tag:theconversation.com,2011:/us/topics/needles-8149/articlesNeedles – The Conversation2022-06-27T03:47:10Ztag:theconversation.com,2011:article/1819392022-06-27T03:47:10Z2022-06-27T03:47:10ZPhysio ‘dry needling’ and acupuncture – what’s the difference and what does the evidence say?<figure><img src="https://images.theconversation.com/files/468636/original/file-20220614-22-2dsj01.jpg?ixlib=rb-1.1.0&rect=17%2C250%2C5725%2C3569&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/woman-relaxes-acupuncture-procedure-acupuncturist-600w-1635120196.jpg">Shutterstock</a></span></figcaption></figure><p>Physiotherapists are increasingly offering needling therapies in addition to their standard care. Many Australian <a href="https://australian.physio/research/prf/translation/five-facts-about-acupuncture-and-dry-needling-musculoskeletal-pain">physiotherapists</a> in private practice now offer dry needling or Western medical acupuncture as part of a treatment approach.</p>
<p>Is it just a fad or does science support it?</p>
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Read more:
<a href="https://theconversation.com/health-check-why-do-my-muscles-ache-the-day-after-exercise-41820">Health Check: why do my muscles ache the day after exercise?</a>
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<h2>Needling, three ways</h2>
<p>Physiotherapists can be trained to use dry needling, Western acupuncture and/or traditional acupuncture. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/23801002/">Dry needling</a> involves penetrating the skin with needles to altered or dysfunctional tissue in order to improve or restore function. This often involves needling muscle trigger points to activate a reflexive relaxation of the muscle. </p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/28739020/">Western acupuncture</a> uses traditional needling <a href="https://www.sciencedirect.com/science/article/pii/S2005290110600143">meridians</a> (the ancient idea of energy channels through the body) and trigger points. But these ideas are applied to Western understandings of anatomy. In Western acupuncture, points are stimulated to create local tissue changes, as well as spinal and brain effects. The goals is to trigger pain-relieving chemicals, muscle activation or relaxation.</p>
<p>Even though traditional acupuncture points are used with this style of needling, Western acupuncture is not viewed as traditional Chinese medicine. </p>
<p><a href="https://healthtimes.com.au/hub/pain-management/44/research/kk1/acupuncture-for-pain-management/1581/">Traditional acupuncture</a> uses meridian lines or other points based on traditional Chinese medicine assessment methods and approaches. </p>
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<a href="https://images.theconversation.com/files/465898/original/file-20220530-26-1cisb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="chinese medicine chart with lines through body" src="https://images.theconversation.com/files/465898/original/file-20220530-26-1cisb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/465898/original/file-20220530-26-1cisb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=387&fit=crop&dpr=1 600w, https://images.theconversation.com/files/465898/original/file-20220530-26-1cisb.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=387&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/465898/original/file-20220530-26-1cisb.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=387&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/465898/original/file-20220530-26-1cisb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/465898/original/file-20220530-26-1cisb.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/465898/original/file-20220530-26-1cisb.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A traditional Chinese medicine acupuncture chart from the 1800s.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/xk6jb43t">Wellcome Collection</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>All physiotherapists trained in either acupuncture or dry needling meet safety standards which are viewed as within scope by the <a href="https://www.ahpra.gov.au/">Australian Health Practitioners Regulatory Agency</a> and the <a href="https://www.physiotherapyboard.gov.au/">Physiotherapy Registration Board</a>. These standards cover the level of training required, registration to practice and safety standards that include needle safety and hygiene to protect the public. </p>
<p>Minor reported <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7015026/#:%7E:text=Examples%20of%20minor%20adverse%20reactions,pain%20during%20or%20after%20treatment.">side effects</a> related to acupuncture including pain and bleeding or bruising from needle insertion are fairly common. But major adverse events – pneumothorax (collapsed lung), excessive bleeding, prolonged aggravation – are rare. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/this-ancient-chinese-anatomical-atlas-changes-what-we-know-about-acupuncture-and-medical-history-140506">This ancient Chinese anatomical atlas changes what we know about acupuncture and medical history</a>
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<h2>What’s needling good for?</h2>
<p>Research into the effectiveness of acupuncture and dry needling is variable. Some studies show comparable results between dry needling and acupuncture, while others show more favourable results for one or the other depending on the condition being treated. </p>
<p>A <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001351.pub2/full?highlightAbstract=dry%7Cdri%7Cneedl%7Cneedling">review</a> that assessed the effects of acupuncture and dry needling for the treatment of low-back pain found they may be useful add-on therapies but could not make firm conclusions due to a lack of quality trials. </p>
<p>Another <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6600071/#CIT0034">review</a> reported the growing popularity of dry needling world wide and across disciplines and points out that many questions still remain regarding the use of needling. </p>
<p>For <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001218.pub3/full?highlightAbstract=acupuncture%7Cmigraine%7Cmigrain%7Cacupunctur">migraine</a> and <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007587.pub2/full?highlightAbstract=acupuncture%7Cheadach%7Ctension%7Cacupunctur%7Cheadache%7Ctype">tension</a> headaches, experts say acupuncture seems to reduce the frequency and intensity of attacks – though more research is needed to compare it to other treatments.</p>
<p>Acupuncture and dry needling may reduce pain and improve function for people with <a href="https://pubmed.ncbi.nlm.nih.gov/17224820/">neck pain</a>. A systematic review found significant differences between acupuncture and “sham acupuncture” (which is performed away from acupuncture points) when used to treat <a href="https://pubmed.ncbi.nlm.nih.gov/22965186/">certain types of chronic pain</a>. However, some research only shows <a href="https://pubmed.ncbi.nlm.nih.gov/33066556/">small and temporary</a> relief for neck pain with dry needling.</p>
<p>Results from randomised control trials support the use of needling for <a href="https://pubmed.ncbi.nlm.nih.gov/27062955">shoulder pain</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/32301166/">tennis elbow</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/32186030/">osteo arthritic knee pain</a>. But a recent systemic review of research reported only weak evidence to support needling to treat <a href="https://pubmed.ncbi.nlm.nih.gov/33760098/">plantarfasciitis and chronic ankle instability</a>. </p>
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<a href="https://images.theconversation.com/files/465896/original/file-20220530-18-ws2b72.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="man lies on treatment bed while physio inserts needles into his back" src="https://images.theconversation.com/files/465896/original/file-20220530-18-ws2b72.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/465896/original/file-20220530-18-ws2b72.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/465896/original/file-20220530-18-ws2b72.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/465896/original/file-20220530-18-ws2b72.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/465896/original/file-20220530-18-ws2b72.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/465896/original/file-20220530-18-ws2b72.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/465896/original/file-20220530-18-ws2b72.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">An increasing number of physiotherapists offer dry needling or acupuncture treatment.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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<h2>Not just for sporting injuries</h2>
<p>Similarly, small randomised control trials have shown acupuncture and dry needling might reduce <a href="https://pubmed.ncbi.nlm.nih.gov/17095133/">problematic jaw pain</a> (<a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/temporomandibular-disorder-tmd#:%7E:text=Temporomandibular%20disorders%20(TMD)%20are%20disorders,may%20result%20in%20temporomandibular%20disorder.">temporo mandibular disorder</a>) and improve mouth opening.</p>
<p>Systematic reviews have reported needling and acupuncture were safe and effective recommendations for the treatment of broad conditions of <a href="https://www.healthline.com/health/tendinopathy">tendinopathy</a> (the breakdown of collagen in tendons) and <a href="https://pubmed.ncbi.nlm.nih.gov/30787631/#:%7E:text=At%20follow%2Dup%20in%20the,for%20the%20management%20of%20FM.">fibromyalgia</a> (chronic pain in the muscles and bones).</p>
<p>For women’s health, acupuncture has been shown to be effective for reducing pain with <a href="https://pubmed.ncbi.nlm.nih.gov/29879061/">periods</a>, compared to no treatment or non-steroidal pain relief medications – but the research had design limitations.</p>
<p>Though <a href="https://www.cochrane.org/CD002962/PREG_acupuncture-or-acupressure-induction-labour#:%7E:text=Acupuncture%20involves%20the%20insertion%20of,with%20onset%20of%20labour%20contractions.">widely used</a> in pregnancy, research into the use of acupuncture to <a href="https://pubmed.ncbi.nlm.nih.gov/32032444/">induce labour</a> reports it may increase satisfaction with pain management and reduce pain intensity. But it may have little to no effect on the rates of caesarean or assisted vaginal birth.</p>
<p>In summary, it appears needling techniques – whether dry needling or acupuncture – generally show positive effects over no treatment or “sham” treatments, but more research and high quality trials are needed. </p>
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<h2>Just one part of a treatment program</h2>
<p>Needling <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001351.pub2/full?highlightAbstract=dry%7Cdri%7Cneedl%7Cneedlin">may be useful</a> as part of multimodal care – that is, when <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4780149/">more than one treatment</a> is used in conjunction to treat a problem. </p>
<p>Physiotherapists may combine needling therapies with exercise prescription, hands-on care including massage, mobilisations and manipulations, and taping techniques. They may also employ therapies that apply external energy such as ultrasound, laser, transcutaneous (under the skin) electrical nerve stimulation and biofeedback.</p>
<p>Finally, while the various needling techniques all use a filiform needle (with a solid filament as opposed to a hollow bore needle), the styles with each can be quite different. Ask what style of needling is being employed to treat you, and if you have a history of finding one style works better for you, discuss this with your practitioner.</p><img src="https://counter.theconversation.com/content/181939/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Dry needling and Western acupuncture don’t incorporate traditional chinese medicine philosophies – but may be helpful for pain and releasing muscle tension.Wayne Hing, Professor, Physiotherapy, Bond UniversityLeigh McCutcheon, Lecturer, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1770252022-03-29T12:35:49Z2022-03-29T12:35:49ZKids afraid of getting shots? Here are 3 easy ways for parents to help them<figure><img src="https://images.theconversation.com/files/451390/original/file-20220310-27-z9ze7b.jpg?ixlib=rb-1.1.0&rect=17%2C0%2C5734%2C3794&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Children are not little adults – they need time to process what is going to happen.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/close-up-of-a-young-african-american-little-girl-royalty-free-image/1300111984">Ivan Pantic/E+ via Getty Images</a></span></figcaption></figure><p>Few things are more challenging than trying to vaccinate a terrified and uncooperative child. I have seen children wedge themselves into a corner and refuse to budge. I have seen them thrash and yell. And I have seen them sit perfectly still, but cry the entire time. </p>
<p>I’m an <a href="https://msm.edu/about_us/FacultyDirectory/Pediatrics/LynnGardner/index.php">associate professor of pediatrics</a> and have been a primary care pediatrician for more than 25 years. I’ve encountered these situations thousands of times in my career.</p>
<p>While getting shots provokes anxiety in most children, the degree of anxiety can be lessened. As a parent, there are three things you can do to improve the vaccine experience for your child. I refer to them as “The Three P’s.” </p>
<h2>Preparation</h2>
<p>It’s important to let your child know they will be receiving vaccines, unless you know your child will have a severe anxious response. You may think it’s best to keep upcoming shots hidden until your child gets to the doctor’s office, but this approach can make them more anxious and less able to cope. Children need some time to process what is going to happen. Let them know on the day of the visit, but with enough time to discuss it with them beforehand.</p>
<p>It is essential that you ask your child how they are feeling about receiving a shot. Giving them the <a href="https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/Managing-Your-Childs-Pain-While-Getting-a-Shot.aspx">opportunity to express their feelings can decrease the amount of stress and anxiety </a> they feel about it. Validate their feelings by telling them you know needles can be a bit scary, but then reassure them that they can handle it. Explain why they’re receiving vaccines and emphasize it is for their overall good.</p>
<p>You should also describe specifically what will happen. For example, tell your child the nurse will clean their arm with an alcohol pad, count to three and then give the injection. It often helps if you have a plan for after the vaccines as well. For example, let your child know they will get to visit a grandparent or go to the park. Try not to reward them with food, as this can <a href="https://www.sciencedaily.com/releases/2016/04/160412090707.htm">inadvertently teach them to emotionally eat</a>. </p>
<p>Giving your child basic information along with the opportunity to express their feelings will save them from having to process what’s happening all at once. This often <a href="http://csefel.vanderbilt.edu/documents/teaching_emotions.pdf">helps children better cope</a> with the process. </p>
<h2>Proximity</h2>
<p>When your child is preparing for the vaccine to be administered, stay physically close to them. Speak to your child in a calm voice and remind them of the things you discussed at home. Let your child hug you with the opposite arm while getting their shot. This is often all it takes to get them through it. </p>
<p>Such support teaches children you will be there for them when they need you, which <a href="https://www.healthychildren.org/English/health-issues/conditions/emotional-problems/Pages/Understanding-Childhood-Fears-and-Anxieties.aspx">builds security</a>. This security, in turn, gives them confidence to try things they may otherwise avoid. </p>
<h2>Praise</h2>
<p>After your child receives their injection, give them a moment to gather themselves – 30 seconds or so. Then tell them how well they did and that you’re proud of them. Point out that they did something they either didn’t want to do or didn’t think they could do. </p>
<p>This teaches children they can do things even when they are afraid or anxious. You can remind children of this experience when they need to get shots again – or if they are afraid or worried about something else, like public speaking or a school project. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/451426/original/file-20220310-23-1rdmhf3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A girl with bandaid on her bicep at the doctor's office. A smiley face is drawn on the bandaid." src="https://images.theconversation.com/files/451426/original/file-20220310-23-1rdmhf3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/451426/original/file-20220310-23-1rdmhf3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451426/original/file-20220310-23-1rdmhf3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451426/original/file-20220310-23-1rdmhf3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451426/original/file-20220310-23-1rdmhf3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451426/original/file-20220310-23-1rdmhf3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451426/original/file-20220310-23-1rdmhf3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Building confidence by doing hard things.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/portrait-of-smiling-little-child-with-adhesive-royalty-free-image/1316865387">portishead1/E+ via Getty Images</a></span>
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<p>Children are not little adults. They don’t always have the capacity to know what they are feeling or to express themselves when needed. It’s up to you to give them the opportunity and space to identify their feelings – and then help validate those feelings. </p>
<p>Preparing your child for vaccines, staying in close proximity to them during the process and praising them for a job well done will help them navigate this often challenging process with more confidence, courage and assurance.</p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://memberservices.theconversation.com/newsletters/?nl=weekly&source=inline-weeklybest">Sign up for our weekly newsletter</a>.]</p><img src="https://counter.theconversation.com/content/177025/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lynn Gardner does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A pediatrician recommends helping your child cope with getting vaccines by employing “The Three P’s” – Preparation, Proximity and Praise.Lynn Gardner, Associate Professor of Pediatrics and Director of Pediatric Residency Program, Morehouse School of MedicineLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1709232021-12-02T23:13:42Z2021-12-02T23:13:42ZIf your child is afraid of — or refusing — a medical procedure, here’s how to help<figure><img src="https://images.theconversation.com/files/435430/original/file-20211202-19-1uxirr1.jpg?ixlib=rb-1.1.0&rect=871%2C116%2C5119%2C3736&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Discussing and practising all the steps of a medical procedure with children can help them overcome fear.</span> <span class="attribution"><span class="source">(AP Photo/Jae C. Hong)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/if-your-child-is-afraid-of-—-or-refusing-—-a-medical-procedure--here-s-how-to-help" width="100%" height="400"></iframe>
<p>The coronavirus pandemic has brought medical procedures, like COVID-19 testing and COVID-19 vaccinations, into our day-to-day lives like never before. These experiences <a href="https://theconversation.com/needle-fears-can-cause-covid-19-vaccine-hesitancy-but-these-strategies-can-manage-pain-and-fear-165009">aren’t easy for everyone</a>, especially for children. </p>
<p>But even outside a pandemic, medical procedures such as vaccinations and blood draws are common throughout childhood. When asked, children reliably say that their biggest concerns about medical procedures are needles and pain. They are also worried that their comfort won’t be taken into account. And <a href="https://doi.org/10.1155/2014/614784">evidence says they’re right</a>.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/435439/original/file-20211202-15-f80ska.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A vial of vaccine and a sheet of round stickers reading 'I got my COVID-19 vaccine' in pink text" src="https://images.theconversation.com/files/435439/original/file-20211202-15-f80ska.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/435439/original/file-20211202-15-f80ska.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=371&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435439/original/file-20211202-15-f80ska.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=371&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435439/original/file-20211202-15-f80ska.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=371&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435439/original/file-20211202-15-f80ska.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=466&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435439/original/file-20211202-15-f80ska.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=466&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435439/original/file-20211202-15-f80ska.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=466&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Children’s negative experiences with things like injections, blood draws and medical tests can not only make them fear these procedures, but can have long-term effects, including avoidance of medical procedures as an adult.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Steve Russell</span></span>
</figcaption>
</figure>
<p>Research is also clear that when children’s pain and fear aren’t well managed during medical procedures, there are both <a href="https://doi.org/10.1097/ajp.0000000000000272">short- and long-term consequences</a>. Procedures can take longer and have an increased risk of adverse events (such as fainting or being physically restrained), and children are likely to need more medications for pain and to develop negative or traumatic memories. </p>
<p>These fears can lead to delays or avoidance of necessary health care, even when children become adults. </p>
<figure class="align-center ">
<img alt="A young girl in a chair wearing a face mask is injected in the arm by a health-care professional in a white coat and face mask." src="https://images.theconversation.com/files/435433/original/file-20211202-13-qwrdv3.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435433/original/file-20211202-13-qwrdv3.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=476&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435433/original/file-20211202-13-qwrdv3.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=476&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435433/original/file-20211202-13-qwrdv3.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=476&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435433/original/file-20211202-13-qwrdv3.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=599&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435433/original/file-20211202-13-qwrdv3.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=599&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435433/original/file-20211202-13-qwrdv3.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=599&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Traumatic stress from medical procedures is in the eye of the beholder: a child’s own experience of the procedure, and fear response to it, are more important than the ‘objective’ severity of the experience.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Ryan Remiorz</span></span>
</figcaption>
</figure>
<p>We have prepared <a href="https://theconversation.com/6-tips-to-prepare-your-child-for-easy-covid-19-testing-147415">tips to make COVID testing</a> and <a href="https://theconversation.com/fear-of-needles-5-simple-ways-to-ease-vaccination-pain-for-your-child-and-yourself-134328">needles comfortable</a>, and those recommendations are really important. But here’s the thing: what helps for pain and low-to-moderate fear isn’t enough when children are very afraid. </p>
<p>If children’s pain and fear aren’t well managed every time, medical procedures can get harder and harder until children begin to refuse. Sometimes people interpret a child’s refusal as misbehaviour. Nothing could be further from the truth. </p>
<p>With repeated negative experiences, a child’s distress and fear can become so high that it can produce a true adrenaline fight-or-flight response, similar to if they were face-to-face with a lion. Traumatic stress from medical procedures is in the eye of the beholder: a child’s own experience of the procedure, and fear response to it, are <a href="https://www.nctsn.org/what-is-child-trauma/trauma-types/medical-trauma/effects">more important than the “objective” severity</a> or how painful or scary it may seem to others. </p>
<h2>Coping with fear and distress</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/435434/original/file-20211202-25-mt7stw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A girl in a chair wearing a face mask and a blue hair ribbon holds her father's hand while getting an injection in her arm." src="https://images.theconversation.com/files/435434/original/file-20211202-25-mt7stw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435434/original/file-20211202-25-mt7stw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435434/original/file-20211202-25-mt7stw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435434/original/file-20211202-25-mt7stw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435434/original/file-20211202-25-mt7stw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435434/original/file-20211202-25-mt7stw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435434/original/file-20211202-25-mt7stw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Encouragement from a parent, and taking some deep breaths, can help children manage procedures.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/John Woods</span></span>
</figcaption>
</figure>
<p>We have heard from parents that they want to know more about what to do when their child is refusing a procedure because of high levels of fear, often resulting from a previous negative or traumatic experience. Sometimes when children become highly distressed, <a href="https://doi.org/10.1177%2F1367493518785777">adults will restrain them</a> in an effort to “just get the procedure over with.” </p>
<p>We want to be clear: Holding a highly distressed child down for a routine medical procedure is never OK, isn’t patient-centred care and has the potential to make things exponentially worse in the long term. </p>
<p>A child’s fear must be taken seriously and addressed before they can benefit from efforts to <a href="https://theconversation.com/fear-of-needles-5-simple-ways-to-ease-vaccination-pain-for-your-child-and-yourself-134328">manage pain</a> and <a href="https://theconversation.com/6-tips-to-prepare-your-child-for-easy-covid-19-testing-147415">low-to-moderate fear</a>. If your child is very afraid of a medical procedure (for example, COVID testing, vaccinations, blood draws, dental treatment), the following science-backed steps are needed. </p>
<h2>Exposure-based therapy</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/435443/original/file-20211202-21316-xmv4ko.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A boy in a red t-shirt with 'I got my vaccine' stickers on it holds up a lollipop" src="https://images.theconversation.com/files/435443/original/file-20211202-21316-xmv4ko.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/435443/original/file-20211202-21316-xmv4ko.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=708&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435443/original/file-20211202-21316-xmv4ko.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=708&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435443/original/file-20211202-21316-xmv4ko.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=708&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435443/original/file-20211202-21316-xmv4ko.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=890&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435443/original/file-20211202-21316-xmv4ko.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=890&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435443/original/file-20211202-21316-xmv4ko.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=890&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">It’s best to make sure your child is ready to make it as positive an experience as possible.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Steve Russell</span></span>
</figcaption>
</figure>
<p>In <a href="https://doi.org/10.1016/j.cpr.2006.10.002">exposure-based therapy</a>, someone gradually faces their fear head on, starting with easier situations and working their way up to more difficult ones. In this case, it involves educating your child about what is going to happen and why, and enabling them to practise gradually facing each step of the medical procedure before the actual procedure itself.</p>
<p><strong>Make space for their feelings and have a conversation.</strong> </p>
<ul>
<li>Validate your child’s concern: acknowledge their feelings and why they make sense (even if you don’t agree or can’t relate).</li>
</ul>
<p><strong>Figure out what is worrying them about the situation.</strong> </p>
<ul>
<li><p>Take an open, non-judgmental and curious approach to understand what scares them about the medical procedure. </p></li>
<li><p>Don’t assume. Ask. Make sure your child <a href="https://doi.org/10.1111/cch.12692">understands what they are being asked to do as part of the medical procedure</a>, why they are being asked to do it, what will happen, what it will feel like, how long it will last and who will be there. Answer any questions that they have and correct any misperceptions. You might need to get some information from a health-care professional so that you have all the answers. </p></li>
<li><p>What is <a href="https://www.anxietycanada.com/wp-content/uploads/2021/08/Evergreen-8-Parenting-Strategies-to-Help-Aug-10-1.pdf">the focus of their fear</a>? Older children and youth can often tell you what they are worried about regarding the procedure. For younger children, you may have to offer suggestions or alternatives and make your best guess. </p></li>
</ul>
<h2>Practise facing the fear</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/435436/original/file-20211202-20750-1yib2jf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man and a little girl in a pink jacket entering a vaccine clinic" src="https://images.theconversation.com/files/435436/original/file-20211202-20750-1yib2jf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435436/original/file-20211202-20750-1yib2jf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435436/original/file-20211202-20750-1yib2jf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435436/original/file-20211202-20750-1yib2jf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435436/original/file-20211202-20750-1yib2jf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435436/original/file-20211202-20750-1yib2jf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435436/original/file-20211202-20750-1yib2jf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">When fear is out of proportion to the danger posed by the procedures, creating a ‘fear ladder’ can help children work through the procedure step by step..</span>
<span class="attribution"><span class="source">(AP Photo/Nam Y. Huh)</span></span>
</figcaption>
</figure>
<p>For fears that are out of proportion to the danger posed, children will need to practise <a href="https://www.anxietycanada.com/general/facing-fears/?_ga=2.97440159.107247054.1637858056-1357261649.1637858056">facing their fear head on</a>. You need to generate a list of fear-inducing situations related to the procedure, such as: </p>
<ul>
<li><p>talking about the procedure;</p></li>
<li><p>seeing pictures or videos of it (tip: make sure these are positive videos where minimal or no distress is shown);</p></li>
<li><p>playing with related toys/equipment;</p></li>
<li><p>driving past the health centre or site where the procedure will take place; and </p></li>
<li><p>the micro-steps leading up to the procedure itself (such as sitting in a chair, having a tourniquet applied or their arm cleaned with an alcohol swab, etc.). </p></li>
</ul>
<p>Order the situations from easiest to hardest by getting a fear rating for each one. This becomes their “fear ladder.” </p>
<figure class="align-center ">
<img alt="A little boy in a face mask holds up his French-language brave child diploma after getting vaccinated" src="https://images.theconversation.com/files/435438/original/file-20211202-23-syqr0v.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435438/original/file-20211202-23-syqr0v.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=413&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435438/original/file-20211202-23-syqr0v.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=413&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435438/original/file-20211202-23-syqr0v.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=413&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435438/original/file-20211202-23-syqr0v.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=519&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435438/original/file-20211202-23-syqr0v.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=519&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435438/original/file-20211202-23-syqr0v.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=519&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Science-backed principles can help children and their parents feel confident about medical procedures.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Paul Chiasson</span></span>
</figcaption>
</figure>
<p>Tip: for children ages five to seven, you can use the <a href="https://pphc.uoguelph.ca/childrens-fear-scale">Children’s Fear Scale</a>; for seven-year-olds and older, a zero-to-10 scale ranging from no fear at all to most fear possible; for younger children, you could order the situations by asking them to make choices in head to head comparisons in which the child picks which one is easier out of two, or if all else fails, your best guess.</p>
<p>Help your child practise facing their fear by experiencing these situations. They have to stay in the situation long enough so that their fear will come down, and/or that they learn whatever they’re worried about isn’t going to happen or if it does, they can survive it. Remember, this is for fears that are worse than the actual danger of the situation. </p>
<p>This is hard work! So, for each exposure or practice, your child should earn a reward. You can set up a reward program to go with each step of the fear ladder. Rewards should be small, something you are OK to withhold if they don’t earn them, and don’t have to cost money (for example, playing a special board game or giving a five-minute massage, rather than a new toy). </p>
<h2>Trouble-shooting</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/435441/original/file-20211202-21-9nb1au.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A Black girl wearing a face mask and a black hair ribbon holds her sleeve up to show the bandage over her vaccination site" src="https://images.theconversation.com/files/435441/original/file-20211202-21-9nb1au.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435441/original/file-20211202-21-9nb1au.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435441/original/file-20211202-21-9nb1au.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435441/original/file-20211202-21-9nb1au.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435441/original/file-20211202-21-9nb1au.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435441/original/file-20211202-21-9nb1au.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435441/original/file-20211202-21-9nb1au.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Children ages seven and up can build their fear ladder using a zero-to-10 scale ranging from no fear at all to most fear possible.</span>
<span class="attribution"><span class="source">(AP Photo/Laura Ungar)</span></span>
</figcaption>
</figure>
<p>Your child has to stay in the situation long enough. If they escape the situation before their fears have subsided to a manageable level, it will just maintain their fear. Taking some deep breaths and encouragement from you can help! </p>
<p>If a step is way more difficult than the previous one (too big a gap in the ladder), try to break down the situation by varying factors like who is there as a support, or start with imagining it first before trying that step in real life. Each step might have to be practised multiple times before the fear reduces. </p>
<p>Don’t rush through — there are no points for speed! It’s best to make sure your child is ready to make it as positive an experience as possible, and to make things easier in the future. Once your child has made it to the top of their ladder, the next step is the procedure itself. </p>
<p>Don’t forget that <a href="https://kidsinpain.ca/wp-content/uploads/2021/11/Vaccine-Pain-Needle-Fear-Resources-v2-November-2021.pdf">strategies to manage pain from medical procedures</a> are also important! For more help, <a href="https://maps.anxietycanada.com/en/courses/child-map/">Anxiety Canada</a> has fantastic resources. </p>
<p>The science-backed principles outlined in this article can help children and their parents to feel confident about medical procedures. As parents and clinicians, we have an opportunity to practise too: preparing and empowering children to take an active role in their health, confident that they are the focus of patient-centred care. </p>
<p><em>This story is part of a series produced by SKIP (Solutions for Kids in Pain), a national knowledge mobilization network whose mission is to improve children’s pain management by mobilizing evidence-based solutions through co-ordination and collaboration.</em></p><img src="https://counter.theconversation.com/content/170923/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Meghan McMurtry has received funding from the Canadian Institutes of Health Research and the Public Health Agency of Canada for research related to needle pain and fear as well as laboratory infrastructure support from the Canadian Foundation for Innovation and the Ministry of Research and Innovation. </span></em></p><p class="fine-print"><em><span>Kathryn Birnie is Associate Scientific Director of Solutions for Kids in Pain (SKIP). </span></em></p>Children who avoid or refuse medical procedures like COVID-19 tests or vaccinations aren’t misbehaving — they need help to manage their fears. Here’s a step-by-step guide to help your child cope.Meghan McMurtry, Associate Professor in Psychology, University of GuelphKathryn Birnie, Assistant Professor and Psychologist in Pediatric Pain, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1616362021-06-11T12:41:33Z2021-06-11T12:41:33ZOver half of adults unvaccinated for COVID-19 fear needles – here’s what’s proven to help<figure><img src="https://images.theconversation.com/files/402979/original/file-20210526-17-1f6ei8o.jpeg?ixlib=rb-1.1.0&rect=0%2C0%2C7951%2C5304&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Though many adults report a fear of needles, most research on needle fear has focused on children.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/portrait-of-a-happy-woman-in-a-car-with-a-get-royalty-free-image/1303039108?adppopup=true">FG Trade/E+ via Getty Images</a></span></figcaption></figure><p>If you’re among the 25% of Americans averse to needles, you’re probably not surprised by the COVID-19 immunization stall. Even for those who want immunity, bribes with beer or lottery tickets may not be enough to override anxiety made worse by <a href="https://doi.org/10.1016/j.vaccine.2015.08.064">pervasive images of needles in the media</a>. </p>
<p>As a <a href="https://www.practicalpainmanagement.com/author/29618/baxter">physician specializing in pain management</a>, I study the impact of pain on vaccination. Research-proven adult interventions for pain, fainting, panic and fear can make vaccination more tolerable. At a minimum, understanding the reasons needle fear has become common might make the embarrassment easier to bear.</p>
<h2>Why needle anxiety has increased</h2>
<p>Needle fear has increased dramatically since a landmark 1995 study by J.G. Hamilton reported that <a href="https://pubmed.ncbi.nlm.nih.gov/7636457/">10% of adults and 25% of children</a> feared needles. In that paper, adult patients who remembered when their fear began described a stressful needle experience around age 5. </p>
<p>The childhood experiences of the patients usually related to an unexpected illness; at the time the Hamilton participants were in preschool, vaccines were scheduled only until age 2. For most people born after 1980, however, <a href="https://www.immunize.org/timeline/">booster injections</a> given between ages 4 to 6 years became a routine part of the vaccine experience. The timing of boosters maximizes and prolongs immunity, but unfortunately falls <a href="http://ppl.childpain.org/issues/v10n2_2008/v10n2_yap.pdf">within the age window</a> when phobias form. A 2012 Canadian study of 1,024 children found that <a href="https://doi.org/10.1016/j.vaccine.2012.05.011">63% of those born in 2000 or later</a> now fear needles. In a 2017 study, my colleagues and I confirmed this increase in prevalence: <a href="https://doi.org/10.1016/j.vaccine.2017.06.029">Half of preschoolers</a> who got all their boosters on one day – often four or five injections at once – were still severely afraid of needles as preteens. </p>
<p>[<em>The Conversation’s science, health and technology editors pick their favorite stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-favorite">Weekly on Wednesdays</a>.]</p>
<p>Unsurprisingly, needle fear affects how willing teens and adults are to get vaccinated. A 2016 study found needle fear to be the most common reason teens didn’t get a <a href="https://doi.org/10.1177/003335491613100304">second HPV vaccine</a>. Health care workers are no exception: A 2018 study found that <a href="https://doi.org/10.1111/jan.13818">27% of hospital employees</a> dodged flu vaccines due to needle fear. And most recently, an April 2021 national survey of 600 not-yet-COVID-19-vaccinated U.S. adults found that <a href="https://www.pollfish.com/dashboard/results/256471406/1978802675">52% reported moderate to severe needle fear</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Nurse applying band-aid to a person's arm." src="https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The shame accompanying needle fear can make it difficult to research among adults.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/90ejoVTj2-M">CDC/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Potential solutions for adults</h2>
<p>For children, evidence shows that addressing their <a href="https://doi.org/10.1016/j.pcl.2013.06.012">fear and pain while distracting them</a> from the procedure is most effective in reducing distress.</p>
<p>While adults are not just big children, combining these concepts with findings from available adult injection studies suggest a few potential interventions. For the many who want a vaccine but need some support, here’s what we know: </p>
<h2>1. Pain reduction</h2>
<p>Relieving injection pain may reduce needle fear by giving patients a feeling of control. For example, a group of patients in New Zealand were repeatedly missing their monthly antibiotic injections for rheumatic heart disease. Their doctors created a special clinic, offering either anesthetics, a vibrating cold device or both during the shot. The interventions in 107 adults <a href="https://doi.org/10.1111/jpc.12400">reduced pain and fear by 50%</a> after three months. Six months later, half the patients still used the interventions, and the special “missed dose” clinic was no longer needed.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Venn diagram showing the intersection of pain, fear, and focus is distress" src="https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=549&fit=crop&dpr=1 600w, https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=549&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=549&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=690&fit=crop&dpr=1 754w, https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=690&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=690&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Interventions targeting the pain, fear and focus components of distress can help reduce needle fear.</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1016/j.pcl.2013.06.012">Amy Baxter</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Specifically for vaccination, <a href="https://doi.org/10.1016/j.pmn.2018.07.001">applying a vibrating cold device</a> to the injection site a minute prior to injection, then pressing just above the site during injection, relieved pain and improved satisfaction for adults, and was <a href="https://doi.org/10.1097/PEC.0b013e318237ace4">most effective for those with needle fear</a>. A <a href="https://doi.org/10.1097/hnp.0000000000000105">horseshoe-shaped plastic device</a> using sharp prongs to confuse the nerves also reduced injection pain but increased anxiety, possibly due to discomfort from the prongs themselves.</p>
<p>Cold spray doesn’t help reduce <a href="https://doi.org/10.1097/ajp.0b013e3181a00414">vaccination pain for children</a>, but has been shown to be more effective than topical anesthetics for <a href="https://doi.org/10.2310/7060.2004.19101">adult injections</a>.</p>
<h2>2. Psychological therapy</h2>
<p><a href="https://www.apa.org/ptsd-guideline/patients-and-families/exposure-therapy">Exposure-based therapy</a> involves asking a patient to rank anxiety caused by parts of a procedure, like seeing a picture of a tourniquet or thinking about sharp things, and gradually exposing them to these parts in a controlled environment. Free <a href="https://martinantony.com/wp-content/uploads/Overcoming-Medical-Phobias1.pdf">self-guided resources</a> are available for fears ranging from flying to spiders. However, <a href="https://doi.org/10.1097/AJP.0000000000000273">none of the three studies</a> testing this approach on adult needle fear showed long-term fear reduction. </p>
<p>One of the studies that taught techniques to reduce fainting, however, was considered a success. Fainting, or <a href="https://www.ncbi.nlm.nih.gov/books/NBK470277/">vasovagal syncope</a>, and needle fear are often conflated. While passing out due to injections is more common with anxiety, it is often <a href="https://doi.org/10.3389/fcvm.2019.00175">a genetic response</a>. Tensing the <a href="https://doi.org/10.1002/da.22616">stomach muscles</a> increases the volume of blood the heart can pump, keeping blood in the brain to prevent lightheadedness during needle procedures.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Health care worker pointing at arm after getting vaccinated." src="https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Planning ahead can help make vaccine day more approachable.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/portrait-of-happy-frontline-helathcare-worker-royalty-free-image/1304460904?adppopup=true">recep-bg/E+ via Getty Images</a></span>
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<h2>3. Distraction</h2>
<p>Surprisingly, there are <a href="https://doi.org/10.1097/AJP.0000000000000270">no studies on adults</a> using distraction for injections. Two studies, however, have found that <a href="https://doi.org/10.1155/2019/9459103">pretending to cough</a> reduces pain from blood draws. </p>
<p>Dropping F-bombs could also help: A recent study found that <a href="https://doi.org/10.3389/fpsyg.2020.00723">swearing reduced pain by one-third</a> compared to saying nonsense words. Distraction with virtual reality games or videos has been shown to be more effective in children, although there have been <a href="https://doi.org/10.2196/17980">mixed results in adults</a>.</p>
<p>Mentally engaging tasks may also help. <a href="https://doi.org/10.1111/wvn.12359">A visual finding task</a> given to children during intramuscular shots has been shown to reduce pain and fear, with 97% rating the experience more pleasant than previous blood draws. Adults may need a more complicated task, but a similar intervention could work for them as well.</p>
<h2>Use multiple interventions and go in with a plan</h2>
<p>To reduce needle fear, research suggests the more interventions, the better. A 2018 study summarizing research on vaccine pain concluded that patient-operated <a href="https://doi.org/10.1080/21645515.2018.1480238">cold and vibration devices combined with distraction techniques</a> were most effective. Canada has implemented a practical <a href="https://immunize.ca/sites/default/files/Resource%20and%20Product%20Uploads%20(PDFs)/COVID-19/preparing-for-your-covid-19-vaccine-a-guide-for-adults_web_e.pdf">national needle fear intervention</a> for their vaccine rollout, emphasizing preparing ahead to help make vaccine day more comfortable. </p>
<p>Adults who don’t like needles are in the majority. Taking control of your vaccination experience may be the best way to combat needle anxiety.</p>
<p><em>Editor’s note: Portions of this article originally appeared in a previous <a href="https://theconversation.com/fear-of-needles-could-be-a-hurdle-to-covid-19-vaccination-but-here-are-ways-to-overcome-it-139029">article published</a> on June 8, 2020.</em></p><img src="https://counter.theconversation.com/content/161636/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Baxter founded and owns Pain Care Labs, makers of Buzzy. She previously received funding from the NICHD for vaccine pain research, and is currently funded by NIDA for work with mechanical stimulation for low back pain as part of the HEAL initiative to end opioid addiction long-term. </span></em></p>Free doughnuts and lotteries may drive some people to get their COVID-19 vaccine. But for those who are afraid of needles, other interventions may be necessary.Amy Baxter, Clinical Associate Professor of Emergency Medicine, Augusta UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1579632021-04-08T20:11:26Z2021-04-08T20:11:26ZPictures of COVID injections can scare the pants off people with needle phobias. Use these instead<figure><img src="https://images.theconversation.com/files/393709/original/file-20210407-17-1exa6m6.jpg?ixlib=rb-1.1.0&rect=2%2C2%2C995%2C558&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">See, no crying or big needles, just a person of colour showing off his plaster. This image does the job without scaring people and demonstrates diversity.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/vaccinated-african-guy-showing-arm-after-1941784336">from www.shutterstock.com</a></span></figcaption></figure><p>This year is shaping up as the year of the COVID-19 vaccination photo, with the pandemic providing seemingly endless photo opportunities. We’ve seen stock photos of people getting vaccinated in news reports, images of the <a href="https://www.abc.net.au/news/2021-02-21/australia-covid-vaccinations-begin-first-shots-administered/13176288">prime minister receiving his shot</a> and health workers posting #vaxxies on social media.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1355800552282615808"}"></div></p>
<p>But evidence shows the wrong images can make <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0199870">some people</a> reluctant to get vaccinated. So our well-meaning efforts to use images to help demystify the vaccination process or share our pride in getting a COVID-19 vaccine can backfire.</p>
<p>Here’s what we can all do to choose and share vaccination images responsibly.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/posting-covid-19-vaccine-selfies-on-social-media-can-cause-anger-frustration-153504">Posting COVID-19 vaccine selfies on social media can cause anger, frustration</a>
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</em>
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<h2>Images are powerful</h2>
<p>Communicating public health strategies like vaccination can be challenging. There can be complex and unfamiliar technical terms and health concepts, and not everyone can understand them. So pictures play an essential role. </p>
<p><a href="https://www.sciencedirect.com/science/article/abs/pii/S0738399105001461">Pictures can</a> draw attention to the message, help people relate to and remember what is being said, and may nudge people to act on a health recommendation. People also rate brochures with pictures <a href="https://pubmed.ncbi.nlm.nih.gov/1419592/">more positively</a> than ones with just text. </p>
<p>Pictures not only provide meaning, they have an emotional impact. Images we see on social media can also shape our perception of social norms (what we believe others are thinking or doing) and <a href="https://www.nature.com/articles/s41562-020-0884-z">our behaviour</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/friday-essay-covid-in-ten-photos-145318">Friday essay: COVID in ten photos</a>
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</em>
</p>
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<p>But what happens when the picture is a <a href="https://www.shutterstock.com/image-illustration/doctor-fighting-coronavirus-using-vaccine-injection-1790691281">giant needle</a>, or a needle poked into <a href="https://www.shutterstock.com/image-photo/male-doctor-holding-syringe-making-covid-1859217856">someone’s arm</a>? We have all seen these images to illustrate media articles about COVID-19 vaccination.</p>
<p>In addition to being a bit gruesome, stock photos commonly used in stories about vaccination are <a href="https://www.self.com/story/vaccine-stock-photos">often inaccurate</a>. The needle might be in the wrong position, the health worker may be <a href="https://www.shutterstock.com/image-photo/doctor-nurse-scientist-researcher-hand-blue-1506051596">wearing gloves</a> when they are not needed or the liquid inside the needle <a href="https://www.shutterstock.com/image-photo/close-woman-doctor-holding-syringe-vaccine-1928393204">seems coloured</a> rather then clear.</p>
<h2>Do vaccination images really matter?</h2>
<p>Yes, vaccination images matter. A study looking at vaccine-related news coverage found nearly <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0199870">one in eight</a> images contained something negative, such as the classic “<a href="https://www.alamy.com/stock-photo-syringe-and-crying-baby-injection-in-arm-137810405.html">crying baby</a>”.</p>
<p>This may lead new parents, who have yet to really experience the vaccination process, to become anxious. And this negative photo may override any positive vaccination messages accompanying it. </p>
<p>This issue is especially important because when a photo <a href="https://journals.sagepub.com/doi/10.1177/0392192107087919">is of someone’s face</a>, it can trigger an emotional response, making it easier for someone to have a strong reaction to that communication.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/393708/original/file-20210407-23-1c9o9lu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Baby crying with vaccine needle" src="https://images.theconversation.com/files/393708/original/file-20210407-23-1c9o9lu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/393708/original/file-20210407-23-1c9o9lu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/393708/original/file-20210407-23-1c9o9lu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/393708/original/file-20210407-23-1c9o9lu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/393708/original/file-20210407-23-1c9o9lu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/393708/original/file-20210407-23-1c9o9lu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/393708/original/file-20210407-23-1c9o9lu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">We can still illustrate vaccination without using scary images like this of a crying baby and an oversized needle.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/vaccination-concept-syringe-crying-baby-350223140">from www.shutterstock.com</a></span>
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<p>We know images can help people <a href="https://www.sciencedirect.com/science/article/abs/pii/S0738399105001461">remember</a> health messages. But if we use an inappropriate photo, such as the wrong needle size or someone looking anxious, this is the image that can stick with us, not the <a href="https://www.sciencedirect.com/science/article/pii/S0738399105001461">public health messages or statistics</a> we intended to convey.</p>
<p>For some people, photos of needles are so scary this might put them off vaccination. While we don’t know precisely which types of needle imagery could stimulate such a response, we know needle phobia is a real issue. In fact, one survey found <a href="https://corporate.target.com/press/releases/2012/08/target-survey-shows-adult-americans-237507">23% of adults</a> have avoided influenza vaccines due to fear of needles. And we don’t want to risk this happening with COVID-19 vaccines. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fear-of-needles-could-be-a-hurdle-to-covid-19-vaccination-but-here-are-ways-to-overcome-it-139029">Fear of needles could be a hurdle to COVID-19 vaccination, but here are ways to overcome it</a>
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<hr>
<h2>What can we do about it?</h2>
<p>Whether we are choosing images for news articles or for our personal social media, it is important we consider the potential impact of the photos we use. Here are some tips for choosing the right image: </p>
<ul>
<li><p><strong>focus on positive outcomes.</strong> Consider showing a <a href="https://www.shutterstock.com/image-photo/woman-looking-happy-after-getting-vaccine-1929048425">smiling person</a> with a <a href="https://www.shutterstock.com/image-photo/vaccination-little-girl-doctors-office-funny-1821728597">plaster on their arm</a> or someone holding a vaccination card or sticker. Flickr provides <a href="https://www.flickr.com/photos/selfmagazine/albums/72157710332198661">free photos</a> that reflect the reality of immunisation and are medically accurate</p></li>
<li><p><strong>humanise the process.</strong> People develop, deliver and receive vaccines. Show these people where possible, instead of disembodied needles </p></li>
<li><p><strong>depict diversity.</strong> Ensure images of vaccination <a href="https://www.shutterstock.com/image-photo/vaccinated-african-guy-showing-arm-after-1941784336">show diversity</a> of ethnicity, gender, age and disability</p></li>
<li><p><strong>imply rather than illustrate vaccination.</strong> Why do we need the needle in the photo? We <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0199870">do not illustrate</a> articles about urinary tract infections in children with photos of urine samples or invasive medical treatments. An image of a health worker speaking to someone with their sleeve rolled up is enough to evoke a mental image of the vaccination process, particularly when it accompanies a story about vaccines</p></li>
<li><p><strong>highlight the vial not the needle.</strong> For stories about vaccine production or rollout with no personal or emotive element, showing the vaccine vial is a neutral option </p></li>
<li><p><strong>avoid inaccurate images.</strong> The emoji of a <a href="https://emojipedia.org/syringe/">needle full of blood</a>? Not a great choice to tell your friends and family you have been vaccinated. The <a href="https://emojipedia.org/adhesive-bandage/">plaster emoji</a> is a good alternative. Publications should check any vaccine images with medical professionals for accuracy. </p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/5-ways-we-can-prepare-the-public-to-accept-a-covid-19-vaccine-saying-it-will-be-mandatory-isnt-one-144730">5 ways we can prepare the public to accept a COVID-19 vaccine (saying it will be 'mandatory' isn't one)</a>
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<img src="https://counter.theconversation.com/content/157963/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Holly Seale is an investigator on a study funded by NHMRC and has previously received funding for investigator driven research from NSW Ministry of Health, as well as from Sanofi Pasteur and Seqirus. She is the Deputy Chair of the Collaboration on Social Science and Immunisation.</span></em></p><p class="fine-print"><em><span>Jessica Kaufman receives funding from the National Health and Medical Research Foundation (Vaccine Barriers Assessment Tool, GNT1164200). She is a member of the Collaboration on Social Science and Immunisation (COSSI) network.</span></em></p>Our well-meaning efforts to use images to help demystify the vaccination process or share our pride in getting a COVID vaccine can backfire.Holly Seale, Associate professor, UNSW SydneyJessica Kaufman, Research Fellow, Vaccine Uptake Group, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1390292020-06-08T12:22:06Z2020-06-08T12:22:06ZFear of needles could be a hurdle to COVID-19 vaccination, but here are ways to overcome it<figure><img src="https://images.theconversation.com/files/337195/original/file-20200524-124822-1grajvf.jpg?ixlib=rb-1.1.0&rect=5%2C5%2C3452%2C2373&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The widespread fear of needles is a public health problem, particularly in the time of COVID-19.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/childrens-doctor-injects-a-vaccine-against-measles-rubella-news-photo/464478020?adppopup=true">Getty Images / Sean Gallup</a></span></figcaption></figure><p>As progress continues toward finding a vaccine that prevents COVID-19, millions of Americans are frightened at even the notion of getting a shot: Studies suggest <a href="https://pubmed.ncbi.nlm.nih.gov/22617633/">63% of young adults</a> – those born in 2000 or later – fear needles.</p>
<p>As a <a href="https://www.practicalpainmanagement.com/author/29618/baxter">physician trained in pediatrics</a>, I think we found the answer for the huge rise in needle phobia. Now – and even more critical: What might alleviate needle pain and fear? </p>
<p>A landmark 1995 study on <a href="https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/jfp-archived-issues/1995-volume_40-41/JFP_1995-08_v41_i2_needle-phobia-a-neglected-diagnosis.pdf">needle phobia</a> reported that 10% of adults and 25% of children were afraid of needles. The study also noted what typically caused their fear: a “needle event” around five years of age.</p>
<p>In 2010, our team conducted a study of vaccination pain in preteens. Of the 120 children screened, 114 said they had needle anxiety. This really surprised us. As with the earlier study, we thought perhaps 25% would be afraid; instead, it was 95%. (Incidentally, some of the parents were annoyed – not a few called their children out for being “wimps.”)</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=305&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=305&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=305&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=383&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=383&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=383&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Needle Fear Correlates with Scheduled Vaccine Injection Number by Birth Year. Spearman’s Rho = .87.</span>
<span class="attribution"><span class="source">AAAAI Annual Meeting</span></span>
</figcaption>
</figure>
<h2>Why there’s more needle phobia</h2>
<p>We wanted to understand what was creating this new anxiety. So we looked at the vaccination records of the group since birth. Maybe then we could find patterns that caused this abrupt rise in fear. </p>
<p>Turned out it was the needles. </p>
<p>Over the past 40 years, we have <a href="https://www.chop.edu/centers-programs/vaccine-education-center/vaccine-history">added 30 injections</a> to a child’s vaccine schedule. This is a good thing: Today in the U.S., kids almost never die from a childhood infectious disease. But needle fear has blossomed. </p>
<p>The number of infant vaccines were fine. But we found that half of kids who got all their preschool boosters on one day – that’s four or five injections at once – were in the <a href="https://pubmed.ncbi.nlm.nih.gov/28647169/">highest quartile of fear</a> five years later. Worth noting: Over the next three years, this group was two-and-a-half times less likely to get the HPV vaccine. </p>
<p>But none of the kids who got only a single shot each visit over the full four- to six-year window was fearful. Perhaps they became resilient, capable of coping with one quick poke. Maybe five injections per visit is too much, particularly when you’re old enough to remember them. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Needle fear could lower vaccination rates.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/marisa-grunder-27-of-wilton-iowa-is-given-a-shot-during-news-photo/89747046?adppopup=true">Getty Images / David Greedy</a></span>
</figcaption>
</figure>
<h2>Potential solutions</h2>
<p>Experts in the field – like <a href="http://www.sickkids.ca/AboutSickKids/Directory/People/T/Anna-Taddio.html">Dr. Anna Taddio</a> of the University of Toronto – realized needle fear could impact vaccination rates. She and other Canadian scientists created <a href="https://www.cmaj.ca/content/187/13/975">guidelines to reduce vaccination pain</a>. Issued in 2015, those guidelines suggested that interventions, occurring while preparing for and receiving the shot, would help. </p>
<p>Interventions can mean distractions. For young children, fear might be reduced by letting them blow their breath on a toy pinwheel. For an older child, it might be through watching videos or listening to music. For pain, topical anesthetics help numb the skin. So does numbing the muscle with “Buzzy,” the vibrating cold device we tested in preteens. Pain is reduced when placed on the shot area for a minute, then moved near the area while the injection takes place. Two <a href="https://pubmed.ncbi.nlm.nih.gov/31021972/">meta-analyses</a> showed Buzzy provided <a href="https://pubmed.ncbi.nlm.nih.gov/30829735/">significant pain and fear relief</a> – a 40% to 74% decrease for children, and a better experience for adults when receiving an <a href="https://pubmed.ncbi.nlm.nih.gov/30425014/">flu shot</a>. </p>
<p>In addition to Buzzy: Cold spray, topical anesthetics and Shotblocker – a horseshoe-shaped device placed near the area of the shot – have been studied for adult injections. Compared to no intervention, they <a href="https://pubmed.ncbi.nlm.nih.gov/30425014/">helped reduce pain</a>.</p>
<p>And in studies looking at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3626759/">blood donation</a>, reducing anxiety and pain can lead to lower rates of the “passing out” feelings in adults. Using vibration combined with cold can also help <a href="https://www.semanticscholar.org/paper/An-integration-of-vibration-and-cold-relieves-pain-Baxter-Cohen/dcfed110e06a76f1687a3155048e1a74e36a01cd">adults who are fearful</a>.</p>
<p>New guidelines could come out later this year. This too will be helpful; our knowledge of vaccine pain has greatly increased over the past five years. Many of the 2015 recommendations were speculative and extrapolated from studies of IV insertions, which do not directly correlate to pain interventions for shots. In addition, many studies evaluating distractions from blowing bubbles to wearing <a href="https://pubmed.ncbi.nlm.nih.gov/29559294/">virtual reality goggles</a> are from lab draws. Reliable data on immunizations is relatively scant.</p>
<h2>Use multiple distractions, go in with a plan</h2>
<p>Yet all the suggested interventions have a commonality. They address pain, fear and the frightening memories of past events by
<a href="https://pubmed.ncbi.nlm.nih.gov/24093902/">changing the patient’s focus</a> during a procedure.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=549&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=549&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=549&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=690&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=690&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=690&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Distress Venn Diagram.</span>
<span class="attribution"><span class="source">https://pubmed.ncbi.nlm.nih.gov/24093902/</span></span>
</figcaption>
</figure>
<p>A <a href="https://pubmed.ncbi.nlm.nih.gov/29792557/">systematic review</a> for vaccine pain concluded that interventions should have cold and vibration, plus distraction elements – for instance, using Buzzy as the patient watches a video or listens to music. The patient should choose the activity, and then remain engaged as the shot is prepared and administered. </p>
<p>If you’re facing a needle – a vaccination, lab draw or blood donation – the best strategy is to have a plan beforehand. Discuss the procedure with the clinician; bring a friend along. Have a game you can play while it’s all happening – that way, the brain is too busy to be afraid, and pain perception goes down. Any smartphone app involving touch and skill is a great place to start. Maybe it’s time to play Pokemon Go again.</p>
<p>A physical intervention during the procedure – pointing, touching, coughing – can help. Or combine rote performance and visual identification. During the poke, look at something on the wall with writing on it; focus on one sentence and count the number of letters with holes in them (for example, there are two in “holes”). This engages the part of the brain responsible for analyzing risk. </p>
<p>Needle phobia is a direct threat to public health. Those who are afraid of shots may not get them. With COVID-19 upon us, addressing needle fear becomes more than making a doctor’s visit more pleasant. Now, it’s truly a lifesaving endeavor.</p>
<p><em>Editor’s Note: An updated version of this article was published on June 11, 2021. <a href="https://theconversation.com/over-half-of-adults-unvaccinated-for-covid-19-fear-needles-heres-whats-proven-to-help-161636">Read it here</a>.</em></p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklysmart">You can get our highlights each weekend</a>.]</p><img src="https://counter.theconversation.com/content/139029/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Baxter founded and works for Pain Care Labs, a dba of MMJ Labs which manufactures and researches neuromodulation pain products Buzzy, VibraCool, and DistrAction cards. She has received funding from NICHD to develop and test Buzzy for vaccine-related pain reduction, and from NIDA to research frequencies and modalities to reduce opioid use resulting from low back pain. </span></em></p>What happens when we have a COVID-19 vaccine – and millions are afraid of a needle?Amy Baxter, Clinical Associate Professor of Emergency Medicine, Augusta UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1343282020-04-29T19:05:06Z2020-04-29T19:05:06ZFear of needles: 5 simple ways to ease vaccination pain for your child (and yourself)<figure><img src="https://images.theconversation.com/files/331539/original/file-20200429-51474-1xkc00c.jpg?ixlib=rb-1.1.0&rect=39%2C3%2C2005%2C1358&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Strategies to ease pain and fear during injections are recommended by health organizations such as the Canadian Paediatric Society.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/selfmagazine/48545962716/in/album-72157710332198661/">(Heather Hazzan, SELF Magazine/flickr)</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Vaccinations are one of the most common reasons for injections in children. But for people who fear needle pain, the mere mention of a vaccination evokes immense dread and bad childhood memories of painful injections at the doctor’s office or at school. </p>
<p>Indeed, <a href="https://doi.org/10.1111/jan.13818Ci">20-50 per cent of kids and 20-30 per cent of adults report significant needle fears</a>. People who are afraid of needles <a href="https://doi.org/10.1111/jan.13818Ci">are less likely to get the flu shot</a> or <a href="http://dx.doi.org/10.1016/j.vaccine.2012.05.011">to have their children vaccinated</a>. They are also more likely to avoid medical care. This means that, unless we develop a needle-free vaccine, managing pain and fear from needles is critical to the success of vaccines — including an eventual coronavirus vaccine. </p>
<p>But don’t fear. As a psychologist with expertise in pain management, I know there is a wealth of research clearly showing how to prevent pain and soothe your needle fears. These five strategies are simple, easy to implement and helpful for all ages — including babies, children and adults. These <a href="https://doi.org/10.1503/cmaj.150391">science-backed strategies</a> are recommended by the <a href="https://www.cps.ca/en/documents/position/managing-pain-and-distress">Canadian Paediatric Society</a> and the <a href="https://www.who.int/immunization/policy/position_papers/reducing_pain_vaccination/en/">World Health Organization</a>, among others. </p>
<h2>1. Plan ahead and be honest</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/330930/original/file-20200428-76586-a3v9p2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/330930/original/file-20200428-76586-a3v9p2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/330930/original/file-20200428-76586-a3v9p2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/330930/original/file-20200428-76586-a3v9p2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/330930/original/file-20200428-76586-a3v9p2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/330930/original/file-20200428-76586-a3v9p2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/330930/original/file-20200428-76586-a3v9p2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Let kids know about the vaccination a few days ahead of time, and create a comfort care plan.</span>
<span class="attribution"><span class="source">(James Gathany/Centers for Disease Control and Prevention)</span></span>
</figcaption>
</figure>
<p>Think ahead about what strategies you plan to use to manage fear or pain during the vaccination. Parents often avoid telling kids they are going for a needle until the very last minute to avoid making them anxious. This often has the opposite effect and causes anxiety to skyrocket, along with distrust.</p>
<p>It’s usually best to tell kids a few days ahead and use that time to create a <a href="http://www.calgarylabservices.com/files/CLSForms/PX-SC290_Attach3.pdf">comfort care plan</a> together with strategies they can use to manage worry and pain. <a href="https://immunize.ca/sites/default/files/resources/parentscanada-ad-feature-needles-dont-have-to-hurt.pdf">Handouts</a> summarize effective pain management strategies in one place to make vaccinations easy peasy when the time comes. </p>
<p>For parents, assessing and managing their own anxiety will enable them to best support their child. Plan to be with your child during the vaccination unless they are older and request to be on their own. </p>
<h2>2. Use numbing cream</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/331538/original/file-20200429-51470-2qtx9r.jpg?ixlib=rb-1.1.0&rect=386%2C15%2C1569%2C1091&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/331538/original/file-20200429-51470-2qtx9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=325&fit=crop&dpr=1 600w, https://images.theconversation.com/files/331538/original/file-20200429-51470-2qtx9r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=325&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/331538/original/file-20200429-51470-2qtx9r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=325&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/331538/original/file-20200429-51470-2qtx9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=408&fit=crop&dpr=1 754w, https://images.theconversation.com/files/331538/original/file-20200429-51470-2qtx9r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=408&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/331538/original/file-20200429-51470-2qtx9r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=408&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Topical anesthetics can be applied in advance to numb the injection area.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/selfmagazine/48545839516/in/album-72157710332198661/">(Heather Hazzan, SELF Magazine/flickr)</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Also called <a href="https://www.aboutkidshealth.ca/Article?contentid=3627&language=English">topical anesthetics</a>, these creams help to numb the skin where the needle will be injected. Topical anesthetics (Emla, Ametop and Maxilene) can be purchased over the counter from any pharmacy and come as a patch or in a tube. </p>
<p>They typically need to be applied to the skin 30 to 60 minutes before the needle, so applying the numbing cream is often something that can be done at home, and later removed at the clinic. Insider tip: Some kids don’t like having the patch removed because it’s like taking off a bandage. Instead, you can apply the numbing cream and wrap the area with cling wrap. </p>
<p>To be sure the numbing cream is applied in the right place on the body, check ahead with a pharmacist or health-care provider to find out where the shot will be injected. </p>
<h2>3. Sit upright</h2>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/331275/original/file-20200429-51489-jw409e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/331275/original/file-20200429-51489-jw409e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=559&fit=crop&dpr=1 600w, https://images.theconversation.com/files/331275/original/file-20200429-51489-jw409e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=559&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/331275/original/file-20200429-51489-jw409e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=559&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/331275/original/file-20200429-51489-jw409e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=702&fit=crop&dpr=1 754w, https://images.theconversation.com/files/331275/original/file-20200429-51489-jw409e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=702&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/331275/original/file-20200429-51489-jw409e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=702&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hold children in a supported sitting position during the injection.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/selfmagazine/48545984852/in/album-72157710332198661/">(Heather Hazzan, SELF Magazine/flickr)</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>It’s best to sit up in a comfortable, relaxed and supported position during the vaccination. Kids can sit on a parent’s lap and be held in a hug either facing the parent or to the side, often called <a href="https://www.youtube.com/embed/YPi3xT6UCOs?rel=0">comfort positions</a>. Lying down or being held down can increase fear and pain, and create a sense of loss of control. </p>
<p>Infants can be <a href="https://youtu.be/3nqN9c3FWn8">cuddled skin-to-skin</a>, clothed only in a diaper, held facing inward against a parent’s bare chest. For kids two years and younger, <a href="https://youtu.be/7NDJ463j2iI">breastfeeding or use of a sweet-tasting solution</a>, such as a small amount of sugar water, is also recommended. </p>
<p>Kids and adults who typically feel faint when getting needles can use a technique called <a href="https://www.uoguelph.ca/pphc/sites/default/files/Muscle-Tension-Resource.pdf">muscle tension</a> to help raise their blood pressure to feel better. To use this technique, sit or lie down and tighten your arm, leg and stomach muscles for about 15 seconds until your cheeks feel flush. Then release tension for 20 to 30 seconds (without fully relaxing) before tensing again and repeating until the needle is over or you stop feeling faint. </p>
<h2>4. Use distraction</h2>
<p>Draw attention away from the pain before and during the injection by <a href="https://doi.org/10.1002/14651858.CD005179.pub4">focusing on something fun, engaging and interactive</a>. Playing games or listening to music on a smartphone is an easy, effective tool for managing pain and distress, and most people have it right in their pocket! </p>
<p>Although high-tech things like virtual reality help, low-tech distractions like talking to someone or imagining something fun work too. Taking a few deep breaths can also help maintain calm and minimize pain. To make it easier for kids, have them blow a pinwheel or bubbles. </p>
<p>For parents, <a href="https://youtu.be/KgBwVSYqfps">try to avoid reassuring your child</a>. Although it’s instinct, saying things like, “I’m sorry” or “It will be over soon” can actually increase pain and distress by inadvertently signalling to the child that there’s something to worry about it. </p>
<h2>5. Talk about what went well</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/331063/original/file-20200428-110734-15e14wl.jpg?ixlib=rb-1.1.0&rect=900%2C0%2C4602%2C4016&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/331063/original/file-20200428-110734-15e14wl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/331063/original/file-20200428-110734-15e14wl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/331063/original/file-20200428-110734-15e14wl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/331063/original/file-20200428-110734-15e14wl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/331063/original/file-20200428-110734-15e14wl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/331063/original/file-20200428-110734-15e14wl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Talking about the experience can help make the next vaccination easier.</span>
<span class="attribution"><span class="source">(Scott Housley/Centers for Disease Control and Prevention)</span></span>
</figcaption>
</figure>
<p>There’s more you can do even when the vaccination is over. <a href="https://doi.org/10.1111/papr.12572">Remembering and talking about what went well after the fact</a> — even if it wasn’t perfect — helps make it less stressful and less painful next time. Plan something fun to celebrate and remember a job well done!</p>
<p>If you or your child are so afraid of needles that you try to avoid them at all costs, you may benefit from additional help. In this case, <a href="http://dx.doi.org/10.1080/16506073.2016.1157204">exposure-based therapy</a> delivered by a trained mental health professional is recommended ahead of time in order to benefit most from the five simple strategies discussed above. </p>
<p>Even though these strategies are easy, science-based and widely recommended, they are unfortunately not always used. Our team at <a href="https://twitter.com/KidsInPain/">Solutions for Kids in Pain (SKIP)</a> is working hard to improve children’s pain management by partnering with researchers, parents and caregivers, health-care providers, children’s health-care institutions and more than 100 other organizations. Our goal is to ensure that information about children’s pain gets into the hands of those who need it faster. </p>
<p>During <a href="https://www.who.int/news-room/events/detail/2020/04/24/default-calendar/world-immunization-week-2020">World Immunization Week</a>, let’s remember that #VaccinesWork and #ItDoesntHaveToHurt. </p>
<p><em>This story is part of a series produced by <a href="https://www.kidsinpain.ca">SKIP (Solutions for Kids in Pain)</a>, a national knowledge mobilization network whose mission is to improve children’s pain management by mobilizing evidence-based solutions through co-ordination and collaboration.</em></p><img src="https://counter.theconversation.com/content/134328/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathryn Birnie is Assistant Scientific Director of Solutions for Kids in Pain (SKIP). </span></em></p>These strategies for easing needle pain and fear make vaccinations and other injections easier for parents and children. They are simple and helpful for all ages, from infants to adults.Kathryn Birnie, Assistant Professor and Psychologist in Pediatric Pain, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/573482016-04-28T03:58:53Z2016-04-28T03:58:53ZFight, flight or … faint? Why some people pass out when they see blood or feel pain<figure><img src="https://images.theconversation.com/files/118258/original/image-20160412-15861-uk0n7c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are a few explanations as to why some people faint when they get needles or feel pain. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/venndiagram/5331296718/">Dave/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Most people find the sight of blood or a hypodermic needle enough to cause some discomfort, but why do some people faint when faced with them? If you’re someone who finds yourself sweating about your upcoming flu jab, you might have your prehistoric ancestors to thank.</p>
<p><a href="https://theconversation.com/explainer-what-are-phobias-9667">Phobias</a> are part of the anxiety disorder family. They are thought to arise because of a learned response to a stimulus following a traumatic event (being bitten by a dog might lead to a fear of dogs), or because of intrinsic adaptive mechanisms that promote survival, which might underlie a fear of spiders or heights.</p>
<p>Most people are familiar with the experience of fear. It may be fear of an upcoming presentation, or of a mouse running across your kitchen floor. Fear is a basic emotion central to the experience of threat, where an animal either fights the threat or runs away. </p>
<p>A phobia, on the other hand, is an intense, pervasive and debilitating fear of something that might seem entirely harmless to others.</p>
<h2>The blood-injection-injury phobia</h2>
<p>The blood-injection-injury phobia is a fairly common phenomenon. It is experienced by approximately <a href="http://www.ncbi.nlm.nih.gov/pubmed/9794020">3% of the population</a>. The phobia can be triggered by the sight of blood, by sustaining an injury, receiving an injection, or some other type of medical procedure. </p>
<p>All humans have a natural tendency to be squeamish in these situations, but for some people the response is more extreme. They experience a temporary spike in heart rate and blood pressure, followed by a dramatic drop. This results in skin pallour, sweating, nausea and fainting.</p>
<p>This fainting response is unique to the blood-injection-injury phobia, in contrast with the usual acceleration of heart rate and elevation in blood pressure in all other phobias.</p>
<p>So why does a fear of blood or needles leave a person weak at the knees, while confrontation with a spider or a Ferris wheel leaves the body armed and ready to fight or run away?</p>
<p>The <a href="http://www.ncbi.nlm.nih.gov/pubmed/15337864">earliest “adaptationist” hypothesis</a> to explain the blood-injection-injury phobia suggests fainting at the sight of blood increases the chance of survival, because a dramatic drop in blood pressure minimises blood loss in the case of injury. However, this does not explain why people faint when faced with needles or minor injuries, where little or no blood loss is involved.</p>
<p>The <a href="http://www.ncbi.nlm.nih.gov/pubmed/3048117">second evolutionary hypothesis</a> posits that blood-induced fainting in mammals is controlled by the same physiological mechanism that regulates disgust. It suggests that, in some people, the sight of their own (or another’s) blood might induce a disgust response.</p>
<p>However, disgust (and associated nausea and vomiting) is thought to have evolved to protect mammals from the risk of disease-laden food. It’s difficult to imagine the adaptive benefit of fainting when confronted with bad chicken; simple avoidance seems like a much better approach to maintaining health and survival.</p>
<p>A <a href="http://www.ncbi.nlm.nih.gov/pubmed/15944875">third explanation</a> describes the adaptive benefit of fainting during periods of inescapable threat in the mid-Paleolithic era. During warfare, confrontation with a “stranger wielding a sharp object” was likely to be associated with threat to life. Humans’ tendency to faint (or “play dead”), rather than attempt to flee or fight, may therefore have evolved as an alternative stress-induced fear-circuitry response.</p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/9794020">Epidemiological studies</a> have consistently shown a higher prevalence of blood-injection-injury phobia in women compared with men. Prevalence of the blood-injection-injury phobia also decreases after puberty in boys. </p>
<p>The Paleolothic-threat hypothesis suggests that, during warfare, a phobic response to the sight of blood or an approaching sharp object was likely to be maladaptive for men who engaged in combat. For women and children, however, this behaviour may have been adaptive; fear-induced fainting may have increased the likelihood of being taken captive rather than being killed.</p>
<p>In an <a href="http://www.ncbi.nlm.nih.gov/pubmed/4009521">interesting research experiment</a>, blood donors were more likely to faint when blood was collected by an experienced phlebotomist rather than an inexperienced phlebotomist. </p>
<p>Consistent with the Paleolithic-threat hypothesis, it was concluded that the novice phlebotomist may have a more deliberate, slower-moving and more talkative approach than their more experienced counterparts. A sharp object held by a fast-moving, non-communicative stranger may resemble more closely a mid-Paleolithic assailant signalling life-threatening danger.</p>
<h2>Why do only some people faint?</h2>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/9754622">Heritability estimates</a> are high in the blood-injection-injury phobia; many people report strong family histories, and concurrence of this phobia is high among twins.</p>
<p>Specific phobias, including the blood-injection-injury phobia, are <a href="http://www.ncbi.nlm.nih.gov/pubmed/9794020">frequently associated with</a> a range of other mental health problems, particularly anxiety disorders. Phobias are also <a href="http://www.ncbi.nlm.nih.gov/pubmed/20099272">more common in individuals</a> who have endured abuse, neglect or trauma in early life.</p>
<p>Some people might actually be <a href="http://www.ncbi.nlm.nih.gov/pubmed/11514377">predisposed to fainting</a> due to a dysregulation in their autonomic nervous system. The blood-injection-injury phobia appears to develop in these individuals as a conditioned fear response, after they endure repeated traumatic fainting episodes.</p>
<p>Given its trademark physiological response, traditional methods of relaxation and deep breathing techniques are not the best approach when it comes to a fear of blood, needles or medical procedures. You might find yourself slowing your heart rate and inadvertently accelerating your trip to the floor. </p>
<p>Instead, engaging in conversation, increasing muscle tone and maintaining tension in your body will keep your heart rate up and your dizziness at bay. This could even provide you with enough distraction until it’s all over.</p><img src="https://counter.theconversation.com/content/57348/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cynthia Murray does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most people find the sight of blood or a hypodermic needle enough to cause some discomfort, but why is it that some people faint when they’re faced with them?Cynthia Murray, Clinical Neuropsychology Registrar and Research Assistant, Neuroscience Research AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/431842015-07-02T01:40:43Z2015-07-02T01:40:43ZForced rehabilitation of drug users in Indonesia not a solution<figure><img src="https://images.theconversation.com/files/86817/original/image-20150630-5864-1q3pbut.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Indonesia is forcing people with drug dependence problems to go into rehab. </span> <span class="attribution"><span class="source">joloei/www.shutterstock.com</span></span></figcaption></figure><p>Earlier this year, Indonesia <a href="https://theconversation.com/bali-nine-duo-executed-the-view-from-indonesia-38392">executed</a> 14 people, including Bali Nine duo Andrew Chan and Myuran Sukumaran, for drug offences. President Joko Widodo <a href="http://www.aljazeera.com/programmes/talktojazeera/2015/03/joko-widodo-strong-message-drug-smugglers-150305131413414.html">portrayed</a> the executions as the ultimate weapon in an expansive “war on drugs” deployed to protect the country’s young generation from an <a href="https://theconversation.com/indonesia-uses-faulty-stats-on-drug-crisis-to-justify-death-penalty-36512"> alleged “national drug emergency”</a>.</p>
<p>But his policy is harming the very people he claims he wishes to protect. </p>
<h2>A problematic approach</h2>
<p>Widodo’s tough approach does not only apply to drug traffickers. The Indonesian government, through its anti-drug agency, the National Narcotics Board (BNN), is <a href="http://www.republika.co.id/berita/nasional/hukum/15/05/23/norwnd-bnn-pecandu-narkoba-wajib-jalani-rehabilitasi">pushing compulsory treatment</a> for people with drug dependence. This coercive approach is jeopardising health gains made by existing harm reduction programs and is fertile ground for corruption and abuse.</p>
<p>BNN pledges to rehabilitate 100,000 drug users in 2015. They aim to double the numbers every year – to 200,000 in 2016 and 400,000 in the year after that. </p>
<p>But there aren’t enough problematic drug users in Indonesia to meet these targets. According to estimates by the Ministry of Health, Indonesia is home to about 74,000 injecting drug users. Only a fraction may choose drug treatment at any given time. </p>
<p>Some civil society groups working on the ground consider even this an overestimation. National Narcotics Board statistics claim a large number of crystal meth and cannabis users, but Indonesian academics argue these numbers have been derived using <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61058-3/fulltext">questionable methods</a>. </p>
<p>There is a strong movement in Indonesia opposing the government’s tough approach. Activists in 15 cities in Indonesia last week joined a <a href="http://supportdontpunish.org/day-of-action-2015/">worldwide</a> call for governments to end the counterproductive war on drugs. </p>
<h2>Mandatory rehab = incarceration</h2>
<p>Last year, seven government bodies in Indonesia, including BNN, the police, the Ministry of Health, and the Ministry of Social Affairs, <a href="http://www.thejakartapost.com/news/2014/03/12/rehab-better-can-drug-users.html">signed a Memorandum of Understanding</a> promoting rehabilitation for drug users. The memorandum appears to promote a more lenient approach to addressing drug use, calling for drug users to be “rehabilitated rather than incarcerated”. </p>
<p>But, in practice, BNN’s special drug eradication squad often seek out and forcibly detain suspected drug users; few people with drug dependence voluntarily choose treatment under the agency’s programs. </p>
<p>Indonesia currently has more than 400 addiction treatment facilities in hospitals, government narcotics clinics, and privately-run centres. But the country lacks formalised national best practice standards for addiction treatment. Options range from medical detox in hospitals and 12-step programs, to religious or spiritual centres that boast “curing” drug dependence using magic, prayer, beatings, and shackling drug users in cages with a ball and chain. </p>
<p>Most share the same goal: abstinence from drugs. And few independently evaluate the effectiveness of their programs. </p>
<p>To meet the 2015 target, the government is establishing <a href="http://slank.com/potlot/tempat-pendaftaran-pelaporan-rehabilitasi-narkoba-gratis/">additional drug rehabilitation centres inside</a> 60 prisons and 30 police and military training academies.</p>
<p>It is hard to imagine how the <a href="http://www.insideindonesia.org/overcrowding-crisis">substandard, overcrowded conditions</a> and limited health facilities of existing prisons in Indonesia can address the nation’s drug woes. <a href="http://www.justiceaction.net/2015/05/surat-terbuka-kepada-slank-tolak-tempat.html">Critics claim</a> sending people to rehabilitation centres in prison is simply another form of imprisonment or involuntary detention. </p>
<h2>Corruption and abuse</h2>
<p>When Indonesia amended its narcotics law in 2009, there was hope for a more balanced response to drugs. The revised law effectively decriminalised possession of small amounts of drugs for personal use by providing judges with the discretion to divert drug users to treatment programs instead of prison. But, in practice, the criminalisation of drug use continued. </p>
<p>Some authorities use the new legal provisions to extract heftier prices from well-off drug users, and downgrade the offence they were charged with. As of May 2015, 36% of prisoners in the country’s 427 overcrowded detention facilities are serving time for drug use.</p>
<p>Working together with the <a href="http://www.pkni.org">Indonesian Drug Users Network</a>, I am documenting a host of coercive and abusive measures carried out by law enforcement in the name of rehabilitation. </p>
<p>Health workers in Jakarta have reported an increase in the number of drug raids since January 2015 in known drug-use hot spots, but also in apartment buildings, schools, and community health clinics. </p>
<p>We found cases of forced urine testing, corruption, extortion, intimidation, and confidentiality breaches. Officers photograph suspected drug users against their will. They offer money in exchange for snitching on friends and family members who may use drugs. They demand access to private client records at methadone substitution clinics and other organisations working with drug users.</p>
<p>The government should seriously reconsider this approach, as <a href="https://www.unodc.org/documents/ungass2016//contributions/civil/count-the-costs-initiative/awdr.pdf">studies have shown</a> that criminalisation and punitive law enforcement approaches can lead to higher drug-related criminality and increased risk of contracting HIV and hepatitis C, among other unintended social and economic costs.</p>
<h2>Compulsory treatment is ineffective</h2>
<p>Indonesia’s coercive measures are at odds with <a href="http://www.unodc.org/southeastasiaandpacific/en/2012/10/ccdus/story.html">a broader tendency</a> in Asia to move away from compulsory treatment and transition toward voluntary, <a href="http://apps.who.int/iris/bitstream/10665/77969/1/9789241504379_eng.pdf">scientifically and medically appropriate approaches</a> to managing drug use. </p>
<p>Compulsory treatment and rehabilitation is costly and ineffective in addressing drug issues; relapse rates are high. There is no evidence that compulsory treatment leads to positive health outcomes among drug users or that it has any effect on drug use rates. </p>
<p>Instead, <a href="http://www.ijdp.org/article/s0955-3959(14)00335-1/fulltext">compulsory treatment</a> in countries such as Cambodia, China, Malaysia, Myanmar, Philippines, Thailand and Vietnam has led to increased HIV risks, added stigma and discrimination against drug users, and <a href="http://www.countthecosts.org/sites/default/files/ihra_compulsory_treatment.pdf">human rights violations</a>.</p>
<p>In July 2012, the United Nations issued a <a href="http://www.unaids.org/en/media/unaids/contentassets/documents/document/2012/jc2310_joint%20statement6march12final_en.pdf">Joint Statement</a> calling for the closure of compulsory drug detention and rehabilitation centres. They called governments to adopt “voluntary, evidence-informed and rights-based health and social services in the community”. </p>
<h2>Alternatives to compulsory treatment</h2>
<p>Harm reduction interventions such as <a href="http://www.who.int/hiv/topics/idu/needles/en/">needle syringe programs</a> and <a href="https://en.wikipedia.org/wiki/Methadone_maintenance">methadone maintenance therapy</a> are some of the world’s most effective and affordable treatments available. If President Widodo is serious about managing Indonesia’s drug problem, he should urgently scale up these proven strategies.</p>
<p>Methadone maintenance therapy reduces heroin use, HIV transmission, criminal activity and risk of drug-related death. The expansion of such programs in Indonesia has helped reduce HIV rates among injectors from 42% in 2011 to 36% in 2013, bringing thousands of drug users closer to health and support services. </p>
<p>Indonesia is also home to some of Asia’s most successful voluntary, community-based treatment programs for drug users. These include <a href="http://rumahcemara.org/en/about-us/">Rumah Cemara</a> and <a href="http://rumahpeka.org/">Rumah Singgah PEKA</a>, which are currently in the process of being documented as best practice treatment models by the United Nations Office on Drugs and Crime (UNODC). </p>
<p>These and more than a dozen programs like them are based in non-government organisations, often run by former drug users and offering a menu of evidence-based harm reduction and treatment options from which clients can choose. </p>
<p>The outcome isn’t always abstinence from drugs, but an improvement in the client’s social function, overall health, productivity, reduction in risky drug use patterns, and personal goals. </p>
<p>From a public health perspective, drug use is best portrayed as existing on a spectrum from beneficial to problematic. The majority of people who try drugs or use them occasionally <a href="https://www.scribd.com/doc/270054187/James-C-Anthony-2002-C109-1557-1574">never develop dependence or problematic use patterns</a>. </p>
<p>Leaders who want to support those dealing with drug dependence should listen to their needs and support them with strategies that work, rather than instituting policies that punish them.</p><img src="https://counter.theconversation.com/content/43184/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claudia Stoicescu is affiliated with Persaudaraan Korban Napza Indonesia (PKNI)/Indonesian Drug Users Network, with whom she is currently collaborating on joint research.</span></em></p>Indonesia’s war on drugs aims to protect the country’s young generation from an alleged “national drug emergency.” But the government’s coercive approach is harming the people it wishes to protect.Claudia Stoicescu, Associate Professor, Public Health, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/405502015-04-28T09:58:20Z2015-04-28T09:58:20ZSyringe exchange in southern Indiana to respond to an increase in HIV cases: better late than never?<p>The recent <a href="http://www.nytimes.com/2015/04/19/us/indiana-says-hiv-outbreak-is-worsening.html">upsurge in HIV cases</a> linked to injection drug use in southern Indiana has thrust the issue of syringe exchange programs (SEPs) into the headlines. While authorities are linking these cases of HIV infection directly to injecting drugs, it is unknown how many are caused by sexual activity with an infected drug user.</p>
<p>Nearly all states prohibit possession of syringes other than for medical need through their drug paraphernalia laws. Syringe access laws that require ID and proof of medical need to purchase them from pharmacies also exist in the majority of states, including Indiana. Federal funding of <a href="http://www.publichealthlaw.net/Research/PDF/syringe.pdf">syringe exchange programs</a> is banned as well. </p>
<p>To respond to the current outbreak, Indiana Governor <a href="http://www.in.gov/gov/">Mike Pence</a> <a href="http://cbs4indy.com/2015/04/20/pence-extends-hiv-emergency-order-in-scott-co-lawmakers-debate-expanding-needle-exchanges/">signed a 30-day exception</a> to the state’s restriction on needle exchange programs. The governor has extended the exception <a href="http://www.usatoday.com/story/news/nation/2015/04/21/ind-needle-exchange/26114799/">for another 30 days</a>, as the state’s legislature considers legalizing needle exchanges in some areas. The Centers for Disease Control and Prevention as well as other federal and state personnel are working to <a href="http://www.indystar.com/story/news/2015/04/21/beyond-needle-exchange-containing-hiv-outbreak/26145339/">contain the outbreak</a>. </p>
<p>This upsurge in HIV cases in Indiana hasn’t exactly come out of nowhere. An increase in Hepatitis C cases (which can also be spread through re-used syringes) began nearly <a href="http://www.indystar.com/story/news/2015/04/21/beyond-needle-exchange-containing-hiv-outbreak/26145339/">fifteen years ago</a> in Scott County, so officials should not have been surprised that a corresponding rise in HIV cases would eventually follow. </p>
<h2>Injection drug use and HIV</h2>
<p>Injection drug use (IDU) is a well known <a href="http://www.cdc.gov/hiv/pdf/statistics_2009_HIV_Surveillance_Report_vol_21.pdf">risk factor for HIV</a>, as well as Hepatitis B and C infections. The fact is that injection drug use accounts for about <a href="http://www.drugabuse.gov/publications/addiction-science/hivaids/injection-drug-use-has-contributed-to-nearly-one-third-cases-hiv">one-third of HIV infections in the country</a> since the beginning of the epidemic. </p>
<p>Transmission of HIV occurs through an exchange of bodily fluids. In the case of injection drug use, transmission can occur not only by sharing needles, but by sharing any of the materials used to <a href="https://www.aids.gov/hiv-aids-basics/prevention/reduce-your-risk/substance-abuse-use/">prepare and inject the drug</a>, such as water or cotton used to filter the solution. </p>
<p>Women are <a href="http://www.cdc.gov/hiv/risk/gender/women/facts/index.html">particularly vulnerable</a>, either from injecting drugs themselves, or from having unprotected sex with injection drug users, and women account for about twenty percent of new HIV infections yearly. </p>
<h2>Why do people reuse syringes?</h2>
<p>In most states, access to syringes is <a href="http://www.publichealthlaw.net/Research/PDF/syringe.pdf">severely restricted</a>. This forces injection drug users to reuse or borrow syringes. </p>
<p>These laws intending to prevent illegal injection drug use, while perhaps well-intentioned, do not prevent it. Drug users do not quit because they don’t have access to new syringes. Not having access to a clean glass doesn’t keep me from being thirsty. Glass or no, I will find a way to get a drink of water. </p>
<p>Being forced to re-use dirty syringes places not only the drug user at risk of greater harm, but the public as well. </p>
<p>In my twenty years of work in the HIV field, I have seen patients who borrowed family members’ insulin syringes, migrant workers who shared syringes used to inject liquid vitamins, hospital workers who recovered used syringes from the trash. These syringes are used repeatedly until the needle is too dull to pierce skin. One HIV-positive person places the entire needle-sharing network at risk.</p>
<p>For example, a 73-year-old grandmother was referred to our HIV clinic after her grandson, a 29-year-old addict, had infected her by using and returning her insulin syringes. </p>
<p>We saw groups of migrant workers who had shared needles to inject the liquid vitamins needed to withstand the hard labor, and who were all now HIV positive. We also saw diabetics who shared insulin syringes to save the expense of new ones. The substance being used doesn’t matter – only the syringe.</p>
<h2>Injection drugs and poverty: a few hours of escape</h2>
<p>Research also shows an association between <a href="http://www.cdc.gov/hiv/risk/other/poverty.html">poverty and both illegal drug use and HIV infection</a>. The stresses of living in poverty are well known, and often people feel the only ways to relieve the stress include escaping through drug use. </p>
<p>In research conducted in 2011, at Indiana University-Purdue University Fort Wayne (IPFW), located in the center of northeast Indiana counties similar to Scott County, the epicenter of the latest outbreak, we interviewed fifty injection drug users about their drug use. Of the people we interviewed, only one was employed and the rest were living in impoverished situations. Some of the women survived by trading sex for drugs, others in the sample sold drugs – either illegal drugs or legal prescription medications. </p>
<p>They all agreed that getting high was one of the only times they felt good, and while they felt guilty about using drugs, they couldn’t give up those few hours of escape that the drugs gave them. Becoming addicted, they then couldn’t quit.</p>
<p>None of the people in our sample used drugs alone; they were accompanied by at least one other person, and everyone shared needles at least “several times.” Frequent unprotected sex was reported, and only one person reported knowing their HIV status. </p>
<p>Frequently, as the CDC <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm64e0424a1.htm?s_cid=mm64e0424a1_x">has reported</a> for Scott County, families use drugs together, making it a multigenerational issue.
In this case some cases also involve pregnant women who, in a resource-poor area, may or may not have access to treatments that would prevent transmission to their unborn child.</p>
<p>That isn’t unusual. Many people with HIV don’t know about their positive status. According to the Centers for Disease Control and Prevention, about <a href="http://www.cdc.gov/hiv/statistics/basics/ataglance.html">14% of 1.2 million HIV positive persons</a> in the US do not know they are HIV positive. </p>
<h2>Syringe exchanges can also provide medical services and drug treatment information</h2>
<p>Given the incidence of HIV infection in rural, impoverished areas, plus the transmission routes of shared injection syringes and unprotected sex, the situation in southern Indiana is not surprising, and a syringe exchange program (SEP) is a logical response. These programs have been around nearly as long as we have known how HIV is transmitted. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/79329/original/image-20150426-14558-79pokx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Syringe exchanges are about more than syringes.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/riekhavoc/6858609934">Kaytee Riek</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>I worked with one such program. A typical SEP trades one sterile syringe for each used syringe. This approach does not put additional syringes on the street. Many programs also include bleach kits and instructions for properly cleaning syringes when clean ones are not available. They also provide condoms and information about safer sexual practices and includes the opportunity for HIV testing. </p>
<p>Research has consistently shown that SEPs <a href="http://www.cdc.gov/idu/facts/aed_idu_syr.pdf">do not increase drug use</a> or the number of used syringes discarded in streets and playgrounds. Further, SEPs provide <a href="http://www.cdc.gov/idu/facts/aed_idu_syr.pdf">a point of contact</a> for obtaining HIV testing, substance abuse counseling, screening for tuberculosis (TB), hepatitis B, hepatitis C, and other infections as well as referral for medical services. </p>
<p>When I handed out a sterile syringe, bleach kit, and condoms, I also included information about drug rehabilitation, jobs, housing, and my business card. More than once, I received phone calls months later from drug users I had contacted through the SEP who then wanted help with recovery.</p>
<h2>Syringe exchanges should be the rule, not the exception</h2>
<p>The response to the Scott County situation <a href="http://www.indystar.com/story/news/2015/04/21/beyond-needle-exchange-containing-hiv-outbreak/26145339/">seems reasonable</a>. However, given the predictability of this current outbreak based on the Hepatitis C increase beginning 15 years ago,the Scott County response comes late in the game. </p>
<p>Any HIV statistics are likely underestimates of the true numbers, and given the percentage of persons who are positive and do not know it, the incidence of known HIV cases in Scott and other Indiana counties is quite likely to increase. </p>
<p>Officials would have served the population better with preventative services in place. Governor Pence and the Indiana State Legislature would do well to put establishment of syringe exchange programs on a fast-track to-do list so there is a way to stem the tide of new HIV infections.</p><img src="https://counter.theconversation.com/content/40550/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeannie D. DiClementi does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Officials in Indiana would have served the population better if syringe exchanges had been in place before the upsurge in HIV cases began.Jeannie D. DiClementi, Associate Professor of Psychology, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/197002013-11-29T15:52:20Z2013-11-29T15:52:20ZFear and trembling through the bloody eye of the needle<figure><img src="https://images.theconversation.com/files/36447/original/jhb2jmrw-1385642559.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Careful now...</span> <span class="attribution"><span class="source">Kineckt</span></span></figcaption></figure><figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/36447/original/jhb2jmrw-1385642559.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/36447/original/jhb2jmrw-1385642559.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/36447/original/jhb2jmrw-1385642559.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/36447/original/jhb2jmrw-1385642559.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/36447/original/jhb2jmrw-1385642559.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/36447/original/jhb2jmrw-1385642559.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/36447/original/jhb2jmrw-1385642559.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Careful now …</span>
<span class="attribution"><span class="source">Kineckt</span></span>
</figcaption>
</figure>
<p>It was late on a Friday afternoon in November. I was a 21 year-old medical student diligently waiting for an opportunity to practice some medical procedures when a patient was admitted who was happy for a student to “have a go” at taking blood. Cue a bit of anxious excitement (clinical medicine was still new to me) before some inner steeling and a formal consent process. Then, in went the needle, out came the blood. Job done. However, just as I was allowing myself to feel self-satisfied, I noticed some blood on the inside of my latex glove. </p>
<p>The horror stories of healthcare professionals being infected with one of those vicious little <a href="http://www.hse.gov.uk/pubns/indg342.pdf">blood borne viruses</a> shot through my mind as effortlessly as the patient’s blood had recently spurted from vein to needle to bottle. As Kierkegaard once said, “there comes a moment in a person’s life when immediacy is ripe”; this was one of mine. </p>
<p>As it turned out – and by sheer dumb luck – the needle had penetrated my glove but not my skin and so I was “safe”. Typically, I did not inform anyone of the <a href="https://theconversation.com/the-nhs-could-go-further-than-the-airline-industry-on-safety-20623">near-miss</a> – the evidence suggests that many healthcare professionals and students <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1079524/">do not report</a> actual needle stick injuries never mind near-misses – and I went my merry (and very relieved) way. </p>
<p>Accidental blood exposure continues to be a pervasive problem in healthcare and needlestick injuries now account for around <a href="https://www.nao.org.uk/report/a-safer-place-to-work-improving-the-management-of-health-and-safety-risks-to-staff-in-nhs-trusts/">17% of accidents</a> in the NHS. Given the invasive nature of some forms of medical care, accidental exposure is never going to be eradicated. However, the <a href="http://www.who.int/occupational_health/activities/5prevent.pdf">risks can be reduced</a>, and health organisations now have a <a href="http://www.hse.gov.uk/biosafety/blood-borne-viruses/employers-responsibilities.htm">legal obligation</a> to put in place measures to minimise the risk to staff.</p>
<h2>Playing ball</h2>
<p>When an accidental exposure occurs, healthcare professionals are advised to seek immediate help from an <a href="http://www.hse.gov.uk/healthservices/needlesticks/">occupational health physician</a> or a doctor working in the Accident and Emergency Department. Part of the goal is to provide reassurance – the actual <a href="http://www.patient.co.uk/doctor/needlestick-injury#ref-1">risk of transmission</a> is very small – but the primary goal is to decide whether special precautions are needed. For example, if the accidental “donor” has HIV the recipient may want to take <a href="http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_089997.pdf">post exposure prophylaxis</a>.</p>
<p>One way to evaluate the risk is to ask the “donor” whether they have a serious blood borne infectious disease. It also makes sense to test the donor’s blood - not least because about a quarter of patients with HIV are <a href="http://www.hpa.org.uk/Publications/InfectiousDiseases/HIVAndSTIs/1211HIVintheUK2012/">unaware that they are infected</a>. </p>
<p>Most patients are happy to provide whatever information is needed and are also happy to give their permission for their blood to be tested. However, some refuse to play ball – perhaps because of fears about <a href="http://www.nat.org.uk/media/Files/Publications/Dec-2009-Confidentiality-in-healthcare-for-PLHIV.pdf">privacy</a>, <a href="http://www.tht.org.uk/our-charity/Campaign/Our-social-policies/Stigma-and-discrimination">stigma and discrimination</a>, and implications for <a href="http://www.nursingtimes.net/whats-new-in-nursing/acute-care/nurses-with-hiv-fear-and-loathing-on-the-frontline/5005832.article">jobs</a> and <a href="http://www.tht.org.uk/myhiv/Telling-people/Healthcare-and-insurance">health insurance</a> – and others are unable to consent because they lack the capacity to do so or because they are dead. Whenever a patient refuses or is unable to consent to a blood test in such circumstances, a plethora of <a href="http://www.bbc.co.uk/radio4/science/ethicscommittee_20070912.shtml">ethical, legal and professional conundrums</a> arise.</p>
<h2>Just say yes</h2>
<p>Let us take the “alive and kicking” patient first. Ethically, one could argue such patients ought to consent to a blood test for a number of reasons. First, the healthcare professional was placed in a risky situation because they were trying to help the patient and so principles of reciprocity, justice and gratitude come into play. Second, the harm to the patient from testing is reasonably small (though not negligible) and the benefit to the healthcare professional (less stress and, potentially, less need to take toxic prophylactic drugs) is reasonably high and so the risk-benefit analysis is favourable. Third, the healthcare professionals’ right to life and health suggest patients have a duty to help if they can.</p>
<p>These kind of arguments will be persusaive to many – which probably explains why most people consent when asked. On the other hand, they do not provide sufficient reason to actually test blood in face of a refusal from a competent patient. This is because it is a fundamental principle of healthcare ethics that competent patients (with very few exceptions) have a <a href="http://virtualmentor.ama-assn.org/2010/06/ccas2-1006.html">right to refuse</a> any examination, procedure, investigation or treatment. </p>
<p>This principle primarily rests on the claim that it is vitally important to protect the rights, autonomy and bodily integrity of patients – especially given the long history of misplaced paternalism in medicine. But it is also based on the need to ensure that patients trust their doctors. For these reasons the right of competent patients to refuse testing is enshrined both in law and in the <a href="http://www.gmc-uk.org/guidance/ethical_guidance/21181.asp">professional guidance</a> issued by the General Medical Council (GMC).</p>
<h2>Eyes wide shut</h2>
<p>But what if the patient is incompetent? If the patient is likely to (re)gain capacity very quickly the sensible option is to <a href="http://www.ncbi.nlm.nih.gov/pubmed/21478425">delay testing</a>. But what if the patient is never likely to (re)gain capacity or is not likely to do so <a href="http://www.bhiva.org/documents/Guidelines/PEPSE/PEPSE2011.pdf">sufficiently quickly</a>? In such circumstances, should healthcare professionals be able to test blood without consent? </p>
<p>It is possible to argue that the very same ethical arguments that provide reasons for thinking patients should consent still apply, and, furthermore, that it is reasonable to test blood on the basis that most patients who have capacity do consent to have their blood taken. But this is moral quicksand. Unless the patient has previously stated their wishes it is impossible to know what they would want to happen now that they no longer have capacity. Simply assuming that the patient would have been a “<a href="http://www.ncbi.nlm.nih.gov/pubmed/17991253">good egg</a>” is <a href="http://www.ncbi.nlm.nih.gov/pubmed/19032307">naïve</a>. Testing without consent is also problematic because patients who lack capacity are vulnerable and are especially prone to being used as mere means to other people’s ends. </p>
<p>Interestingly, the GMC previously supported the testing of blood without consent in <a href="http://www.gmc-uk.org/serious_communicable_diseases_1997.pdf_25416216.pdf">exceptional situations</a>. But following the introduction of the <a href="http://www.legislation.gov.uk/ukpga/2004/30/contents">Human Tissue Act 2004</a> and the <a href="http://www.legislation.gov.uk/ukpga/2005/9/contents">Mental Capacity Act 2005</a> the GMC <a href="http://www.gmc-uk.org/guidance/update_serious_communicable_diseases.asp">changed its guidance</a> to make it abundantly clear that, in their eyes, “current law does not permit the testing the infection status of an incapacitated patient solely for the benefit of a healthcare worker”. It is also worth noting that when this question was recently raised in parliament the <a href="http://www.saferneedles.org.uk/?page=41&id=112">response from the government</a> was that testing in such a situation could only be done if it was in the patient’s best interests.</p>
<h2>Sickness unto Death</h2>
<p>So what if the patient has died in the intervening time since the accidental exposure occurred? This may seems a little fanciful, but such injuries often happen during resuscitation or in intensive care or during emergency surgery – that is, in situations when patients can die quite suddenly.</p>
<p>Where the patient has died, the ethical analysis certainly shifts because there is widespread consensus that the dead have <a href="http://jme.bmj.com/content/29/3/130.full">fewer interests</a> than the living. Indeed, some argue that the dead have no interests at all. But we the living do have some interest in what happens to our bodies after we die (especially if we hold certain <a href="http://www.funeralwise.com/customs/islam/">religious beliefs</a>). And most of us care about what happens to the bodies of our loved ones, as the response to the <a href="http://www.theguardian.com/uk/2004/aug/06/health.alderhey">Alder Hay organ-retention “scandal”</a> clearly demonstrates. Still, whether these interests outweigh the interests of living healthcare professionals who might benefit significantly if the tissue samples of the dead were tested, seems very debatable.</p>
<p>The GMC used to state that healthcare professionals could test a dead patient’s blood if there was good reason to think that they had a serious infectious disease and if a healthcare worker had been exposed, but this <a href="http://www.gmc-uk.org/serious_communicable_diseases_1997.pdf_25416216.pdf">guidance has now been withdrawn</a>. This is because the <a href="http://www.medicalprotection.org/england-factsheet-needlestick-injuries.pdf">law now states</a> that the testing of tissue samples from the deceased for the benefit of healthcare professionals is only acceptable if the patient consented before they died or if the patient had not declared a preference either way <em>and</em> a relative or friend is happy for this to occur. </p>
<p>When I experienced my needlestick near-miss I happened to be reading Kierkegaard’s Sickness unto Death. This did not help my morbid state of mind during those moments of barely controlled panic and it may be argued that my response was melodramatic. But it is important to realise that healthcare professionals who are accidentally exposed to patient’s bodily fluids often suffer <a href="https://www.som.org.uk/news/media-releases/single-media/article/healthcare-and-other-workers-at-risk-of-psychiatric-trauma-from-needlestick-injuries-shows-new-resea/">significant amounts of anxiety</a> while they await the “outcome” of the incident. They also belong to the same moral community as the patients that they are trying to help. </p>
<p>This does not mean living patients should be tested without their consent, but it does mean that there ought to be a presumption in favour of testing where the will of a recently deceased patient is unknown.</p><img src="https://counter.theconversation.com/content/19700/count.gif" alt="The Conversation" width="1" height="1" />
It was late on a Friday afternoon in November. I was a 21 year-old medical student diligently waiting for an opportunity to practice some medical procedures when a patient was admitted who was happy for…Carwyn Hooper, Lecturer in Medical Ethics and Law, St George's, University of LondonLicensed as Creative Commons – attribution, no derivatives.