Evaluation of Cartoon Visuals versus Traditional Nursing Instruction for patients after Degenerative disc herniation surgery: A Randomized Controlled Trial

Evaluation of Cartoon Visuals versus Traditional Nursing Instruction for patients after Degenerative disc herniation surgery: A Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Cartoon Visuals versus Traditional Nursing Instruction for patients after Degenerative disc herniation surgery: A Randomized Controlled Trial Po- Fen Hsieh, Chun-Jung Lin, Cheng-You Lu, Kuan-Yu Lin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7773921/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Jan, 2026 Read the published version in European Spine Journal → Version 1 posted 16 You are reading this latest preprint version Abstract Purpose This study aimed to incorporate cartoon visuals into nursing instructions for degenerative disc herniation surgery and test whether cartoon visuals in preoperative nursing instructions can help improve the accuracy of knowledge memory, satisfaction, and anxiety during hospitalization. Methodology The experimental study was conducted from January to June 2024 and involved 84 patients undergoing surgery for degenerative disc herniation. Participants were randomly assigned by computer into two groups, and preoperative and postoperative tests were conducted to understand the patient's anxiety, self-care knowledge, and satisfaction: the "traditional group" received standard paper-based nursing instructions, while the "experimental group" received cartoon visual nursing instructions teaching. Results The study results were statistically significant differences in self-care knowledge (P=0.02) and satisfaction (p<0.001) among the experimental and traditional groups. There were no statistical differences in situational and trait anxiety, but the experimental group scores decreased. Another finding was that there was a statistically significant difference (P=0.02) in the experimental group, where the number of days of hospital stay was lower than that in the traditional group. Conclusion This study showed patients could improve their self-knowledge, reduce situational anxiety, increase satisfaction through cartoon visuals, and reduce the number of hospitalized days. Therefore, the engaging content of cartoon visuals can relieve patients' nervousness about surgery, increase their trust and cooperation, and further improve the effect of doctor-patient communication. Degenerative Disc Herniation Cartoon visuals nursing guidance Anxiety Self-care knowledge Figures Figure 1 Introduction Patients with degenerative disc disease often experience symptoms such as lower back pain, lower extremity weakness, loss of sensation, and an inability to stand, sit, or walk for long periods. When these symptoms persist and cannot be improved with conservative treatment and affect the quality of life, spinal surgery is required to relieve them [ 1 ]. Patients’ preoperative concerns often stem from unfamiliarity and uncertainty about the procedure, exacerbated by a lack of communication between medical staff [ 2 ]. About 60–87% of patients undergoing spinal surgery experience preoperative anxiety [ 3 ]. Additionally, preoperative anxiety is associated with increased analgesic use, prolonged stay in post-anesthesia care, delayed admission to the operating room, and prolonged hospital stay. These effects increase suffering and medical costs [ 4 ]. Nowadays, surgical patients have few hospitalization days due to health insurance, and their pre-operative examination schedule is tight. When learning nursing instructions, patients may be anxious or nervous and fail to understand the content thoroughly [ 5 ]. Providing complete nursing guidance before surgery can effectively reduce patients' learning anxiety and improve learning outcomes [ 6 ]. However, in clinical practice, nurses often provide pre and post-operative nursing instructions by reading the contents of paper nursing instruction sheets. The contents of the instructions usually vary from person to person, and the busy working environment often causes nurses sometimes to leave the nursing instructions incomplete. The cartoon education approach has been effectively used as a teaching tool and helped improve the nursing staff's knowledge and expertise to ensure quality patient care [ 7 ]. Cartoon education can achieve good results in the preoperative education of surgical patients. It can strengthen patients' memory points of preoperative health education, promote patients' understanding of relevant preoperative knowledge, and improve patient satisfaction. It is worthy of vigorous promotion and use and is fast and effective [ 8 ]. Therefore, according to the above inference, cartoon education nursing instructions are a very effective teaching tool. The engaging content of cartoon visuals can relieve patients' nervousness about surgery, increase their trust and cooperation, and further improve the effectiveness of doctor-patient communication. This study aimed to incorporate cartoon visuals into nursing instructions for degenerative disc herniation surgery and test whether cartoon visuals in nursing instructions can help improve the accuracy of knowledge memory, satisfaction, and anxiety during hospitalization and reduce the number of hospitalized days. Methods The study was carried out according to the Declaration of Helsinki. The Research Ethics Committee of 113006 approved the study protocol. Participants were given written informed consent and assent before participating in the study. Participants This study adopted a quasi-experimental research design using computer random sampling. The "traditional group" received standard paper-based nursing instructions, while the "experimental group" received cartoon visuals nursing instruction teaching. The study subjects were patients who underwent surgery for degenerative disc herniation in the surgical ward of a regional teaching hospital in central Taiwan from January to June 2024. The conditions for accepting cases are: (1) patients diagnosed with degenerative disc herniation by a physician; (2) patients aged 20 or above; (3) patients with clear consciousness and no hearing or visual impairment; (4) patients who can communicate verbally or in writing. (5) After the purpose of the study is explained, those who agree to participate sign the research consent form. Exclusion criteria include: (1) under 20 years old; (2) all persons with a diagnosis code for mental illness; and (3) foreigners. The study involved 84 patients undergoing surgery for degenerative disc herniation. Participants were randomly assigned by computer into two groups, including 42 in the experimental group and 42 in the control group, and preoperative and postoperative tests were conducted to understand the patient's anxiety, self-care knowledge, and satisfaction. Questionnaire The self-care knowledge questionnaires for degenerative disc herniation surgery are mainly used to understand the degree of knowledge of patients about the care of degenerative disc herniation surgery. Based on the literature review, 10 questions of the self-care knowledge questionnaires for lumbar surgery were formulated. The mechanism, etiology, surgical content, and postoperative precautions are included after degenerative disc herniation surgery. The scoring method is 10 points for correct answers, 0 points for incorrect answers or unknown answers, and the score range is 0 to 100 points. Cumulative score: The higher the value, the more correct the patient's self-care knowledge is. Three experts with surgical backgrounds performed expert validity, and the average CVI was 0.96, which is considered good content validity. This study used the State-Trait Anxiety Inventory (STAI) [ 9 ] as an assessment tool for the anxiety responses of the research subjects which are: (1) The Trait Anxiety Inventory refers to a relatively stable individual anxiety tendency, which is relatively long-lasting and stable (2) The Situational Anxiety Scale refers to the anxiety feelings of varying intensity that occur when an individual experiences tension, anxiety, worry, etc. in a particular situation or moment. Measure to understand the outcome indicators after different intervention measures. Nursing Guidance Satisfaction Scale. Medical care is a service. This scale is used to understand the patient's satisfaction with different nursing guidance methods and as a reference for future quality improvement. Based on the results of the literature review (Wang et al., 2023), this scale is self-developed and invites three experts with professional backgrounds to perform expert validity. There are 10 questions related to service satisfaction. The options are very satisfied, satisfied, dissatisfied, and very dissatisfied, and the scores are "4 points", "3 points", "2 points", and "1 point". Scoring method: Based on the Likert 1–4-point method, The higher the score, the higher the satisfaction level, with a score range of 20–40 points. The higher the score, the higher the satisfaction level. If the score is between 0 and 19, it is very dissatisfied. If the score is between 20 and 29, it is unhappy. If the score is between 30 and 39, it is satisfied. It is higher than 40 and is very satisfying. Cartoon visuals nursing instructions development Cartoon visuals nursing instructions for patients undergoing surgery for degenerative disc herniation. The Cartoon visuals were prepared based on the relevant literature and clinical medical nursing instructions leaflets and was based on the opinions and personal clinical experience of 3 experts. The content includes: The mechanism, etiology, surgical indications and complications of degenerative disc herniation surgery", "Postoperative care and precautions during hospitalization," "Purpose of using a back brace and back brace wearing skills," "Daily care of the wound after returning home," "Correctness of daily posture after returning home," etc. The researchers acted as demonstrators and narrators, and a clinical nurse used a digital phone to film the actual situation in color, using the five major themes mentioned above as the script. The filmed script content was converted into the final video using Evercam software. Cartoon visuals nursing instructions, about 10 minutes long. Statistical Analysis This study used Microsoft Excel to create data files and SPSS for the Windows 22.0 software package for statistical analysis. Descriptive statistics include frequency distribution, percentage, mean, standard deviation, and maximum and minimum values ​​to describe the distribution of independent and dependent variables. Inferential statistical methods included an independent t-test, a one-way ANOVA test with Bonferroni post hoc correction, and Pearson’s correlation. Results were deemed statistically significant for p-value < 0.05. Results The essential attributes were tested using the Chi-square test for homogeneity of the subjects in the traditional group and the experimental group. The personal background information of the subjects in the two groups (including gender, age, education level, and chronic disease history) was compared. There were no significant differences in pain index. The results of this study indicate that the two groups of research subjects are homogeneous in all essential data, so the research results can exclude the influence of sampling bias. The results showed no difference between cartoon visuals nursing instructions and paper health education before the test (Table 1 ). Table 1 Comparison of basic demographic data between the traditional group and the experimental group Characteristics Traditional group (n = 42) Experimental group (n = 42) n % n % p-value Gender Male 20 47.6 24 57.1 Female 22 52.4 18 42.9 Age 40–49 3 7.14 5 11.9 50–59 10 23.8 12 28.6 60–69 13 31.0 9 21.4 70–79 7 16.7 7 16.7 80–89 9 21.4 9 21.4 .84 Education level Junior high school (inclusive) 14 33.3 18 42.9 Senior high school and above 28 66.7 24 57.1 1.0 Marriage Married 33 78.6 33 78.6 Unmarried 0 0 2 4.7 Divorce 5 11.9 5 11.9 Widowed 4 9.5 2 4.7 .45 Occupation work 4 9.5 6 14.3 business 3 7.1 7 16.7 Medical related 1 2.4 0 0 Services 1 2.4 0 0 Military, public and teaching positions 1 2.4 2 4.8 Housekeeping 15 35.7 13 31.0 retire 4 9.5 2 4.7 none 13 31.0 12 28.6 .64 Pain Index 1–3 points (mild) 1 2.4 1 2.4 4–6 points (moderate) 31 76.2 29 73.8 7–10 points (severe) 10 23.8 12 26.1 .70 This study used the "Self-Care Knowledge Scale," "Situational Anxiety Scale," "Trait Anxiety Scale," and "Satisfaction Scale" to evaluate the traditional group and experimental group patients before health education intervention. The scores of the two groups are presented in terms of mean and standard deviation, and the independent sample t-test is used for analysis, as shown in Table 2 . Table 2 Comparison of pre-test differences between the traditional group and the experimental group item Experimental group Traditional group p-value M ± SD M ± SD Self-care knowledge 74.76 ± 5.05 74.28 ± 5.00 0.66 Situational Anxiety 43.33 ± 2.32 43.57 ± 3.16 0.695 Trait Anxiety 44.55 ± 2.30 44.93 ± 2.70 0.489 Satisfaction 21.05 ± 1.83 21.19 ± 2.08 0.739 SD, standard deviation,*p < .05 **p < .01 ***p < .001 This study used the "Self-Care Knowledge Scale," "Situational Anxiety Scale," "Trait Anxiety Scale," and "Satisfaction Scale" to evaluate the traditional group and experimental group patients after health education intervention. The mean and standard deviation were used to present the scores of the two groups, and the independent sample t-test was used for analysis. The study showed that there was a statistically significant difference in self-care knowledge post-test (p = .02); in situational anxiety post-test, there was no difference between the two groups post-test (p = 0.116 ); in the trait anxiety post-test, there was no difference between the two groups in the post-test (p = 0.848); in the satisfaction post-test, experimental group patients (36.09 ± 0.82) and traditional (25.14 ± 0.63) group, there was a statistically significant difference (p < 0.001) (Table 3 ). Table 3 Comparison of post-test differences between the traditional group and the experimental group item Experimental group Traditional group p-value M ± SD M ± SD Self-care knowledge 95.71 ± 4.18 92.33 ± 4.15 0.020* Situational Anxiety 41.33 ± 3.22 42.33 ± 2.49 0.116 Trait Anxiety 44.74 ± 2.40 44.86 ± 3.22 0.848 Satisfaction 36.09 ± 0.82 25.14 ± 0.63 <.001*** SD, standard deviation,*p < .05 **p < .01 ***p < .001 This study evaluated the length of hospital stay in the traditional and experimental groups, presented the two groups with mean and standard deviation, and used independent sample t-test analysis. The results showed that the average value of the traditional group was 5.31 ± 0.81 days, and the average value of the experimental group was 4.79 ± 0.81 days. There was a statistically significant difference between the two groups (p = 0.002) (Fig. 1 ). Discussion This study showed that cartoon visuals improved self-care knowledge and hospital satisfaction. In this study, using cartoon visuals to provide nursing instructions to patients effectively reduced the length of hospital stay. Traditional paper-based nursing instructions have long been the cornerstone of clinical health education, often characterized by nurses delivering paper-based nursing instruction messages with limited patient interaction. These nursing instructions are usually delivered in a nurse-centered environment, centralizing paper-based nursing instruction knowledge and content, but they may lack patient involvement. However, learning is fundamentally an active process that requires collaboration between nurses and patients to make care delivery enjoyable and effective. Our study confirms that cartoon visuals have better knowledge acquisition. This is consistent with the study by Kathiah et al. (2024), which showed that cartoon visuals have good results as an auxiliary learning tool [ 10 ]. Cartoon visuals significantly improve short-term recall of health information among adult patients in different healthcare settings compared with traditional paper-based nursing instructions. This suggests that cartoon visuals can be valuable for providing information to patients in various healthcare settings [ 11 ]. This study uses cartoon visuals to receive complete information learning and mutual communication with medical staff to clarify doubts in the patient's mind. It can help patients reduce anxiety and achieve satisfactory recovery in the overall care process. Cartoon visuals are durable, adaptable, and can communicate complex messages, using visual and narrative elements to enhance patient knowledge [ 12 ]. The results of this study showed that there was no difference in situational anxiety and trait anxiety between the two groups after intervention with cartoon visuals, but the scores of situational anxiety and trait anxiety in the experimental group decreased, indicating that cartoon multimedia nursing guidance can reduce anxiety. Tou et al. 2013 showed that cartoon visuals provided before surgery can reduce patients' anxiety and improve their hospital experience. Therefore, this intervention is an inexpensive, easily administered, and comprehensive approach to reducing anxiety in the surgical population [ 13 ]. Compared with traditional paper-based nursing instructions, cartoon visuals significantly reduce the length of hospital stay. This suggests that nursing guidance with cartoon visuals can help reduce hospital stays and be cost-effective. This is consistent with the study by Rice et al. in 2017, which pointed out that comprehensive nursing guidance can effectively reduce the number of days of hospitalization [ 14 ]. This study utilized cartoon visuals, which can be viewed anytime, anywhere, and repeatedly, regardless of the patient's time in the hospital. Patients can master preoperative degenerative disc herniation surgery knowledge and deepen their understanding of the treatment process by watching it multiple times daily. It is also consistent with the study by Hogan et al. (2024) that nursing guidance can enable patients to master and understand more knowledge content and reduce the number of days of hospitalization [ 15 ]. Conclusion As society develops, people's lifestyles and habits are constantly changing. Mobile devices have become widely popular and dependent on the general public. Our traditional face-to-face, paper-based, oral nursing instructions take more time and are stiffer in format. Paper nursing instructions have relatively high requirements on patients' reading level and comprehension ability. The nursing instructions in the animated video are based on mobile devices and can be expressed quickly and intuitively through simple text, engaging illustrations, and vivid images. You can watch it again anytime, anywhere, no matter how long you are in the hospital, just like the nurses repeating and diligently carrying out nursing instructions at any time. It makes up for the shortcomings of traditional nursing instructions. The results of this study once again confirmed that providing preoperative nursing instructions through cartoon visual effects can help patients better understand relevant preoperative knowledge, improve patient satisfaction, and reduce the number of hospitalized days. It is worth promoting and using quickly and effectively. Author contribution Kuan-Yu Lin was involved in the study concept and design, performed data acquisition and analysis, and drafted the manuscript and figures. Po-Fen Hsieh was involved in the study concept and design and drafted the manuscript and figures. Chun-Jung Lin performed data acquisition and analysis. Cheng-You Lu were responsible for specimen collection. Declarations The authors have no personal, financial, or institutional interest in any materials or devices described in this article. Author Contribution Author contribution Kuan-Yu Lin was involved in the study concept and design, performed data acquisition and analysis, and drafted the manuscript and figures. Po-Fen Hsieh was involved in the study concept and design and drafted the manuscript and figures. Chun-Jung Lin performed data acquisition and analysis. Cheng-You Lu were responsible for specimen collection. Data availability The detailed participants’ data supporting this study's findings are available to the corresponding author upon reasonable request. References Hoffeld K, Lenz M, Egenolf P et al (2023) Patient-related risk factors and lifestyle factors for lumbar degenerative disc disease: a systematic review. Neurochirurgie 69:101482. https://doi:10.1016/j.neuchi.2023.101482 Cheng JYJ, Wong BWZ, Chin YH et al (2021) Preoperative concerns of patients undergoing general surgery. Patient Educ Couns 104:1467–1473. https://doi:10.1016/j.pec.2020.11.010 Lee JS, Park YM, Ha KY et al (2016) Preoperative anxiety about spinal surgery under general anesthesia. Eur Spine J 25:698–707. https://doi:10.1007/s00586-015-3788-2 Laufenberg-Feldmann R, Kappis B, Cámara RJA et al (2018) Anxiety and its predictive value for pain and regular analgesic intake after lumbar disc surgery - a prospective observational longitudinal study. BMC Psychiatry 27:82. https://doi:10.1186/s12888-018-1652-8 Madkhali MM, Mojiri ME, Mobarki OA et al (2024) Prevalence, Determinants, and Coping Strategies of Preoperative Anxiety Among Surgical Patients: A Cross-Sectional Study in Jazan. Saudi Arabia Cureus 16:e68454. https://doi:10.7759/cureus.68454 Ruiz Hernández C, Gómez-Urquiza JL, Pradas-Hernández L et al (2021) Effectiveness of nursing interventions for preoperative anxiety in adults: A systematic review with meta-analysis. J Adv Nurs 77:3274–3285. https://doi:10.1111/jan Lin CH, Lin CJ, Lin KY (2023) Using wound cartoon visual education to enhance nurses' knowledge of wound care. J Vis Commun Med 46:97–104. https://doi:10.1080/17453054.2023.2197955 Lian X, Tan M, Zeng H et al (2024) Study on the effect of cartoon video education before orbital operation. Minerva Gastroenterol (Torino) 70:112–114. https://doi:10.23736/S2724-5985.23.03441-1 Spielberger CD, Gorsuch R, Lushene R (1970) State-trait anxiety inventory (pp. 3–8) Kathiah R, Daya AP, Mp et al (2024) Evaluating the Impact of Cartoon-Based Learning on Student Performance and Engagement in Medical Education: An Experimental Study. Cureus 16:e54684. https://doi:10.7759/cureus.54684 Hansen S, Jensen TS, Schmidt AM et al (2024) The Effectiveness of Video Animations as a Tool to Improve Health Information Recall for Patients: Systematic Review. J Med Internet Res 26:e58306. https://doi:10.2196/58306 Alemany-Pagès M, Azul AM, Ramalho-Santos J (2022) The use of comics to promote health awareness: A template using nonalcoholic fatty liver disease. Eur J Clin Invest 52:e13642. https://doi:10.1111/eci.13642 Tou S, Tou W, Mah D (2013) Effect of preoperative two-dimensional animation information on perioperative anxiety and knowledge retention in patients undergoing bowel surgery: a randomized pilot study. Colorectal Dis 15:e256–e265 Rice H, Say R, Betihavas V (2018) The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review. Patient Educ Couns 101:363–374. https://doi:10.1016/j.pec.2017.10.002 Hogan A, Hughes L, Coyne E (2024) Nurses' assessment of health literacy requirements for adult inpatients: An integrative review. Health Promot J Austr 35:504–517. https://doi:10.1002/hpja.780 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 05 Jan, 2026 Read the published version in European Spine Journal → Version 1 posted Editorial decision: Revision requested 16 Oct, 2025 Reviews received at journal 13 Oct, 2025 Reviewers agreed at journal 12 Oct, 2025 Reviewers agreed at journal 10 Oct, 2025 Reviews received at journal 08 Oct, 2025 Reviewers agreed at journal 08 Oct, 2025 Reviewers agreed at journal 07 Oct, 2025 Reviewers agreed at journal 06 Oct, 2025 Reviewers agreed at journal 06 Oct, 2025 Reviewers agreed at journal 05 Oct, 2025 Reviewers agreed at journal 05 Oct, 2025 Reviewers agreed at journal 05 Oct, 2025 Reviewers invited by journal 05 Oct, 2025 Editor assigned by journal 04 Oct, 2025 Submission checks completed at journal 04 Oct, 2025 First submitted to journal 03 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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02:19:46","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":73284,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7773921/v1/d8760fe01265e7f0df5b9af8.html"},{"id":93732105,"identity":"7b47ab64-d326-4d1c-8aca-ec4b6ed5d4ab","added_by":"auto","created_at":"2025-10-17 02:27:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23514,"visible":true,"origin":"","legend":"\u003cp\u003eThe difference in length of hospital stays between the two groups after receiving cartoon visuals nursing instruction.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7773921/v1/186509a5fa18e08454d5b706.png"},{"id":100068586,"identity":"b0254426-d269-45bc-a0e2-c31f60c94660","added_by":"auto","created_at":"2026-01-12 16:00:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":668158,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7773921/v1/9ae7f3aa-79cc-4706-9a30-5671a4b2fd94.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of Cartoon Visuals versus Traditional Nursing Instruction for patients after Degenerative disc herniation surgery: A Randomized Controlled Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePatients with degenerative disc disease often experience symptoms such as lower back pain, lower extremity weakness, loss of sensation, and an inability to stand, sit, or walk for long periods. When these symptoms persist and cannot be improved with conservative treatment and affect the quality of life, spinal surgery is required to relieve them [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Patients\u0026rsquo; preoperative concerns often stem from unfamiliarity and uncertainty about the procedure, exacerbated by a lack of communication between medical staff [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. About 60\u0026ndash;87% of patients undergoing spinal surgery experience preoperative anxiety [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Additionally, preoperative anxiety is associated with increased analgesic use, prolonged stay in post-anesthesia care, delayed admission to the operating room, and prolonged hospital stay. These effects increase suffering and medical costs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNowadays, surgical patients have few hospitalization days due to health insurance, and their pre-operative examination schedule is tight. When learning nursing instructions, patients may be anxious or nervous and fail to understand the content thoroughly [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Providing complete nursing guidance before surgery can effectively reduce patients' learning anxiety and improve learning outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, in clinical practice, nurses often provide pre and post-operative nursing instructions by reading the contents of paper nursing instruction sheets. The contents of the instructions usually vary from person to person, and the busy working environment often causes nurses sometimes to leave the nursing instructions incomplete.\u003c/p\u003e\u003cp\u003eThe cartoon education approach has been effectively used as a teaching tool and helped improve the nursing staff's knowledge and expertise to ensure quality patient care [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Cartoon education can achieve good results in the preoperative education of surgical patients. It can strengthen patients' memory points of preoperative health education, promote patients' understanding of relevant preoperative knowledge, and improve patient satisfaction. It is worthy of vigorous promotion and use and is fast and effective [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, according to the above inference, cartoon education nursing instructions are a very effective teaching tool.\u003c/p\u003e\u003cp\u003eThe engaging content of cartoon visuals can relieve patients' nervousness about surgery, increase their trust and cooperation, and further improve the effectiveness of doctor-patient communication. This study aimed to incorporate cartoon visuals into nursing instructions for degenerative disc herniation surgery and test whether cartoon visuals in nursing instructions can help improve the accuracy of knowledge memory, satisfaction, and anxiety during hospitalization and reduce the number of hospitalized days.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e The study was carried out according to the Declaration of Helsinki. The Research Ethics Committee of 113006 approved the study protocol. Participants were given written informed consent and assent before participating in the study.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eThis study adopted a quasi-experimental research design using computer random sampling. The \"traditional group\" received standard paper-based nursing instructions, while the \"experimental group\" received cartoon visuals nursing instruction teaching. The study subjects were patients who underwent surgery for degenerative disc herniation in the surgical ward of a regional teaching hospital in central Taiwan from January to June 2024. The conditions for accepting cases are: (1) patients diagnosed with degenerative disc herniation by a physician; (2) patients aged 20 or above; (3) patients with clear consciousness and no hearing or visual impairment; (4) patients who can communicate verbally or in writing. (5) After the purpose of the study is explained, those who agree to participate sign the research consent form. Exclusion criteria include: (1) under 20 years old; (2) all persons with a diagnosis code for mental illness; and (3) foreigners. The study involved 84 patients undergoing surgery for degenerative disc herniation. Participants were randomly assigned by computer into two groups, including 42 in the experimental group and 42 in the control group, and preoperative and postoperative tests were conducted to understand the patient's anxiety, self-care knowledge, and satisfaction.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eQuestionnaire\u003c/h3\u003e\n\u003cp\u003eThe self-care knowledge questionnaires for degenerative disc herniation surgery are mainly used to understand the degree of knowledge of patients about the care of degenerative disc herniation surgery. Based on the literature review, 10 questions of the self-care knowledge questionnaires for lumbar surgery were formulated. The mechanism, etiology, surgical content, and postoperative precautions are included after degenerative disc herniation surgery. The scoring method is 10 points for correct answers, 0 points for incorrect answers or unknown answers, and the score range is 0 to 100 points. Cumulative score: The higher the value, the more correct the patient's self-care knowledge is. Three experts with surgical backgrounds performed expert validity, and the average CVI was 0.96, which is considered good content validity.\u003c/p\u003e\u003cp\u003eThis study used the State-Trait Anxiety Inventory (STAI) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] as an assessment tool for the anxiety responses of the research subjects which are: (1) The Trait Anxiety Inventory refers to a relatively stable individual anxiety tendency, which is relatively long-lasting and stable (2) The Situational Anxiety Scale refers to the anxiety feelings of varying intensity that occur when an individual experiences tension, anxiety, worry, etc. in a particular situation or moment. Measure to understand the outcome indicators after different intervention measures.\u003c/p\u003e\u003cp\u003eNursing Guidance Satisfaction Scale. Medical care is a service. This scale is used to understand the patient's satisfaction with different nursing guidance methods and as a reference for future quality improvement. Based on the results of the literature review (Wang et al., 2023), this scale is self-developed and invites three experts with professional backgrounds to perform expert validity. There are 10 questions related to service satisfaction. The options are very satisfied, satisfied, dissatisfied, and very dissatisfied, and the scores are \"4 points\", \"3 points\", \"2 points\", and \"1 point\". Scoring method: Based on the Likert 1\u0026ndash;4-point method, The higher the score, the higher the satisfaction level, with a score range of 20\u0026ndash;40 points. The higher the score, the higher the satisfaction level. If the score is between 0 and 19, it is very dissatisfied. If the score is between 20 and 29, it is unhappy. If the score is between 30 and 39, it is satisfied. It is higher than 40 and is very satisfying.\u003c/p\u003e\n\u003ch3\u003eCartoon visuals nursing instructions development\u003c/h3\u003e\n\u003cp\u003eCartoon visuals nursing instructions for patients undergoing surgery for degenerative disc herniation. The Cartoon visuals were prepared based on the relevant literature and clinical medical nursing instructions leaflets and was based on the opinions and personal clinical experience of 3 experts. The content includes: The mechanism, etiology, surgical indications and complications of degenerative disc herniation surgery\", \"Postoperative care and precautions during hospitalization,\" \"Purpose of using a back brace and back brace wearing skills,\" \"Daily care of the wound after returning home,\" \"Correctness of daily posture after returning home,\" etc. The researchers acted as demonstrators and narrators, and a clinical nurse used a digital phone to film the actual situation in color, using the five major themes mentioned above as the script. The filmed script content was converted into the final video using Evercam software. Cartoon visuals nursing instructions, about 10 minutes long.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThis study used Microsoft Excel to create data files and SPSS for the Windows 22.0 software package for statistical analysis. Descriptive statistics include frequency distribution, percentage, mean, standard deviation, and maximum and minimum values ​​to describe the distribution of independent and dependent variables. Inferential statistical methods included an independent t-test, a one-way ANOVA test with Bonferroni post hoc correction, and Pearson\u0026rsquo;s correlation. Results were deemed statistically significant for p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe essential attributes were tested using the Chi-square test for homogeneity of the subjects in the traditional group and the experimental group. The personal background information of the subjects in the two groups (including gender, age, education level, and chronic disease history) was compared. There were no significant differences in pain index. The results of this study indicate that the two groups of research subjects are homogeneous in all essential data, so the research results can exclude the influence of sampling bias. The results showed no difference between cartoon visuals nursing instructions and paper health education before the test (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of basic demographic data between the traditional group and the experimental group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eTraditional group (n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003eExperimental group (n\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e47.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e57.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e52.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e7.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e23.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60\u0026ndash;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e31.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e70\u0026ndash;79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e80\u0026ndash;89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u003cp\u003e.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJunior high school (inclusive)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e33.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e42.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSenior high school and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e66.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e57.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarriage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e78.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e78.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e4.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDivorce\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e9.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e4.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u003cp\u003e.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ework\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e9.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ebusiness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e16.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMedical related\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eServices\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMilitary, public and teaching positions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e4.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHousekeeping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e35.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e31.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eretire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e9.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u003cp\u003e4.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003enone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e31.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e28.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u003cp\u003e.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain Index\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;3 points (mild)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u0026ndash;6 points (moderate)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e76.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e73.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u0026ndash;10 points (severe)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e23.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e26.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u003cp\u003e.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c12\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis study used the \"Self-Care Knowledge Scale,\" \"Situational Anxiety Scale,\" \"Trait Anxiety Scale,\" and \"Satisfaction Scale\" to evaluate the traditional group and experimental group patients before health education intervention. The scores of the two groups are presented in terms of mean and standard deviation, and the independent sample t-test is used for analysis, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of pre-test differences between the traditional group and the experimental group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eitem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExperimental group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTraditional group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-care knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.76\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.28\u0026thinsp;\u0026plusmn;\u0026thinsp;5.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.66\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSituational Anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.57\u0026thinsp;\u0026plusmn;\u0026thinsp;3.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.695\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrait Anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44.55\u0026thinsp;\u0026plusmn;\u0026thinsp;2.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.489\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSatisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.19\u0026thinsp;\u0026plusmn;\u0026thinsp;2.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.739\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD, standard deviation,*p\u0026thinsp;\u0026lt;\u0026thinsp;.05 **p\u0026thinsp;\u0026lt;\u0026thinsp;.01 ***p\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis study used the \"Self-Care Knowledge Scale,\" \"Situational Anxiety Scale,\" \"Trait Anxiety Scale,\" and \"Satisfaction Scale\" to evaluate the traditional group and experimental group patients after health education intervention. The mean and standard deviation were used to present the scores of the two groups, and the independent sample t-test was used for analysis. The study showed that there was a statistically significant difference in self-care knowledge post-test (p\u0026thinsp;=\u0026thinsp;.02); in situational anxiety post-test, there was no difference between the two groups post-test (p\u0026thinsp;=\u0026thinsp;0.116 ); in the trait anxiety post-test, there was no difference between the two groups in the post-test (p\u0026thinsp;=\u0026thinsp;0.848); in the satisfaction post-test, experimental group patients (36.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82) and traditional (25.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63) group, there was a statistically significant difference (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of post-test differences between the traditional group and the experimental group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eitem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExperimental group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTraditional group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-care knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95.71\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e92.33\u0026thinsp;\u0026plusmn;\u0026thinsp;4.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.020*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSituational Anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.116\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrait Anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44.74\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44.86\u0026thinsp;\u0026plusmn;\u0026thinsp;3.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.848\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSatisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;.001***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD, standard deviation,*p\u0026thinsp;\u0026lt;\u0026thinsp;.05 **p\u0026thinsp;\u0026lt;\u0026thinsp;.01 ***p\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis study evaluated the length of hospital stay in the traditional and experimental groups, presented the two groups with mean and standard deviation, and used independent sample t-test analysis. The results showed that the average value of the traditional group was 5.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81 days, and the average value of the experimental group was 4.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81 days. There was a statistically significant difference between the two groups (p\u0026thinsp;=\u0026thinsp;0.002) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed that cartoon visuals improved self-care knowledge and hospital satisfaction. In this study, using cartoon visuals to provide nursing instructions to patients effectively reduced the length of hospital stay.\u003c/p\u003e\u003cp\u003eTraditional paper-based nursing instructions have long been the cornerstone of clinical health education, often characterized by nurses delivering paper-based nursing instruction messages with limited patient interaction. These nursing instructions are usually delivered in a nurse-centered environment, centralizing paper-based nursing instruction knowledge and content, but they may lack patient involvement. However, learning is fundamentally an active process that requires collaboration between nurses and patients to make care delivery enjoyable and effective. Our study confirms that cartoon visuals have better knowledge acquisition. This is consistent with the study by Kathiah et al. (2024), which showed that cartoon visuals have good results as an auxiliary learning tool [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCartoon visuals significantly improve short-term recall of health information among adult patients in different healthcare settings compared with traditional paper-based nursing instructions. This suggests that cartoon visuals can be valuable for providing information to patients in various healthcare settings [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This study uses cartoon visuals to receive complete information learning and mutual communication with medical staff to clarify doubts in the patient's mind. It can help patients reduce anxiety and achieve satisfactory recovery in the overall care process. Cartoon visuals are durable, adaptable, and can communicate complex messages, using visual and narrative elements to enhance patient knowledge [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe results of this study showed that there was no difference in situational anxiety and trait anxiety between the two groups after intervention with cartoon visuals, but the scores of situational anxiety and trait anxiety in the experimental group decreased, indicating that cartoon multimedia nursing guidance can reduce anxiety. Tou et al. 2013 showed that cartoon visuals provided before surgery can reduce patients' anxiety and improve their hospital experience. Therefore, this intervention is an inexpensive, easily administered, and comprehensive approach to reducing anxiety in the surgical population [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCompared with traditional paper-based nursing instructions, cartoon visuals significantly reduce the length of hospital stay. This suggests that nursing guidance with cartoon visuals can help reduce hospital stays and be cost-effective. This is consistent with the study by Rice et al. in 2017, which pointed out that comprehensive nursing guidance can effectively reduce the number of days of hospitalization [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This study utilized cartoon visuals, which can be viewed anytime, anywhere, and repeatedly, regardless of the patient's time in the hospital. Patients can master preoperative degenerative disc herniation surgery knowledge and deepen their understanding of the treatment process by watching it multiple times daily. It is also consistent with the study by Hogan et al. (2024) that nursing guidance can enable patients to master and understand more knowledge content and reduce the number of days of hospitalization [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAs society develops, people's lifestyles and habits are constantly changing. Mobile devices have become widely popular and dependent on the general public. Our traditional face-to-face, paper-based, oral nursing instructions take more time and are stiffer in format. Paper nursing instructions have relatively high requirements on patients' reading level and comprehension ability. The nursing instructions in the animated video are based on mobile devices and can be expressed quickly and intuitively through simple text, engaging illustrations, and vivid images. You can watch it again anytime, anywhere, no matter how long you are in the hospital, just like the nurses repeating and diligently carrying out nursing instructions at any time. It makes up for the shortcomings of traditional nursing instructions. The results of this study once again confirmed that providing preoperative nursing instructions through cartoon visual effects can help patients better understand relevant preoperative knowledge, improve patient satisfaction, and reduce the number of hospitalized days. It is worth promoting and using quickly and effectively.\u003c/p\u003e\u003cp\u003eAuthor contribution Kuan-Yu Lin was involved in the study concept and design, performed data acquisition and analysis, and drafted the manuscript and figures. Po-Fen Hsieh was involved in the study concept and design and drafted the manuscript and figures. Chun-Jung Lin performed data acquisition and analysis. Cheng-You Lu were responsible for specimen collection.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors have no personal, financial, or institutional interest in any materials or devices described in this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor contribution Kuan-Yu Lin was involved in the study concept and design, performed data acquisition and analysis, and drafted the manuscript and figures. Po-Fen Hsieh was involved in the study concept and design and drafted the manuscript and figures. Chun-Jung Lin performed data acquisition and analysis. Cheng-You Lu were responsible for specimen collection.\u003c/p\u003e\u003ch2\u003eData availability\u003c/h2\u003e\u003cp\u003eThe detailed participants\u0026rsquo; data supporting this study's findings are available to the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHoffeld K, Lenz M, Egenolf P et al (2023) Patient-related risk factors and lifestyle factors for lumbar degenerative disc disease: a systematic review. Neurochirurgie 69:101482. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.neuchi.2023.101482\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.neuchi.2023.101482\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheng JYJ, Wong BWZ, Chin YH et al (2021) Preoperative concerns of patients undergoing general surgery. Patient Educ Couns 104:1467\u0026ndash;1473. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.pec.2020.11.010\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.pec.2020.11.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee JS, Park YM, Ha KY et al (2016) Preoperative anxiety about spinal surgery under general anesthesia. Eur Spine J 25:698\u0026ndash;707. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1007/s00586-015-3788-2\u003c/span\u003e\u003cspan address=\"https://doi:10.1007/s00586-015-3788-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLaufenberg-Feldmann R, Kappis B, C\u0026aacute;mara RJA et al (2018) Anxiety and its predictive value for pain and regular analgesic intake after lumbar disc surgery - a prospective observational longitudinal study. BMC Psychiatry 27:82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1186/s12888-018-1652-8\u003c/span\u003e\u003cspan address=\"https://doi:10.1186/s12888-018-1652-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMadkhali MM, Mojiri ME, Mobarki OA et al (2024) Prevalence, Determinants, and Coping Strategies of Preoperative Anxiety Among Surgical Patients: A Cross-Sectional Study in Jazan. Saudi Arabia Cureus 16:e68454. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.7759/cureus.68454\u003c/span\u003e\u003cspan address=\"https://doi:10.7759/cureus.68454\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRuiz Hern\u0026aacute;ndez C, G\u0026oacute;mez-Urquiza JL, Pradas-Hern\u0026aacute;ndez L et al (2021) Effectiveness of nursing interventions for preoperative anxiety in adults: A systematic review with meta-analysis. J Adv Nurs 77:3274\u0026ndash;3285. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1111/jan\u003c/span\u003e\u003cspan address=\"https://doi:10.1111/jan\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLin CH, Lin CJ, Lin KY (2023) Using wound cartoon visual education to enhance nurses' knowledge of wound care. J Vis Commun Med 46:97\u0026ndash;104. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1080/17453054.2023.2197955\u003c/span\u003e\u003cspan address=\"https://doi:10.1080/17453054.2023.2197955\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLian X, Tan M, Zeng H et al (2024) Study on the effect of cartoon video education before orbital operation. Minerva Gastroenterol (Torino) 70:112\u0026ndash;114. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.23736/S2724-5985.23.03441-1\u003c/span\u003e\u003cspan address=\"https://doi:10.23736/S2724-5985.23.03441-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpielberger CD, Gorsuch R, Lushene R (1970) State-trait anxiety inventory (pp. 3\u0026ndash;8)\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKathiah R, Daya AP, Mp et al (2024) Evaluating the Impact of Cartoon-Based Learning on Student Performance and Engagement in Medical Education: An Experimental Study. Cureus 16:e54684. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.7759/cureus.54684\u003c/span\u003e\u003cspan address=\"https://doi:10.7759/cureus.54684\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHansen S, Jensen TS, Schmidt AM et al (2024) The Effectiveness of Video Animations as a Tool to Improve Health Information Recall for Patients: Systematic Review. J Med Internet Res 26:e58306. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.2196/58306\u003c/span\u003e\u003cspan address=\"https://doi:10.2196/58306\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlemany-Pag\u0026egrave;s M, Azul AM, Ramalho-Santos J (2022) The use of comics to promote health awareness: A template using nonalcoholic fatty liver disease. Eur J Clin Invest 52:e13642. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1111/eci.13642\u003c/span\u003e\u003cspan address=\"https://doi:10.1111/eci.13642\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTou S, Tou W, Mah D (2013) Effect of preoperative two-dimensional animation information on perioperative anxiety and knowledge retention in patients undergoing bowel surgery: a randomized pilot study. Colorectal Dis 15:e256\u0026ndash;e265\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRice H, Say R, Betihavas V (2018) The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review. Patient Educ Couns 101:363\u0026ndash;374. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1016/j.pec.2017.10.002\u003c/span\u003e\u003cspan address=\"https://doi:10.1016/j.pec.2017.10.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHogan A, Hughes L, Coyne E (2024) Nurses' assessment of health literacy requirements for adult inpatients: An integrative review. Health Promot J Austr 35:504\u0026ndash;517. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi:10.1002/hpja.780\u003c/span\u003e\u003cspan address=\"https://doi:10.1002/hpja.780\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Degenerative Disc Herniation, Cartoon visuals nursing guidance, Anxiety, Self-care knowledge","lastPublishedDoi":"10.21203/rs.3.rs-7773921/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7773921/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e This study aimed to incorporate cartoon visuals into nursing instructions for degenerative disc herniation surgery and test whether cartoon visuals in preoperative nursing instructions can help improve the accuracy of knowledge memory, satisfaction, and anxiety during hospitalization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology \u0026nbsp;\u003c/strong\u003eThe experimental study was conducted from January to June 2024 and involved 84 patients undergoing surgery for degenerative disc herniation. Participants were randomly assigned by computer into two groups, and preoperative and postoperative tests were conducted to understand the patient's anxiety, self-care knowledge, and satisfaction: the \"traditional group\" received standard paper-based nursing instructions, while the \"experimental group\" received cartoon visual nursing instructions teaching.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u0026nbsp;\u003c/strong\u003eThe study results were statistically significant differences in self-care knowledge (P=0.02) and satisfaction (p\u0026lt;0.001) among the experimental and traditional groups. There were no statistical differences in situational and trait anxiety, but the experimental group scores decreased. Another finding was that there was a statistically significant difference (P=0.02) in the experimental group, where the number of days of hospital stay was lower than that in the traditional group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eThis study showed patients could improve their self-knowledge, reduce situational anxiety, increase satisfaction through cartoon visuals, and reduce the number of hospitalized days. Therefore, the engaging content of cartoon visuals can relieve patients' nervousness about surgery, increase their trust and cooperation, and further improve the effect of doctor-patient communication.\u003c/p\u003e","manuscriptTitle":"Evaluation of Cartoon Visuals versus Traditional Nursing Instruction for patients after Degenerative disc herniation surgery: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 02:19:41","doi":"10.21203/rs.3.rs-7773921/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-16T07:48:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-13T12:47:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"290655758894257580290301505875006930701","date":"2025-10-12T06:28:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80014524084291835087831967666069254771","date":"2025-10-10T13:36:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-08T16:33:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"189230654717160444558977157194229317944","date":"2025-10-08T15:09:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66054088313041694953283096903068907996","date":"2025-10-07T13:37:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12327041892040254555182396854308996489","date":"2025-10-06T17:02:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115599139641563780183955526086916590453","date":"2025-10-06T04:12:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272475882976014755085858001156951627168","date":"2025-10-05T19:56:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78908623699615602074975053977871129607","date":"2025-10-05T15:00:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317948867551029674785829519435817028134","date":"2025-10-05T13:46:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-05T13:32:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-04T10:33:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-04T10:31:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Spine Journal","date":"2025-10-03T13:32:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-spine-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"esjo","sideBox":"Learn more about [European Spine Journal](http://link.springer.com/journal/586)","snPcode":"586","submissionUrl":"https://submission.springernature.com/new-submission/586/3","title":"European Spine Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"a34c7c44-c4f6-4729-b76c-d0f8ff77d4e0","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T15:59:37+00:00","versionOfRecord":{"articleIdentity":"rs-7773921","link":"https://doi.org/10.1007/s00586-025-09608-z","journal":{"identity":"european-spine-journal","isVorOnly":false,"title":"European Spine Journal"},"publishedOn":"2026-01-05 15:56:55","publishedOnDateReadable":"January 5th, 2026"},"versionCreatedAt":"2025-10-17 02:19:41","video":"","vorDoi":"10.1007/s00586-025-09608-z","vorDoiUrl":"https://doi.org/10.1007/s00586-025-09608-z","workflowStages":[]},"version":"v1","identity":"rs-7773921","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7773921","identity":"rs-7773921","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}