FEAR OF INJECTIONS IN YOUNG ADULTS: PREVALENCE AND ASSOCIATIONS

INTRODUCTION

Broadly defined, the fear of injections has been associated with fear of needles, hospitals, surgical operations, wounds, pain, doctors, and dentists. Most research in this area has focused on injection phobia, which is the more dramatic form of this type of anxiety.^1–5 A recent study estimated the lifetime prevalence of this phobia in the American population at 3.5% and the median age of onset at 5.5 yr.⁶ The phenomenon of injection-injury phobia was found to be more common in females and lower in the elderly. Unpublished observations at our travel health clinic led us to the hypothesis that the prevalence of fear of injections is substantially higher. In addition, we found little published data, either quantitative or qualitative, on the epidemiology, causes, and associations of fear of injections.

Injection phobia can be a major impediment to the provision of important health care measures, e.g., vaccinations, blood donations, and preparation for intravenous infusions.⁷ A recent study among Irish mothers found that barriers to uptake of the Haemophilus influenza vaccine included a fear of vaccine overload and distress at separate injections.⁸ This fear may include health care personnel as well.⁹ Fear of injections may lead to syncopal attacks, with dire consequences.^10,11 Identification of the specific factors associated with fear of injections could, for example, improve planning of the workspace and procedures inside vaccination clinics¹² and, ultimately, increase the acceptance of vaccinations.

According to data provided by the World Tourism Organization, more than 50 million travelers visit tropical countries each year.¹³ These travelers are advised to take multiple vaccinations before travel. As such, this population appears to be an almost-unbiased sample for the study of injection phobia. The characteristics of this type of population and its attitude toward injections in general, and multiple vaccinations in particular, have never been explored.

MATERIALS AND METHODS

RESULTS

Altogether, 400 travelers participated in the study (95% response rate). Their median age was 25 (range, 11–80), and slightly more than half (54.3%) were men. Their baseline demographics are given in Table 1. Most of the travelers went to Southeast Asia (70%), and smaller proportions (20%) to South America and Africa (5%). Eighty-five travelers (21.7%; 95% confidence interval [CI], 17.3–25.6%) indicated that they were afraid of injections, and seven of these (8.2%; 95% CI, 3.4–16.2%) said the fear was of an unreasonable magnitude (1.75% of the entire cohort). No travelers included in this study fainted during or after their vaccinations. All those who filled out the questionnaires received injections.

Univariate analysis of the factors associated with the fear of injections revealed a significant association with 10 variables (Table 2). Overall, females were more afraid than males, and older people were less afraid than young people. Multivariate analysis revealed that four parameters were highly and independently associated with injection phobia (Table 3): watching other people get injections, fear of pain, size of the needle, and a history of fainting. The sensitivity, specificity, and discrimination accuracy of this model were 79.5%, 78.0%, and 78.3%, respectively.

Univariate analysis of factors associated with past fainting revealed eight variables to be highly significant (Table 4). Multivariate analysis showed that fear of needles, unreasonable fear (subjective), and a bad past experience with injections were all independently and positively associated with fainting (P < 0.0001). Among those with a past history of fainting, the percentage of subjects afraid of needles was more than double than among those not afraid (Figure 1). In contrast, empathy shown by the medical team was significantly but inversely associated with fainting (P < 0.0001). The sensitivity, specificity, and discrimination accuracy of this model in predicting fainting were 72.2%, 82.1%, and 81.4%, respectively.

Subjective scoring by the travelers of vaccination-associated parameters revealed that they considered the protection afforded by the vaccines to be the most important factor (4.9 ± 0.5; mean ±S.D., on a scale of 0–5), followed by the length of protection (4.4 ± 0.9) and empathy shown by the medical team (3.8 ± 1.2). Saving money was the least important factor (3.3 ± 1.6).

We found that demographic factors such as being a medical staff member (P = 0.3), being a regular injector (P = 0.7), or previous hospitalization (P = 0.6) were insignificant predictors of fear of injections.

Our travelers expected to receive a mean (±SD) of 2.7 ± 1.5 injections during their visit, and actually received 2.9 ± 1.0 injections (range, 1–5; P = 0.06). The same mean figure of 2.7 injections per day was considered a reasonable number. A combination vaccine would have encouraged 85.3% of the travelers to receive vaccinations before travel, and 92.5% believed that a combination vaccine might ease completion of the necessary vaccine series. Of six potential predictors of a positive attitude toward combination vaccines—age, sex, education, being a member of a medical staff, fear of injections, and past fainting—none was significantly associated with such an attitude.

DISCUSSION

To elucidate the frequency and associations of variables influencing injection phobia, we conducted a survey of a large cohort of travelers attending our travel clinic. The questionnaire responses revealed that more than a fifth of them had fear of injections, and that of those who were afraid, 8.2% had a fear that was of unreasonable magnitude. These figures reflect higher rates than previously estimated² but agree with a recent study among children.¹² Yet both figures may represent an underestimation, as phobic patients tend to avoid the phobic stimulus, and travelers with the highest degree of fear could travel without vaccination.¹⁴ The high rate of injection phobia that we found fits our hypothesis that the rate is substantial and in accordance with those found in dental clinics around the world.^15,16

Reducing the fear of injections may have an enormous impact. About 12 billion injections are administered each year.^17,18 Every year, about 100 million children receive routine immunizations;¹⁹ this is the age group in which fear of injections is highest. In addition, 50 million people travel to developing countries each year and thus require vaccinations. Low vaccination coverage among travelers has been associated with international spread of potentially lethal diseases.²⁰ In addition, morbidity and mortality have been associated with lack of typhoid vaccine among travelers to Nepal,¹⁴ tickborne encephalitis among U.S. military forces deployed in Bosnia,²¹ and meningococcal disease among Hajj pilgrims.²² Other fields that may be affected by fear of injections are blood donations,²³ blood sampling for routine tests, and preparation for intravenous infusion lines.

Our observations suggest that certain architectural and behavioral variables within travel clinics can be optimized to reduce the fear of injections. First, the vaccination corner should be separated from the waiting area, as vaccinees are significantly influenced by watching other people receive their vaccines. The curtain used in our setting may have performed inadequately, as it did not block out voices. Second, the nurse should attempt to conceal the preparation of the vaccine from the vaccinee, particularly from those who are prone to be afraid. In a study performed at a dental clinic in Germany, 47% of the respondents considered the sight of the injection needle fear-provoking.²⁴ Practically, however, this suggestion may be difficult to apply, as the nurse starts to prepare the syringe after the traveler has entered the vaccination area. Fear of pain can be minimized by prior application of an anesthetic patch containing lidocaine/prilocaine to the skin. A question regarding any history of fainting should be incorporated into travel clinic questionnaires to help sort out those who might suffer another vasovagal syncope.

Vaccinations are often taken poorly, even by hospital staff members.^9,25 The development of combination vaccines, so that fewer injections would be required, would provide an elegant and effective solution to this problem.^26,27 Our travelers received 1–5 vaccinations at their first visit. The great majority of them (92.5%) believed that a combination vaccine might ease the completion of the necessary vaccine series. The present study is thus another call to boost the development of such vaccines.

Health care professionals regard injections as routine, yet for other individuals, they arouse anxiety. We believe that future studies should address the issues of how to diminish this fear. Tentative avenues include allowing a relative or friend to enter the vaccination room, using distraction devices such as music or television, using topical analgesics, and psychotherapy.