Needle Fears and Phobias: The “Last Mile” Problem in Medical Organizations

Medical practice leaders and managers must address not only the health of patients but also the health and wellbeing of their employees. During epidemics and pandemics such as COVID-19, leaders and managers are called upon to address the health of independent contractors, locums, and vendors, because infectious diseases spread from human to human regardless of the relationship of a human host to the organization. The battle to eradicate and contain the spread of infectious diseases is fought on several fronts, including mass vaccination campaigns.

Vaccination campaigns are deployed to fight not only deadly new diseases such as COVID-19, but also endemic infectious diseases such as influenza and measles, both of which also can be deadly.

Vaccine Hesitancy: Fear of Needles

The government, healthcare industry, and mass media are all focused on reducing vaccine hesitancy. Vaccine hesitancy exists along a continuum from “vaccine ready” to “vaccine neutral” to “vaccine resistant.”(1) The prevalence of vaccine resistance (i.e., unlikely to get vaccinated) among healthcare workers has been proven to be 11%.(1) Several forces drive vaccine hesitancy, including fear of needles.(2) The popular press is beginning to highlight fear of needles as an underrecognized obstacle to establishing herd immunity.(3)

Needle fears and phobias are more common than most would imagine. Needle fears and phobias among adults initially do not appear to be a significant problem because few adults admit to suffering from needle phobia, and avoidance is the cardinal sign of needle phobia. This means that healthcare workers underestimate the problem because those with needle phobias do not show up for any appointment or procedure that is likely to involve needles. Therefore, it appears at first that there is no problem, but epidemiologic evidence shows that there is one.

Epidemiology of Needle Phobia and Fears

The prevalence of needle phobia in the general population ranges from 3.5% to 20%.(4) This indicates that 11.5 to 66 million Americans suffer from needle phobia. Turning our attention to the healthcare workforce, it is estimated that more than 1 in 4 hospital employees (27%) and about 1 in 12 (8%) of healthcare workers at hospitals avoided the influenza vaccination.(5)

Shame and Stigma

Not only is needle phobia underrecognized, but shame and stigma also are associated with this obstacle to getting vaccinated.(6) One of my patients told me that she told a nurse before getting her first COVID-19 vaccination that she was afraid of needles. The nurse chastised and embarrassed this 29-year-old woman by telling her to “stop acting like a baby.” One of my physician colleagues who discovered I was writing a book on needle phobia confidentially told me of his fear of needles and said he would have to look for another employer if the hospital adopted a mandatory vaccination policy because he would be too embarrassed to admit that he suffers from needle phobia—particularly as a physician. In both cases, these individuals are not politically, ideologically, or religiously opposed to vaccinations, but they are scared. When you are scared, you avoid that which frightens you. What about your patients, your employees, and your colleagues? What are you proactively and compassionately doing in your medical practice to identify and then address the fears and phobias of your fellow workers and your patients?

Approach to Identifying, Managing, and Treating Needle Fears and Phobias

The first step in managing these fears is to assume that the prevalence rate of needle phobia in your organization and among your patient population is the same as national estimates, unless you have data to the contrary. It is beyond the scope of this article to pinpoint the ethical challenges associated with soliciting information regarding vaccination status, vaccination documentation, and whether an individual employee or patient is avoiding getting vaccinated due to an underlying fear of needles. You do not have to know the prevalence rate of this fear in your own organization, however, to offer information, education, resources, and support similar to other worksite wellness programs.

Determine whether your existing internal or contracted programs and services offer information, education, resources, and support focused on fear of needles and needle phobia.

The second step is to determine whether your existing internal or contracted programs and services offer information, education, resources, and support focused on fear of needles and needle phobia. Internal programs and services that may offer such help include occupational health and safety; human resources; training and development; patient education and counseling; and medical affairs. External or contracted programs and services that may offer such assistance include the Employee Assistance Program (EAP) and the worksite wellness program.

The third step is to design and deliver a focused campaign seeking to direct individual employees and patients to the support that they need to overcome their fear of needles in a way that is respectful and compassionate. The ideal program design should follow Prochaska’s stages of change model, because getting vaccinated is a behavior (Figure 1).(7)

Figure 1. Prochaska’s stages of change model.(7)

Each of these stages is described in the following sections with an application to moving individual employees and patients to the act of getting vaccinated:

1. Precontemplation (I won’t; I can’t): Precontemplation is the stage at which individuals do not intend to change their behavior in the near future. For many, they lack credible information to guide their behavior. Among individuals in this stage, there are two types: I won’t, and I can’t. Those falling under the “I won’t” type willfully refuse to accept information pinpointing health risks and the necessity of vaccination. The other type, “I can’t,” includes those individuals who acknowledge the health risks and necessity of vaccination but cannot make it happen due to internal or external barriers. Intervention: Provide information about the advantages and disadvantages of getting vaccinated as well as the pros and cons of maintaining the status quo. Then, provide information about needle fears and phobias. Share the information that needle fears and phobias can be managed and treated. Key messages should focus on vaccine efficacy, and how to reduce common side effects such as pain at the injection site.(8)

2. Contemplation (I may): Contemplation is the stage in which individuals are aware that a problem exists and are genuinely considering beating it but have not yet decided to act. Intervention: Identify obstacles beyond needle fears and phobias while at the same time addressing concerns about getting vaccinated. In addition, assess coping resources and other support systems to make getting vaccinated more tolerable. Assess readiness for change. Do not focus on financial incentives, given recent evidence demonstrating that financial incentives fail to boost vaccination willingness at all income levels.(8)

3. Preparation (I will): Preparation is a stage that includes both intention and a commitment to act. This behavioral commitment typically will translate into action within a month. Intervention: Write down realistic goals followed by a timeline of all activities related to getting vaccinated. Reach out to support system if needed. Practice self-comfort tools such as Applied Tension Technique and positive self-talk to make your vaccination experience more tolerable. Develop realistic goals and timeline as well as provide positive reinforcement. To move an individual employee or patient from preparation to action may involve offering some type of exposure therapy. Exposure therapy is the gold standard for treating needle phobia.(9) One-session treatment for individuals(10) and large groups(11) has demonstrated clinical efficacy. Check to see if your EAP, worksite wellness program, or occupational health and safety program offers exposure therapy or can make a referral.

4. Action (I am): Action is the stage in which individuals change their behavior to beat their problems. Action involves the most explicit behavioral changes and necessitates a significant amount of time and energy. Intervention: Seek out social support if needed. Encourage individual employees or patients to assert themselves by letting others know that they may need more time and more compassion. Remind them to implement their comfort tools to make the vaccination experience more tolerable. Then, encourage them to treat themselves after getting vaccinated.

5. Maintenance (I still am): Maintenance is the stage in which individuals work to continue the behavior over time and, if appropriate, across different settings. Intervention: Remind the individual employee or patient to recall how they met the challenge before. Encourage them to engage in self talk to energize themselves toward repeating the same or similar behavior in the same or similar setting. Finally, remind them to connect with their support system to let them know that they may be calling upon them again.

Conclusion

The path to herd immunity for COVID-19 and toward making healthcare workplaces safer during the annual influenza season is filled with many obstacles, including needle fear and phobia. Effective and ethical leadership demands that obstacles be identified and removed to reach organizational goals and objectives. In the case of infectious diseases marked by excess morbidity and mortality, organizational goals are tightly coupled with societal and community goals. Launch your organizational campaign to remove the obstacle of needle fears and phobias by proactively offering information, resources, tools, and support now. Each day that leaders and managers choose to keep needle fears and phobias “in the closet,” the risk of infection, morbidity and mortality continues.

References

1. Ratzan S, Schneider EC, Hatch H, Cacchione J. Missing the point—how primary care can overcome COVID-19 vaccine “hesitancy.” N Engl J Med. 2021; 384:e100. doi: 10.1056/NEJMp2106137 

2. Thomson OP, MacMillan A, Draper-Rodi J, et al. Opposing vaccine hesitancy during the COVID-19 pandemic—a critical commentary and united statement of an international osteopathic research community. Int J Osteopath Med. 2021;39. www.journalof​osteopathicmedicine.com/article/S1746-0689(21)00005-5/fulltext . doi: 10.1016/j.ijosm.2021.02.002

3. McMurty CM. Needle fear is an underrecognized vaccination challenge. The New York Times. May 21, 2021. www.nytimes.com/2021/05/21/opinion/needle-fear-vaccine-covid.html .

4. Love AS, Love RJ. Considering needle phobia among adult patients during mass COVID-19 vaccinations. J Prim Care Community Health. 2021;12:1-4. doi.org/10.1177/21501327211007393

5. McLenon J, Rogers MAM. The fear of needles: a systematic review and meta-analysis. J Adv Nurs. 2019;75(1):30-42. doi: 10.1111/jan.13818

6. Kaplan RM. Stop taking shots at those who fear them. The Wall Street Journal. April 8, 2021. www.wsj.com/articles/stop-taking-shots-at-those-who-fear-them-11617920512 .

7. Norcross JC, Krebs PM, Prochaska JO. Stages of change. J Clin Psychol. 2011;67(2):143-154.

8. Kreps S, Dasgupta N, Brownstein JS, et al. Public attitudes toward COVID-19 vaccination: the role of vaccine attributes, incentives, and misinformation. NPJ Vaccines. 2021;6(1):73. doi: 10.1038/s41541-021-00335-2

9. Choy Y, Fyer AJ, Lipsitz JD. Treatment of specific phobia in adults. Clin Psychol Rev. 2007; 27:266-286. doi: 10.1016/j.cpr.2006.10.002

10. Öst LG, Sterner U, Fellenius J. Applied tension, applied relaxation, and the combination in the treatment of blood phobia. Behav Res Ther. 1989;27:109-121. doi: 10.1016/0005-7967(89)90069-7

11. Wannemueller A, Fasbender A, Kampmann Z, et al. J. Large-group one-session treatment: a feasibility study of exposure combined with applied tension or diaphragmatic breathing in highly blood-injury-injection fearful individuals. Front Psychol. 2018;9:1534.