Virtual Reality in the Management of Hematophobia in Hospital Settings: Impact on Anxiety Reduction

doi:10.21203/rs.3.rs-4957378/v1

Introduction: Hematophobia, a specific phobia that triggers an irrational fear of blood and related procedures such as venipuncture, can lead to the avoidance of essential medical care. Virtual reality (VR) has emerged as a promising tool to reduce anxiety associated with these procedures. This study aimed to determine the prevalence of hematophobia among patients who visit the hospital for venipuncture and to evaluate the impact of VR on reducing anxiety and fear during venipuncture, considering variables such as gender, age, number of annual hospital visits, and service.

Material and Method: An analytical and experimental study was conducted, randomized 1:1, with a sample of 185 patients of both sexes, aged between 18 and 70 years, divided into two groups: clinical analysis laboratory and hematology day hospital. Anxiety was assessed using the Visual Analog Scale (VAS), and the severity of hematophobia was measured with the Blood-Injection Phobia Inventory (BIPI).

Results: VR was more effective in reducing anxiety in patients with moderate hematophobia, with a significant reduction in pre- and post-puncture anxiety scores (p=0.012). VR was particularly effective in patients under 40 years of age (p=0.039), while no statistical significance was observed in patients over 65 years of age.

Conclusions: VR is effective in reducing anxiety during venipuncture, especially in patients with moderate hematophobia and those under 40 years of age. Its application needs to be personalized according to the clinical context.

Hematophobia

Virtual reality

Anxiety

Venipuncture

Specific phobia

Clinical interventions

Anxiety reduction.

Specific Clinical Context: This study is a pioneer in examining the use of VR to treat hematophobia in settings such as laboratory testing and day hospitals, offering clear evidence on its integration into clinical practice.

Demographic and Technological Data: New insights are revealed into how the effectiveness of VR varies by patient age and technological familiarity, areas previously underexplored, opening new avenues for personalized care.

Impact on Clinical Practice: By demonstrating the efficacy of VR in the management of hematophobia, this study may transform the way these phobias are addressed in the clinical setting, promoting more personalized care.

Hematophobia, or the irrational fear of blood, is an anxiety disorder classified as a specific phobia. This disorder involves an intense fear of objects or situations related to blood, needles, injections, and wounds, leading to avoidance and escape behaviors (Abado, Aue, & Okon-Singer, 2021). Individuals with specific phobia of blood, injections, and injuries (SIH) often experience symptoms such as dizziness, paleness, nausea, sweating, hyperventilation, and feelings of disgust. In severe cases, they may develop a vasovagal response, characterized by a rapid fainting episode with spontaneous recovery in approximately 20 seconds, known as a biphasic response: an initial phase of increased heart rate and blood pressure, followed by a sudden drop in blood pressure (Mason, Gaston, Pestell, & Page, 2021).

According to the DSM-5, specific phobias involve disproportionate fear or anxiety in response to a specific situation, persisting for six months or more and affecting the individual's daily routine (Azarpanah, Farhadloo, Vahidov, & Pilote, 2021). The active avoidance and resistance of the phobic situation can interfere with social, occupational, or other important areas of life for those affected (Kiss, Birkás, Zilahi, & Zsido, 2022).

The prevalence of hematophobia varies significantly depending on the context and the population studied. While in the general population, the prevalence of severe hematophobia is estimated to be between 3% and 4% (Hamilton, 1995), specific studies in clinical settings reveal much higher rates. For instance, McMurtry et al. (2011) found that among children undergoing frequent medical procedures, the prevalence could reach up to 30%. Similarly, in dental patients, Oosterink et al. (2009) reported a prevalence of hematophobia close to 31%, suggesting that repeated exposure to situations involving blood or injections significantly increases the incidence of this phobia. This disparity in prevalence underscores the importance of contextualizing studies on hematophobia, considering that the frequency and type of exposure to triggering situations play a crucial role in the manifestation of this phobia.

1.1 Hematophobia in the hospital environment

The identification of patients with hematophobia is crucial in hospital settings due to the frequency of situations involving blood. Nursing staff must be trained to recognize and manage these patients, as their exposure to blood can trigger episodes of extreme anxiety or fainting, increasing the risk of falls and injuries (Gold & Mahrer, 2018). The ability to identify these patients allows for more sensitive and tailored care to their needs (Vega, Whitney, Hannah, & Smith, 2022).

The avoidance of diagnostic procedures due to hematophobia has significant economic and clinical implications. Avoidance of critical diagnostic procedures, such as blood tests, due to this fear, can lead to delayed diagnoses of serious diseases like cancer, which increases healthcare costs and reduces treatment options, in addition to raising mortality rates (Pennestrì et al., 2024; Kim et al., 2021). In chronic diseases like diabetes, the lack of regular monitoring due to hematophobia can result in severe and costly complications, such as retinopathy or nephropathy (Romeo et al., 2019). Similarly, in renal patients, this phobia hinders adequate monitoring and increases the risk of serious complications (Tummalapalli et al.,2020).

Fear of venipuncture not only affects treatment adherence but can also trigger adverse physiological responses, such as vasovagal syncope, complicating the process and raising costs due to the need to repeat procedures (Milutinović et al., 2021; Girgin & Göl, 2020). Effective management of hematophobia, through trained personnel, can improve the patient experience and reduce anxiety for both patients and nursing staff (Gökçe & Arslan, 2023; Birkhoff et al., 2021).

1.2 Using virtual reality to manage hematophobia

VR has emerged as an effective tool for managing hematophobia in medical settings (Kılıç et al., 2021). This technology allows for the creation of controlled three-dimensional environments that simulate reality, providing an immersive experience that can be used to distract and treat patients (Jiang, Upton, & Newby, 2020). VR offers several benefits in the management of hematophobia:

Reduction of direct exposure: VR allows patients to distract themselves in a virtual environment, minimizing direct exposure to blood and other anxiety-inducing stimuli (Gerçeker et al., 2020).

Environment control: Patients can choose relaxing virtual environments, which helps reduce anxiety levels and improves the hospital experience (Oh et al., 2023).

Gradual exposure: VR enables controlled and gradual exposure to situations related to hematophobia, facilitating increased tolerance to these stimuli (Gao et al., 2020).

Cognitive distraction: Immersion in engaging virtual environments diverts the patient’s attention away from the source of their fear, reducing the intensity of emotional reactions (Gershon, Zimand, Pickering, Rothbaum, & Hodges, 2004).

Virtual exposure therapy: VR is effectively used in exposure therapy to treat phobias, providing a safe and controlled environment to gradually face fears (Mosso-Vázquez, Gao, Wiederhold, & Wiederhold, 2014).

Improvement of patient experience

The use of VR can make medical visits and procedures less stressful, benefiting both patients and medical staff (Walther-Larsen et al., 2019).

The implementation of VR in hospitals has been shown to reduce pain and anxiety in patients during painful medical procedures. A pediatric study demonstrated that VR can significantly decrease pain and anxiety in patients during blood draws, especially in those with higher sensitivity to anxiety (Dumoulin et al., 2019). Another study found that VR more significantly reduces pain sensations compared to traditional methods, particularly in cases of severe pain (Georgescu, Fodor, Dobrean, & Cristea,2020).

Additionally, VR is useful in managing acute pain in chronic and post-surgical treatments, reducing heart rate, respiration, and blood pressure (Chuan, Zhou, Hou, Stevens, & Bogdanovych, 2020). In the field of psychology, VR has proven to be as effective as traditional live exposure therapies for treating specific phobias, presenting itself as an accessible and controllable alternative (Carl et al., 2019). Similarly, VR has been shown to be effective in reducing pain and anxiety in cancer patients, improving their experience and treatment self-efficacy (Birkhoff et al., 2021).

Hematophobia represents a significant challenge in the hospital setting, both for patients and nursing staff. Conducting studies on this phobia is crucial to improving the identification and management of patients, as well as providing emotional support and reducing staff stress. Although the implementation of VR in hospitals can enhance the patient experience and the quality of healthcare, contributing to a safer and more compassionate environment for everyone, studies are needed to develop and implement protocols for this purpose.

2.1 Design

Analytical and experimental study with a 1:1 randomized design. The research is divided into two sample groups:

Sample 1: Patients in a clinical laboratory undergoing venipuncture for blood collection. Participants are distributed into two groups: the case group, which receives the VR intervention during venipuncture, and the control group, which undergoes venipuncture without the use of VR.

Sample 2: Patients in the hematology day hospital, where venipuncture is performed for the administration of treatments. These patients are also divided into a case group (with VR) and a control group (without VR).

2.2. Ethics

The study adhered to the Declaration of Helsinki. Ethical approval (protocol PI 82/2023) was obtained from the Research Ethics Committee on November 29, 2023. All participants signed an informed consent form.

2.3. Data Collection

Prior to the application of the diagnostic procedure, the responsible healthcare personnel assessed the patient's profile and compliance with the established inclusion and exclusion criteria to determine their eligibility as a study subject. The inclusion criteria required participants to be men or women between 18 and 85 years of age, undergoing venipuncture for blood collection or peripheral vein cannulation, and to have signed an informed consent form indicating their understanding and willingness to participate in the study. Exclusion criteria included refusal to sign the informed consent, inability to understand, read, and sign the informed consent and complete the questionnaires due to issues such as lack of proficiency in Spanish, having neurological or psychiatric disorders that could interfere with participation, a history of epileptic seizures, and severe visual and auditory impairments that would prevent correct sensory feedback with VR. Patients who had previously applied topical anesthetic to the puncture site were also excluded. If the patient met the established criteria, the possibility of participating in the study was presented, with explanations provided regarding the purposes, conditions, and benefits, as well as the potential risks involved. Additionally, an information sheet was provided, and any doubts or questions were addressed. If the patient agreed to participate, they completed and signed the informed consent form. Subsequently, participants were randomly assigned to the different study groups. In all cases, anxiety assessment questionnaires were administered before the puncture, using the Visual Analog Scale (VAS) for Anxiety and the Blood-Injection Phobia Inventory (BIPI). The VAS was then administered again after the puncture. The BIPI is a questionnaire designed to assess specific phobia of blood, injections, and related medical procedures, measuring the cognitive, physiological, and behavioral reactions of the individual in phobic situations on a scale of 0 to 3. This tool allows for the identification of the severity of the phobia and guides appropriate therapeutic interventions, such as cognitive-behavioral therapy. The Spanish version has been validated and shows adequate reliability for clinical use (Borda Mas, López Jiménez, & Pérez San Gregorio, 2010). The Visual Analog Scale (VAS) for Anxiety is a simple and widely used tool for assessing the level of anxiety at a given moment. It consists of a 10 cm horizontal line, where the left end represents "no anxiety" and the right end "the most anxiety imaginable." The patient marks the point that best reflects their level of anxiety, facilitating a quick and useful assessment in clinical and research contexts (Lesage, Berjot, & Deschamps, 2012). The collected information was stored in a database for subsequent processing and analysis.

2. 4 Equipment

For the creation of the "relax experience" aimed at reducing anxiety in patients, the Oculus Quest 2 device was used. This advanced VR system is an all-in-one solution that does not require external sensors and offers six degrees of freedom (6DoF), enabling precise tracking of both head and body movements. The device features redesigned Touch controllers that provide greater stability, which is crucial for maintaining immersion without causing discomfort in patients. The device offers a fast-switching LCD display with a resolution of 1832 × 1920 pixels per eye and refresh rates of 60, 72, and 90 Hz, ensuring a smooth visual experience. The integrated 3D positional audio contributes to auditory immersion, enabling a surround sound experience essential for relaxation sessions.

Selection of VR Content: The process of identifying the most suitable VR content for patients' needs was based on several key criteria. Visually, natural environments with soft colors and slow movements were selected to avoid overstimulation. Patients had the option to choose between two types of environments: a mountain landscape, characterized by its serenity and vastness, or a tranquil beach with gentle waves and a calming horizon. For the acoustic dimension, relaxing ambient sounds were chosen, such as the sound of running water in the mountain setting or the sound of waves and seagulls in the beach setting, leveraging the device’s 3D positional audio to create an immersive auditory experience. The pace of the experience was designed to be constant and predictable, avoiding abrupt changes that could cause anxiety rather than alleviate it. Movements within the virtual experience were limited to smooth and gradual transitions, optimized for the 6DoF tracking capability of the Oculus Quest 2, ensuring a relaxing immersion without the risk of disorientation or dizziness.

2.5 Variables

2.5.1 Outcome Variables

The primary outcome variable of this study is venipuncture-related anxiety, measured using the Visual Analog Scale (VAS) and the Blood-Injection Phobia Inventory (BIPI). The VAS is employed both before and after the venipuncture procedure to assess the level of anxiety experienced by patients, as it provides a direct quantitative measurement of anxiety levels, while the BIPI allows for a specific assessment of the degree of hematophobia present in the patients.

2.5.2. Predictor Variables

The predictor variables in this study include both demographic characteristics and procedure-specific factors. The demographic variables are:

Age: Classified into three groups: ≤40 years, 41–65 years, and > 65 years.

Sex

Male and female.

Number of annual visits to healthcare services

Classified into < 2, 3–4, 5–6, and > 6 visits.

The procedure-specific variables include:

Use of VR glasses: Patients who used VR glasses during venipuncture versus those who did not.

Hospital service

Differentiating between the blood draw clinical laboratory and the hematology day hospital.

Degree of hematophobia

Assessed using the BIPI and classified as high, medium, and low according to the quartiles obtained in the sample.

These predictor variables are used to analyze their impact on pre- and post-venipuncture anxiety, as well as to determine possible differences in the perception of the experience between patients who received the VR intervention and those who did not. The analysis of these variables allows for the identification of factors that may influence the effectiveness of VR as a strategy to reduce anxiety in patients with hematophobia during venipuncture.

2.6 Statistical Analysis

According to data from the 2022 Activity Report of the Department of Health, Elche General Hospital, 5,474 sessions were conducted in the Hematology Day Hospital, which, combined with the 15,390 venipunctures performed in the central laboratory of the department, sum to a total of 20,864 venipunctures. The prevalence of hematophobia is estimated at 31%, so by establishing a 95% confidence level and a 10% confidence interval, a sample of 82 venipunctures per group was calculated, resulting in a total sample of 185 patients for the study.

The normality of the data was checked using the Shapiro-Wilk test, and the Wilcoxon test was applied to address the slight imbalance in the sample between the population with and without VR glasses, given that the study variables did not follow a normal distribution. For the study, we considered that a significant difference exists between the results when p < 0.05.

2.7 Study Hypothesis

Null Hypothesis (H0): VR therapy during venipuncture does not have a significant effect on reducing anxiety in patients with the same degree of hematophobia before the procedure.

Alternative Hypothesis (H1): VR therapy during venipuncture has a significant effect on reducing anxiety in patients with the same degree of hematophobia before the procedure.

2.8 Objectives of the Study

Determine the prevalence of hematophobia among patients who visit the hospital for venipuncture and evaluate the impact VR on reducing anxiety and fear during venipuncture in patients with varying degrees of hematophobia, based on gender, age, number of annual hospital visits, and service.

Results Obtained from the Study on the Prevalence of Hematophobia in Patients Undergoing Venipuncture and the Effect of VR on Anxiety and the Perception of the Experience

3.1. Sample Characteristics (Table 1)

The study sample included 185 patients, divided into two groups: 87 from the laboratory and 98 from the hematology day hospital. The gender distribution showed a higher proportion of women (65.9%) compared to men (34.1%). Regarding age, the predominant group was patients under 40 years old (40%), followed by those between 41 and 65 years old (35.1%) and those over 65 years old (24.9%).

In terms of annual visits to healthcare services, 48.1% of patients visited more than 6 times per year, while 23.2% visited less than 2 times. The distribution by hospital service indicated that 53% of the patients belonged to the laboratory and 47% to the hematology day hospital. Regarding the use of VR glasses, 52.4% of the patients used them during venipuncture.

The degree of hematophobia was assessed using the Blood-Injection Phobia Inventory (BIPI). The levels of the variable Degree of Hematophobia were established according to the quartiles obtained from our sample and represent: A) High, total BIPI test score > 218; B) Medium, total BIPI test score between 52 and 218; and C) Low, total BIPI test score ≤ 52. The prevalence of hematophobia was distributed as follows: 32.4% of the patients had a high degree of hematophobia, 31.9% had a medium degree, and 35.7% had a low degree of hematophobia.

Table 1

Sociodemographic description of the total population and by hospital service.
Full Sample		N	%
Sex	Male	63	34.1
	Female	122	65.9
Age	<=40	74	40
	<=65	65	35.1
	> 65	46	24.9
Hospital Service	Clinical Laboratory	87	53
	Day Hospital (DH)l Hematology	98	47
Annual visits to the hospital	< 2	43	23.2
	3–4	36	19.5
	5–6	17	9.2
	> 6	89	48.1
VR glasses	Not	88	47.6
	Yes	97	52.4
Clinical Laboratory
Sex	Male	26	29.9
	Female	61	70.1
Age	<=40	56	64.4
	<=65	29	33.3
	> 65	2	2.3
Annual visits to the hospital	< 2	39	44.8
	3–4	28	32.2
	5–6	6	6.9
	> 6	14	16.1
VR glasses	Not	43	49.4
	Yes	44	50.6
Hematophobia Grade	High	31	35.6
	Medium	25	28.8
	Low	31	35.6
Day Hospital (DH)l Hematology
Sex	Male	37	37.7
	Female	61	62.3
Age	<=40	18	18.4
	<=65	36	36.7
	> 65	44	44.9
Annual visits to the hospital	< 2	4	4.1
	3–4	8	8.2
	5–6	11	11.2
	> 6	75	76.5
VR glasses	Not	45	45.9
	Yes	53	54.1
Hematophobia Grade	High	29	29.6
	Medium	34	34.7
	Low	35	35.7

3.2 Distribution of Hematophobia Degree by Sex (Table 2)

The study did not find significant differences in the distribution of the degree of hematophobia between men and women. The overall mean score of the Blood-Injection Phobia Inventory (BIPI) was 169.68 for men and 212.74 for women, suggesting that women tend to exhibit a higher intensity of hematophobia, although this difference is not statistically significant (p = 0.229). Among patients with a high degree of hematophobia, the mean scores were 430.68 in men and 497.37 in women, again without statistical significance (p = 0.239). For those with a medium degree of hematophobia, the scores were very similar between men (114.98) and women (116.47), with a p-value of 0.980, indicating virtually no difference. In the low degree of hematophobia, the mean scores were 19.52 in men and 18.79 in women, also showing no significant difference

Table 2

Distribution of the Degree of Hematophobia by Sex.
	Sex	N	%	Average	Percentile			P value*
					25	50	75
Total BIPI	Male	63	34.1	169.68	28	61	266	0.229
Total BIPI	Female	122	65.9	212.74	37	109	324	0.229
	Degree of Hematophobia	Sex	N	%	Average			P value*
Total BIPI	High	Male	19	30.2	430.68			0.239
		Female	41	33.6	497.37			0.239
	Medium	Male	17	26.9	114.98			0.980
		Female	42	34.4	116.47			0.980
	Low	Male	27	42.9	19.52			0.708
		Female	39	32.0	18.79			0.708
*p-values were calculated using the Wilcoxon test, chosen due to the non-normal distribution of the data, with a significance level set at p < 0.05

The study results also provide relevant information on the patients' responses in the different spheres of hematophobia evaluated by the BIPI (Table 3):

Cognitive Sphere

The mean score for the cognitive sphere in the total sample is 70.314, with a standard deviation of 84.657. When analyzed by gender, men have a mean of 61.302 with a standard deviation of 81.113, while women have a higher mean of 74.967 with a greater standard deviation of 97.221. Although women appear to have a slightly higher cognitive response, this difference is not statistically significant (p = 0.27).

Physiological Sphere

The physiological sphere shows the most intense and varied response, with a total mean of 88.395 and a standard deviation of 105.9. For men, the mean is 77.333 with a standard deviation of 36.413, while women have a higher mean of 94.107 and a standard deviation of 86.388. Despite this trend, the difference between men and women is not significant (p = 0.217).

Behavioral Sphere

The behavioral sphere presents the lowest mean score (39.368) with a standard deviation of 52.384, indicating less intense reactions with lower variability in the total sample. Men show a mean of 31.048 with a high standard deviation of 110.065, while women have a mean of 43.664 and a standard deviation of 58.641. However, this difference also does not reach statistical significance (p = 0.317).

Table 3

General and Gender Results in the Different Spheres of Hematophobia
Full Sample	BIPI Sphere	Average	Dispersion	P value*
	Cognitive	70,314	84,657	-
	Physiological	88,395	105,9	-
	Behavioral	39,368	52,384	-
Male	Cognitive	61,302	81,113	0.27
Female	Cognitive	74.967	97,221	0.27
Male	Physiological	77.333	36,413	0.217
Female	Physiological	94.107	86,388	0.217
Male	Behavioral	31.048	110,065	0.317
Female	Behavioral	43.664	58,641	0.317
*p-values were calculated using the Wilcoxon test, chosen due to the non-normal distribution of the data, with a significance level set at p < 0.05

3.3 Differences in means of pre- and post-puncture anxiety, according to the degree of hematophobia, hospital service and use or not of VR (Table 4)

Table 4

Difference in Pre-Post Puncture Anxiety between the Use of VR Glasses and Degree of Hematophobia.
Full Sample	Degree of Hematophobia	VR glasses	Anxiety Medium	P value*
Difference between Pre-Post Anxiety	High	Not	3.15	0.366
		Yes	3.62
	Medium	Not	1.04	0.005*
		Yes	2.45
	Low	Not	1.07	0.893
		Yes	1.05
HD.Hematology	Degree of Hematophobia	VR glasses	Anxiety Medium	P value*
Difference between Pre-Post Anxiety	High	Not	3.64	0.466
		Yes	4.26
	Medium	Not	1.14	0.134
		Yes	2.25
	Low	Not	0.94	0.722
		Yes	1.05
Clinical Laboratory	Degree of Hematophobia	VR glasses	Anxiety Medium	P value*
Difference between Pre-Post Anxiety	High	Not	2.80	0.933
		Yes	2.72
	Medium	Not	0.917	0.012*
		Yes	2.769
	Low	Not	1.273	0.693
		Yes	1.05
p-values were calculated using the Wilcoxon test, chosen due to the non-normal distribution of the data, with a significance level set at p < 0.05

Pre-puncture anxiety was assessed using a Visual Analog Scale (VAS). Patients with high hematophobia had a mean pre-puncture anxiety of 5.88 (without VR glasses) and 5.85 (with VR glasses). Those with moderate hematophobia showed a mean pre-puncture anxiety of 3.30 (without VR glasses) and 2.27 (with VR glasses). For patients with low hematophobia, the mean pre-puncture anxiety was 1.46 (without VR glasses) and 1.18 (with VR glasses).

Post-puncture anxiety was also measured using the VAS. Patients with a high degree of hematophobia who did not use VR glasses had a mean post-puncture anxiety of 2.71, compared to 2.27 for those who did use them. For patients with moderate hematophobia, post-puncture anxiety was 1.23 (without VR glasses) and 0.85 (with VR glasses). In the group with low hematophobia, post-puncture anxiety was 0.32 (without VR glasses) and 0.13 (with VR glasses).

Differences in Mean Pre- and Post-Anxiety by Hospital Service - In the laboratory hospital service, patients with a moderate degree of hematophobia who used VR glasses showed a significant reduction in anxiety (p = 0.012), while in the day hospital, this trend was not significant (p = 0.134).

3.4 Differences in means of pre- and post-puncture anxiety, according to the degree of anxiety and use or not of VR (Table 5)

Table 5

Differences in pre- and post-puncture anxiety means, according to the degree of anxiety and whether or not VR was used
Pre-puncture anxiety VAS score	VR glasses	Anxiety Medium Post-puncture	P value*
Less than or equal to 1	Not	0.148	0.778
	Yes	0.057	0.778
Greater than 1 and less than or equal to 3	Not	0.444	0.882
	Yes	0.500	0.882
Greater than 3 and less than or equal to 5	Not	2.456	0.031*
	Yes	0.778	0.031*
Greater than 5	Not	3.913	0.123
	Yes	2.956	0.123
p-values were calculated using the Wilcoxon test, chosen due to the non-normal distribution of the data, with a significance level set at p < 0.05

Patients with a pre-puncture anxiety of 4–5 points experienced a significant reduction in post-puncture anxiety with the use of VR glasses (p = 0.031).

3.5 Differences in Anxiety according to the use of VR Glasses, Age and Degree of Hematophobia (Table 6)

Table 6

Difference in Pre-Post Puncture Anxiety between the use of VR Glasses and Degree of Hematophobia.
Full Sample	Degree of Hematophobia	Age	VR glasses	Difference Anxiety Medium	P value*
Difference between Pre-Post Anxiety	High	<=40	Not	2.667	0.039*
			Yes	4.000
		> 40/<=65	Not	3.800	0.318
			Yes	2.400
		> 65	Not	3.500	0.99
			Yes	3.667
	Medium	<=40	Not	0.667	0.012*
			Yes	3.091
		> 40/<=65	Not	1.182	0.065
			Yes	2.571
		> 65	Not	1.333	0.839
			Yes	1.375
	Low	<=40	Not	1.667	0.778
			Yes	1.467
		> 40/<=65	Not	1.100	0.673
			Yes	0.800
		> 65	Not	0.750	0.759
			Yes
p-values were calculated using the Wilcoxon test, chosen due to the non-normal distribution of the data, with a significance level set at p < 0.05

Patients under 40 years old with a high degree of hematophobia showed a significant reduction in pre-post anxiety when using VR glasses (p = 0.039). Similarly, those with a moderate degree of hematophobia also showed a significant reduction (p = 0.012). For patients over 65 years old, the reduction in anxiety with the use of VR glasses was not significant.

3.6 Differences in Anxiety by Sex, Use of VR Glasses and Degree of Hematophobia (Table 7)

Table 7

Difference in Pre-Post Puncture Anxiety According to Sex, Use of VR Glasses and Degree of Hematophobia.
Full Sample	Sex	Degree of Hematophobia	VR glasses	Difference Anxiety Medium	P value*
Difference between Pre-Post Anxiety	Male	High	Not	3.667	0.158
			Yes	5.143
		Medium	Not	1.500	0.137
			Yes	3.111
		Low	Not	1.667	0.169
			Yes	0.833
	Female	High	Not	2.864	0.761
			Yes	3.053
		Medium	Not	0.833	0.019*
			Yes	2.208
		Low	Not	0.789	0.243
			Yes	1.250
p-values were calculated using the Wilcoxon test, chosen due to the non-normal distribution of the data, with a significance level set at p < 0.05

Women with a moderate degree of hematophobia who used VR glasses showed a greater reduction in pre-post anxiety compared to those who did not use them, with a significant difference (p = 0.019). In men with a moderate degree of hematophobia, a trend towards anxiety reduction was also observed with the use of VR glasses, although this difference did not reach statistical significance due to the smaller male sample size.

The prevalence of hematophobia in our sample was distributed as follows: 32.4% of the patients had a high degree of hematophobia (BIPI > 218), 31.9% had a moderate degree (BIPI between 52 and 218), and 35.7% had a low degree (BIPI ≤ 52). These results are consistent with the literature, where McMurtry et al. (2011) found similar scores in children with high hematophobia, validating our definition. Borda Más et al. (2010) and Fredrikson et al. (1996) also established similar thresholds, reinforcing the validity of our categories. The high internal consistency of the BIPI, with a Cronbach's α of 0.98 (Borda Más et al., 2010), supports the reliability of the instrument.

In this research, no significant differences were found in the distribution of hematophobia levels between men and women according to the BIPI. Although women had slightly higher average scores across all levels of hematophobia, these differences were not statistically significant. This finding aligns with previous studies exploring gender differences in blood and injection-related phobias. Siev et al. (2023) pointed out that both anxiety sensitivity and disgust sensitivity are predictors of injection fear in both sexes, although they do not fully explain the gender differences in fear severity. Jessup et al. (2020) suggested that repeated exposure to feared stimuli may reduce anxiety in both sexes, although women tend to report more intense emotional responses. Mayor et al. (2021) indicated that, although women generally score higher on measures of blood and injection phobia, these differences do not always translate into significantly different avoidance behaviors.

The results also showed significant differences in pre- and post-puncture anxiety reduction according to gender, hematophobia level, and the use of VR glasses. Women with moderate hematophobia who used VR experienced a greater decrease in anxiety (p = 0.019) compared to those who did not use VR. In men with moderate hematophobia, a trend toward anxiety reduction with VR was also observed, although it did not reach statistical significance. This is consistent with studies indicating that women tend to experience higher levels of anxiety during medical procedures and therefore may benefit more from VR (Gerçeker et al., 2019; Wooding, 2021). Women's greater receptivity to visual distraction strategies such as VR could explain their greater anxiety reduction in blood or injection phobia situations (Reichenberger et al., 2019; Tarrant, 2019). In men, the lack of statistical significance could be due to a smaller sample size and lower intensity of the anxious response, suggesting that VR may be more effective in those with moderate to high levels of anxiety (Jiang et al., 2020). Despite this, VR remains a promising tool for both sexes, with evidence supporting its use in reducing fear and anxiety during medical procedures.

Regarding the effectiveness of VR in reducing anxiety according to the degree of hematophobia, it was observed that VR is more effective in patients with moderate hematophobia, while its effect is less pronounced in those with high or minimal hematophobia, especially in hospital contexts such as laboratories and day hospitals. Jiang et al. (2020) found that VR is effective in reducing specific fears in patients with blood phobia, although its effectiveness varies depending on the severity of the phobia and the clinical context. Kılıç et al. (2021) also highlight VR as a promising tool for reducing fear and anxiety in medical procedures, although they suggest that more studies are needed in populations with severe phobias. Van Loenen et al. (2022) concluded in their meta-analysis that VR can be as effective as cognitive-behavioral therapy for treating severe anxiety disorders, but they noted that patient response may vary, indicating that it is not a universal solution.

Additionally, Gerçeker et al. (2019) demonstrated that VR can significantly reduce pain and anxiety during blood draws in pediatric patients, suggesting its usefulness in contexts where effective distraction is required. However, Lognoul et al. (2020) warned about the limitations of VR, such as "virtual reality sickness," which could reduce its effectiveness in certain patients.

The BIPI, while validated and reliable, presents practical challenges as it requires time and adequate reading ability from patients. In contrast, the Visual Analog Scale (VAS), which is quicker and more intuitive, has proven equally effective in identifying pre-venipuncture anxiety. A score of 4 or 5 on the VAS, indicating moderate anxiety, correlates significantly with moderate hematophobia according to the BIPI. Patients with this score show a significant reduction in post-puncture anxiety when VR is used (Eijlers et al., 2019; Arifin et al., 2023). In clinical settings where simplicity and speed are crucial, the VAS could be a practical and effective alternative to the BIPI. Additionally, VR is particularly effective in patients with moderate levels of pre-procedure anxiety, while its effectiveness diminishes in those with very low or high levels, highlighting the need to tailor interventions according to the patient's anxiety profile (Gao et al., 2023; Gerçeker et al., 2019).

The study also showed that patients under 40 years old with a high degree of hematophobia experienced a significant reduction in anxiety when using VR (p = 0.039), as did those with moderate hematophobia (p = 0.012). In patients over 65 years old, the reduction in anxiety with VR did not reach statistical significance. These differences may be attributed to the acceptance and familiarity with technology across generations. Individuals under 40 are generally more familiar with new technologies such as VR, facilitating its acceptance and effectiveness in clinical contexts. This familiarity allows for deeper immersion and more effective distraction during stressful procedures (Hoffman et al., 2021). On the other hand, patients over 65, although they may benefit from VR, often face barriers such as decreased visual and auditory acuity and less familiarity with digital interfaces, which could limit their ability to fully engage in the virtual experience (Choi et al., 2020).

The analysis of pre- and post-puncture anxiety shows that VR significantly contributes to anxiety reduction across different degrees of hematophobia. In patients with high hematophobia, pre-puncture anxiety was similar with or without VR, but post-puncture anxiety was lower with VR. In patients with moderate hematophobia, anxiety reduction was more pronounced with VR. Garrett et al. (2022) and Wang et al. (2022) also found that VR significantly reduces anxiety during medical procedures, suggesting that these effects may extend to different age groups and clinical settings. Mason et al. (2021) emphasize that VR can complement cognitive-behavioral therapy in managing pre-puncture anxiety. However, compared to other studies, the anxiety reduction observed in our study was less pronounced, which could be due to differences in initial anxiety severity or the population studied. Wu et al. (2021) reported greater anxiety reduction with VR in patients with general anxiety disorders. Phelan et al. (2023) underscore the importance of designing effective VR environments for managing pain and anxiety, which could explain variability in results. Furthermore, the effectiveness of VR may vary according to demographic and clinical factors such as age and gender, highlighting the need to personalize the use of VR in each specific clinical case (Smith et al., 2020).

This study, a pioneer in identifying the clinical circumstances and patient profiles where VR is most effective in reducing anxiety in patients with hematophobia, presents some limitations. The sample, limited to a single hospital center, restricts the generalization of the results. Additionally, the higher proportion of women in the sample may introduce gender bias, which could have influenced the perceived effectiveness of the VR intervention. Future studies should better control for gender proportion equality to obtain more balanced and representative conclusions.

The use of self-report tools such as the Visual Analog Scale (VAS) and the Blood-Injection Phobia Inventory (BIPI) could have introduced perception and response biases. Furthermore, variability in patients' familiarity with VR technology may have influenced the intervention's effectiveness, and the possible placebo effect was not adequately controlled. External factors, such as the physical environment and interactions with healthcare staff, were also not fully controlled, which could have affected the observed anxiety levels. Lastly, the absence of long-term follow-up limits the evaluation of the persistence of VR effects.

Despite these limitations, this study establishes an important precedent by demonstrating the potential of VR in specific clinical contexts for managing hematophobia, highlighting the need to personalize interventions according to the patient profile and clinical environment. Future studies should expand on this work by including more diverse and multicentric samples, using objective measurements in addition to self-reports, and designing better controls for patient expectations and external factors. Additionally, the implementation of long-term follow-up will allow for the evaluation of the durability of VR effects and the exploration of its application in different clinical contexts, thereby consolidating the findings of this pioneering study.

This study confirms the high prevalence of hematophobia in patients undergoing venipuncture and underscores the effectiveness of VR in reducing anxiety associated with these procedures. However, the findings demonstrate that the efficacy of VR varies depending on the degree of hematophobia, the clinical context, and the patient’s familiarity with the technology, suggesting that its application should not be generalized as a simple distraction tool.

Additionally, the results indicate that although women scored higher in all spheres of hematophobia and across different severity levels, the differences between men and women were not statistically significant. This implies that the intensity of hematophobia and its manifestation in the cognitive, physiological, and behavioral spheres are similar between both genders. Therefore, approaches to managing hematophobia should be personalized but do not necessarily need to differentiate strictly by gender in interventions.

The relevance of these findings is highlighted in several key aspects. VR has proven to be especially effective in patients with moderate hematophobia, and its inclusion in hospital protocols could significantly improve the patient experience. However, the personalization of interventions is crucial; VR should not be uniformly applied to all patients but rather adapted to individual characteristics such as age, familiarity with technology, and the severity of hematophobia to maximize its effectiveness.

Finally, the need to develop and standardize protocols for the implementation of VR in clinical settings becomes evident. These protocols should establish clear criteria for patient selection and session duration, ensuring the efficient and effective application of this technology in reducing anxiety associated with hematophobia

CONFLICT OF INTEREST

The authors report no conflict of interest.

FUNDING STATEMENT

“Not applicable”

Author Contribution

Ángeles Triviño-Martínez. ORCID: 0000-0002-6544-0555 EMAIL: [email protected] Wrote the main manuscript textReviewed the manuscriptPrepared tablesFieldwork with patientsObtain informed consentCristina Carreño-Cutillas. ORCID: 0009-0002-9181-7544 EMAIL: [email protected] Wrote the main manuscript textReviewed the manuscriptObtain informed consentFieldwork with patientsIrene Azorín-Maciá. ORCID: 0009-0007-1207-2756 EMAIL: [email protected] the manuscriptObtain informed consentFieldwork with patientsJosé Carlos Sola-Verdú ORCID: 0000-0001-9354-2500 EMAIL: [email protected] the manuscriptDesign and develop virtual reality contentProvides material resourcesAlejandro Mira ORCID: 0009-0001-7245-6504 EMAIL: [email protected] Reviewed the manuscriptDesign and develop virtual reality contentProvides material resourcesAIJU 3 Reviewed the manuscriptDesign and develop virtual reality contentProvides material resourcesEsther Soler-Climent. ORCID: 0000-0002-8543-4865 EMAIL: [email protected] the main manuscript textReviewed the manuscriptPrepared tablesResearch team coordination

Acknowledgement

NOT

Data Availability

Data is provided within the manuscript or supplementary information files

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No competing interests reported.

Virtual Reality in the Management of Hematophobia in Hospital Settings: Impact on Anxiety Reduction

Status:

Version 1

Abstract

HIGHLIGHTS

1. INTRODUCTION