.6%) and scientific/governmental web searches (n = 307, 64.4%). General websites and social media were also commonly cited (58.7% and 56.2%, respectively), while brochures or pamphlets (31.2%) and movies or TV shows (28.3%) were reported less frequently. The substantial reliance on informal sources, such as friends, family, and social media, alongside professional channels, highlights that patients’ anesthesia-related knowledge is shaped by both authoritative and lay influences, which may affect the accuracy of their understanding and the concerns they have. Among participants who indicated receiving information about anesthesia from HCPs, the majority expressed high levels of satisfaction. Specifically, 43.7% (n = 100) were very satisfied, and an additional 36.7% (n = 84) reported being satisfied.

Overall, participants reported high levels of anesthesia-related awareness and positive attitudes toward anesthesia care (Table 3). Most participants (84.5%) agreed or strongly agreed that anesthesia-related information is crucial for surgical decision-making, and 74.8% correctly indicated that anesthesia consent is required before surgery. Trust in anesthesiologists’ judgment was also high, with 86.5% reporting complete or mostly trust. In addition, 81.3% reported that more information about anesthesiologists’ training would increase their comfort prior to surgery, and 66.9% rated anesthesiologist experience as extremely important when making surgical decisions. These high levels of trust and the perceived importance of anesthesiologist qualifications, juxtaposed with the substantial proportion of participants (64.4%) who did not know the duration of postgraduate training required, suggest that patients assign considerable weight to anesthesiologists’ expertise even when their factual knowledge about the specialty is incomplete.

Table 3. Comparison of anesthesia-related knowledge, attitudes, and preferences by educational background (N = 477).

Descriptive statistics are presented as frequencies and percentages. Group comparisons between healthcare-related and non-healthcare-related participants were assessed using the Chi-square test. A p-value < 0.05 was considered statistically significant.

Responses were generally similar between participants with healthcare-related backgrounds and those with non-healthcare-related backgrounds. The observation that participants with a healthcare background were more knowledgeable about training duration, yet showed no difference in trust or attitudes, suggests that factual knowledge about the specialty and trust in anesthesiologists may operate through separate pathways. Trust seems to be influenced by factors beyond knowledge of professional training requirements.

Statistical comparison using a Chi-square test revealed no significant association between participant gender and anesthesiologist gender preference (χ²(3) = 4.25, p = 0.235), indicating that gender-based preference is not strongly influenced by the respondent's gender (see Figure 3).

The table presents participants’ levels of concern regarding various anesthesia-related events, summarized as mean scores along with standard deviations and the distribution of responses across four concern categories: not concerned, neutral, somewhat concerned, and very concerned (see Table 4). Overall, the data indicate that the highest levels of concern are related to severe and potentially life-threatening complications. Specifically, complications such as death from anesthesia, never waking up and going into a coma, brain damage, memory loss, and being awake but paralyzed during surgery all have high mean concern scores (ranging from 3.01 to 3.19) and the largest proportion of respondents expressing that they are very concerned (55%–62%). Conversely, less severe or transient complications like sore throat, nausea and vomiting, and dizziness have lower mean concern scores (2.28–2.56) and higher percentages of respondents who are not concerned or neutral about these events. Notably, pain and broken teeth are intermediate in concern, with a substantial proportion of participants indicating they are somewhat concerned or very concerned. This discrepancy between concern for rare catastrophic events and relative indifference toward common minor side effects suggests a mismatch between patients’ perceived and actual risks, which may reflect limited exposure to balanced risk communication during preoperative counseling.

Table 4. Concerns regarding anesthesia-related complications, N = 477.

In the multivariable linear regression model of the primary outcome (Consent Hesitancy Score), the overall model was statistically significant (F(17, 459) = 2.72, p < 0.001; adjusted R² = 0.058; Table 5). Male gender was associated with a lower hesitancy score compared with female gender (β = −3.52, 95% CI −5.07 to −1.96, p < 0.001). Compared with employed participants, those identifying as housewives (β = −3.46, 95% CI −6.35 to −0.57, p = 0.019) and retired participants (β = −4.98, 95% CI −8.60 to −1.35, p = 0.007) had lower hesitancy scores. Residence in the Western region was associated with a higher hesitancy score compared with the Central region (β = + 2.61, 95% CI 0.02–5.19, p = 0.049). Age, academic background, prior surgery, information source (healthcare provider or scientific/governmental website), and comorbidity status were not independently associated with the hesitancy score after adjustment.

Table 5. Multivariable linear regression of factors associated with the consent hesitancy score (N = 477).

Observations: 477; F(17, 459) = 2.72, p < 0.001; Adjusted R² = 0.058.

The Consent Hesitancy Score was modeled as a continuous outcome (range 10–40). β indicates the adjusted mean change in hesitancy score associated with each predictor level relative to its reference category, holding all other covariates constant. Statistical significance was set at p < 0.05.

In the multivariable logistic regression model, several factors were associated with higher odds of awareness of anesthesia-related complications (Table 6). Prior surgery with anesthesia was associated with increased awareness (OR = 1.77, 95% CI: 1.16–2.71, p = 0.008). Participants who reported obtaining information from healthcare providers (OR = 1.88, 95% CI: 1.11–3.25, p = 0.021) or from scientific/governmental websites (OR = 1.70, 95% CI: 1.10–2.65, p = 0.018) also had higher odds of awareness compared with those who did not report these sources.

Table 6. Multivariable logistic regression of factors associated with self-reported awareness of anesthesia-related complications (N = 477).

Self-reported awareness was modeled as a binary outcome: Yes vs. Unsure/No. Odds ratios were derived from multivariable logistic regression adjusting for gender, age, occupation, academic background, surgical history, comorbidity status, information sources, and region of residence. Statistical significance was set at p < 0.05

Age was associated with awareness. Compared with the 18–25-year group, participants aged 26–35 years had higher odds of awareness (OR = 2.02, 95% CI: 1.04–4.03, p = 0.041), and those aged 36–45 years had higher odds (OR = 4.24, 95% CI: 1.80–10.38, p = 0.001). The association was not statistically significant for participants aged ≥46 years (p = 0.109).

Male gender was associated with lower odds of awareness compared with female gender (OR = 0.62, 95% CI: 0.40–0.97, p = 0.036). Participants reporting one or more comorbidities had higher odds of awareness (OR = 1.80, 95% CI: 1.08–3.01, p = 0.024). Being a student showed a marginal association with increased awareness (OR = 1.92, 95% CI: 1.00–3.76, p = 0.053). Other occupational categories, region of residence, and non-healthcare-related academic backgrounds were not significantly associated with awareness.

Females reported higher concern scores than males for most anesthesia-related complications (Table 7). The largest differences were observed for pain (mean 3.15 vs. 2.75, p < 0.001), being awake but paralyzed during surgery (3.34 vs. 2.90, p < 0.001), and dizziness (2.71 vs. 2.36, p < 0.001). Females also reported higher concern regarding nausea and vomiting (p < 0.001), sore throat (p = 0.012), never waking up/going into a coma (p = 0.028), and teeth breaking (p = 0.009).

Table 7. Association between gender and concerns regarding anesthesia complications.

Values represent mean concern scores (± SD) on a 4-point Likert scale ranging from 1 (Not concerned) to 4 (Very concerned). P-values were obtained using independent samples t-tests to compare mean scores between females and males. Statistical significance was considered at p < 0.05.

There were no statistically significant gender differences for memory loss, brain damage, or death from anesthesia (p > 0.05 for all).

4 Discussion

While patient awareness and fears surrounding anesthesia are well-documented, less is known about the specific factors that contribute to hesitancy during the informed consent process. This study sought to address this gap by identifying predictors of a newly developed ‘Consent Hesitancy Score.’ The primary finding was that female gender and residence in the Western region were independently associated with higher consent hesitancy, whereas being a housewife or retired was associated with lower hesitancy. These findings suggest that patient attitudes toward consent are shaped by a combination of demographic and social factors that extend beyond simple knowledge deficits or general fears, offering new insights for patient-centered communication in the preoperative setting.

The finding that female participants reported higher consent hesitancy is a key result that aligns with our secondary observation that women also expressed significantly greater concern about anesthesia-related risks. This pattern is consistent with extensive literature showing a higher prevalence of preoperative anxiety among women (5, 8, 14). This suggests that higher hesitancy may be a direct manifestation of this heightened anxiety and risk perception, underscoring the need for communication strategies that specifically aim to identify and address the concerns that are more prominent among female patients. In contrast, the association between being a housewife or retired and lower hesitancy is a novel finding that warrants careful interpretation. It is possible that these groups possess different life experiences or levels of trust in the healthcare system compared to the employed reference group. Alternatively, this finding could reflect unmeasured confounding variables, and further research is needed to explore the underlying reasons for this association. Similarly, the higher hesitancy score observed among residents of the Western region should be interpreted with caution. While statistically significant, this finding may be a proxy for unmeasured socioeconomic or cultural factors and should be considered exploratory, requiring validation in larger, multi-regional studies before any firm conclusions can be drawn.

4.1 Interpretation of main findings in context

Our findings support and extend prior regional and international work showing that substantial segments of the public have incomplete understanding of anesthesiology. As early as the 1990s, surveys in the United Kingdom reported limited patient awareness of anesthesiologists’ qualifications and duties (15). In another British survey, approximately 63% of patients knew anesthesiologists were medical doctors (16). In our study, roughly 80% recognized anesthesiologists as specially trained physicians higher than the 55.3% reported in a 2006 study from Riyadh (17). This may reflect gradual improvements in public exposure to anesthesia information and health education in Saudi Arabia. Nonetheless, a meaningful minority of patients still did not recognize anesthesiologists’ medical training, and misconceptions regarding broader responsibilities in perioperative monitoring, critical care, and pain management appear to persist (17, 18).

4.2 Comparison with Saudi and international literature

Our results align with the nationwide Saudi survey by Almutairi et al., which reported generally moderate knowledge and misconceptions about anesthesiologists’ expertise, with better knowledge among those with prior surgical experience (19). Similarly, we observed higher awareness among participants with previous surgery involving anesthesia. We also found that female participants demonstrated higher awareness and greater concern regarding anesthesia-related complications, consistent with the sex differences reported in Almutairi et al. (19) and with observations from other settings (14). Studies by Arefayne et al. and Rajput et al. also describe persistent underrecognition of anesthesiologists’ professional scope and contributions relative to surgeons, despite ongoing public visibility of anesthesiology, particularly during the COVID-19 pandemic (20, 21).

4.3 Information sources and awareness

Our findings show aa statistical association between information sources and self-reported awareness of anesthesia-related complications. Participants who obtained information from healthcare professionals or from scientific/governmental websites had higher odds of awareness of anesthesia-related complications. This is consistent with findings reported by Wu et al. in China, where clinicians and reputable scientific websites were important sources of anesthesia-related knowledge (22). At the same time, continued reliance on informal information sources described by Rajput et al. suggests variability in information-seeking behaviors that may be culturally and contextually influenced. although causality cannot be inferred from this cross-sectional design (21). Together, these observations suggest that delivering anesthesia education through trusted clinical channels and reliable online platforms may be beneficial, but this hypothesis requires testing in prospective or interventional studies. The analysis of information sources included 447 participants due to incomplete responses for this section.

4.4 Fear profile and sex differences

This study also provides insight into the profile of anesthesia-related fears. The highest concern was directed toward severe, catastrophic outcomes (e.g., death, not waking up/going into a coma, permanent paralysis, or brain damage), whereas fewer participants were very concerned about more common transient side effects such as postoperative nausea or sore throat. This pattern mirrors results from a cross-sectional study conducted in Jeddah, where patients were more concerned about rare complications and less concerned about common side effects (23). In our study, females reported significantly higher concern scores across most anesthesia-related risks compared with males, similar to findings from Los Angeles (14). This difference may relate to the higher prevalence of preoperative anxiety among women, which has been reported across multiple studies, including work from Serbia (5, 8). Prior studies have also highlighted patient fears surrounding catastrophic outcomes such as death or prolonged unconsciousness (20, 21). Furthermore, Demirel et al. reported an association between lower health literacy and higher preoperative anxiety, suggesting that addressing educational gaps may help reduce anxiety and improve perioperative experience (24).

4.5 Communication, consent, and practical implications

Although participants in our study reported generally high satisfaction with anesthesiologist communication, satisfaction does not necessarily imply comprehension. García-Álvarez and García-Sánchez reported that many patients experience difficulty understanding formal anesthesia consent forms despite explicit written materials (25). These findings underscore that improving readability alone may be insufficient and that communication strategies should be adapted to patient needs. Informed consent and perioperative safety depend on patients’ understanding of anesthesia risks, roles, and procedures; without this understanding, patients may not fully adhere to preoperative instructions or may experience undue fear that negatively shapes the perioperative experience (8, 18). Intensified preoperative fear and anxiety have also been associated with worse postoperative outcomes (8). Taken together, these findings support efforts to clarify anesthesiologists’ roles during consent discussions and to strengthen patient-centered communication, such as ensuring anesthesiologists introduce themselves, explain plans in understandable terms, and invite patient questions and preferences, thereby encouraging a more engaged role in decision-making.

4.6 Future directions

Future research should evaluate tailored educational interventions (e.g., structured preoperative counseling and multimedia tools). Longitudinal studies could clarify whether improving anesthesia literacy translates into reduced perioperative anxiety, improved consent quality, and better postoperative recovery outcomes.

Although this study explored multiple domains related to anesthesia understanding, it did not employ a validated tool to assess anesthesia literacy as a unified construct. Therefore, the findings should be interpreted as reflecting selected aspects of knowledge, perceptions, and concerns rather than a comprehensive literacy measure.

4.7 Limitations

This study should be interpreted in light of several limitations. First, the cross-sectional design precludes establishing causal relationships between participant characteristics and anesthesia literacy or anxiety-related outcomes. Second, although the study included patients from two secondary-care institutions in Riyadh, generalizability may be limited due to regional and institutional differences. The sample also over-represented younger adults, residents of the central region, and students. This distribution may not adequately reflect the broader surgical population in Saudi Arabia, particularly older adults, individuals from rural or underrepresented regions, and patients with more complex comorbidities. These groups may differ in their perioperative understanding, information sources, and levels of anesthesia-related concern. Therefore, the generalizability of the findings is limited and the results should be interpreted with caution. Third, the study relied on self-reported responses, which may introduce response bias, including recall bias related to prior anesthesia experiences and social desirability in reporting perceptions. The study also could not verify the accuracy of participants’ self-assessed knowledge. Third, the study relied on self-reported responses, which may introduce response bias, including recall bias related to prior anesthesia experiences and social desirability in reporting perceptions. In addition, anesthesia-related awareness was assessed using self-reported measures rather than objective knowledge testing. Participants who reported being “aware” may not necessarily possess accurate or comprehensive understanding of anesthesia-related concepts. Therefore, the findings reflect perceived awareness rather than objectively measured knowledge and should be interpreted accordingly. Additionally, the inability to determine the total number of patients approached precluded calculation of a response rate.

Another limitation is that anesthesia literacy was not assessed using a validated multidomain instrument. The primary outcome relied on a single self-reported awareness item, which may not fully capture the complexity and depth of patients’ understanding. Therefore, the findings should be interpreted as reflecting selected aspects of knowledge, perceptions, and concerns rather than a comprehensive measure of anesthesia literacy.

Additionally, the lack of detailed recruitment flow data, including the number of patients approached and those who declined participation, limits the ability to assess response rate and potential selection bias. Also, health literacy was not assessed using validated instruments, which may influence patients’ understanding, perceptions, and anesthesia-related concerns. Lastly, despite adjustment for multiple covariates in the multivariable analysis, residual confounding from unmeasured factors (e.g., prior healthcare experiences, baseline anxiety traits, or cultural influences) cannot be excluded. The awareness variable was dichotomized by combining “not aware” and “unsure” responses into a single category to provide a conservative estimate of definite awareness and to ensure sufficient statistical power for regression analysis. However, we acknowledge that “unsure” may represent partial awareness rather than complete lack of knowledge.

Despite these limitations, the survey development process, including expert review and pilot testing, supports the clarity and feasibility of the instrument. Future research using longitudinal designs, broader geographic representation, and deeper exploration of cultural influences may further substantiate and extend these findings.

5 Conclusion

This study identified persistent knowledge gaps among surgical patients regarding anesthesia and anesthesiologists’ roles, despite generally high trust in anesthesiologists and high satisfaction with anesthesia-related communication. Participants reported greater concern about rare, severe anesthesia-related complications, whereas common side effects elicited lower concern. Information obtained from healthcare professionals and trusted digital resources was associated with greater patient awareness. The study did not directly measure misconceptions in a structured way, so any relationship with misconceptions remains speculative.

Variation in awareness across demographic factors (gender, age, education, and employment status) suggests that preoperative education and counseling approaches should account for heterogeneity in patient knowledge and concerns. These findings are consistent with the need for anesthesiologists to engage more actively in preoperative education, but further research (e.g., randomized controlled trials) is needed to determine whether such efforts improve awareness or outcomes.

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Footnotes

Edited by: Hong Liu, UC Davis Health, United States

Reviewed by: Mohamed Issak, University of Dongola, Sudan

Anwar Zahran, An-Najah National University, Palestine