Needle fear is a common problem in children undergoing immunization. To ensure that the individual child’s needs are met during a painful procedure it would be beneficial to be able to predict whether there is a need for extra support. The self-reporting instrument facial affective scale (FAS) could have potential for this purpose. The aim of this study was to evaluate whether the FAS can predict pain unpleasantness in girls undergoing immunization. Girls, aged 11-12 years, reported their expected pain unpleasantness on the FAS at least two weeks before and then experienced pain unpleasantness immediately before each vaccination. The experienced pain unpleasantness during the vaccination was also reported immediately after each immunization. The level of anxiety was similarly assessed during each vaccination and supplemented with stress measures in relation to the procedure in order to assess and evaluate concurrent validity. The results show that the FAS is valid to predict pain unpleasantness in 11-12-year-old girls who undergo immunizations and that it has the potential to be a feasible instrument to identify children who are in need of extra support to cope with immunization. In conclusion, the FAS measurement can facilitate caring interventions.
Immunizations are common procedures in the life of most children [
Engaging the heart in caring means taking individuals’ health-related experiences into consideration [
According to Galvin and Todres’ [
Carter [
Galvin and Todres [
Patient-centred care means involving the patient in decisions about their own health issues and is regarded as important for good quality [
The facial affective scale.
Additionally it has been shown that pictures, such as faces, facilitate children being able to understand and communicate the meaning of pain unpleasantness in contrast to pain intensity [
The aim of this study was to evaluate whether the FAS can predict pain unpleasantness in girls undergoing immunization.
The participants in the study were females aged 11 to 12 years from three different schools located in western Sweden who were fluent in the Swedish language. The participants were offered vaccinations against HPV. Immunization against HPV is part of the Swedish vaccination programme for girls and is given on three occasions.
The primary outcome in this study is whether the FAS scores of expected pain unpleasantness predict the FAS scores of experienced pain unpleasantness. The FAS scores assess a child’s emotional or affective reaction to a pain experience and range from “happiest feeling possible” to “saddest feeling possible.” It only takes approximately half a minute to administer and assess the FAS score [
Anxiety is described as a complex combination of fear, apprehension, and worry. Anxiety scores can be assessed by a visual analogue scale (VAS-A) with the anchor’s “no anxiety” and “the worst known anxiety.” The VAS-A has shown validity in assessing perioperative anxiety in children aged 7–16 years and has shown significant correlations with the STAIY (State-Trait Anxiety Inventory for Youth) [
Stress affects the body and the brain in many ways and appears when a person experiences a threat. The verbal rating scale for stress (VRSS) reports the recent experience of stress on a verbal rating scale (0–5). A test of VRSS showed no statistical evidence for systematic disagreement or random disagreement, which indicates that it is a valid and reliable scale [
Data were collected between September 2012 and September 2013. Each child reported FAS scores three times in conjunction with each vaccination, that is, a total of nine times (Figure
Measurement points.
The participants also reported their experienced pain unpleasantness in relation to each of the three vaccinations, just before and during the immunization. The scores during the immunizations were collected immediately afterwards.
To further test the concurrent validity of the FAS, two other instruments were used in conjunction with each immunization. The girls reported their anxiety on a VAS-A, and the scores during the immunizations were collected immediately afterwards [
The statistics were calculated using IBM SPSS Statistics for Windows, version 21. The FAS has been validated in earlier studies using parametric statistics [
The FAS scores before each immunization were compared with the FAS scores during each immunization using linear regression analysis. The linear regression analysis was repeated for each immunization, that is, three times. The dependent variable was the output, that is, the experienced pain unpleasantness, and the independent variable was the expected pain unpleasantness. A beta score close to 1 indicates a strong connection between independent and dependent variables.
The comparison between experienced pain unpleasantness (FAS scores) before the immunizations and the experienced pain unpleasantness (FAS scores) during the immunizations was tested by a paired
The concurrent validity was tested by a Pearson correlation test that compared the FAS scores and the VRSS scores as well as the FAS scores and the VAS-A scores during the immunizations. A correlation coefficient close to 1 indicates a strong correlation [
Guidelines for research involving human subjects were followed. Written information was provided to both children and parents, and verbal information was given in school. Voluntariness as well as the right to withdraw from the study at any time without any explanation and consequences was highlighted. The benefit of the study was considered greater than the risks. If the children agreed to participate, the parents were asked for written consent. All participants received a cinema ticket. The study was approved by the regional ethical review board (Dnr: 466-12).
Two invited girls declined to participate and one girl dropped out of the offered immunization and consequently from this study. In the end, 37 study participants, aged 11 to 12 years, participated in this study. Some of the study participants declined to report their expected pain unpleasantness on the FAS; 31 study participants (84%) reported their expected pain unpleasantness before the first immunization, 28 study participants (76%) before the second immunization, and finally 32 study participants (86%) before the third immunization. All study participants assessed their pain unpleasantness before and during each vaccination and anxiety and stress during each vaccination.
Most study participants reported a moderate level of expected pain unpleasantness on the FAS (mean 0.56) before all three immunizations (Table
Expected level of pain unpleasantness using the FAS.
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Min. | Max. | Mean | SD | |
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Expected pain unpleasantness 1 | 31 | 0.17 | 0.75 | 0.56 | 0.20 |
Expected pain unpleasantness 2 | 28 | 0.04 | 0.85 | 0.61 | 0.24 |
Expected pain unpleasantness 3 | 32 | 0.04 | 0.85 | 0.61 | 0.22 |
The number and proportions of study participants who did or did not feel pain unpleasantness.
Vaccination 1 | Vaccination 2 | Vaccination 3 | ||||
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Expected FAS | ||||||
FAS score ≥0.75 | 14/31 | 45% | 15/28 | 54% | 19/32 | 59% |
FAS score ≤0.47 | 13/31 | 42% | 7/28 | 25% | 11/32 | 34% |
Experienced FAS | ||||||
FAS score ≥0.75 | 17/37 | 46% | 21/37 | 57% | 11/37 | 30% |
FAS score ≤0.47 | 11/37 | 30% | 9/37 | 24% | 16/37 | 43% |
The study participants reported their pain unpleasantness just before the first (mean 0.64), second (mean 0.58), and third vaccinations (mean 0.52).
Thirty-seven study participants reported their experienced pain unpleasantness, anxiety, and stress during each immunization (Table
Descriptive statistics.
Min. | Max. | Mean | SD | |
---|---|---|---|---|
First immunization | ||||
Experienced FAS | 0.04 | 0.85 | 0.59 | 0.22 |
Experienced VAS-A | 0 | 9 | 4.02 | 2.51 |
Experienced VRSS | 0 | 4 | 1.56 | 1.03 |
Second immunization | ||||
Experienced FAS | 0.04 | 0.85 | 0.63 | 0.20 |
Experienced VAS-A | 0 | 8.5 | 3.78 | 2.36 |
Experienced VRSS | 0 | 4 | 1.51 | 1.15 |
Third immunization | ||||
Experienced FAS | 0.04 | 0.85 | 0.54 | 0.21 |
Experienced VAS-A | 0 | 6.6 | 2.63 | 2.02 |
Experienced VRSS | 0 | 3 | 1.19 | 0.94 |
The study participants also reported moderate experienced pain unpleasantness on the FAS during all three immunizations. However, the FAS scores did not increase significantly from directly before to immediately after, which reflected the feelings during the first (
The comparison of the expected pain unpleasantness (FAS scores) before the first vaccination and the experienced pain unpleasantness (FAS scores) during the first vaccination showed beta 0.59 (
The Pearson correlation test showed significant correlations between the FAS, VAS-A, and VRSS during all three of the immunizations (Table
The Pearson correlation test.
Immunization | 1 | 2 | 3 |
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FAS | FAS | FAS | |
VAS-A |
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VRSS |
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The self-reporting instrument, FAS, acceptably predicted adolescent study participants’ level of pain unpleasantness when undergoing immunizations. Since needle-related fear has been found to be as common as in 63% of children and youth [
The study participants’ FAS scores did not significantly change over time, making it possible to use this instrument to predict pain unpleasantness. The FAS may then be used for screening to identify children who will experience immunization unpleasantness. This facilitates providing these children with extra support and can perhaps help them to cope better with the procedure during immunizations. Moreover, if nurses use a validated assessment scale to find children who need extra support it will minimize the risk of nurses using their own preunderstanding of pain instead of the children’s perspectives [
Despite the fact that some study participants did not expect or experience pain unpleasantness, the number scoring substantial pain unpleasantness (FAS score ≥ 0.75) should not be ignored. Similarly, an estimated one-sixth of children aged 12 assessed high FAS scores both before and during a needle-related procedure [
It is an advantage if an instrument is easy to use and can actually predict pain unpleasantness. This study showed that the FAS instrument has the potential to meet this requirement. While the FAS discriminates pain unpleasantness from pain intensity [
Children who undergo immunizations can feel uncomfortable, that is, experience a fear of needles. However, not all children are afraid of immunizations. Forsner et al. found that children’s emotional experiences when undergoing a venepuncture varied greatly, and some of the children’s narratives even suggested that they “love shots” [
Carter [
Nurses administer immunizations to children and thereby contribute to child health, but, unfortunately, some children are afraid of needle procedures [
Warning or sympathizing using language that refers to negative experiences may not facilitate children feeling better [
One limitation of this study is the small population. The study ought therefore to be repeated with a larger population. On the other hand, the study design was strengthened by the fact that there were no dropouts during the immunizations and, in addition, it permitted each child to repeat the measurement on the FAS up to nine times. The fact that only girls participated in the study could also be considered a weakness, but, to date, only girls have received HPV immunizations in Sweden. It would in any case be valuable to repeat the study design with boys. Finally, since the findings are limited to young adolescents, further studies should focus on whether children in other age groups are able to predict own pain unpleasantness on the FAS.
The FAS is valid for predicting, as well as measuring, pain unpleasantness in 11-12-year-old girls who undergo immunizations. This instrument consequently has the potential to identify children who are in need of extra support to cope with the situation, facilitating individualized prevention and caring interventions for children undergoing immunizations.
The authors declare that there is no conflict of interests regarding the publication of this paper.
The authors would like to thank the participants of the study who generously gave of their time and shared their experiences. They would also like to thank the school nurses who helped them in conjunction with the data collection. This research project was supported by grants from the Ebba Danelius Foundation and the Gertrud Östlinder Foundation.