Damian Sendler: Some chronic diseases may necessitate frequent and long-term needle exposure in patients, and this may be a necessary part of treatment or even life support for some. Haemodialysis patients with kidney failure require an average of 6 large-bore needle insertions per week, or at least 312 insertions per year. Multiple injections, infusions, and blood tests are also required for chemotherapy or insulin treatments.
Damian Jacob Sendler:Needle apprehension is a common deterrent to medical care [1–3]. There is a wide range of needle phobias, from mild discomfort to full-blown apprehension [4]. In the Netherlands, 16.1 percent of the general adult population was found to be afraid of injections [5]. Adults in the Netherlands, South Korea, Sweden and the United States all have needle phobia. Females are more likely to suffer from needle phobia and needle fear than men [9–11]. These include desensitization therapy [12] and techniques to counteract vasovagal syncope, such as tense muscles [13]. There are a number of approaches that can be used to help people overcome more severe needle phobias or anxieties. Individuals with high levels of needle apprehension have previously been recommended for exposure-based interventions [4]. Patients who are willing to put up with needle discomfort as a cost of survival are likely to underreport it. In clinical care, it is not systematically measured; as a result, it is under-recognized, making management difficult for both clinicians and patients.
Dr. Sendler: Needle fear and its treatment have been studied mostly in children [14, 15] or infrequently exposed populations such as the ones undergoing dental procedures [12] and vaccinations [16, 17]. Given the rising prevalence of chronic diseases around the world[18, 20] and the need to assist clinicians in the treatment of this cohort, we synthesized the literature on the prevalence and management of needle phobia.
Among adults who had previously or currently received chemotherapy, the prevalence of needle phobia ranged from 17% to 52% [2, 24–26]. (Table 2, section 1a). There have been two studies looking at people’s reactions to blood and injections, and both found that 21/124 (17%) and 36/197 (18%) reported needle fear. The Blood-Injection Symptom Scale (BISS) [26], the Blood-Injection Injury Scale [25], and a semi-structured interview [2] were all self-report measures of ‘needle fear.’ Needle phobia was defined as a visual analogue scale anxiety, fear, aversion, and stress score of 5 [24].
Table 2, section 1b, shows that 25–47% of adults undergoing peritoneal dialysis or haemodialysis [1, 28–30] reported needle phobia. In the pilot study conducted by Mulder et al. [29] to validate the Dialysis Fear of Injection Questionnaire (DFIQ) in haemodialysis patients, 20/45 (44 percent) of the participants reported a fear of injection needles. Participants in the validation component (n = 86) reported feeling scared, nervous, or worried the “moment the nurse comes to insert the needle” in 22/86 (26 percent), 36/86 (41 percent), or worried in 28/86 (33 percent) of the cases.
A total of 198/551 peritoneal dialysis and haemodialysis patients (36%) and 73/208 (37%) indicated that they had needle fear in response to two questions administered by the researchers [30]. More than a quarter of those who refused haemodialysis cited their fear of needles and complications as a factor [1]. More than half of those surveyed (81/173, or 47 percent) said they were afraid of needles, according to a questionnaire developed by researchers [28]. 11/73 (15 percent) of haemodialysis patients interviewed in person stated that they were unable to get an arteriovenous fistula created because of a fear of needles [33].
Using the D-FISQ (Diabetes Fear of Injecting and Self-testing Questionnaire), researchers were able to estimate the percentage of adults with insulin-treated diabetes who were afraid to inject themselves (Table 2, section 1c) between 0.2% and 43%. D-FISQ scores were higher in patients with severe anxiety, as measured by the State Anxiety Scale (SAS), in 350 diabetics [36]. When searching for articles on the prevalence of needle fear, injection phobia or blood-injury-injection phobia, a literature review abstract found that 28 percent of insulin injection recipients had needle phobia [38].
Six percent of insulin-users scored 3 on the Barriers to Diabetes Questionnaire items “I am afraid of injecting myself” and “I am afraid to prick my finger,” indicating “serious problems” with needles. Patients with type 2 diabetes were surveyed via face-to-face interviews to determine the prevalence of primary non-adherence with insulin and the barriers to insulin initiation. 105/225 participants in this study were found to have delayed insulin treatment by 47 percent. As many as one in three patients (37/105) had needle phobia because they were afraid of the pain. Patients with Type 2 diabetes who received injectable antidiabetic therapies (IAT) were found to be afraid of injections, with 185/500 (37 percent) reporting that they felt fear when thinking about a needle. Fear of injection was cited by 67 percent of Endocrinologists in a survey of 200 physicians, according to the study.
Seventy-seven percent of Type 2 diabetics interviewed said they avoided insulin therapy because they feared the pain it would cause them. Of the 32 patients who refused insulin despite medical advice, this number rose to eighty percent (70%). “Needle phobia” was the most common negative attitude toward starting insulin in 205/293 (70 percent) of patients with type 1 diabetes who completed the Chinese Attitudes to Taking Insulin Questionnaire. An author-created questionnaire found that 33% of insulin-treated patients (115/115) had high injection anxiety scores, 14% had avoided injections, and 42% said they would be “troubled by more frequent injections” [43].
35–53 percent of diabetics who had never used insulin reported fear of self-injection or anticipation of pain during injections [3, 39]. No insulin was given to 56/200 (28%) of the non-insulin-dependent type 2 diabetes patients because of concerns about pain and a “inability to take” daily needling for 50% of the patients (although it is unclear whether this was due to distress or anxiety) [41]. More than one in three diabetic patients who initially refused insulin or were given it by a doctor said they were afraid of needles. 218/243 (90 percent) of unwilling diabetics were afraid of needles, compared with 130/225 (58 percent) of willing diabetics [52]. Based on results from The Fear Questionnaire [54], fewer blood glucose readings were taken and glycemic control was worse in patients with type 1 diabetes who were fearful of blood and injury [35].
One RCT of 25 adult chemotherapy patients [24], a report of a treatment protocol [27], a cross-sectional survey of 208 breast cancer patients [2], two case reports [31 and 48], a recommendation report [32] and a narrative report [49] were among the eight sources that discussed needle fear management.
A study by Kettwich et al. [24] included a stress-reducing needle and syringe (decorated barrel with colorful glitter stickers) in the chemotherapy treatment of 25 adults (Table 2, Section 1a). Anxiety, aversion, fear and overall stress were measured using a visual analogue scale of 0–10, with higher scores indicating greater fear. Before the intervention, 52% of the sample had a fear of butterfly needles (determined by a score of 5 or more). Using stress-relieving devices on this group resulted in a 92 percent (P0.001) reduction in aversion, anxiety, fear, and overall stress; however, no further data were collected.
It was found that stress management techniques like mindful moist mouth, stress balls, and progressive muscle relaxation can help patients undergoing intravenous chemotherapy cope with their stress [27]. Aside from medication and caregiver presence, other “anxiety control strategies” included safety behaviors (e.g. taking a break during procedures and distracting yourself with something else). Health professionals’ “discomfort warnings” contributed to patients’ discomfort, as noted by authors in their study There was no evaluation of strategies.
According to Cox & Fallowfield [2,] the treatment environment (e.g. room, bed, chair) should be “varierated” by the nursing staff in order to keep patients distracted and avoid needle anxiety before chemotherapy; however, implementation and evaluation were not carried out in this case.
Damian Sendler
Rapid desensitization and exposure were used in three sessions to help a 64-year-old dialysis patient who was afraid of needles get over his fear [31]. Lie down in a reclined position, keep your facial muscles and arms tense, and imagine a situation that makes you angry. Changes in blood pressure and pulse were observed as a result of biofeedback monitoring of blood pressure and pulse. A therapist used imaginal exposure to simulate needling. At other times, the patient was in charge of the twice-daily exposure tasks.
British Renal Society guidelines for dealing with patient needle anxiety were based on the consensus opinion of 15 nurses from 13 UK dialysis units and research evidence, where applicable [32]. [32] There was a wide range of suggestions for preparing patients for needling, desensitization, written arteriovenous access plans, visual routines, relaxation, and a calm environment included. Though not described in detail, listening, trusting one’s patients with one another, and using coping strategies were all emphasized by the authors.
In a study by Feitosa et al. [34], nurses, endocrinologists, dieticians, and obstetricians examined the impact of a multidisciplinary diabetes education program on the fear of self-injecting and testing in 65 pregnant women with pre- or gestational diabetes who were taking insulin during pregnancy. Hyperglycemia, diet, and lifestyle were all addressed, as was instruction in blood glucose self-monitoring and insulin injection administration. A brief D-FISQ was completed by women at their initial check-up and again within the final two weeks of pregnancy or shortly after delivery. 43.1 percent of pre-intervention participants reported having needle phobia. There were no specific strategies for needle fear in the intervention, but fear of self-injection decreased from 39 percent to 13 percent (p = 0.001) and fear of self-testing decreased from 28 percent to 14 percent (p 0.012). As a result of the study, women with pre-gestational diabetes who were afraid of self-injection and blood glucose testing decreased from 40% and 33%, respectively, to 15% and 15%. (not statistically significant).
Damian Jacob Markiewicz Sendler: Patients with “severe fear” (undefined) can be informed of alternative insulin pumps or desensitization techniques by a “behaviour counsellor” (undefined) as a way to address needle fear as a barrier to insulin use [49]. Behavioral modification techniques, topical anesthetic cream, anxiety education, pre-medication, and alternative therapies (no-needle jet injection devices) [48] were all used to manage a 33-year-old diabetic woman.
This study found that adults with cancer, diabetes, or kidney failure have a high prevalence of needle phobia and distress. A wide range of scientific methods, from non-evidence-based recommendations to a single randomised controlled trial, were used to identify 32 different heterogeneous articles. In adults with chronic diseases, only eight studies have addressed the management of needle fear. These were even less detailed in terms of strategies, such as when and how often they should be delivered, or how they should be evaluated. As a result, there is a lack of evidence that this issue is critical for patient well-being, where refusal or avoidance of treatments can lead to a lower quality of life, shorter lifespan, or death. When it comes to treatment avoidance among these groups, needle fear is frequently mentioned [1–3]. However, high-quality evidence of strategies or interventions is needed in clinical care to better manage this problem.
The prevalence of needle phobia in patients with diabetes, cancer, and kidney failure ranges from 0.2 to 80 percent, from 17 to 52 percent, and from 25 to 47 percent, according to various studies. Because of differences in demographics, frequency of medical procedures, or patient characteristics, needle fear may be more prevalent in certain populations [9, 24]. When it comes to measuring needle apprehension, there are many different ways to do it. Both the D-FISQ and the DFIQ have been used to assess fear of injection and self-testing in diabetics and kidney failure patients, respectively (see e.g. 29; 34; 36; 42; 45; 46; 53). These include psychometric self-report tools [25–26], investigator-created surveys [1, 28, 30, 41, 50–52], and face-to-face interviews [2, 33–40]. When it comes to needle phobia, self-report measures were used rather than a formal diagnostic assessment [2, 24, 28, 51].
Damian Jacob Sendler
There is a clear need for validated patient-reported measures in chronic disease cohorts where needle exposure is high to screen for needle fear on a regular basis based on the prevalence estimates. Where possible, needle fear assessment measures, like the D-FISQ, should be used in the context of a therapy program. As needle fear is linked to treatment refusal, screening may be warranted prior to treatment initiation or in the early weeks and months of therapy when fear appears elevated [1, 42, 43, 55]. [1, 33, 40, 44, 52] There may be an opportunity to educate and intervene early on if patients’ fears or misconceptions about therapy can be identified early on. Preventing complications and reducing stress for patients is likely to result from this. Simple questions about a patient’s preferences for treatment, including how they feel about needles, can help validate their fears and open a dialogue about how those fears can be managed when standardized measures aren’t available or feasible.
Damien Sendler: Fear of needles can range from mild to severe enough to be diagnosed as a phobia by a medical professional [56]. As a result, the authors in this review rarely made the distinction between fear of needles, fear of needle pain, and a diagnosed anxiety disorder like a phobia. Management can range from simple, targeted interventions to an intensive psychological treatment program, in accordance with the continuum of distress. Those with a medically documented fear of needles will need the latter, which can only be administered by a qualified clinician such as a psychologist or psychiatrist. Selected peer-reviewed studies included in this scoping review found evidence of the effectiveness of exposure therapy and desensitization therapy for such individuals, but there was no evidence of their use in conjunction with other chronic disease therapies, nor were there any studies that evaluated the efficacy in the context of these therapies.
Patients with a mild to moderate fear of needles may benefit from cognitive behavioral therapy that incorporates relaxation and cognitive restructuring techniques as well as educational programs. It was found that stress management, distraction, and relaxation were all effective methods for reducing fear [2, 27, 32]. Only one study described a formal evaluation of an educational program that resulted in a reduction in needle distress, even though it did not include targeted interventions for this [34]. The use of different needling devices and the provision of non-needle treatments were also suggested as therapeutic modifications [2, 24, 49]. A lack of high-quality evidence for intervention protocols to prevent or alleviate needle fear among adults with chronic disease has been identified in the current review, with little to no replication of findings. These findings may be due to the fact that healthcare providers fail to recognize patients’ needle distress and fail to conduct systematic screening. Pain and needle phobia were frequently found to be intertwined in certain individuals.
Chronic disease therapies necessitate a thorough examination of needle apprehension over time and the development of interventions tailored to the specific context and features.
Research articles on the fear of needles in patients afflicted by arthritis, asthma or other chronic conditions were not found in this review. In addition, these patients may necessitate regular blood draws as part of their clinical evaluation. Furthermore, invasive procedures performed in the hospital may be necessary. Future studies on needle phobia should include these patients as well.
