Sage Journals: Discover world-class research

Abstract

Introduction

Seasonal influenza remains a challenge in the United Arab Emirates, and vaccination is an important preventive measure. However, fear of needles may be an obstacle in vaccination efforts.

Objective

The purpose of this study was to determine, in a non-clinical sample obtained from the UAE, how much of an impact fear of needles has on the decision to receive the seasonal influenza vaccine.

Methods

In the period September-December 2022, 372 participants were surveyed on their willingness to be vaccinated, their level of vaccine knowledge, and their level of fear of needles. Logistic regression models were used to assess the impact of fear of needles and vaccine knowledge on the decision to accept the seasonal influenza vaccine.

Results

Fear of needles and vaccine knowledge are significant predictors in the decision to receive the vaccine. There were no gender or ethnic differences in fear of needles, but there were differences in the decision to receive the vaccines, with women and non-Arabs being more hesitant.

Conclusion

Fear of needles may be an important variable to account for in public policies designed to improve vaccination rates in the UAE. For public health policy in the UAE, this implies that authorities must dedicate efforts to manage fear of needles in the general population. Efforts to address fear of vaccines in the general population must be made with proper training of nurses. Alternatively, authorities may need to seek oral alternatives for the administration of the seasonal influenza vaccine.

Keywords

seasonal influenza United Arab Emirates fear of needles vaccine knowledge nursing

Introduction

Review of Literature

While COVID-19 has been an immediate concern, seasonal influenza remains a long-term problem worldwide. According to some estimations, each year 3–5 million people suffer a severe form of the disease (Vincent et al., 2014). In the United Arab Emirates (UAE), influenza still presents some challenges, as flu outbreaks have been reported each year towards the end of summer (Saeed, 2022).

It has been frequently posited that the best approach to the persistent problem of seasonal influenza is effective vaccination (Medlock & Galvani, 2009). This should be administered on a yearly basis, as the immune system needs a constant boost, in anticipation of the risks brought forth by the seasonal changes (Dos Santos, 2019). In this endeavor, nurses play a crucial role, as they bear the responsibility of administering the shot.

Yet, as with many other vaccines, the problem of hesitancy persists. Much research has been previously done on the main factors that lie behind vaccine hesitancy. Conspiracy mongering is one such factor extensively documented. Pertwee et al. (2022) explain that major factors, “such as anxieties around the pace of technological change or feelings of political disempowerment, are not within the control of the medical community.” This implies that despite the major breakthroughs in protection against viral infections, a wider psychosocial aspect remains an obstacle to the effective management of viral epidemics. Possibly due to political transformations and the global shift towards populist political styles (Bergmann, 2018), conspiracy theories are on the rise worldwide (Andrade, 2020), and many of these theories target medical aspects. In the UAE, vaccine hesitancy is still a problem (Andrade et al., 2022), although there is currently very little research on the role that conspiratorial thinking may play in this regard.

Medical conspiracy theories ultimately lead to disinformation (Grimes, 2020), and consequently, knowledge about vaccines has also been extensively documented as a predictor of people's willingness to receive the vaccine. Previous studies report that higher educational levels predict greater acceptance of vaccine jabs (Navin et al., 2019). But this also pertains to specific knowledge about vaccines (Montagni et al., 2020), and on that basis, governments have realized that the best approach to curb vaccine hesitancy is through educational efforts (Burke et al., 2019; Kernéis et al., 2017; Ropeik, 2013). In the UAE, this educational approach has been embraced extensively (Ahamed et al., 2021; Nizam et al., 2022; Ortashi et al., 2013).

Yet, these concerns may reflect some bias derived from the cognitive revolution in psychology. For, other far more mundane variables may also be at play in seasonal influenza vaccine acceptance. An important additional variable to consider is trypanophobia, or the fear of needles. This has long been a concern in nursing research. One systematic review concludes that “the fear of needles can delay or result in avoidance of preventive measures such as vaccination” (McLenon & Rogers, 2019). The same study informs that “approximately one in six healthcare workers in long-term care facilities and 1 in 13 healthcare workers in hospitals avoided influenza vaccination because of the fear of needles” (McLenon & Rogers, 2019). This number raises concern, as presumably, nurses and healthcare workers would be psychologically more prepared to overcome the fear of needles, and therefore, the number in the general population may be higher.

Health authorities in the UAE have satisfactorily dealt with health educational efforts, and the seasonal influenza vaccine is widely available throughout the nation. Nurses have been properly instructed to promote the application of the seasonal influenza vaccine in the general population. Yet, it remains to be seen if some additional focus is needed. If fear of needles turns out to be an important factor in predicting seasonal influenza vaccine acceptance, then it is necessary for authorities to address this issue and find working solutions, some of which pertain especially to the nursing profession.

Objectives

In this study, we test this hypothesis: in predicting seasonal influenza vaccine acceptance, fear of needles is a predictive factor. Additionally, on the basis of demographic information, we test if there are correlations of fear of needles with gender and ethnicity.

Methods

Design

A survey was applied to participants in the sample. The survey had 5 sections.

First, demographic information was collected (age, gender, ethnicity). Ethnicity was divided into two groups: Arabs and non-Arabs. Age was divided into two groups split by the median.

Second, the Injection Phobia Scale-Anxiety (IPS-Anx) was included. This is a questionnaire that assesses the level of fear participants express in their reaction to the prospect of receiving an injection (Olatunji et al., 2010), and has been frequently used in nursing research. The IPS-Anx can be applied with 8 items based on a Likert scale, such as “Giving a blood sample by having a finger pricked” and “Getting an injection in the buttock.” Participants rate their level of anxiety from 1 (lowest) to 5 (highest).

Third, a vaccine knowledge scale devised by Zingg & Siegrist (2012) was included. This is an instrument composed of 9 items, which assess subjects’ knowledge about how vaccines work. Items are arranged on a Likert scale from 1 (strongly disagree) to 5 (strongly agree), presenting true statements (e.g., “The immune system of children is not overloaded through many vaccinations”) and false statements (e.g., “Many vaccinations are administered too early, so that the body's own immune system has no possibility to develop”); false statements were scored reversely. Higher scores indicate a higher level of knowledge of how vaccines work.

Fourth, the Patient Health Questionnaire (PHQ-4) was included. This is an instrument with 4 statements that assess subjects’ mental health along two dimensions: depression (“Over the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things?”) and anxiety (e.g., “Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?”). Responses are structured around Likert scales (0 = Not at all; 3 = Nearly every day), with higher scores indicating higher levels of depression and anxiety.

Fifth, the following question was asked: “Have you received the seasonal influenza vaccine in the last 6 months, or do you intend to do so in the coming 6 months?”, with Yes/No as options. Answers with “yes” were interpreted as indicating seasonal influenza vaccine acceptance; answers with “no” were interpreted as indicating seasonal influenza vaccine hesitancy.

Research Questions

The present study seeks to answer the following research questions: 1) How is influenza vaccine acceptance in a sample in the UAE related to vaccine knowledge, fear of needles, anxiety and depression. 2) Are there gender differences in influenza vaccine acceptance, fear of needles and vaccine knowledge? 3) Are there ethnicity differences in influenza vaccine acceptance, fear of needles and vaccine knowledge? 4) Are there age differences in influenza vaccine acceptance, fear of needles and vaccine knowledge?

Sample

Convenient (non-probabilistic) sampling was used, on the basis of willingness and availability to answer a survey. They were recruited from the general population in the emirates of Ajman, Sharjah and Dubai.

Sample size was calculated on the basis of Slovin's criterion. With an estimated population of 10,000,000, a margin of error of 5% and a confidence level of 95%, required sample size would be 385. Responses were obtained by approaching face-to-face each participant and requesting them to scan a QR code with their phones, that would take them to the questionnaire. 372 returned complete answers, and 19 returned incomplete answers. Participants with incomplete answers were discarded. Therefore, response rate was 95%.

Responses were collected via web communication, data repositories accessed through links and QR codes (Microsoft Office), and face-to-face interactions. Data was collected during the period September-December 2022.

Inclusion and Exclusion Criteria

Inclusion criteria was being an adult, having sufficiency in English, and being a resident in the UAE.

Institutional Review Board Approval, Informed Consent and Human Subjects’ Rights

The research protocol was approved by an Institutional Review Board (Ajman University's Research Ethics Committee # M-F-H-25-May), in compliance with the principles of the Helsinki declaration. All participants were informed of the nature of the study, were informed they could abandon the survey at any time, and were requested to provide consent before proceeding to answer questions.

Statistical Analysis

Distributions of IPS-Anx and Vaccine Knowledge were split into quartiles. Distributions of the anxiety dimension and depression dimension of the PHQ-4 were split into two groups (positive, negative) along cutoff points (≥3). Each of the subsequent new groupings were tested for association (chi-square test) with demographic variables (age, gender, ethnicity).

A logistic regression model was built. Influenza vaccine acceptance was the dependent variable; IPS-Anx (as continuous variable), Vaccine Knowledge (as continuous variable), age (as dichotomous variable), anxiety (as dichotomous variable), depression (as dichotomous variable), gender (as dichotomous variable) and ethnicity (as dichotomous variable) were the independent variables.

Statistical significance was placed at p ≤ 0.05.

Statistical analyses were done using Jamovi software.

The IPS-Anx has been validated in various contexts (Bani et al., 2020) and has had acceptable levels of reliability (Bani et al., 2022). The scale measuring vaccine knowledge has been validated in previous applications, and is considered to have acceptable reliability (Andrade et al., 2022). The PHQ-4 has been validated in previous studies (Kroenke et al., 2009), and is considered reliable (Löwe et al., 2010).

Results

Sample Characteristics

54% of participants were male, 46% were female. Mean age was 32.8, S.D. = 9.22; the sample was split into two groups (younger/older) using the median (32) as reference.

70% of participants reported not accepting the seasonal influenza vaccine shot, 30% reported accepting it. 43% reported being negative for depression, 57% reported being positive for depression. 41% reported being negative for anxiety, 59% reported being positive for anxiety.

Research Questions Results

Chi-square matrix of association of variables is presented in Table 1. Males had significantly higher levels of vaccine acceptance (p = 0.008), higher levels of vaccine knowledge (p = 0.001), lower levels of injection anxiety (p = 0.001), and lower levels of depression ratings (p = 0.03) than females. There were no significant differences in anxiety ratings (p = 0.12).

Table 1.

Chi-Square Matrix.

	n	Males	Females	χ2, p-value	Arabs	Non-Arabs	χ2, p-value	Younger	Older	χ2, p-value
Sample size (n)	372	202	170	_	189	183	-	188	184	-
Vaccination Acceptance		-	-	χ2 = 7.11, p = 0.008	-	-	χ2 = 4.74, p = 0.03	-	-	χ2 = 0.78, p = 0.38
Yes	111	36%	23%	-	35%	25%	-	32%	28%
No	261	64%	77%	-	65%	75%	-	68%	72%
IPS-Anx		-	-	χ2 = 84.3, p < 0.001	-	-	χ2 = 3.74, p = 0.3			χ2 = 3.31, p = 0.35
0–25% (Q1)	99	41%	9%	-	31%	22%	-	30%	23%	-
25–50% (Q2)	101	10%	48%	-	27%	27%	-	28%	26%	-
50–75% (Q3)	82	24%	19%	-	21%	24%	-	19%	25%	-
75–100% (Q4)	90	25%	24%	-	22%	27%	-	23%	26%	-
Vaccine Knowledge		-	-	χ2 = 27.7, p < 0.001	-	-	χ2 = 4.76, p = 0.19	-	-	χ2 = 9.52, p = 0.02
0–25% (Q1)	110	34%	24%	-	30%	30%	-	27%	32%	-
25–50% (Q2)	76	10%	32%	-	20%	21%	-	24%	16.80%	-
50–75% (Q3)	114	35%	26%	-	27%	34%	-	26%	36%	-
75–100% (Q4)	72	21%	18%	-	23%	15%	-	23%	15%	-
Anxiety		-	-	χ2 = 2.43, p = 0.12	-	-	χ2 = 7.22, p = 0.01	-	-	χ2 = 1.19, p = 0.28
Negative (< 3)	154	45%	41%	-	48%	34%	-	44%	39%	-
Positive (3+)	218	55%	63%	-	52%	66%	-	56%	61%	-
Depression		-	-	χ2 = 4.62, p = 0.03	-	-	χ2 = 0.61, p = 0.43	-	-	χ2 = 0.44, p = 0.51
Negative (<3)	158	48%	37%	-	44%	40%	-	44%	41%	-
Positive (≥3)	214	53%	64%	-	56%	60%	-	56%	59%	-

There was an association between ethnicity and vaccine acceptance, with Arabs having higher levels of vaccine acceptance. There was no association between ethnicity and injection anxiety. There was an association between ethnicity and vaccine knowledge. There were significant ethnicity differences in anxiety, with non-Arabs reporting higher levels. There were no differences in depression across ethnicities.

There was no association between age groups and vaccine acceptance. There was no association between age group and injection anxiety. There was an association between age group and vaccine knowledge, with the younger group having higher levels of knowledge. There were no significant age differences in anxiety. There were no significant differences in depression across age groups.

The logistic regression model is presented in Table 2. After incorporating all variables in a multiple logistic regression model for seasonal influenza vaccine acceptance, three predictors variables showed statistically significant adjusted odds ratios: injection anxiety, vaccine knowledge and depression.

Table 2.

Logistic Regression. Dependent Variable: Seasonal Influence Vaccine Acceptance. Complete Dataset (n = 372).

	Unadjusted				Adjusted
Predictor	Estimate	Odds ratio	95% CI	p-value	Estimate	Odds ratio	95% CI	p-value
IPS-Anx	−0.23	0.80	0.76–0.84	<0.001	−0.29	0.75	0.69- 0.81	< 0.001
Vaccine knowledge	0.07	1.07	1.03–1.12	0.003	0.12	1.13	1.06–1.19	<0 .001
Gender (reference level: males)	−0.62	0.54	0.34–0.85	0.008	−0.25	0.78	0.42–1.47	0.44
Age (reference level: older)	−0.2	0.82	0.52–1.28	0.38	0.12	1.13	0.63–2.01	0.68
Nationality (reference level: Arabs)	−0.5	0.61	0.39–0.95	0.03	−0.34	0.71	0.40–1.28	0.25
Anxiety (reference level: negative)	−1.4	0.25	0.16–0.4	<0.001	−0.58	0.56	0.13–2.43	0.44
Depression (reference level: negative)	−0.67	0.51	0.33–0.8	0.003	1.49	4.43	1.06–18.56	0.04

Discussion

In this study, acceptance rates of seasonal influenza vaccine (30%) for this sample were above the minimum rate recommended by the WHO (≥159 doses per 1000 population) (Palache et al., 2014). In this endeavor, nursing efforts (as reflected in this sample) have met the standard. Nevertheless, the figure still warrants concern, as the number of vaccinated individuals may need to increase in order to achieve robust herd immunity (Kim, 2014).

As per the logistic regression analysis, it is evident that, apart from vaccine knowledge, fear of needles was also associated with the decision to take the seasonal influenza vaccine. This calls for a revision of priorities in policies to increase vaccination rates. While many studies have found strong evidence of the role played by vaccine knowledge in preventing vaccine hesitancy (Abebe et al., 2021; Betsch & Wicker, 2012; Đorđević et al., 2021; Jung et al., 2013; Voo et al., 2021; Zheng et al., 2022), virtually none have assessed the predictive power of fear of needles.

The results of the present study are therefore very important, to the extent that it relates to an important phenomenon in moral psychology and decision theory: akrasia, or weakness of will (A. Mele, 2010). Subjects may know very well that doing something is in their favor, but still refuse to do it, presumably because they lack willpower. Weakness of will has been evidenced in behaviors such as smoking (A. R. Mele, 2012) and overeating (Mann, 2008). The results of this study suggest that weakness of will may also be at play in this sample: while participants may understand how vaccines work and the need to receive the seasonal influenza shot, they may still be hesitant about it, not exclusively due to cognitive factors, but rather, due to weakness of will as a result of fear of needles. Even if this fear of needles is disproportionate to the actual threat, and the benefits of getting a vaccine outweigh the risks and harms by a large factor, subjects may still be hesitant, largely because of akrasia.

Fear of needles has been a relatively unexplored phenomenon amongst psychologists and nursing researchers, but some research sheds some light about its possible origins and features. Various symptoms have been observed in people who fear needles upon receiving an injection: fainting (Wright et al., 2009), vasovagal reactions (Deacon & Abramowitz, 2006), syncope (Martens et al., 2017), and nausea and vomiting (Sokolowski et al., 2010).

As with many situations that evoke fear reactions in people, there may be two origins in this phenomenon. First, there is the influence of classical conditioning (Du et al., 2008). As per the model of behaviorist theory, whenever a subject encounters an unpleasant situation, paired stimuli may be associated with that experience, and henceforth, fear reactions develop in response to the associated stimulus. Jenkins (2014) explains the case as follows: “a patient who recalls being held down as a child while receiving vaccinations, or undergoing anaesthetic, will have learned a paired association of ‘needles plus doctors equals pain and distress’. Therefore, being back in that situation produces distress, to the extent that sufferers will simply avoid the situation.”

Second, the evolutionary background of the human species may prime subjects towards fear of needles (Bracha et al., 2005). In the context of human evolution, being pricked by a sharp object represented a significant danger, as it dramatically increased the probability of suffering an injury, thus leading to infections and even death. Those individuals who instinctively avoided sharp objects therefore had an evolutionary advantage. As Orenius et al. (2018) explain, “a heritable predisposition to abruptly increase vagal tone and collapse flaccidly rather than freeze or attempt to flee or fight in response to an approaching sharp object or the sight of blood may have evolved as an alternative survival reaction.”

In similar studies done in other regions by nursing researchers, fear of needles has also been found to be a relevant factor in predicting subjects’ willingness to receive vaccines. For example, in a study with the question “Does the Fear of Needles Influence Jamaicans’ Willingness to be vaccinated against COVID-19?”, it is concluded that “trypanophobia affects Jamaicans’ willingness to be vaccinated” (Bourne et al., 2022). In another similar study in Canada, it is stated that “24% of parents and 63% of children reported a fear of needles. Needle fear was the primary reason for immunization non-compliance for 7% and 8% of parents and children, respectively” (Taddio et al., 2012).

In a systematic review, it is concluded that “people's queasiness at the thought of needles and blood were associated with levels of vaccine hesitancy across 24 countries” (Hornsey, 2021). Another study reported that about 10% of the population in developed countries suffer from fear of needles, and that prevents them from vaccinating (Hamilton, 1995).

Fear of needles may be a derivate of generalized anxiety. Previous research shows that particular phobias are comorbid with other anxiety disorders (Beck et al., 2005; Essau, 2003; Kaufman & Charney, 2000). The results of the present study also suggest this, as fear of needles has a moderate (very close to strong) correlation with anxiety. While the directionality of this relation is not established, it is presumable that generalized anxiety antecedes fear of needles, and consequently, a possibly effective way of dealing with fear of needles is by addressing generalized anxiety in individuals. In this endeavor, nursing professionals who work on thwarting the fear of needles amongst patients, must also engage in psychological work to address generalized anxiety.

It is interesting to note that in previous studies, fear of needles has been found to be higher amongst women (McLenon & Rogers, 2019). In this study, those results are reproduced. One possible explanation for this is that the fear of needles may be associated with social vulnerability (Milovanović et al., 2017). While the UAE still has strong patriarchal traditions, authorities have gone a long way in expanding opportunities for women and narrowing the gender gap in many variables (Al Khayyal et al., 2020; Allagui & Al-Najjar, 2018), and that may partly explain the results in this sample. Ultimately, this narrowing of the gender gap in many aspects of social life may reflect the lack of gender differences in fear of needles.

The results of the present study also suggest that there was a gender difference in seasonal influenza vaccine acceptance, with men more willing to accept the vaccine. This finding is similar to the evidence found in other studies, where women are more likely to be vaccine hesitant (Liu & Li, 2021; Reno et al., 2021; Schwarzinger et al., 2021). This finding also indicates that while fear of needles is an important predictor of vaccine acceptance, other variables must be at play in the gender difference regarding seasonal influenza vaccine acceptance.

Given that the UAE is a multicultural society with differences between Arabs and non-Arabs, ethnicity is an important variable to consider in any study concerning public health and nursing practices. In this study, no relevant ethnic differences were found in fear of needles amongst participants of this sample. But, very much as with gender, there was a difference between Arabs and non-Arabs in their acceptance of seasonal influenza vaccine, with Arabs having greater levels of acceptance. This also indicates that fear of needles was not the sole variable to account for ethnic disparities in vaccine acceptance. Previous research indicates that perceived ethnic discrimination plays an important role in vaccine hesitancy (Morgan et al., 2022; Savoia et al., 2021; Willis et al., 2022). This may be the case with the current sample obtained in the UAE (Pasha-Zaidi, 2015; Vora, 2008), as non-Arab migrant workers may harbor feelings of alienation and this may prevent them from receiving the seasonal influenza shot.

Interestingly, in the present study, anxiety was not associated with the decision to take the vaccine, but depression did have a positive association with vaccine acceptance. The fact that depression and acceptance of vaccines were associated might seem at first counterintuitive but some plausible explanations may be explored. For example, individuals experiencing depression might be more attuned to their health and more likely to engage in health-seeking behaviors; this increased awareness may lead them to prioritize preventive measures like getting vaccinated against the flu (Madison et al., 2021). Likewise, depressed individuals may perceive themselves as more vulnerable to illness or complications, prompting them to take proactive steps to protect their health, including getting vaccinated against influenza (Orth et al., 2016). Furthermore, healthcare providers often recommend influenza vaccination, and individuals with depression may be more likely to follow medical advice; the trusting relationship between patients with depression and their healthcare providers could play a role in this decision. Individuals with depression may actively seek out health information, including the benefits of vaccination; this increased awareness could lead to a greater willingness to receive the influenza vaccine (Maciaszek et al., 2022).

Strengths and Limitations

This study was sufficiently powered so as to avoid a Type-II error (and hence accept false negatives). This was a particular strength. Likewise, it approached the study of variables that remain largely unstudied in the Middle East and North Africa (MENA) region.

However, some limitations remain. Due to the challenges of recruiting subjects to answer a survey, this study relied on convenient sampling. The non-probabilistic characteristic of this study may have skewed some of the results. Future studies should work with stratified sampling, including participants from all emirates in the UAE. Likewise, although the sample was sufficiently large so as to return statistically significant results, future studies should include larger sample sizes so as to arrive at more robust conclusions.

Due to the ethical challenges in obtaining informed consent from participants, this study focused on adults. Fear of needles may be more intense in children, and consequently, the fact that children were left out of this study may not reflect sufficiently well the state of affairs in the UAE, regarding fear of needles. Future research on this topic in the UAE should also focus on children.

Implications for Practice

Given that fear of needles is an important factor in predicting acceptance of seasonal influenza vaccine, UAE authorities must reconsider its emphasis on educational aspects of vaccine acceptance, and place greater emphasis on the handling of fear of needles. Non-painful oral administration of the vaccine may serve as an alternative (Liebowitz et al., 2020), as it is expected that this mode of administration may find greater acceptance in the population.

Likewise, increased training programs for nursing staff are necessary, so as to properly handle the anxiety suffered by patients in receiving injections (Igoumenidis & Suhonen, 2021; Nir et al., 2003). This can be done on various dimensions. Nurses may strive to have open and honest conversations with individuals about their fear of needles; understanding the specific concerns and anxieties can help tailor the approach to address their needs (Duncanson et al., 2021). Nurses must also consider educating patients about the procedure, emphasizing the benefits of vaccinations or medical interventions; clear and accurate information can demystify the process and alleviate anxiety (Gaskell et al., 2005). Another proven technique is to engage the patient in conversation about non-medical topics to divert their attention from the procedure; using distraction techniques, such as asking about their interests or discussing a pleasant experience, can help reduce anxiety (Wang et al., 2022). Some practitioners also recommend teaching deep-breathing exercises or mindfulness techniques to help patients relax before and during the procedure; slow, controlled breathing can reduce overall anxiety and stress (McWhorter & Gil-Rivas, 2014). Allowing patients to choose a comfortable position for the procedure may also be effective, as some people may feel less anxious lying down, while others prefer to sit; providing a sense of control can help reduce anxiety (Lacey et al., 2008).

Some research suggests that the gradual exposure of individuals to the needle by showing them the equipment and explaining each step also helps; this step-by-step approach can help desensitize the fear and make the experience less overwhelming (McMurtry et al., 2016). Furthermore, as with any health intervention, establishing a trusting relationship with the individual is fundamental; a caring and empathetic approach can significantly reduce anxiety (Ives & Melrose, 2010). Some practitioners have also recommended offering a small reward or incentive after the procedure; additionally, having distractions such as music, videos, or toys can help take the person's mind off the needle (McMurtry et al., 2015).

Conclusion

The results obtained from this sample suggest that the seasonal influenza vaccine program has been moderately successful, but there is still need for improvement and there must be greater efforts in reaching larger sectors of the population in the UAE. While educational efforts are very relevant in this endeavor, the most relevant finding in this study suggests that when it comes to making the decision to receive the seasonal influenza vaccine, the fear of needles is also an important factor. This is a very important finding for nurses, as their demeanor in administering vaccines may have a considerable impact on the subjective perception of needles amongst patients.

Footnotes

Availability of data and material

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Ethical approval

Protocols were approved by Ajman University's IRB.

Funding

The authors disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: This work was supported by the Ajman University Funded Research Grant,(grant number 2022-IRG-MED-11 ).

ORCID iD

Dalia Bedewy

References

Abebe

Shitu

Mose

(2021). Understanding of COVID-19 vaccine knowledge, attitude, acceptance, and determinates of COVID-19 vaccine acceptance among adult population in Ethiopia. Infection and Drug Resistance, 14(14), 2015. https://doi.org/10.2147/IDR.S312116

Ahamed

Ganesan

James

Zaher

W. A.

(2021). Understanding perception and acceptance of Sinopharm vaccine and vaccination against COVID–19 in the UAE. BMC Public Health, 21(1), 1–11. https://doi.org/10.1186/s12889-021-11620-z

Al Khayyal

A. O.

Alshurideh

Al Kurdi

Salloum

S. A.

(2020). Women empowerment in UAE: A systematic review. 742–755.

Allagui

Al-Najjar

(2018). From women empowerment to nation branding: A case study from the United Arab Emirates. International Journal of Communication, 12(18), 18.

Andrade

(2020). Medical conspiracy theories: Cognitive science and implications for ethics. Medicine, Health Care and Philosophy, 23(3), 505–518. https://doi.org/10.1007/s11019-020-09951-6

Andrade

Bedewy

Bani

(2022). Motivational factors to receive the COVID-19 vaccine in the United Arab Emirates: A cross-sectional study. Journal of Community Health, 23(3), 1–9. https://doi.org/10.1007/s10900-022-01084-6

Bani

Pepe

Zorzi

Ardenghi

Rampoldi

Strepparava

(2020). Validation of the Italian version of the Injection Phobia Scale-Anxiety and application to blood donors. Mediterranean Journal of Clinical Psychology, 8(3).

Bani

Zorzi

Russo

Ardenghi

Rampoldi

Strepparava

M. G.

(2022). Psychometric properties and validation of the Italian version of the Medical Fear Survey-Short Version. Mediterranean Journal of Clinical Psychology, 10(2).

Beck

A. T.

Emery

Greenberg

R. L.

(2005). Anxiety disorders and phobias: A cognitive perspective. Basic books.

10.

Bergmann

(2018). Conspiracy & populism: The politics of misinformation. Springer.

11.

Betsch

Wicker

(2012). E-health use, vaccination knowledge and perception of own risk: Drivers of vaccination uptake in medical students. Vaccine, 30(6), 1143–1148. https://doi.org/10.1016/j.vaccine.2011.12.021

12.

Bourne

P. A.

Allen

Crumbie

Scille

Simpson

Fallah

Campbell

Foster

McLean

Parkes

D. R.

(2022). Does the Fear of Needles Influence Jamaicans’ Willingness to be vaccinated against COVID-19?

13.

Bracha

H. S.

Bracha

A. S.

Williams

A. E.

Ralston

T. C.

Matsukawa

J. M.

(2005). The human fear-circuitry and fear-induced fainting in healthy individuals. Clinical Autonomic Research, 15(3), 238–241. https://doi.org/10.1007/s10286-005-0245-z

14.

Burke

Schwartz

Breda

(2019). Don’t hesitate, vaccinate! An influenza vaccine education program. 54(4), 553–556.

15.

Deacon

Abramowitz

(2006). Fear of needles and vasovagal reactions among phlebotomy patients. Journal of Anxiety Disorders, 20(7), 946–960. https://doi.org/10.1016/j.janxdis.2006.01.004

16.

Đorđević

J. M.

Mari

Vdović

Milošević

(2021). Links between conspiracy beliefs, vaccine knowledge, and trust: Anti-vaccine behavior of Serbian adults. Social Science & Medicine, 277, 113930. https://doi.org/10.1016/j.socscimed.2021.113930

17.

Dos Santos

(2019). Challenges in implementing yearly enhanced safety surveillance of influenza vaccination in Europe: Lessons learned and future perspectives. Human Vaccines & Immunotherapeutics, 15(11). https://doi.org/10.1080/21645515.2019.1608745

18.

Jaaniste

Champion

G. D.

Yap

C. S.

(2008). Theories of fear acquisition: The development of needle phobia in children. Pediatric Pain Letter, 10(2).

19.

Duncanson

Le Leu

R. K.

Shanahan

Macauley

Bennett

P. N.

Weichula

McDonald

Burke

A. L.

Collins

K. L.

Chur-Hansen

(2021). The prevalence and evidence-based management of needle fear in adults with chronic disease: A scoping review. Plos One, 16(6), e0253048. https://doi.org/10.1371/journal.pone.0253048

20.

Essau

C. A.

(2003). Comorbidity of anxiety disorders in adolescents. Depression and Anxiety, 18(1), 1–6. https://doi.org/10.1002/da.10107

21.

Gaskell

Binns

Heyhoe

Jackson

(2005). Taking the sting out of needles: Education for staff in primary care. Paediatric Nursing, 17(4), 24. https://doi.org/10.7748/paed.17.4.24.s19

22.

Grimes

D. R.

(2020). Health disinformation & social media: The crucial role of information hygiene in mitigating conspiracy theory and infodemics. EMBO Reports, 21(11), e51819. https://doi.org/10.15252/embr.202051819

23.

Hamilton

J. G.

(1995). Needle phobia: A neglected diagnosis. Journal of Family Practice, 41(2), 169–182.

24.

Hornsey

(2021). The psychology of the anti-vaccine movement. The Biochemist, 43(4), 52–54. https://doi.org/10.1042/bio_2021_162

25.

Igoumenidis

Suhonen

(2021). Virtuous nurses and the COVID-19 vaccine. Nursing Ethics, 28(7–8), 1093–1095. https://doi.org/10.1177/09697330211061254

26.

Ives

Melrose

(2010). Immunizing children who fear and resist needles: Is it a problem for nurses? 45(1), 29–39.

27.

Jenkins

(2014). II. Needle phobia: A psychological perspective. British Journal of Anaesthesia, 113(1), 4–6. https://doi.org/10.1093/bja/aeu013

28.

Jung

Lin

Viswanath

(2013). Associations between health communication behaviors, neighborhood social capital, vaccine knowledge, and parents’ H1N1 vaccination of their children. Vaccine, 31(42), 4860–4866. https://doi.org/10.1016/j.vaccine.2013.07.068

29.

Kaufman

Charney

(2000). Comorbidity of mood and anxiety disorders. Depression and Anxiety, 12(S1), 69–76. https://doi.org/10.1002/1520-6394(2000)12:1+<69::AID-DA9>3.0.CO;2-K

30.

Kernéis

Jacquet

Bannay

May

Launay

Verger

Pulcini

Abgueguen

Ansart

Bani-Sadr

(2017). Vaccine education of medical students: A nationwide cross-sectional survey. American Journal of Preventive Medicine, 53(3), e97–e104. https://doi.org/10.1016/j.amepre.2017.01.014

31.

Kim

T. H.

(2014). Seasonal influenza and vaccine herd effect. Clinical and Experimental Vaccine Research, 3(2), 128–132. https://doi.org/10.7774/cevr.2014.3.2.128

32.

Kroenke

Spitzer

R. L.

Williams

J. B.

Löwe

(2009). An ultra-brief screening scale for anxiety and depression: The PHQ–4. Psychosomatics, 50(6), 613–621. https://doi.org/10.1016/s0033-3182(09)70864-3.

33.

Lacey

C. M.

Finkelstein

Thygeson

M. V.

(2008). The impact of positioning on fear during immunizations: Supine versus sitting up. Journal of Pediatric Nursing, 23(3), 195–200. https://doi.org/10.1016/j.pedn.2007.09.007

34.

Liebowitz

Gottlieb

Kolhatkar

N. S.

Garg

S. J.

Asher

J. M.

Nazareno

Kim

McIlwain

D. R.

Tucker

S. N.

(2020). Efficacy, immunogenicity, and safety of an oral influenza vaccine: A placebo-controlled and active-controlled phase 2 human challenge study. The Lancet Infectious Diseases, 20(4), 435–444. https://doi.org/10.1016/S1473-3099(19)30584-5

35.

Liu

G. M.

(2021). Hesitancy in the time of coronavirus: Temporal, spatial, and sociodemographic variations in COVID-19 vaccine hesitancy. SSM-Population Health, 15, 100896. https://doi.org/10.1016/j.ssmph.2021.100896

36.

Löwe

Wahl

Rose

Spitzer

Glaesmer

Wingenfeld

Schneider

Brähler

(2010). A 4-item measure of depression and anxiety: Validation and standardization of the patient health questionnaire-4 (PHQ-4) in the general population. Journal of Affective Disorders, 122(1–2), 86–95. https://doi.org/10.1016/j.jad.2009.06.019

37.

Maciaszek

Lenart-Bugla

Szcześniak

Gawłowski

Borowicz

Misiak

Rymaszewska

(2022). Does mental health affect the decision to vaccinate against SARS-CoV-2? A cross-sectional nationwide study before the vaccine campaign. Frontiers in Psychiatry, 13, 810529. https://doi.org/10.3389/fpsyt.2022.810529

38.

Madison

A. A.

Shrout

M. R.

Renna

M. E.

Kiecolt-Glaser

J. K.

(2021). Psychological and behavioral predictors of vaccine efficacy: Considerations for COVID-19. Perspectives on Psychological Science, 16(2), 191–203. https://doi.org/10.1177/1745691621989243

39.

Mann

(2008). Framing obesity in economic theory and policy. Review of Social Economy, 66(2), 163–179. https://doi.org/10.1080/00346760701668461

40.

Martens

R. J.

Geijselaers

S. L.

Stehouwer

C. D.

Henry

R. M.

(2017). Timing of syncope during blood sampling–the Maastricht study. European Journal of Internal Medicine, 43, e46–e47. https://doi.org/10.1016/j.ejim.2017.05.024

41.

McLenon

Rogers

M. A.

(2019). The fear of needles: A systematic review and meta-analysis. Journal of Advanced Nursing, 75(1), 30–42. https://doi.org/10.1111/jan.13818

42.

McMurtry

C. M.

Riddell

R. P.

Taddio

Racine

Asmundson

G. J.

Noel

Chambers

C. T.

Shah

, & Team, Help. (2015). Far from “just a poke”: Common painful needle procedures and the development of needle fear. The Clinical Journal of Pain, 31, S3–S11. https://doi.org/10.1097/AJP.0000000000000272

43.

McMurtry

C. M.

Taddio

Noel

Antony

M. M.

Chambers

C. T.

Asmundson

G. J.

Pillai Riddell

Shah

MacDonald

N. E.

Rogers

(2016). Exposure-based interventions for the management of individuals with high levels of needle fear across the lifespan: A clinical practice guideline and call for further research. Cognitive Behaviour Therapy, 45(3), 217–235. https://doi.org/10.1080/16506073.2016.1157204

44.

McWhorter

L. G.

Gil-Rivas

(2014). The effect of brief functional relaxation on college students’ needle anxiety during injected vaccinations. Journal of American College Health, 62(3), 166–172. https://doi.org/10.1080/07448481.2013.867862

45.

Medlock

Galvani

A. P.

(2009). Optimizing influenza vaccine distribution. Science, 325(5948), 1705–1708. https://doi.org/10.1126/science.1175570

46.

Mele

(2010). Weakness of will and akrasia. Philosophical Studies, 150(3), 391–404. https://doi.org/10.1007/s11098-009-9418-2

47.

Mele

A. R.

(2012). Backsliding: Understanding weakness of will. Oxford University Press.

48.

Milovanović

Tomović

Janković

S. M.

Grubor

Nikolić

Mijajlović

Mrvić

Divjak

Milojević

(2017). Factors influencing the fear of needles among students of medicine and pharmacy. Acta Facultatis Medicae Naissensis, 34(2), 147–158. https://doi.org/10.1515/afmnai-2017-0016

49.

Montagni

Mabchour

Tzourio

(2020). Digital gamification to enhance vaccine knowledge and uptake: Scoping review. JMIR Serious Games, 8(2), e16983. https://doi.org/10.2196/16983

50.

Morgan

K. M.

Maglalang

D. D.

Monnig

M. A.

Ahluwalia

J. S.

Avila

J. C.

Sokolovsky

A. W.

(2022). Medical mistrust, perceived discrimination, and race: A longitudinal analysis of predictors of COVID-19 vaccine hesitancy in US adults. Journal of Racial and Ethnic Health Disparities, 10, 1–10. https://doi.org/10.1007/s40615-022-01368-6

51.

Navin

M. C.

Wasserman

J. A.

Ahmad

Bies

(2019). Vaccine education, reasons for refusal, and vaccination behavior. American Journal of Preventive Medicine, 56(3), 359–367. https://doi.org/10.1016/j.amepre.2018.10.024

52.

Nir

Paz

Sabo

Potasman

(2003). Fear of injections in young adults: Prevalence and associations. The American Journal of Tropical Medicine and Hygiene, 68(3), 341–344. https://doi.org/10.4269/ajtmh.2003.68.341

53.

Nizam

Iqbal

Mashood

El Nebrisi

(2022). Analyzing COVID-19 vaccine hesitancy among university students in UAE: A cross-sectional study. Dubai Medical Journal, 5(3), 1–12. https://doi.org/10.1159/000523993

54.

Olatunji

B. O.

Sawchuk

C. N.

Moretz

M. W.

David

Armstrong

Ciesielski

B. G.

(2010). Factor structure and psychometric properties of the injection phobia scale–anxiety. Psychological Assessment, 22(1), 167. https://doi.org/10.1037/a0018125

55.

Orenius

LicPsychm Säilä

Mikola

Ristolainen

(2018). Fear of injections and needle phobia among children and adolescents: An overview of psychological, behavioral, and contextual factors. SAGE Open Nursing, 4, 2377960818759442. https://doi.org/10.1177/2377960818759442

56.

Ortashi

Raheel

Shalal

Osman

(2013). Awareness and knowledge about human papillomavirus infection and vaccination among women in UAE. Asian Pacific Journal of Cancer Prevention, 14(10), 6077–6080. https://doi.org/10.7314/APJCP.2013.14.10.6077

57.

Orth

Robins

R. W.

Meier

L. L.

Conger

R. D.

(2016). Refining the vulnerability model of low self-esteem and depression: Disentangling the effects of genuine self-esteem and narcissism. Journal of Personality and Social Psychology, 110(1), 133. https://doi.org/10.1037/pspp0000038

58.

Palache

Oriol-Mathieu

Abelin

Music

(2014). Seasonal influenza vaccine dose distribution in 157 countries (2004–2011). Vaccine, 32(48), 6369–6376. https://doi.org/10.1016/j.vaccine.2014.07.012

59.

Pasha-Zaidi

(2015). Judging by appearances: Perceived discrimination among south Asian muslim women in the US and the UAE. Journal of International Women’s Studies, 16(2), 70–97. https://doi.org/10.5861/ijrsp.2013.357

60.

Pertwee

Simas

Larson

H. J.

(2022). An epidemic of uncertainty: Rumors, conspiracy theories and vaccine hesitancy. Nature Medicine, 28(3), 456–459. https://doi.org/10.1038/s41591-022-01728-z

61.

Reno

Maietti

Fantini

M. P.

Savoia

Manzoli

Montalti

Gori

(2021). Enhancing COVID-19 vaccines acceptance: Results from a survey on vaccine hesitancy in northern Italy. Vaccines, 9(4), 378. https://doi.org/10.3390/vaccines9040378

62.

Ropeik

(2013). How society should respond to the risk of vaccine rejection. Human Vaccines & Immunotherapeutics, 9(8), 1815–1818. https://doi.org/10.4161/hv.25250

63.

Saeed

(2022). Knowledge, attitudes, behaviors and, risk perception towards seasonal influenza and vaccination among adult population of UAE. Periodicals of Engineering and Natural Sciences (PEN), 10(2), 30–40. https://doi.org/10.21533/pen.v10i1.2752

64.

Savoia

Piltch-Loeb

Goldberg

Miller-Idriss

Hughes

Montrond

Kayyem

Testa

M. A.

(2021). Predictors of COVID-19 vaccine hesitancy: Socio-demographics, co-morbidity, and past experience of racial discrimination. Vaccines, 9(7), 767. https://doi.org/10.3390/vaccines9070767

65.

Schwarzinger

Watson

Arwidson

Alla

Luchini

(2021). COVID-19 vaccine hesitancy in a representative working-age population in France: A survey experiment based on vaccine characteristics. The Lancet Public Health, 6(4), e210–e221. https://doi.org/10.1016/S2468-2667(21)00012-8

66.

Sokolowski

C. J.

Giovannitti

J. A.

Boynes

S. G.

(2010). Needle phobia: Etiology, adverse consequences, and patient management. Dental Clinics, 54(4), 731–744. https://doi.org/10.1016/j.cden.2010.06.012

67.

Taddio

Ipp

Thivakaran

Jamal

Parikh

Smart

Sovran

Stephens

Katz

(2012). Survey of the prevalence of immunization non-compliance due to needle fears in children and adults. Vaccine, 30(32), 4807–4812. https://doi.org/10.1016/j.vaccine.2012.05.011

68.

Vincent

Awada

Brown

Chen

Claes

Dauphin

Donis

Culhane

Hamilton

Lewis

(2014). Review of influenza A virus in swine worldwide: A call for increased surveillance and research. Zoonoses and Public Health, 61(1), 4–17. https://doi.org/10.1111/zph.12049

69.

Voo

J. Y. H.

Lean

Q. Y.

Ming

L. C.

Al-Worafi

Y. M.

Ibrahim

(2021). Vaccine knowledge, awareness and hesitancy: A cross sectional survey among parents residing at sandakan district, Sabah. Vaccines, 9(11), 1348. https://doi.org/10.3390/vaccines9111348

70.

Vora

(2008). Producing diasporas and globalization: Indian middle-class migrants in Dubai. Anthropological Quarterly, 81(2), 377–406. https://doi.org/10.1353/anq.0.0010

71.

Wang

Guo

Xiong

(2022). Effects of virtual reality-based distraction of pain, fear, and anxiety during needle-related procedures in children and adolescents. Frontiers in Psychology, 13, 842847. https://doi.org/10.3389/fpsyg.2022.842847

72.

Willis

D. E.

Montgomery

B. E.

Selig

J. P.

Andersen

J. A.

Shah

S. K.

Reece

Alik

McElfish

P. A.

(2022). COVID-19 Vaccine Hesitancy and Racial Discrimination among US Adults. Preventive Medicine Reports, 102074. https://doi.org/10.1016/j.pmedr.2022.102074

73.

Wright

Yelland

Heathcote

S.-K.

Wright

(2009). Fear of needles-nature and prevalence in general practice. Australian Family Physician, 38(3), 172–176.

74.

Zheng

Jiang

(2022). Factors influencing COVID-19 vaccination intention: The roles of vaccine knowledge, vaccine risk perception, and doctor-patient communication. Patient Education and Counseling, 105(2), 277–283. https://doi.org/10.1016/j.pec.2021.09.023

75.

Zingg

Siegrist

(2012). Measuring people’s knowledge about vaccination: Developing a one-dimensional scale. Vaccine, 30(25), 3771–3777. https://doi.org/10.1016/j.vaccine.2012.03.014

Fear of Needles and Seasonal Influenza Vaccine Acceptance Amongst Adults in the United Arab Emirates: A Cross-Sectional Study and Implications for Nursing

Abstract

Introduction

Objective

Methods

Results

Conclusion

Keywords

Introduction

Review of Literature

Objectives

Methods

Design

Research Questions

Sample

Inclusion and Exclusion Criteria

Institutional Review Board Approval, Informed Consent and Human Subjects’ Rights

Statistical Analysis

Results

Sample Characteristics

Research Questions Results

Discussion

Strengths and Limitations

Implications for Practice

Conclusion

Footnotes

Availability of data and material

Declaration of Conflicting Interests

Ethical approval

Funding

ORCID iD

References