The Effect of Multimodal Virtual Reality Experience on the Emotional

Responses Related to Injections

Katherine Chin, Marissa Thompson and Mounia Ziat

Information Design and Corporate Communication, Bentley University, 175 Forest Street, Waltham, U.S.A.

Keywords:

Trypanophobia, Mid-air Haptics, Virtual Reality, Emotional Regulation, Distraction Therapy, Fear Reduction,

Pain Reduction.

Abstract:

The objective of this study is to determine if using a multimodal experience, haptics and audio in a virtual

environment, can change the emotional responses related to injections. Participants were poked with a blunt

end needle in three conditions, where they were asked to look away from the needle, look at the needle

directly, or interact haptically with bubbles in a virtual environment. Participants were asked to rate the arousal

(calm-fear), valence (happy-unhappy), and pressure felt (no pressure-high pressure) for each trial. Our results

showed that participants preferred the haptics-VR condition as indicated by their comments and signiﬁcant

valence scores. They described the simulation as relaxing, fun, and pleasant. The results support the idea that

multisensory simulation can be effective in increasing participants’ happiness through distraction in stressful

or fearful situations.

1 INTRODUCTION

In the current work, we investigated whether distrac-

tion using a multimodal experience of mid-air haptics

in a virtual environment can reduce the anxiety and

stress related to needles as opposed to an experience

without multimodal stimulation. Furthermore, condi-

tions of looking directly at the injection site or look-

ing away from it were tested. We relied on a tactile

phenomenon known as tactile suppression (Ziat et al.,

2010) where a tactile stimulation is suppressed by an-

other tactile stimulus. Because our central nervous

system receives a vast amount of sensorimotor infor-

mation, the brain has developed a mechanism to sup-

press some incoming information. Putting this into

application, using tactile feedback can help suppress

the tactile sensation coming from the needle. While

we did not directly address a sensory suppression in

this study; which can be visual, auditory, or haptic,

the phenomenon has been studied in multiple sensory

modalities (Porcu et al., 2014).

Several studies have already explored the inﬂu-

ence of haptics on emotions in a multimodal context

(Eid and Al Osman, 2015) (Tsalamlal et al., 2018)

(Ziat and Raisamo, 2017) and the effectiveness of

haptics for pain treatment. One study reported signif-

icant results of tactile feedback reducing deafferenta-

tion pain through a multimodal experience using a

VR headset and vibrotactile motors on the hand (Sano

et al., 2016). Another notable study tested ultrasound

tactile stimulation with virtual reality for pain distrac-

tion. Authors found a pain tolerance increase and

higher-than-midpoint values for valence and arousal,

indicating more positive emotions associated with the

multimodal experience (Karafotias et al., 2017).

2 RELATED WORK

Virtual reality has been proven to effectively reduce

perceived pain. For burn patients undergoing painful

treatments while using virtual reality, a reduction of

activity in the pain-related areas in the brain has been

observed in the insula, the thalamus, and the pri-

mary and secondary somatosensory cortex (Hoffman,

2004) (Das et al., 2005). Another study showed that

haptic feedback can enhance the realism of a virtual

reality experience (Krogmeier et al., 2019).

The healthcare industry is always looking for

means to help individuals overcome fear and pain.

Injections, magnetic resonance imaging scans, pre-

operative and post-operative care, blood draws, blood

donations, and waiting rooms are situations where

people experience high anxiety or pain. (Canbulat

et al., 2014) (Ditto and France, 2006) (Hamilton,

1995) (Kain et al., 2006) (Karanci and Dirik, 2003)

(Munn and Jordan, 2013) (Pineault, 2007).

128

Chin, K., Thompson, M. and Ziat, M.

The Effect of Multimodal Virtual Reality Experience on the Emotional Responses Related to Injections.

DOI: 10.5220/0010195601280134

In Proceedings of the 16th Inter national Joint Conference on Computer Vision, Imaging and Computer Graphics Theory and Applications (VISIGRAPP 2021) - Volume 2: HUCAPP, pages

128-134

ISBN: 978-989-758-488-6

When it comes to injections, up to two thirds

of children and one fourth of parents are afraid of

needles (Taddio et al., 2012). It is more common

for children than adults to suffer from needle-related

or injection phobia/fear, known as Belonephobia or

Trypanophobia (Doctor et al., 2008) (Orenius et al.,

2018), and the need for distraction in younger chil-

dren may be greater than in older children. In a study

on how children perceive pain, children reported nee-

dle related procedures as very painful (Kortesluoma

and Nikkonen, 2004). Treating children who have a

fear of needles can also be a stressful and difﬁcult ex-

perience for nurses (Ives and Melrose, 2010).

When administering immunizations, a study has

shown that distraction can be a more effective means

to help children cope with pain and fear than parental

comfort (Manimala et al., 2000). In another study

where children were distracted by an iPad during im-

munizations, parents reported that the children expe-

rienced less distress, crying, and need for being held

(Shahid et al., 2015).

3 PRE-STUDY SURVEY

As children are a demographic that displays high anx-

iety during injections (Taddio et al., 2012), we, ﬁrst,

conducted interviews with three parents to get a better

understanding of the immunization process for chil-

dren. We wanted to learn about the feelings expe-

rienced by patients during injections and the strate-

gies used by parents and practitioners to help children

cope with the fear and pain.

Parents were asked to walk through their chil-

dren’s experiences while getting an injection and dis-

cuss the most difﬁcult aspects of this experience.

They rated their perception of children’s valence on

a scale from 1 to 5 (extremely unhappy-extremely

happy). They were also asked what comforting strate-

gies they try on their children before and during injec-

tions, how receptive the children were to toys when

stressed, and what were the most effective methods

for calming the children. Parents were asked how im-

portant they felt it was that hospitals would ease the

tension during injections on a scale of 1 to 5 not im-

portant -very important) and what they believe would

be an ideal injection process.

Parents reported that their children were less

happy before and during injections, and the children

were usually scared when seeing a doctor or nurse.

Easing the tension during an injection was very im-

portant for parents as they can become stressed from

the non-cooperation of their children. They usually

bring toys, and often pat their children to calm them

down. Overall, this short survey shows that injec-

tions are negative experiences for children and par-

ents, with parents believing that positive injection ex-

periences are important, and touch brings comfort to

their children. These preliminary interviews were

used for collecting additional qualitative ﬁndings to

inform the direction of the study; this data had less

bearing on the results.

4 PRELIMINARY STUDY

In the current work, we wanted to test the effect of

multimodal experiences beyond visual and auditory

sensations on fear and pain. Our hypothesis was par-

ticipants would rate arousal, valence, and pressure

lower when they were poked with the needle during

the tactile-VR simulation. The null hypothesis is that

there would be no difference in ratings between par-

ticipants’ experience when using the virtual simula-

tion and when not using the virtual simulation. Our

objective is to discover if multimodal experiences re-

duce fear and pain as well as increase happiness dur-

ing injections. During and after ratings were collected

for a VR experience that lasts over time. For this

study, each trial was short in requesting before and

during the rating experience.

4.1 Participants

5 adult participants between the ages of 24 and 64

were recruited, including 2 males and 3 females. Due

to the COVID-19 lockdown which mandated limited

contact with others, participants were volunteers from

the entourage of the authors themselves. It was not

possible to recruit participants in-person at this time.

Nevertheless, the requirement for a minimum number

of participants for a formative study was met (Nielsen,

2000). They were provided with a consent form to

agree to their voluntary participation to the experi-

ment. Some participants may have an emotional re-

action to seeing a nurse or doctor. For this reason, we

chose to minimize the injector’s visual presence and

dialogue to isolate the condition most suitable for this

experiment, the needle itself.

Figure 1: A syringe with a blunt needle tip was used for the

mock injections.

The Effect of Multimodal Virtual Reality Experience on the Emotional Responses Related to Injections

129

Figure 2: The mock injection was administered two inches

below the wrist.

4.2 Apparatus

A syringe with a blunt needle tip was used (Fig. 1)

for ethical and safety consideration during the exper-

iment. The syringe resembles an injection needle,

which provides a more realistic experience of an ac-

tual injection. In Fig. 2, the needle tip was applied

to the same area, two inches below from the wrist,

on the ventral side participants’ left forearms for each

trial. Although there may be multiple injection sites,

we chose to use the site most common for IVs. It is

important to note that the injection site was consistent

for all the participants.

For tactile feedback, an Ultraleap STRATOS Ex-

plore development kit was used. It consists of an ul-

trasound mid-air haptics array and a hand tracking

sensor. The 192-transducer array emits ultrasound

into the user’s hand to create tactile sensations. Ad-

ditionally, the sensor’s camera tracks the spatial ori-

entation of the user’s hand in real time. The virtual

hand, which is displayed over a virtual array that rep-

resents the Ultraleap device, can interact with virtual

bubbles and feel tactile sensations concurrently. The

Oculus Rift CV1. was used during the virtual inter-

action to view and hear the virtual environment. Al-

though VR headsets are recommended for those 13

and older, the concerns involving younger children

are mainly for long-term usage. Younger children can

still use a VR headset, but for a limited time, which is

relatively short when a nurse is providing a shot.

4.3 Stimuli

In this test, three visual conditions were compared:

“Look Away” where participants are looking away

from the injection arm, “Look At” where participants

are asked to look directly at the injection arm, and

“Simulation,” where participants are exploring a vir-

Figure 3: Multimodal VR experience of nature environment

visuals, popping bubbles tactile feedback, and waterfall au-

dio.

tual environment and feeling tactile feedback when

they interact with objects. Both Look Away and Look

At conditions were included to mimic common injec-

tion scenarios yet separate biasness of seeing the in-

jection or anticipating the shot.

For the Simulation condition, a nature virtual re-

ality environment was built using Unity (Unity, n.d.)

as shown in Fig. 3. A nature setting was used to

induce the biophilia effect (Kellert, 1995) (Lidwell

et al., 2010) (Wells, 2000), also known as healing

through nature, which helps participants feel more re-

laxed and less stressed when presented with a real or

artiﬁcial visual depiction of nature. In this environ-

ment, the viewer stood on a boulder surrounded by a

pool of water and cliffs. They could also view a pink

willow tree to their left and a waterfall to their right.

Waterfall ambient noise, which resembles the sound

of a high waterfall with a substantial volume of water

crashing into a pool of water, was added to enhance

the realism of the setting.

For the tactile feedback, participants placed their

hand on the virtual array (Gray block under the virtual

hand in Fig. 4) and began popping bubbles. The ul-

trasound array created tactile waves on the skin when

bubbles popped or collided with the virtual hand. An

auditory feedback of the popping bubble was heard

each time a bubble was popped by the participant to

reinforce the tactile sensation.

5 PROCEDURE

The environment setup was similar to an injection

chair that is commonly used in a doctor’s ofﬁce. Par-

ticipants sat in a chair with each of their forearms rest-

ing on elevated platforms (small tables and boxes) as

shown in Fig. 4a. The ergonomics of this layout also

ensures that neither arm will experience fatigue. The

ultrasound array was placed approximately 20 cen-

timeters below the participants’ right hand for opti-

mal accuracy in hand detection, as demonstrated in

Fig. 4b.

Additionally to the three visual conditions (Look

HUCAPP 2021 - 5th International Conference on Human Computer Interaction Theory and Applications

130

Figure 4: (a) Ergonomics were considered to prevent arm

fatigue by utilizing a table and boxes as armrests. (b) Ultra-

sound array is placed approximately 20 centimeters under

the right hand.

at, Look Away, Simulation), there was a contact con-

dition where a pressure was applied on the skin with

the cannula, and a no-contact condition where the

needle hovered over the area without touching the

skin. These two injection types prevent participants

from becoming accustomed with the needle stimulus

and to avoid any anticipation about the contact with

the needle. A total of 18 trials (3 visual x 2 injection

x 3 repetitions) were run for each participant with a

randomized order.

For each trial, participants were asked to report

whether they felt a sensation of pressure on their

skin. If participants’ answer was afﬁrmative, addi-

tional questions related to valence, arousal, and pres-

sure were asked. More speciﬁcally, on a 10 point

scale, participants were asked to provide a score for

the arousal dimension, with one representing calm

and a score of ten representing fear. For valence, a

score of one represented happy and a score of ten rep-

resented unhappy. Finally, for pressure, a score of one

represented feeling no pressure and a score of ten rep-

resented feeling high pressure.

After the experiment, there was a verbal follow-up

with the participants where they reported any phobia

of needles and ranked the three conditions and modal-

ities (visual, auditory, tactile) by preference.

6 RESULTS

Fig. 5 displays the grand mean ratings of valence,

arousal, and pressure for the three conditions (Look

Away, Look At, Simulation). Because of a small sam-

ple and the nature of the data (ordinal), the difference

in arousal, valence, and pressure ratings were anal-

ysed using the non-parametric Friedman test. Our

hypothesis is participants will have lower ratings for

arousal, valence, and pressure in the simulation con-

dition than the other two conditions.

For valence, Friedman test was signiﬁcant (χ

5.65, p <0.05). In the simulation condition, the ma-

jority of participants felt calmer as the mean valence

rating was the lowest for participants. The test was

not signiﬁcant for both arousal (χ

= 3.44, p >0.05)

and pressure (χ

= 2.21, p >0.05).

Although the data for arousal and pressure did not

show a statistically signiﬁcant difference, the ratings

for the Simulation condition were lower than the Look

At or Look Away conditions. The means for the Look

Away and Look At conditions were closer to each

other (see Fig. 5).

Figure 5: Grand mean for the ”Look Away,” ”Look At,” and

”Pressure” conditions among the participants. From left to

right: Arousal, Valence, and Pressure ratings.

6.1 Post-survey

Participants were asked to rank the conditions from

highest preference to lowest preference. They all

chose the Simulation condition ﬁrst, the Look At con-

dition second, and the Look Away condition third.

One of the participants reported Trypanophobia but

her responses were not different from the other par-

ticipants.

They described the Simulation condition as “re-

laxing,” “calming,” “peaceful,” and “immersive.”

They also mentioned that the simulation disengaged

attention away from injections. The popping bubbles

were often labelled as “pleasant,” “fun,” and “realis-

tic,” while the haptic feedback made the simulation

more effective in distracting them from the needle.

One participant explained that if the bubbles were not

included in the environment, it would have been less

effective. Additionally, participants mentioned that

both visual and auditory effects of the waterfall were

realistic and relaxing. Finally, seeing the virtual hand

interact with the haptic bubbles enhanced the realism

The Effect of Multimodal Virtual Reality Experience on the Emotional Responses Related to Injections

131

of the simulation.

Participants least favoured the Look Away condi-

tion. They all preferred to see the needle than wait

for the action to happen. Participants disliked the an-

ticipation factor of the Look Away condition because

they were waiting anxiously for the needle to make

contact with their skin as opposed to knowing when

the needle would poke the skin. They stated that the

visual feedback made them feel “calmer,” “at ease,”

and “in control” since they felt there was a sense of

comfort to see what the needle would do to the skin.

Moreover, for the Look Away and Look At condi-

tions, participants had found the room environment

“more boring” and “less interesting” than the virtual

environment. For the ranking of the modalities, the

visual and tactile conditions were ranked ﬁrst by two

participants each, while one participant ranked the

auditory condition ﬁrst. The second most favourite

modalities were tactile and auditory by two partici-

pants each.

7 DISCUSSION AND

CONCLUSION

Our study shows that multimodal immersive expe-

riences can increase happiness, reduce anxiety and

boredom, and potentially reduce fear for adults re-

ceiving injections. Although the participants were

only adults, it can be inferred that the responses would

be stronger in children since ﬁndings from a previ-

ous study showed a greater percentage of children

than adults experienced trypanophobia (Taddio et al.,

2012). Multimodal experiences are also highly pre-

ferred as a distraction tool for unpleasant experiences.

Participants favoured and expressed positive senti-

ments about the simulation. They described the sim-

ulation as relaxing, fun, and enjoyable. The data re-

vealed that arousal and pressure ratings were not sig-

niﬁcant, but the data for the valence rating was signif-

icant. This indicates that participants felt signiﬁcantly

happier during the virtual simulation than when they

looked away or looked at the injection site.

In addition, all participants correctly identiﬁed if

stimuli had made contact or no contact to their arms.

The fact that participants reported that the multi-

modal condition was an effective distraction from the

syringe suggests that sensory suppression occurred.

Similar studies have examined the effect of virtual re-

ality and haptic sensation for pain distraction. One

study showed that when there is physical interaction

in a virtual reality experience, tactile feedback can in-

crease pain tolerance (Karafotias et al., 2017). Our

study differs by focusing on the multimodal expe-

rience without isolating the VR, haptic, or auditory

conditions separately. The study was designed to

more closely simulate conditions that may occur in a

healthcare facility by isolating the look at, look away,

or multimodal experience conditions.

In the future, we would like to further investigate

the timing and location of the injection, the devices

and visualizations used, the age and number of partic-

ipants, and how closely the experiment would match

an actual doctors ofﬁce. Since suppression phenom-

ena are very complex and ill understood, investigating

the timing and location of the mock injection’s tactile

stimulation (same arm vs different arm) emitted from

the haptic array would allow a better understanding of

how different locations and timing inﬂuence suppres-

sion.

As we had tested virtual reality and tactile concur-

rently, it would be beneﬁcial to test the tactile, visual,

and auditory sensations separately to compare uni-

modal versus multimodal effectiveness. This could

help determine which sensations are the most effec-

tive in unimodal and multimodal situations. Addition-

ally, non-contract mid-air haptics and contact tactile

feedback, such as surface touch (Meyer et al., 2014)

or vibrotactile haptics (Ziat et al., 2006) (Ziat et al.,

2005), could be compared to investigate how the na-

ture of the haptic stimulation affects the level of im-

mersion. Furthermore, many participants preferred to

look at the injection site, so a possible visualization

could be a nurse’s hand holding a syringe as a future

investigation.

Because of the COVID-19 lockdown, number of

participants were limited to ﬁve. When deemed safe

and possible, we plan to expand the number of partic-

ipants and conduct a summative study on a younger

demographic, potentially adolescent patients between

the ages of 13 and 18. Additionally, a study could be

done with children under 13. Because virtual reality

devices recommend users to be 13 years or older, the

study could be modiﬁed for children under 13 years of

age by using a monitor display with speakers instead.

Patients could experience anxiety in real-life sit-

uations induced by an unsettling and unfamiliar hos-

pital environment as well as the administration of the

injection by a staff member. This was not tested in our

current experiment as participants came from the im-

mediate environment of the authors. For this reason,

we would like to extend our experiment to include a

more realistic scenario allowing us to analyze the ef-

fectiveness in real life application.

Finally, the implementation of a similar system

is cost-effective (around $150 USD) using NVIDIA

Jetson Nano Developer Kit, a Google Cardboard VR

headset, a 5-inch cell phone, and a 48-transducer ul-

HUCAPP 2021 - 5th International Conference on Human Computer Interaction Theory and Applications

132

trasonic directive speaker kit. This would allow prac-

tical application in hospitals without signiﬁcantly in-

creasing cost.

ACKNOWLEDGEMENTS

The authors would like to thank Jia Fogelberg and

Sangjun Yoon for assisting in the data collection of

the pre-experiment survey.

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