Effectiveness of video-based education versus music therapy on anxiety, experience, and co-operation among patients undergoing magnetic resonance imaging: A randomized controlled trial

Deepika Bist; Tarika Sharma; Shalini Thapar

doi:10.4103/jascp.jascp_3_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 2 | Issue : 2 | Page : 51-58

Effectiveness of video-based education versus music therapy on anxiety, experience, and co-operation among patients undergoing magnetic resonance imaging: A randomized controlled trial

Deepika Bist¹, Tarika Sharma¹, Shalini Thapar²
¹ Department of Nursing, College of Nursing, Institute of Liver and Biliary Sciences, New Delhi, India
² Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India

Date of Submission	08-Mar-2021
Date of Acceptance	04-Apr-2021
Date of Web Publication	19-Aug-2021

Correspondence Address:
Dr. Deepika Bist
Set no. -329, Block -19, BSNL Colony, Sector-2, New Shimla, Shimla - 171 009, Himachal Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jascp.jascp_3_21

Abstract

Background: With the increasing use of magnetic resonance imaging (MRI) in diagnostic radiology, the problem of anxiety is also encountered more often in patients undergoing MRI. Anxious patients may not co-operate well with the procedure resulting in poor image quality. Repetition of sequences to acquire the images of better quality prolongs the total scan time and precludes optimal patient experience. For satisfactory completion and clinical usefulness of the scan, patient compliance is vital. Aim: The aim of this study is to assess the effectiveness of video-based education (VBE) versus music therapy (MT) on anxiety, experience, and co-operation among patients undergoing MRI. Materials and Methods: Randomized controlled trial pre- and posttest-based study was carried out among 90 patients undergoing MRI who were randomly allocated to VBE group (30), MT group (30), and control group (30). The data on anxiety, experience, and cooperation were collected using the appropriate tools. Patients in VBE group were provided with VBE, patients in MT group received MT and control group received routine procedural instructions. Results: No significant differences were found in VBE group, MT group, and control group in terms of posttest anxiety scores. With regard to mean experience scores, the VBE group had better experience (81.70 ± 3.153) as compared to the control group (77.27 ± 6.817). A significant strong positive correlation was found between experience and co-operation of patients in VBE group (r = 0.860, P < 0.001) and MT group (r = 0.640). All of the patients (100%) agreed that VBE was easy to understand and also suggested to use VBE for all patients undergoing MRI procedure. Most of the patients (96.7%) found MT effective during the waiting time of MRI procedure and useful for diverting the mind. Conclusions: Both VBE and MT were effective in improving the experience and co-operation of patients undergoing MRI as compared to routine procedural instructions in the control group.

Keywords: Anxiety, co-operation, experience, magnetic resonance imaging, music therapy, video-based education

How to cite this article:
Bist D, Sharma T, Thapar S. Effectiveness of video-based education versus music therapy on anxiety, experience, and co-operation among patients undergoing magnetic resonance imaging: A randomized controlled trial. J Appl Sci Clin Pract 2021;2:51-8

How to cite this URL:
Bist D, Sharma T, Thapar S. Effectiveness of video-based education versus music therapy on anxiety, experience, and co-operation among patients undergoing magnetic resonance imaging: A randomized controlled trial. J Appl Sci Clin Pract [serial online] 2021 [cited 2023 Mar 29];2:51-8. Available from: http://www.jascp.org/text.asp?2021/2/2/51/324116

Introduction

Magnetic resonance imaging (MRI) provides high-quality imaging without using ionizing radiation. Patients often experience anxiety before undergoing MRI and it is increased by the hospital environment, which can be intimidating to patients.[1-3] Due to anxiety, many medical procedures can get affected with unwanted effects, such as reduction in quality of the procedure, patient's comfort, compliance, and satisfaction with the overall experience of procedure and hospital as well.^[4] In a survey of radiographers, 71.6% of respondents stated that patient anxiety was a common issue in the MRI.^[5] One study showed that video film information helps to decrease patient anxiety.^[6] One of the studies provides support for the notion that listening to music during an MRI examination significantly reduces patient anxiety.^[7] A single-case study was conducted of a participant in the music therapy (MT) in the medical imaging study. The results showed that MT session allowed patient to experience an increase in relaxation and a decrease in anxiety levels, as evidenced by pre- and post-session measurements and objective observations and suggested that rhythmic entrainment can be a useful MT intervention for individuals before diagnostic imaging to assist with eliciting a relaxation response and decreasing anxiety levels.^[8] Patients also tend to have limited knowledge regarding diagnostic procedures with the main sources of information being family and friends.^[9] Furthermore, over half of patients do not know the type of investigation they will receive when coming to the radiology department. This limited information decreases a patient's perceived level of control over the situation, thereby increasing their anxiety.^[10] There are little data available on the effects of video-based education (VBE) versus MT in the adult population, especially in countries such as India. Therefore, this study aimed at assessing the effectiveness of VBE versus MT on anxiety, experience, and cooperation among patients undergoing MRI.

The primary objective was to assess the effectiveness of VBE versus MT on anxiety, experience, and co-operation among patients undergoing MRI.

Materials and Methods

Based on the nature of the problem and its objectives, a quantitative research approach was used. Randomized controlled trial (CTRI No.-NCT04545086) based on pre-test and post-test design was adopted as VBE and MT was administered as a part of an interventions. Power analysis^[11] was done to calculate the sample size and included 30 patients in the VBE group, MT group, and control group each. Patients were selected by the convenient sampling technique and randomized into two groups by the computer-generated random numbers with the help of random allocation software block randomization. This software produces as its output a sequence of allocation based on the selected type of blocking.^[12] The consort flow diagram is shown in [Figure 1].

Figure 1: Consort flow diagram. VBE Group: Video Based Education Group, MT Group: Music Therapy Group, n: number of patients

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The present study included patients who were willing to participate, undergoing MRI with or without contrast, having age between 18 and 60 years, alert and oriented, able to comprehend, speak and listen to English or Hindi, not having hearing and visual impairment, available during a period of data collection, undergoing MRI of abdomen and pelvis.

The patients who were unconscious, critically ill and sedated, visiting radiology department for other procedures such as computed tomography scan and having pain score of 3–10 on Universal Pain Assessment Scale were excluded from the study.

The independent variables were VBE and MT; the dependent variables included anxiety, experience, and co-operation.

Various tools were used to collect the data for the study and included subject data sheet (demographic characteristics and clinical characteristics) to collect the demographic and clinical data, State-Trait Anxiety Inventory Form Y-1^[13] for measuring the pretest and posttest anxiety, Patients' Scan Experience Scale to measure the experience score, Cooperation Scale for MRI procedure to measure the cooperation score, Patients' Opinionnaires on VBE to gather the opinions about VBE, Patients' Opinionnaires on MT to gather the opinions about MT, and data related to patients' cooperation was obtained from radiographers.

Content validation of tools based on content validity index criteria where experts were requested to judge the items for their relevancy, representativeness, comprehensiveness, clarity, ambiguity and simplicity, which was done by 11 experts from different fields such as medical-surgical nursing, psychiatric nursing, and also by radiographers and nursing officers from the department of radiology. Tool try-out was done on ten patients at the selected hospital. The purpose of the try-out was to check the items for clarity, feasibility, practicability, and reliability. On the whole, tools were found to be clear, unambiguous, and understandable.

The parallel form reliability with Zung Self-rating Scale of State-Trait Anxiety Inventory Form Y-1 was 0.75. Cronbach's alpha for Patients' Scan Experience Scale and Co-operation Scale for MRI Procedure was 0.93 and 0.75, respectively.

As a part of the intervention, VBE was planned with the purpose to reduce the anxiety related to the MRI procedure, to improve the experience and co-operation of patients during the whole duration of the procedure. The researchers in coordination with the medical education telemedicine unit prepared the video and later validated on the basis of relevancy, representativeness, comprehensiveness, clarity, ambiguity, and simplicity by experts from the field of radiology and medical surgical nursing. The blueprint and script of the video were prepared. The video was recorded from the reception area, patient preparation area, MRI room, and console area. The whole procedure was recorded to maintain the authenticity of the video. Followed by video recording, the audio instructions bilingually (English and Hindi) were recorded, merged with video and slides, and editing was done. In the video, the researcher included prepreparation for MRI Scan, do's and don'ts in the MRI scanning room, demonstration of a patient undergoing an MRI scan, what to expect from MRI and the order in which it would happen, the time duration of the scan, what is expected from the patient during the procedure and care after the MRI procedure. The duration of the video was 7 min.

For providing MT, researchers selected soft instrumental music after extensive review, total 30 soft instrumental music of old songs were given to peer group out of which 20 songs were selected, which was then tried out on ten patients. Out of 20 music tracks, 13 were selected by the patients, which consist of soft classical instrumental music tracks. These tracks were validated by five music experts and later merged. The duration of merged songs was 7 min.

Routine procedural instructions included verbal information about do's and don'ts related to MRI, precautions, health history related to kidney diseases, instructions to be followed during MRI scan, and what to expect inside the MRI scanning room.

VBE, MT, and routine procedural instructions for respective groups were administered in separate rooms in the radiology department to prevent the contamination of data.

Ethics

The Institution Review Board clearance was obtained by two processes, Scientific Review Committee and Ethics Committee. The approval was granted by letter no F15/(2/2.25)/2017/HO (M)/ILBS. The study was registered under the clinical trial registry of India.

Before the final data collection, a pilot study was conducted on nine patients (10% of total sample size) three in each group to check for the feasibility of the study. The pilot study sample was excluded from the total number of the study sample. Initially, it was planned to administer music inside scan room during the MRI procedure which was not found feasible during the pilot study; hence, it was decided to provide MT during waiting time before MRI scanning. Necessary corrections and modifications were done based on the findings of the pilot study.

Data collection procedure

Final data collection was done from September 2019 to November 2019. The patient information sheet was provided, and informed written consent was taken from the patients [Figure 1]. Pretest in terms of assessment of anxiety before the administration of VBE, MT, and routine procedural instructions during waiting with STAI Y-1 and measurement of pulse rate, blood pressure, respiratory rate was done for patients in the VBE group, MT group, and control group.

Interventions

VBE, MT and routine procedural instructions were administered to VBE group, MT group and control group patients, respectively.

Assessment of anxiety with STAI Y-1 (a four-point Likert scale evaluates the current state of anxiety, asking how respondents feel “right now,” using items that measure subjective feelings of apprehension, tension, nervousness, worry, and activation/arousal of the autonomic nervous system) within 20 min after administering VBE, MT, and routine procedural instructions was done. In all three groups, the Patient Scan Experience Scale was administered to patients for the assessment of experience after MRI procedure (semantic differential scale which contains 12 items with response on seven-point rating scale of bipolar adjectives) and the Co-operation Scale for MRI procedure (five-point Likert scale measuring the frequency, namely never, rarely, sometimes, and always) was administered to radiographers for the assessment of cooperation. Radiographers blinding was done to avoid biases.

Opinionnaires (Four-point Likert Scale with four alternative responses such as, to great extent, to some extent, very little, and not at all) were also administered to patients in VBE and MT group to gather opinions regarding interventions after the MRI procedure.

Statistical analysis

IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp was used to analyze the data. Descriptive statistics such as frequency and percentage and inferential statistics such as paired t-test, one-way analysis of variance, mean, standard deviation, and Pearson correlation coefficient were used as appropriate.

Results

The details related to patients' demographic, clinical profile, and pretest anxiety scores are given in [Table 1] which clearly states that both groups were homogenous and comparable at baseline. About 60% of patients in the VBE group, 73.3% in MT group, and 76.7% in the control group had no or low anxiety at baseline (P = 0.532).

Table 1: Frequency and percentage distribution showing comparison of patients in the video based education Group, music therapy group and control group in terms of their demographic, clinical characteristics and baseline anxiety scores n₁+n₂+n₃=30+30+30

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Pre- and posttest anxiety scores were assessed using STAI Y-1 form and analyzed using paired t-test which depicts that the mean and standard deviation of pre- and posttest anxiety score in VBE group was 37.90 ± 7.581, 29.47 ± 2.543, in MT group was 34.83 ± 6.701, 29.70 ± 3.621, and in control group was 33.93 ± 6.591 and 31.60 ± 5.581, respectively. There was a significant difference between pretest anxiety scores and posttest anxiety scores among patients in the VBE group (P < 0.001), MT group (P < 0.001), and control group (P = 0.032) [Figure 2]. There was no significant difference found in terms of posttest anxiety scores among patients in the VBE group, MT group, and control group [Table 2].

Figure 2: Line Graph showing mean anxiety scores in pretest and posttest among video based education group, music therapy group, and control group.(Source; original)

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Table 2: Mean and standard deviation of posttest anxiety scores among patients in video based education group, music therapy group and control group n₁+n₂+n₃=30+30+30

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[Table 3] depicts that the mean experience score of the VBE group was 81.70 ± 3.153, MT group was 79.97 ± 5.580, and control group was 77.27 ± 6.817. There was a significant difference in terms of mean experience scores among patients in the VBE group, MT group, and control group. Further post hoc analysis using Bonferroni correction was done to assess the direction of significance, which showed that, in the VBE group, experience score was significantly higher as compared to the control group inferring that patients in the VBE group had significantly better experience with MRI procedure than the control group [Table 4]. There was no significant difference found in mean cooperation scores among patients in the VBE group (39.37 ± 2.470), MT group (39.00 ± 3.474), and control group (38.37 ± 3.368), as the P value was 0.461.

Table 3: Mean and standard deviation of experience scores among patients in video based education group, music therapy group and control group n₁+n₂+n₃=30+30+30

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Table 4: Post hoc analysis using bonferroni correction showing pair wise comparison of mean experience score among patients in video based education group, music therapy group and control group n₁+n₂+n₃=30+30+30

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A significant strong positive correlation was found between the experience and co-operation of patients in the VBE group (r = 0.860, P ≤ 0.001) and in the MT group (r = 0.640, P ≤ 0.001) [Figure 3] and[Figure 4], which signifies that the patients in VBE group and MT group who had a better experience, cooperated well during the MRI procedure.

Figure 3: Scatter plot diagram showing positive correlation between the experience scores and cooperation scores in video based education group. (Source; original)

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Figure 4: Scatter plot diagram showing positive correlation between the experience scores and cooperation scores in music therapy group. (Source; original)

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In terms of association, a significant association was found between anxiety scores and diagnosis (F = 5.259, P = 0.012) among patients in the VBE Group. The patients with liver disease had a significantly lower anxiety score as compared to patients with pancreatitis (P = 0.011) or any other conditions such as extrahepatic biliary obstruction, bicornuate uterus, and acute abdomen. Experience scores were found to be significantly associated with age. Patients in the VBE group who were in the age group of more than 45–60 years had a significantly better experience as compared to those in the age group of 18–31 years with P = 0.009.

A significant association was found between anxiety and education (F = 6.008, P = 0.002) and history of previous MRI (t = −2.097, P = 0.045) among patients in the MT group. The patients who were graduates had high anxiety as compared to other categories of education. Furthermore, the patients who had a previous history of MRI had low anxiety.

When item-wise analysis of patients' opinions was done, it was found that most of the patients accepted the VBE before undergoing the MRI procedure. More than 80% of patients reported that they had gained confidence while undergoing an MRI procedure. All of the patients agreed that VBE was easy to understand, and also suggested using VBE for all patients undergoing MRI procedures [Figure 5].

Figure 5: Bar chart showing item wise percentage distribution of opinions regarding video based education among patients in video based education group.(Source; Original)

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Furthermore, the item-wise analysis for MT revealed that more patients (96.7%) found MT effective during the waiting time of the MRI procedure and useful for diverting the mind. All of the patients agreed upon using MT for all of the patients undergoing MRI procedure. None of the patients found music annoying or slow [Figure 6]. Because of additional findings, one open-ended question was also asked at the end of opinionnaires which revealed the data in the form of verbatim. Most of the patients believed that VBE must be used as an educational means for all patients coming for MRI procedure, also found it easy to understand and felt relaxed during the whole MRI procedure.

Figure 6: Bar chart showing item wise percentage distribution of opinions regarding Music Therapy among patients in music therapy group. (Source; original)

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The patients have expressed their positive views on the use of MT during waiting hours. Most of the patients found the music relaxing, soothing, and helpful to pass time during the waiting period before undergoing the MRI procedure.

Discussion

Patients often experience anxiety before MRI, which results in poor overall experience and cooperation. In the present study, a significant difference was found between pretest anxiety scores and posttest anxiety scores among patients undergoing MRI in VBE group, MT group, and control group. There was no significant difference in terms of posttest anxiety scores among patients in VBE group, MT group and control group. The P value was found significant (0.009) for mean experience score among VBE group, MT group, and control group and post hoc revealed that the VBE group had better experience compared to control group with MRI procedure when VBE was administered. There was no significant difference in mean cooperation scores among patients in VBE group, MT group, and control group. A significant strong positive correlation was found between experience and cooperation of patients in VBE group and MT group. All of the patients agreed that VBE was easy to understand and also suggested to use VBE for all patients undergoing MRI procedure. Most of the patients (96.7%) found MT effective during waiting time of MRI procedure and useful for diverting the mind.

In the current study, no significant changes were seen in all three groups based on posttest anxiety scores, whereas data also show that there was a significant decrease in posttest anxiety scores among all three groups as compared to pretest anxiety scores. In contrast to this finding, one study results showed that there was statistically significant reduction in post intervention anxiety in video group compared to the control group (P = 0.001).^[9] Patients are sometime oblivious about how they may react and MRI scanning room environment may cause sudden and unexpected anxiety reaction.

One more study exhibited the dissimilar findings where highly significant difference was found between the two groups (study and control group). There was a decrease in the level of anxiety in the study group who received preinstructions about MRI procedure than in the control group.^[14]

The findings of a clinical trial conducted on patients undergoing cardiovascular MRI showed that^[4] video group scored better than the standard group in regard to relaxation (P = 0.039), which is consistent with the findings of current study which showed better experience as compared to the control group when VBE was administered (P = 0.009). When patients were given information through video, the information was grasped better and retained for a longer duration, it is therefore clear that detailed visual information helped them to understand the procedure well hence improving the overall experience.

The present study also suggested the use of VBE and MT to reduced anxiety. Previous studies which have incorporated relaxation and information provision into information have also successfully reduced anxiety.^[7] Once the patient knows what to expect, he or she will attain a higher degree of relaxation that will reduce the anxiety.

The current study showed that there was a significant difference between pre- and posttest anxiety (P ≤ 0.001) after MT. One study also suggests that patients who received MT intervention had significantly lower anxiety level (P < 0.05).^[15] Another study was also found consistent with our study whose results showed that the post intervention anxiety score significantly reduced in both music groups but not in control group.

In the current study, the MT group (79.97 ± 5.580) patients had better experience as compared to control group (77.27 ± 6.817) patients. The findings are consistent with the study which showed that mean patient experience score for the control group was 1.74 ± 0.63, and for cases, it was 1.67 ± 0.60 where lower scores are assigned to better experience, which suggest that cases who received music interventions had better experience as compared to the control group.^[16]

In the current study, opinions were taken from patients about use of VBE which revealed suggestions regarding the use of VBE during waiting time for all patients who are undergoing MRI procedure as they believed that it improved overall experience. These findings were similar with a study by Narender Kumar et al., where it was found that total 85.5% had an opinion regarding utilization of waiting time by providing information regarding MRI and 87.5% subjects wished to know the procedure beforehand. There was a significant difference found between the educational groups and regarding opinion about the unpleasant experience (P = 0.0042).^[17]

In corroboration with the results of the current study suggesting that previous history of MRI is significantly associated with anxiety scores signifies that patients having the previous history of MRI had low anxiety (P = 0.045). With similar to these findings, one study showed that 51.4% of patients were anxious before the scan, with reported cause predominantly being either worry about the results and findings, the enclosed space, or a combination of both. They found that additional information in various forms is expected to have a positive impact on reducing patients' anxiety and suggested that first time attending patients with no history of previous MRI are likely to be more anxious.^[8] In contrast, a study done by Tornqvist on extended written information had reported that anxious or claustrophobic patients will always remain in fear before their scan regardless of having previous experience with MRI procedure.^[18] This contrast results in various studies were due to the inclusion of different patient cohorts, with contrast studies including patients with known anxiety tendencies. Furthermore, claustrophobic patients were not included in the study.

In a study conducted on evaluating patients' experience of MRI showed no significant correlation between patients' information and experience of anxiety. Similar to these findings, the present study also revealed no correlation between VBE and Anxiety.^[19] This may be because of difference in proportion of patients having previous MRI experience.

Open-ended question showed that music caused a positive change in the environment and provided relaxation during the MRI scan^[11] which is also consistent with the present study where patients believed that music helped patient to relax and thus reduces anxiety level.

In the present study, it seems that VBE as a part of the intervention proposed has had overall positive effects. Following the results of this study, the recommendation focuses on implementing VBE into routine practice. The video can be watched by patients in a waiting room or radiology staff could also use VBE to inform patients about MRI procedures. The findings from this study can be used for future research examining other strategies to reduce anxiety and improve scan experience. Severe anxiety during MRI scanning may cause patient motion, inducing image artefacts that can decrease the diagnostic value of the examination. Physicians working in radiology department are in the best position to understand the problems of patients undergoing MRI. Anxiety assessment and its management through nonpharmacological method should be used for providing quality care to patients.

Strengths of the current study include the use of multiple interventions containing information and relaxation strategies, opinionnaires were also used with an open-ended question to collect the views from patients regarding the use of interventions. In order to reduce the chances of data contamination VBE, MT and routine procedural instructions for respective groups were administered in separate rooms in the radiology department and to avoid biasness, radiographers' blinding was done. The Music tracks were patient preferred and validated by music experts. VBE was provided by developing the video with an authentic setting where the main study was to be conducted. The goal of connecting with the patients is to reduce the anxiety of patients before MRI procedure. Often health-care workers need to go into the MRI room to reassure and explain things to the patient and then retake many sequences. This step was circumvented by playing a video while the patient is waiting. A lot of time was potentially saved. For the anxiety assessment, the state form of STAI inventory was used to assess the current state of anxiety.

This study uses small sample size and single setting and was conducted only for patients undergoing MRI of abdomen and pelvis. The study can be conducted in different settings for making broad generalizations and can be carried out on larger sample.

In older children age more than 13 years, VBE can be implemented to reduce anxiety and use of sedation and other modes of video can be used such as animation. A study was conducted on 24 healthy children ages 5–11 years to evaluate an animation video to help prepare children for MRI, specifically for decreasing in-scanner motion and examination failure. There were significant improvements in scores regarding what to expect, checking for metal and keeping still. There were no significant changes in other knowledge-based topics. There were significant improvements anxiety scores.^[20] Another study carried out on 50 pediatric patients' shows significant improvement in relaxation and baseline procedural understanding scores in intervention group of age 13–17 years, but no significance among children <13 years of age.^[21]

Conclusions

Based on the study findings, it can be concluded that both VBE and MT were effective in improving the experience of patients undergoing MRI as compared to control group. With better experience, patients cooperated more with the procedure in VBE and MT group as compared to control group. Most of the patients accepted the use of VBE as a part of routine procedure and all of the patients agreed upon the use of MT during waiting time before undergoing MRI.

Acknowledgments

The authors thank all the patients for participating in the study. The present research would not be possible without the valuable assistance of numerous people from college of nursing, and people from department of radiology, experts and most importantly the guide.

Plagiarism tool used

URKUND.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Key Points

This paper demonstrates that non pharmacological strategies such as video-based education and MT are effective in reducing anxiety and improve experience and co-operation among patients
Nurses can implement it in the practice by providing monitory and functional support in the health care settings.
Nursing conferences and in service education programs can be organized for the better management of patients who undergo magnetic resonance imaging and reducing cost to the patients as well as hospital.

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