The Impact of Injection Anxiety on Education of Travelers About Common Travel Risks
Despite many travelers receiving at least one vaccination during the pre-travel consultation, little is known about travelers' fear of injections and the impact this may have on educating travelers about health risks associated with their trip. This study aimed to investigate: (1) the prevalence of injection anxiety in travelers attending a pre-travel consultation, (2) whether anxiety due to anticipating a vaccination adversely affects recall of information and advice, and (3) whether clinicians can recognize travelers' anxiety, and how they respond to anxious travelers.
Consecutive adult travelers (N = 105) attending one of two inner-city travel clinics completed self-report measures of state anxiety, injection anxiety, and symptoms of needle phobia immediately before and after their pre-travel consultation. Clinicians were also asked to rate travelers' anxiety and report any anxiety management strategies. Standardized information was presented during the consultation and recall of information and advice was assessed immediately post-consultation. Delayed recall (24 hours) was assessed for a subsample (20%) of participants.
More than one third of travelers reported feeling nervous or afraid when having an injection (39%). Travelers' state anxiety was related to their psychological and physiological reactions to needles, and reduced significantly post-consultation. Recall of information and advice varied, with failure of recall ranging from 2 to 70% across 15 items, and delayed recall being significantly lower. No relationship was found between recall and anxiety. Clinician-rated anxiety moderately correlated with travelers' self-reported anxiety.
A significant proportion of travelers experienced injection anxiety when attending the pre-travel consultation, with some travelers reporting symptoms consistent with criteria for Blood Injection Injury phobia. There were important gaps in recall of information and advice about common travel risks. Although no relationship was found between recall and anxiety, this may have been due to the sample and setting.
Injection anxiety occurs when an individual experiences excessive fear in response to the anticipation or experience of having an injection. It is characterized by both psychological and physiological reactions (eg, feeling nervous, feeling disgust, and fainting). At the extreme end of the spectrum, fear of injections is classified as a specific phobia in the category of Blood Injection Injury phobias, where a person experiences fear, recognized to be excessive, in response to stimuli related to blood, injury, injections, or other invasive medical procedures. The term “needle phobia” is also used, which includes fear of injections and other medical procedures involving needles. In addition to causing distress, injection anxiety and needle phobia can lead to avoidance of medical procedures and failure to adhere to treatment recommendations.[2-4]
Prevalence estimates vary depending on the criteria used. Several studies have reported a point prevalence of 2% to 3%.[5-7] Other studies have estimated that 10% to 20% of people experience excessive anxiety about injections.[8, 9] It is difficult to assess prevalence accurately, partly because of the spectrum of responses and the lack of standardized measurement tools, but also because a proportion of affected individuals avoid medical treatment that might involve needles. Nonetheless, it is consistently found that a proportion of people attending medical settings experience significant anxiety about injections. Little is known about the impact of injection anxiety in the travel clinic setting, however. One study in an Israeli travel clinic found that 22% of travelers attending for pre-travel health advice were afraid of injections, with 8% of travelers reporting fear recognized to be unreasonably intense.
Anxiety can limit the impact of patient education by adversely affecting patients' ability to concentrate on, understand, and recall health information. During the pre-travel consultation, the information discussed with the traveler includes information about vaccination and a variety of other health risks and preventative measures. It is not known what proportion of travelers, who attend specifically anticipating a vaccination, experience significant anxiety, or whether anxiety about injections affects travelers' ability to recall health advice and information.
Health professionals have an important role in supporting and reassuring travelers who are afraid of injections, although this depends on the ability of professionals to accurately identify an anxious individual, particularly if the individual does not spontaneously disclose his/her fear. One study found a moderate correlation between phlebotomist ratings and patient self-ratings of anxiety, with phlebotomists using distraction as a technique with 13% of patients. It is not known to what extent travel health professionals are able to identify travelers experiencing injection anxiety or how they manage this.
This study aimed to:
- identify the prevalence of anxiety about injections in travelers attending a pre-travel consultation who anticipated a vaccination;
- investigate whether anxiety about injections adversely affects recall of information and advice;
- explore whether health professionals are able to accurately identify anxious travelers and how they respond to them.
Participants were consecutive adults attending one of two inner-city travel clinics for pre-travel advice. Eligible travelers were attending the clinic for the first time regarding their trip, anticipated receiving a vaccination, and were able to conduct the consultation in English without an interpreter.
The clinics provided information and advice, travel-related vaccinations, and preventative medication. One clinic (site 1) was attached to the tropical diseases department of a university teaching hospital. The second (site 2) was based in the high street store of a travel company. The clinics were based in different areas of a large city (8 million residents). The clinicians at both sites specialized in travel medicine (doctors and nurses at site 1 and doctors at site 2). In both clinics, travelers paid for vaccinations and medication, but not for advice.
Measures Completed by Travelers
Fear of Injections
The contact fear subscale of the Injection Phobia Scale-Anxiety (IPS-Anx) was used to measure travelers' fear of having an injection. This scale consists of eight items from the full IPS-Anx scale (items 1, 2, 5–8, and 15–17) and has been shown to have good internal consistency (α = 0.90–0.97). The items are scored on a 5-point Likert scale with a scoring range of 0 to 4 representing no anxiety to maximum anxiety.
Symptoms of Needle Phobia
Eleven items from the Blood Draw Questionnaire were used to assess travelers' psychological and physiological reactions to having an injection or blood taken. The items were 8 to 18 from the full 20-item questionnaire. Four items are scored using a 5-point scale, six items using a binary scale (yes/no), and one item using a 6-point scale.
The 6-item Short Form of the State-Trait Anxiety Inventory (STAI, Form Y[14, 15]) was used to assess travelers' anxiety during the clinic visit. Items are rated on a 4-point Likert scale ranging from not at all to very much. The Short Form has been shown to have good internal consistency (α = 0.82), and has produced scores similar to the full 20-item STAI.[15, 16]
Recall of Health Information
As there was no preexisting measure of recall of information from the pre-travel consultation, a questionnaire was developed. To ensure ecological validity, clinic staff were asked what information and advice they wanted travelers to recall. Four topics that were considered to be relevant to all travelers were chosen (vaccination, road safety, bite prevention, and travelers' diarrhea). Within these topics, 15 items of information and advice were identified. Ten of the 15 items were scored using a binary scale (0–1) and 5 items using a 3-point scale (0–2).
Measures Completed by Clinicians
Clinician-rated anxiety: Clinicians were asked to rate how nervous or anxious the traveler appeared on a 5-point scale from not at all to extremely.
Anxiety management strategies: Clinicians were asked to note any strategies used during the consultation in response to travelers' anxiety about vaccination.
Checklist of information given: To ensure standardization of information provided to travelers during the consultations, clinicians were asked to complete a checklist of the 15 items of information from the recall questionnaire after each consultation.
Objective Check of Information Discussed With Travelers
A random sample of consultations (N = 15) was audio-recorded and transcribed. Two of the authors (LN and LF) independently reviewed the anonymized transcripts using structured implicit abstraction[17, 18] to identify the presence of the 15 items of information from the information provided by the clinician in each transcript.
Travelers were invited to participate on arrival. Written consent was obtained for retrieval of demographic and vaccination information from clinic records, audiotaping of their consultation, and a follow-up telephone interview 24 hours later.
Prior to the consultation, participants completed the measures of state anxiety, fear of injections, and symptoms of needle phobia. During the consultation, the clinician provided information, advice, and vaccinations as needed, including the information specified in the standardized checklist. Immediately post-consultation, participants completed the measures of state anxiety and recall. The clinician rated the traveler's anxiety and reported any anxiety management strategies used.
Participants who consented to a follow-up interview were administered the recall questionnaire by telephone the following day.
The project was approved by the North London REC 2 research ethics committee and the Joint UCLH/UCL/Royal Free Biomedical Research R&D Unit.
A total of 105 travelers (49 men and 56 women) were recruited, with a mean age of 38.8 years (SD 13.9, range 18–73) (Table 1). The majority of participants were white (85%), British (70%), and educated at university level (89%). Tourism was the main reason given for the trip (70%). The majority of travelers had previously received travel vaccinations (65%). Sixty participants received one vaccination during the visit, 25 received two, 13 received three, and 1 received five vaccinations. Six participants did not receive a vaccination during their consultation as it was not needed. Forty-six travelers who were approached declined to participate, the main reason given being lack of time.
Table 1. Participant demographics
|Gender|| || || |
|Ethnicity|| || || |
|White British||27||39||66 (63%)|
|White Other||14||9||23 (21%)|
|Asian British||2||3||5 (5%)|
|Black British||0||2||2 (2%)|
|Black Other||2||3||5 (5%)|
|Education|| || || |
|Secondary level||2||10||12 (11%)|
|Destination of travel|| || || |
|South America||7||7||14 (13%)|
|Round the world trip||0||2||2 (2%)|
|Not disclosed||1||0||1 (1%)|
|Reason for travel|| || || |
|General travel: tourism||27||43||70 (67%)|
|Visiting family||4||6||10 (10%)|
|Travel vaccination history|| || || |
|Previously vaccinated||30||39||69 (65%)|
|Not previously vaccinated||14||9||23 (22%)|
|Not disclosed or unsure||3||10||13 (12%)|
Twenty travelers participated in the follow-up telephone interview (9 men and 11 women, with a mean age of 38.7 years, SD 14, range 27–70).
Anxiety About Injections
From the Blood Draw Questionnaire, travelers reported a variety of psychological and physiological symptoms in response to injections or having blood taken (Table 2). These included feeling nervous or afraid, fear of fainting, actually fainting, and finding injections painful or disgusting.
Table 2. Travelers' reactions to procedures involving needles
|Afraid of fainting||90 (86%)||7 (7%)||8 (8%)|
|Find it painful||85 (81%)||17 (16%)||3 (3%)|
|Find it disgusting||92 (88%)||9 (9%)||4 (4%)|
|Concerned that it might be dangerous or harmful to health||97 (92%)||5 (5%)||3 (3%)|
|Usually feel nervous or afraid||64 (61%)||41 (39%)|
|Feel I am more afraid than I should be||82 (78%)||23 (22%)|
|Feel like I am about to faint||81 (77%)||24 (23%)|
|Actually fainted (lost consciousness)||94 (90%)||11 (10%)|
|Avoided procedures with needles because of fear||99 (94%)||6 (6%)|
|Feel the fear has negatively affected important areas of my life or caused a lot of distress||105 (100%)||0 (0%)|
The mean score on the IPS-Anx contact fear subscale was 10.6 (SD 7.3, range 0–30), which compares with previously published means of 11.5 (SD 8.5) to 14.1 (SD 7.9) for predominantly white, university-educated samples; 23.8 (SD 5.1) for participants satisfying clinical criteria for Blood Injection Injury phobia; and 6.3 (SD 6.8) for participants without phobia. Although the IPS-Anx subscale does not provide a cutoff score for clinically significant injection anxiety, scores greater than 2 SDs above the nonphobia mean (19.9) indicate respondents who are likely to have symptoms of phobia. Twelve participants (11%) in this study scored 20 or above on this measure.
Travelers' state anxiety reduced significantly after the consultation, from a pre-consultation mean score of 9.7 (SD 3.6) to 8.6 (SD 3.0) post-consultation (p < 0.001, Wilcoxon signed-rank test).
Travelers who reported psychological or physiological symptoms had higher contact fear and state anxiety than travelers who did not report symptoms, and showed a greater reduction of state anxiety post-consultation (Table 3).
Table 3. Anxiety in travelers reporting reactions to procedures involving needles
|Travelers responding very or extremely to:|| || || |
|Afraid of fainting||22.6 (5.5)||15.8 (4.2)||11.3 (2.1)|
|Find it painful||20.7 (7.5)||16.0 (2.6)||9.3 (2.5)|
|Find it disgusting||23.0 (5.6)||15.3 (4.9)||9.5 (2.4)|
|Concerned that it might be dangerous or harmful to health||14.0 (5.6)||13.0 (1.0)||9.0 (3.5)|
|Travelers responding yes to:|| || || |
|Usually feel nervous or afraid||15.0 (6.0)||11.5 (3.9)||9.1 (3.1)|
|Feel that I am more afraid than I should be||18.3 (6.7)||13.0 (3.9)||9.7 (3.0)|
|Have felt like I am about to faint||16.6 (6.1)||12.4 (4.1)||10.2 (3.3)|
|Actually fainted (lost consciousness)||18.7 (6.2)||14.1 (4.7)||10.6 (2.8)|
|Avoided procedures with needles because of fear||17.3 (9.4)||12.7 (3.5)||9.3 (3.0)|
Recall of Information
Travelers' mean recall score was 12.2 (SD 3.6) out of a potential score of 20. The recall scores showed considerable variability across items, with failure of recall ranging from 2 to 70% of travelers across items (Table 4). The majority of travelers failed to recall effectiveness of diarrhea medication, duration of diarrhea symptoms, proportion of travelers affected by diarrhea, and risky situations on the roads during a trip. Travelers who participated in follow-up interviews had lower recall scores after 24 hours, with a mean immediate recall of 13.6 (SD 3.1) and mean delayed recall of 12.3 (SD 1.9) [t(19) = 3.0, p < 0.01].
Table 4. Recall of information and omission of information provided during the consultation
|1. Proportion of travelers affected by diarrhea||63 (60%)||1|
|2. Duration of diarrhea symptoms||65 (62%)||15|
|3. Strategies to avoid diarrhea during a trip||26 (25%)||1|
|4. Effectiveness of diarrhea medication||73 (70%)||4|
|5. Strategies to manage diarrhea, in addition to medication||21 (20%)||11|
|6. Risky situations on the roads during a trip||55 (52%)||0|
|7. Strategies to avoid road traffic injuries during a trip||36 (34%)||0|
|8. Diseases the traveler was vaccinated against today||3 (3%)||0|
|9. Duration of vaccine effectiveness||30 (29%)||3|
|10. Potential side effects from today's vaccination||30 (29%)||2|
|11. Duration of vaccination side effects||28 (27%)||4|
|12. Whether alcohol should be avoided after vaccination||26 (25%)||6|
|13. Diseases caused by insect bites||12 (12%)||2|
|14. Strategies to prevent insect bites||2 (2%)||0|
|15. Where to apply insect repellent on the body||7 (7%)||11|
Analysis of the 15 transcripts from the consultations indicated variability in the information provided by clinicians. Eleven of the 15 items of information or advice were not mentioned, with the frequency of omission ranging from 1 to 15 consultations (Table 4). Items most frequently omitted were duration of diarrhea symptoms, strategies to manage diarrhea apart from medication, and where to apply insect repellent on the body.
Anxiety and Recall of Information
No relationships were found between recall and state anxiety (STAI) or injection anxiety (IPS-Anx) (Spearman's rho, all p > 0.05) or any psychological or physiological reactions to injections (Blood Draw Questionnaire) (Spearman's rho and Mann–Whitney U-test, all p > 0.05).
Clinicians' Responses to Travelers' Anxiety
Clinicians reported that 46% of travelers appeared not at all nervous or anxious, 35% as very little, 14% as somewhat, 3% as very, and 1% as extremely. Clinicians' ratings correlated moderately with travelers' own ratings of anxiety (Spearman's rho = 0.34 for IPS-Anx, p < 0.001; 0.26 for pre-consultation state anxiety, p < 0.01).
Clinicians reported using anxiety management strategies in 72% of consultations (71 of 99). The most frequent strategy was reassurance (65 consultations), followed by distraction (10 consultations), and having the traveler lie down (5 consultations). In nine consultations, a combination was used, mainly distraction and reassurance.
A proportion of travelers expecting a vaccination at their pre-travel consultation reported significant psychological and physiological reactions to procedures involving needles. More than one third of travelers reported that they usually felt nervous or were afraid of injections, and most of these felt that they were more afraid than they should be. Nearly one quarter of travelers reported feeling faint, with some being afraid of fainting, and 1 in 10 having fainted on a previous occasion. A small number of travelers had previously avoided procedures involving needles. Travelers' reports of marked or persistent fear that is recognized to be unreasonable, in conjunction with anxiety provoked by exposure to the feared stimulus and a strong vasovagal response, are consistent with criteria for Blood Injection Injury phobia. Comparing the sample to previously published norms, 11% of the travelers reported a response to needles, which was indicative of Blood Injection Injury phobia. The reduction in state anxiety after the consultation suggests that travelers were experiencing injection anxiety on arrival at the clinic, which abated after the feared event. Travelers may have been anxious for other reasons when attending the consultation (eg, about the trip, feeling under time pressure to get back to work, or simply anxiety about attending a health care consultation). However, travelers who reported that they normally experienced psychological and/or physiological reactions to needles were more anxious and reported more symptoms of fear, suggesting that fear of injections increases anxiety over and above the normal experience of attending a pre-travel consultation.
Clinicians' ratings of travelers' anxiety moderately correlated with travelers' self-assessments, indicating that clinicians were able to detect anxiety to an extent. The ability to accurately identify travelers who are anxious is a prerequisite to offering appropriate support. Addressing anxiety can help with reducing the experience of pain,[19, 20] which is a particular feature of injection anxiety. The clinicians employed a small number of strategies, mainly using reassurance and distraction to acknowledge the person's anxiety while maintaining the routine of the consultation. Clinicians may have underestimated travelers' anxiety because of an expectation that very few travelers are anxious, or travelers may themselves underestimate their own anxiety or prefer not to disclose it. Time pressures, either on the part of the traveler or the clinician, may also have reduced the likelihood that psychological issues would be discussed. As the clinicians specialized in travel medicine, they may not have had the necessary training in psychological care required to identify and respond to anxiety disorders.
Although there were significant gaps in the recall of information and advice post-consultation, no association was found between recall and anxiety. As the sample comprised mainly well-educated and experienced travelers, their preexisting knowledge may have influenced response to the recall questionnaire. Furthermore, the small numbers of vaccination-naïve travelers, who may experience higher anxiety, may have reduced the ability to detect an association. The sample of consultations recorded as a fidelity check also indicated some variability in the information provided, which may also have influenced recall.
Further work in this area could establish whether anxiety about injections affects recall of new information and advice, particularly priority information relating to an individual traveler's needs, rather than information about general travel risks. A baseline check of traveler knowledge pre-consultation would address the potentially confounding effect of preexisting knowledge. A fidelity check of information delivered by the clinician is essential to confirm which new pieces of information are discussed, for which recall can be assessed. Further research could also investigate clinicians' reasons for not providing information, for example, by obtaining a post-consultation account. Clinicians may perceive certain pieces of information to be less relevant to an individual traveler, or they may use other contextual cues to make judgments about what travelers already know and the amount of details to provide. The timing of information (before or after the vaccination) would also need to be considered. Although it is standard practice to provide information after the vaccination in specialized travel clinics in the UK, this may not be universal. Travelers' perceptions of the effectiveness of anxiety assessment and management strategies used by clinicians could also be investigated.
The authors wish to thank the travelers who participated in this study, the clinic staff at the Hospital for Tropical Diseases Travel Clinic, and F. Nicholson at Trailfinders Clinic London.
Declaration of Interests
R. H. B. is supported by UCL Hospitals Comprehensive Biomedical Research Centre, Infection Theme. Otherwise, the authors state that they have no conflicts of interest.