The present study examined mothers’ conceptualization and management of pain in their children during routine immunization. All of the participants found the immunization experience to be distressing. They minimized their concern regarding pain by focusing on the benefits of immunization and dismissing the pain as short lived and needing to be endured. Participants reported the use of non-pharmacological analgesic techniques, such as distraction, to comfort their children. When medications were used, it was usually oral analgesics to prevent or treat vaccine fevers occurring after immunization. Participants were largely unaware about topical anesthetics. They expressed a willingness to use them if endorsed by their physicians, who were identified as their main trusted source of pain management information.
These findings are consistent with our previous data (regarding pain management practices during immunization) that demonstrate a gap between evidence-based recommendations of topical anesthetics and current practices (6
). These findings also reflect the broader literature on pain management that addresses the role of societal attitudes in the under-treatment of pain (10
) such as the relative unimportance given to pain compared with other ailments (such as fever) (11
), views about pain as a necessary part of life experience, the notion that pain is a part of immunization and a short-lived experience, and concerns about over-medication with analgesics leading to tolerance or addiction (13
Previous research has shown that the rate of vaccination deferral is associated with the number of vaccine injections due to be administered at a visit (15
). Interestingly, some participants in the present study attributed pain to fear rather than the other way around. Fear occurs if a child assesses a situation as threatening and, with respect to needles, develops primarily through negative memories formed during past experiences with needles (17
). Fear can magnify the pain experienced by children during subsequent immunizations.
All mothers reported using nonpharmacological methods to reduce pain during their children’s immunizations. Psychological interventions such as distraction are effective in reducing immunization pain; however, they depend on the ability of adults to effectively engage a child’s attention (18
). Parental interventions can attenuate child pain and distress; however, parents do not reliably use them, and previous training is recommended.
While these findings might seem intuitive, they point to the need to critically re-examine and question the current assumptions and practices. Pain relief is considered a ‘basic human right’ (19
), and the fundamental principle of responsible medical care is to ‘first do no harm’ (20
). Given the solid evidence base for the effectiveness and safety of topical anesthetics in children (5
), there is clearly a need to study whether parents, health care practitioners and policymakers are participating in a social construction of pain management, and whether children would benefit from a critical reflection and analysis of this issue. As noted in the introduction, there are a range of factors that affect whether change occurs (and the extent of change) in health care (7
). In previous studies (6
), we have documented that parents are capable of administering topical anesthetics in their children and are willing to pay for analgesics to reduce immunization pain in their children. Parents are willing to pay more than the actual cost of topical anesthetics (approximately $5 to $8 per dose). On the other hand, according to our findings, using topical anesthetics is not compatible with prevailing norms and values. For example, participants’ physicians did not provide information about their use and there is a prevailing value of accepting and enduring the ‘short-term’ pain of immunization. There is also a lack of knowledge about topical anesthetics and they are not discussed during the physician visit. The present article is an initial step toward examining attitudes and practices, and how interventions can be developed to enable the use of evidence-based practices that minimize pain and the resulting implications.
Because physicians were identified as trusted sources of information, strategies are needed to support them as pain management educators. Qualitative studies are currently being conducted with health care professionals (including paediatricians, family practice physicians, clinic nurses and public health nurses) performing vaccine injections to provide insight into their attitudes toward pain and preferred education strategies and resources that would enable them to educate their patients and families and support evidence-based pain management practice changes.
The qualitative methods used allowed an in-depth exploration of participants’ opinions, which has not previously been done. Credibility of findings was improved by the use of multiple coders, checking emergent codes with participants in subsequent interviews, and validation of interviews by content and method experts. The number of interviews is indicative of the time-intensive nature of qualitative research, and the achievement of saturation of key themes suggests that the number of interviews was sufficient. It is possible that the timing of the interview – during the women’s stay at hospital following the birth of their baby – might have affected the findings, but the consistency of the findings with other research minimizes this concern.
The findings are limited to a sample of women located in a downtown hospital. We do not know how the results would compare for women living in a rural or remote setting, as well as for fathers. Many fathers accompany their children to immunization appointments and they may have attitudes that are different from mothers. We chose to initially investigate mothers due to our experience with mothers as the primary caregivers involved in immunization appointments. In many regions of Canada, physicians, particularly paediatricians, play a minor or no role in the administration of routine vaccines provided through publicly funded programs. It will be important to conduct additional studies to examine attitudes toward and practices regarding pain management during immunization with different groups and within the context of different health care and geographical settings.