CARD at school helps students win against needle fear

Vaccine campaigns – whether for flu, COVID or childhood vaccines – depend on vaccinating large numbers of people to stop the spread of illness. But for many people, especially kids, getting a needle generates fear and anxiety, and even leads to dizziness and fainting. The implications of these negative experiences can be far-reaching.

“Pain and fear are the most common side effects of vaccinations and can lead to negative experiences. People who have a negative experience with getting a vaccine are more likely to develop a fear of needles and become vaccine-hesitant, and they may even avoid health care and vaccines entirely,” says Anna Taddio, professor at the Leslie Dan Faculty of Pharmacy.

“Negative experiences during childhood vaccinations and other needle procedures are particularly impactful and can shape a lifetime of health care behaviours. For both individual and public health, it’s important that we work to reduce pain and fear and improve the overall vaccination experience.”

Taddio’s research has focused on reducing pain during vaccination, particularly for children. She and her team have developed an intervention called CARD (Comfort, Ask, Relax, Distract) – a person-centred approach to ease pain and anxiety related to vaccination – and tested the intervention in a variety of settings, including schools.

CARD invites vaccine recipients to choose strategies from the letter categories to reduce pain, fear and related symptoms. It provides suggestions for patients to find ways to get comfortable, ask questions to be prepared, keep calm, and shift their attention from the needle. Taddio’s team has also developed a checklist for health care providers to support recipient choices and implement other evidence-based strategies to improve the vaccination experience.

“Negative experiences during childhood vaccinations and other needle procedures are particularly impactful and can shape a lifetime of health care behaviours. For both individual and public health, it’s important that we work to reduce pain and fear and improve the overall vaccination experience.”

“The CARD system was created to turn the research evidence into practical steps for clinicians and organizations as well as vaccine recipients and their support persons,” says Taddio. “Across different vaccination settings, it has been shown to be effective at reducing the negative symptoms associated with vaccine injections and to improve the vaccination experience.”

In previous research, the approach has been shown to reduce fear and pain, as well as fainting and fear-based responses, during vaccinations.

New research in a recently published supplement in Human Vaccines and Immunotherapeutics focused on the implementation of CARD and its effect on vaccine experience in a variety of real-world settings, including elementary schools and university-based pop-up vaccination clinics. Together, the articles provide evidence that CARD is a practical, easy-to-implement tool that is effective in improving the vaccine experience for both vaccine recipients and health care providers.

CARD boosted vaccination in schools with lower uptake

Considering the importance of positive vaccination experiences in childhood, CARD is a particularly valuable tool for school-based vaccination programs. In Ontario, students in grade 7 are offered three vaccines (meningococcal conjugate, hepatitis B, and human papillomavirus) at school-based clinics organized by the local public health unit.

In the 2023–2024 school year, Wellington Dufferin Guelph (WDG) Public Health partnered with Taddio’s team to implement CARD in 29 schools in the area’s public and Catholic school boards that had the lowest rates of vaccination uptake. In schools that used CARD, adjustments were made to the clinic area to minimize fear. Students were educated about CARD and invited to choose their preferred coping strategies for vaccination, and nurses supported them in their choices. The schools that did not use CARD implemented their usual vaccination clinic preparations.

The public health unit found that vaccination rates in the schools that implemented CARD increased between 5 and 10 per cent from the year before, while vaccination rates in the other schools were essentially unchanged. Nurses and students at the schools using CARD reported more positive interactions with students.

Based on these positive results, WDG Public Health will continue to use CARD and is expanding it to include all of its school-based vaccination clinics.

“CARD has supported school-based vaccinations by reducing stress, while empowering students with tools to confidently navigate healthcare – often for the first time without a parent present,” says Karen Mulvey, manager of vaccine preventable disease at WDG Public Health. “Its evidence-based, client-focused approach improves health literacy and vaccine uptake through a unified, respectful, and supportive framework.”

CARD provides positive experiences for pharmacists delivering vaccines

CARD was also used during pop-up flu and COVID-19 vaccine clinics at U of T, led by the Discovery Pharmacy, in late 2022 and 2023. Pop-up clinics have the potential to vaccinate large numbers of people, but they don’t always offer comfort or privacy for recipients; however, Discovery Pharmacy organizers implemented training in CARD and adapted the clinic according to CARD recommendations.

Vaccine recipients indicated in surveys that they had a better vaccine experience when CARD was implemented, compared to their previous vaccine experiences, and fear and pain scores were lower in clinics where CARD was used. The pharmacy students who were administering the vaccines in the pop-up clinics reported positive experiences implementing CARD, saying that it improved the clinic’s structure and flow and helped them address the needs of vaccine recipients.

While the patient experience has been a key outcome of CARD studies, the experiences of pharmacists and pharmacy students are just as critical to having the tool implemented outside of research studies.

“Pharmacists are delivering more vaccines and want to integrate tools that are feasible and effective,” says Taddio. “Our results in pop-up clinics and community pharmacies show that implementing CARD did not take additional time, and improved the safety of vaccination administration, making it a win-win.”

“If CARD is used widely, we can help eliminate fear and pain as barriers to vaccine uptake.”