Review Highlights Effective Strategies to Reduce Vaccine Distress

Key Takeaways

• A systematic review and meta-analysis of 17 randomized and quasi-randomized trials found that educational and implementation ("process") interventions reduced distress associated with vaccine injections across multiple populations.
• Educating vaccine recipients produced the largest reduction in self-reported vaccination distress among the interventions evaluated.
• Multicomponent approaches, such as the CARD (Comfort Ask Relax Distract) system, significantly reduced distress and increased use of evidence-based distress-reducing strategies.
• Educating clinicians and caregivers also improved uptake of distress-reducing interventions, while caregiver education modestly reduced observer-rated distress in vaccine recipients.

Pain, fear, and anxiety during vaccination remain common and can contribute to negative vaccination experiences, needle fear, and future vaccine avoidance. While evidence-based strategies to reduce vaccination distress have been available for years, implementation has varied across clinical settings. Understanding whether educational and implementation interventions improve distress outcomes is important for informing updated clinical practice recommendations and improving vaccination experiences for patients of all ages.

A systematic review and meta-analysis published in The Clinical Journal of Pain evaluated the effectiveness of process interventions designed to reduce distress during vaccine injections. The review was conducted as part of the 2026 update to the HELPinKids&Adults clinical practice guideline. Investigators searched five electronic databases for randomized and quasi-randomized controlled trials evaluating educational or implementation interventions directed toward clinicians, support persons, vaccine recipients, or multiple stakeholder groups. Seventeen studies met inclusion criteria. Outcomes included self- or observer-reported distress, knowledge of distress-reducing interventions, and implementation of evidence-based strategies. Evidence certainty was assessed using the GRADE framework, and pooled effects were summarized using random-effects meta-analysis with standardized mean differences (SMDs).

Across the 17 studies, educating clinicians increased use of distress-reducing interventions (SMD 0.66; low-certainty evidence). Education for support persons modestly reduced observer-rated distress (SMD -0.30; moderate-certainty evidence), increased implementation of distress-reducing strategies (SMD 0.67; low-certainty evidence), and improved caregiver knowledge (SMD 0.25; moderate-certainty evidence). Education directed at vaccine recipients resulted in a large reduction in self-reported distress (SMD -0.80; low-certainty evidence). Multicomponent interventions—including the CARD system—produced a small but high-certainty reduction in self-reported distress (SMD -0.21) and increased use of distress-reducing interventions (SMD 0.60; moderate-certainty evidence).

The authors noted several limitations. Most studies were conducted in high-income countries, particularly Canada, which may limit generalizability. Sixteen of the 17 included trials were judged to have a high overall risk of bias, largely because blinding was not feasible. In addition, the certainty of evidence ranged from low to high depending on the intervention and outcome assessed. Despite these limitations, the review incorporated substantially more evidence than the 2015 guideline update and included new randomized studies evaluating multicomponent implementation strategies. Overall, the authors conclude that educational and implementation interventions targeting clinicians, caregivers, vaccine recipients, and healthcare organizations can meaningfully reduce vaccination-related distress and improve adoption of evidence-based comfort strategies. They recommend integrating these process interventions into routine vaccination programs as part of updated clinical practice guidance.

Clinician Questions

Which educational intervention produced the largest reduction in vaccination distress?

Among the interventions evaluated, education directed at vaccine recipients produced the largest reduction in self-reported distress (SMD -0.80), although the certainty of evidence was rated as low. Multicomponent interventions also reduced distress, with high-certainty evidence supporting a smaller overall effect.

How effective was caregiver education during vaccination?

Education for parents and caregivers likely produced a small reduction in observer-rated distress during vaccination while also increasing caregiver knowledge and use of evidence-based distress-reducing strategies. Benefits were observed whether education occurred before or on the day of vaccination.

What is the CARD system?

The CARD (Comfort Ask Relax Distract) system is a multicomponent implementation framework that educates clinicians, vaccine recipients, and support persons while promoting evidence-based coping strategies during vaccination. Across multiple randomized studies, CARD reduced vaccination distress and increased use of distress-reducing interventions in school- and community-based vaccination settings.