​17 MAY 2022



First local study conducted by SingHealth Polyclinics (SHP) has demonstrated the feasibility and acceptability of using an immersive Virtual Reality (VR) called SILVER (Soothing Immunisation Leveraging on Virtual Reality Experience) during childhood immunisation. The results from the study showed that it is safe and effective in alleviating anxiety among children and parents during vaccination.

Adherence to childhood immunisation is often associated with significant fear and anxiety towards pain among children and their parents during the procedure. Injections resulting in pain, triggers phobia and distress in children for subsequent vaccinations. The unpleasant experience by the children obliquely causes anxiety among their accompanying parents, which ultimately lead to vaccine hesitancy.

In 2019, the World Health Organization (WHO) announced vaccine hesitancy as one of the top 10 threats to global health. Paediatricians from the American Academy of Paediatrics found that 75 per cent of parents sought to delay immunisation due to concerns of their child’s discomfort and approximately 45 per cent of the children aged 4 to 6 years old showed serious distress during immunisation.

Dr Chang Zi Ying, Associate Consultant and Clinic Director of SHP-Sengkang said, “The need for an acceptable solution to overcome immunisation barriers is important, as adhering to childhood vaccinations would protect the child from life-threatening infectious diseases such as measles, mumps, rubella and varicella. In addition, children who uptake the annual influenza vaccination will be protected from the rapidly evolving strains, which can spread readily in childcare facilities and schools.” Dr Chang is also the main author of this research paper.

Distraction is a common non-pharmacologic technique used to attenuate pain and anxiety during painful medical procedures in paediatric patients4. Both passive distraction, such as watching television or listening to music, and active distraction, such as interactive toys and electronic games, have shown to reduce pain and anxiety in variable degrees.

“VR application immerses the user into another simulated environment, which provides the approach of distraction. Although it is relatively new in paediatric procedures in our local primary care setting, it has been well established in some other countries such as Australia. This pilot study using SILVER, has showed potential mitigation of reducing distress and fear in children undertaking immunisation”, added Dr Chang. 

SILVER is a software, which enacts a 2 minutes’ story of a mascot called Burp. Once the child wears the VR headset, the child can see a spell book with a giant blue crystal tower floating above. Burp will inform the child to assist him to power up his crystal tower, after which, he will use the magic wand to tap on the child’s left shoulder to coincide with the point of injection. The rune on the child’s left shoulder is then activated to enable magical power to flow from it to the crystal tower.

The study screened and recruited 30 children between the ages of 4 to 10 years old at SHP-Sengkang. They were randomised between an intervention group using the VR, and a control group with standard procedure for their immunisations. Both groups consist of 15 participating children. According to Steven A. Julious, a sample size of 12 per group for a pilot study is recommended.

The feasibility was assessed by the response rate to the use of VR during immunisation by the end users, namely the nurses who administered the vaccine, the children and their parents. The overall response rate was high. All of the end users, except one young child (4-year-old) in the intervention group, accepted the use of VR. None of the children experienced any adverse effect in this study, which validated the safety of using the immersive VR during the procedure.

The Faces Pain Scale-Revised (FPS-R) and the Children’s Fear Scale (CFS) were used to determine the children’s pain and anxiety respectively, while the Visual Analogue Scale (VAS) was used to evaluate the anxiety level of accompanying parents and attending nurses. 

To capture the children’s actual experienced of pain and anxiety during the immunisation, the assessment of anxiety for a child was carried out within 2 minutes before and after the injection, while the assessment of pain was captured 2 minutes right after the injection. 

The results showed decline in the children’s pain score in the intervention group compared to the control group. However, the result did not attain statistical significance due to the number of participants in the study. In addition, more than 73 per cent of the children in the intervention group were willing to return for future immunisation, compared to only 40 per cent in the control group. 

The change in parental anxiety score was also significantly reduced by the value of -4 in the intervention group compared to the control group.

Eight nurses who administered the vaccines in both groups more than one time, showed no major difference in the change of their anxiety level. This substantiated the usability of the immersive VR among nurses during the vaccination.

"Visits to the clinic may be a daunting experience for many, especially for young children who need to undergo vaccinations. SILVER helps to enhance and transform the patient’s clinical experience through immersive technology such as virtual reality, allowing them to step into another reality and alleviates their anxiety during their visits”, Dr Goh Chi Keong, Managing Director, AI2Labs.

“The feasibility of this study could potentially be applied in immunisation for older children, who may struggle during the administering of vaccines. It may become an additional tool to be used in children with special needs and those with immunisation phobia. It is also timely now as Singapore is implementing the COVID-19 vaccination for children aged 5 to 11 years old, where a second dose is required. We hope that this would mitigate one of the barriers, such as needle phobia, to prevent vaccine hesitancy towards seasonal influenza and other childhood vaccinations”, said Clinical Associate Professor (Dr) Tan Ngiap Chuan, Director of Research, SHP and Vice-chair, Research, SingHealth-Duke NUS Family Medicine Academic Clinical Programme (FM ACP).

“We aim to eventually scale up this pilot study for subsequent trials, to provide more in-depth validation on this new technology for childhood immunisation in the primary care setting,” added Prof Tan.

1 World Health Organization. Ten Threats To Global Health 2019. 2019; Available from: https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

2 Hough-Telford C, Kimberlin DW, Aban I, Hitchcock WP, Almquist J, Kratz R, OConnor KG. Vaccine Delays, Refusals, and Patient Dismissals: A Survey of Pediatricians. PEDIATRICS 2016 Sep 1;138(3):e20162127–e20162127. [doi: 10.1542/peds.2016-2127]

3 Jacobson RM, Swan A, Adegbenro A, Ludington SL, Wollan PC, Poland GA. Making vaccines more acceptable — methods to prevent and minimize pain and other common adverse events associated with vaccines. Vaccine 2001 Mar;19(17–19):2418–2427. [doi: 10.1016/S0264-410X(00)00466-7]

4 Koller D, Goldman RD. Distraction Techniques for Children Undergoing Procedures: A Critical Review of Pediatric Research. J Pediatr Nurs 2012 Dec;27(6):652–681. [doi: 10.1016/j.pedn.2011.08.001]

5 Julious SA. Sample size of 12 per group rule of thumb for a pilot study. Pharm Stat 2005 Oct;4(4):287–291. [doi: 10.1002/pst.185]

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About SingHealth Polyclinics
SingHealth Polyclinics (SHP) comprises a network of nine polyclinics that provides primary healthcare services and plays an integral role in empowering patients, their families and communities to take charge of their health and wellness. SHP practises Family Medicine, providing seamless, patient-centred treatment and preventive healthcare that is affordable and accessible to all through its network of polyclinics.

SingHealth Polyclinics is a member of Singapore Health Services (SingHealth) – an Academic Medical Centre offering over 40 clinical specialties through a network of acute hospitals, national specialty centres, community hospitals and polyclinics.

For more information, please visit polyclinic.singhealth.com.sg