Elsevier

Vaccine

Volume 31, Issue 25, 7 June 2013, Pages 2772-2777
Vaccine

Reducing children's pain and distress towards flu vaccinations: A novel and effective application of humanoid robotics

https://doi.org/10.1016/j.vaccine.2013.03.056Get rights and content

Highlights

  • We examine how a humanoid robot can distract children during vaccination.

  • A humanoid robot reduces pain and distress for children during vaccination.

  • This study launches new research into humanoid robotics for pain management.

Abstract

Objective

Millions of children in North America receive an annual flu vaccination, many of whom are at risk of experiencing severe distress. Millions of children also use technologically advanced devices such as computers and cell phones. Based on this familiarity, we introduced another sophisticated device – a humanoid robot – to interact with children during their vaccination. We hypothesized that these children would experience less pain and distress than children who did not have this interaction.

Method

This was a randomized controlled study in which 57 children (30 male; age, mean ± SD: 6.87 ± 1.34 years) were randomly assigned to a vaccination session with a nurse who used standard administration procedures, or with a robot who was programmed to use cognitive-behavioral strategies with them while a nurse administered the vaccination. Measures of pain and distress were completed by children, parents, nurses, and researchers.

Results

Multivariate analyses of variance indicated that interaction with a robot during flu vaccination resulted in significantly less pain and distress in children according to parent, child, nurse, and researcher ratings with effect sizes in the moderate to high range (Cohen's d = 0.49–0.90).

Conclusion

This is the first study to examine the effectiveness of child–robot interaction for reducing children's pain and distress during a medical procedure. All measures of reduction were significant. These findings suggest that further research on robotics at the bedside is warranted to determine how they can effectively help children manage painful medical procedures.

Introduction

Vaccinations have an enormous benefit, yet create significant pain and distress for children [1]. This paradox has spurred the development and evaluation of strategies to reduce distress experienced by many children during vaccinations [2]. Cognitive-behavioral interventions show promise with considerable, but not consistent, empirical support [3], [4], [5], [6], [7], [8], [9]. In fact, utilization of some strategies such as encouraging caregivers to reassure their children and demonstrate empathy may result in higher levels of pain/distress compared to baseline control [10], [11], and children are not likely to use coping strategies they are taught [12]. A frequently used intervention is to instruct children to blow. Although it reduces researchers’ ratings of children's pain behaviors, children's, nurses’, and parents’ ratings of children's pain are not lower when compared to a control group [5]. There are many studies that report significant pain reduction when blowing is combined with a visual stimulus as a form of distraction, such as party blowers; however, ratings of pain are not consistently lower [7], [8]. Drawing on limited attentional capacity theory [13], it is possible that cognitive-behavioral intervention will have a limited impact on reducing children's pain when these stimuli are not as intense as the painful stimulus. In other words, the valence towards the distraction and blowing has to be stronger than towards the needle. Another advanced form of technology, virtual reality, has been explored for procedural-related distraction [14], but has shown mixed results, with associated nausea and headaches [15], [16]. To address these challenges we evaluated the use of a humanoid robot as a highly engaging and novel method of facilitating distraction and blowing for reducing distress during childhood immunizations with the goal of reducing the burden to children, their families, and health care professionals.

Research on children's use of technologically advanced computer driven machines (e.g., cell phones) across the age spectrum throughout many countries in the world is well underway [17], [18]. The study of other computer driven devices, such as robots and their contact with children, has recently emerged [19], [20]. These studies indicate that children are eager, receptive, and “pre-programmed” to engage with robots. Many children, for example, would befriend a robot and tell it secrets [19]. Indeed, robots are being designed to exhibit socially engaging and entertaining behaviors, a field known as developmental robotics [21].

The use of robots in health care began in 2001 with the introduction of a specialized robot arm to perform surgery on patients at Children's Hospital Boston. Robots have also been used to dispense and transport medication and materials in hospitals [22]. Mobile robot systems are also being tested as a means for physicians to communicate remotely with their patients and for lifting patients. Another type, humanoid robots, is designed to resemble human characteristics such as appearance and movement. Many are uniquely programmed to work with people, capable of both verbal and nonverbal communication. With emerging research suggesting that mobile robot systems and robot arms improve patient care [23], [24], it seemed timely to examine whether a humanoid robot could reduce pediatric pain and distress.

We introduced a small humanoid robot in a pediatric hospital to implement cognitive-behavioral strategies while children received a flu vaccination. The robot utilized strategies (distraction and blowing) that have some empirical support, and seem as effective as other forms of psychological intervention, for reducing children's pain distress while undergoing vaccination [4], [9]. Given the propensity of children for engagement with a robot, it was expected that they would enthusiastically respond to one in a hospital setting. Thus, it was hypothesized that children who were distracted by a robot during their flu vaccination would experience lower levels of pain and distress than children without such distraction.

Section snippets

Participants

The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Conjoint Health Ethics Research Board of the University of Calgary. The steps followed in the conduct of the research design are found in the Consort E-Flowchart. Children admitted to, or attending out-patient clinics at the Alberta Children's Hospital in October 2011 were referred for flu vaccination, provided by the Infectious Diseases Clinic by their physicians, or signed up for

Participant characteristics

This sample consisted of 30 boys and 27 girls ages 4–9 years (M = 6.87, SD = 1.34). The majority of children had no injections (n = 44, 77.2%), 9 (15.8%) had 1–2 injections, and 4 (7.1%) had 3 or more injections in the previous month. Many children (n = 23, 40.4%) had a chronic medical condition (e.g., asthma, cystic fibrosis). As shown in Table 1, there were no significant differences in participant characteristics between the two study conditions. In particular, age and sex were comparable. Also, the

Discussion

To our knowledge, no study has reported the application of a humanoid robot in the health care setting. This is a preliminary randomized controlled study, which determined that when distractions are facilitated by a robotic device, children experience significantly less pain and distress compared to children who are given little or no distraction during a commonly performed medical procedure, vaccination. With effect sizes in the moderate to high range, these effects are considered clinically

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