Calm vaccination experiences: Strategies to help manage fear of pain and needles

• Some people who are fearful of vaccinations and needles will avoid being immunised.
• Support these individuals by providing them with opportunities to talk before booking an appointment.
• Various strategies can be used to help manage anxiety and fear, both before and during the vaccination.

The CARD System is a selfdirected tool, adapted for different age groups, to promote calm vaccination experiences

Anxiety and fear of vaccination pain and of needles is common throughout the world. It contributes to vaccine hesitancy, lowering immunisation coverage and increasing the risk of vaccine-preventable diseases. People want advice on what they can do, and they expect health providers to minimise injection pain and distress.

Mitigation of injection pain and anxiety

In 2010, Anna Taddio and colleagues published Canadian evidence-based clinical practice guidelines for reducing the pain of infant/childhood vaccination.¹ Based on these, WHO established globally feasible pain mitigation guidelines and recommended vaccinators were taught strategies to discuss with parents/caregivers and vaccine recipients. In 2016, these recommendations were adapted for the New Zealand context (see panel).

The Immunisation Advisory Centre (IMAC) has been teaching these strategies, focused largely on babies and children, for the past five years through its vaccinator courses. This is supported by an IMAC fact sheet, Mitigating vaccination pain and distress (tinyurl.com/IMACresources), and included in the Immunisation Handbook 2020 (health.govt.nz; see chapter 2).

In 2018, a 15-minute period of exercise using resistance bands was shown to reduce reported vaccination pain in female but not male students.² This may be more feasible in school-based vaccination programmes. Other research suggests exercise may also improve immune response and reduce vaccine side effects.

High levels of anxiety or fear of needles

Recently, further options were explored for those who have high levels of anxiety, are prone to fainting or have needle phobia. This group, including both adults and children, struggle when receiving vaccinations, such that many will avoid immunisation altogether.^3–5

As detailed in the new IMAC fact sheet Fear of needles or needle phobia, the strategies most likely to support vaccination for those fearful of needles are as follows:

Before vaccination – it is helpful for all staff in the practice to be aware of any patient who has a fear or phobia of needles by documenting this in the notes. Rather than getting an automated appointment, these people are better to be telephoned – first, to book an appointment early in the day; and second, to discuss their preferred strategies for managing their anxiety or fear. They can also be encouraged to bring a support person with them.

Muscle tension exercises – these reduce dizziness and fainting associated with needle fear and can be taught/practised in advance of the appointment. The “how to” of these are described in detail in the fact sheet.

Exposure-based interventions – these were published in further Canadian clinical practice guidelines and are used for those aged over seven years, including teens and adults with high levels of needle fear. Researchers identified a 10-step fear hierarchy related to needle fear, which can be used in this intervention.⁶

EBI involves either live or virtual session(s) (maybe via telemedicine) of cognitive behavioural therapy conducted by specially educated health professionals. This is not something to try exploring the day before the vaccination. The early EBI research for vaccination is very positive and further outcome studies are likely.

Tactile stimulation – stroking of the arm near the injection site may reduce distress for older children, teens and adults, but has not yet been proven effective, and it is not effective for babies or infants.^7,8

Images of vaccination – showing needles being inserted in arms is not helpful. It is suggested to avoid showing these and instead to use photos or videos of people who are relaxed after having their vaccination.

The CARD™ System

Recently, IMAC has established an agreement with Professor Taddio and team to adapt their CARD System for the New Zealand environment.^9,10 The system has recently been adopted by Canadian health services for their COVID-19 vaccination programme, with resources on preparing for vaccination available for adults and for caregivers of adults. Expect to hear more about this tool in the future. In the meantime, here is a summary.

The CARD System is a self-directed tool, adapted for different age groups, to promote calm vaccination experiences using four themes, or CARDs: Comfort, Ask questions, Relax, Distract. The system also provides a list of tips for vaccination day.

Comfort – this involves preparation by the vaccine recipient so they know what to expect and have some self-comfort strategies, such as eating before the appointment, wearing clothing that allows easy access to the upper arm, and suggestions to keep their arm relaxed.

Ask questions – if the vaccine recipient has any concerns, it is suggested they ask an informed, trusted person in advance. Answering such questions as, “What will happen?”, “What will it feel like?” and “Will I have privacy?” will make a difference.

Relax – what relaxation practices are they are familiar with that may be useful? Do they want someone with them? Many people will be familiar with deep abdominal breathing, but for those who are not, they can choose to follow straightforward instructions and practice this before their appointment.

Distract – some people choose to watch the injection, but many prefer to be distracted. The vaccine recipient can take something with them, play a game or watch a video on their phone, listen to music, or they may be content to talk to the vaccinator.

Conclusion

Experienced vaccinators are already skilled at providing calm vaccinations for all age groups. We now have many strategies to assist in this, which will be useful to increase immunisation coverage for the COVID-19 pandemic and beyond.

However, some strategies, such as the CARD System, require tools and recipient preparation in advance of vaccination. Exercise requires resistance bands and supervision by suitable leaders. Others, such as EBIs, require identifying those whose high level of anxiety or fear prevents them from choosing vaccination. Further research is expected to provide more robust evidence.

Patricia Wells-Morris is an education and e-learning coordinator at the Immunisation Advisory Centre