Turning distress into distraction: using virtual reality during penicillin injections for rheumatic fever

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain a major public health burden in Aotearoa New Zealand, disproportionately affecting Māori and Pacific tamariki (children).^1,2 For over 70 years, secondary prophylaxis to prevent ARF progression has relied on benzathine penicillin G (BPG), administered as a 4-weekly intramuscular injection, usually for a minimum of 10 years.³ This regimen is difficult to sustain, as, alongside health system failures, treatment pain, fear and frequency contribute to poor adherence.^4–6

Many tamariki associate secondary prophylaxis with distress, with each visit a source of dread, compounding over years of treatment and placing strain on whānau (families) who often co-ordinate logistics and emotional support.^4,5 Given the long duration of prophylaxis, strategies that reduce injection-related distress are important, because missed or delayed doses can compromise protection against rheumatic fever recurrence or progression to RHD. In this context, approaches that improve the experience of injections may support engagement with care.

Virtual reality (VR) to minimise distress

One potential approach is VR, which has emerged as a promising non-pharmacological distraction therapy, with well-documented evidence supporting its use to reduce procedural pain and anxiety across a range of clinical settings.^7–10 By combining visual, auditory and interactive stimuli, VR immerses users in an alternative environment that diverts attention away from medical procedures. In paediatrics, VR has been shown to significantly reduce anxiety and pain during intravenous cannulation, chemotherapy infusions and for procedural pain in paediatric emergency department settings.^11–13 Other approaches to reducing injection-related pain, including lignocaine and vibration (Buzzy Bee^®) or cooling devices, have also shown promise in rheumatic fever prophylaxis settings.^14,15 However, these approaches do not specifically address procedural anxiety or emotional distress associated with repeated injections.

Subcutaneous injections of penicillin (SCIP)

Alongside efforts to improve the experience of injections, alternative delivery approaches have also been developed. A SCIP regimen delivers high-dose penicillin via subcutaneous injection at 10-week intervals. Studies have shown that SCIP is safe and well tolerated, achieving sustained penicillin concentrations.^16,17 In addition, patients overwhelmingly prefer it over monthly injections, reporting markedly less injection pain and treatment burden.¹⁸ Importantly, SCIP’s 10-week regimen has improved quality of life and adherence for many whānau.¹⁹

However, despite these advances, some patients continue to experience procedural pain and distress with injections. This highlights the need to further enhance patient experience. Accordingly, we conducted a pilot study within an ongoing phase IIA clinical trial evaluating SCIP, with the aim of exploring the feasibility and acceptability of immersive VR distraction during SCIP injections and its potential to reduce pain and anxiety.

Methods

Participants were children and young people receiving SCIP as secondary prophylaxis for rheumatic fever as part of a phase IIA trial (ACTRN12624000333516) in the Wellington Region of New Zealand. Participants enrolled in the trial were eligible for inclusion in this study, which took place between 16 September 2025 and 13 February 2026. SCIP dosing and administration procedures are described in detail elsewhere.¹⁶ SCIP administration typically takes between 15 and 25 minutes,¹⁸ but may take longer for some participants depending on comfort and the need for pauses. Participants were able to receive their injections in their usual care setting, including at home, school or in clinic, according to participant and whānau preference. Participants with conditions that would prevent safe engagement with VR, including seizure disorders or significant visual impairment, were excluded.

Participants used the immersive Nature Treks VR application on a Meta Quest 3S headset (Meta, United States of America) (Figure 1). The application provides a choice of calming virtual environments, such as tropical beaches or ocean scenes, which participants selected prior to the procedure. Participants were given approximately 5–10 minutes prior to the SCIP procedure to familiarise themselves with the headset and VR environment and confirm whether they wished to proceed. The headset was fitted immediately before the injection and worn throughout the procedure, during which participants engaged with the VR environment as a distraction (Figure 1c).

Participants were asked to rate their anxiety before and after the injection using a 0–10 visual analogue scale (VAS).²⁰ Pain was assessed by asking for their usual pain score for this injection and their pain during the current injection, using the Wong–Baker FACES Pain Rating Scale.^21,22 Acceptability and user experience were assessed by a researcher immediately following the procedure using structured feedback questions and observational notes. Structured questions included whether participants would choose to use VR again and whether they would recommend it to others. Participants were also asked to describe their experience using VR during the SCIP procedure. Caregivers provided feedback based on their observations of their child’s experience. The researcher also recorded observational data on participant distress, engagement with the VR environment, and overall flow of the injection procedure. Nurses provided feedback on the use of VR, including its impact on participant comfort and procedural delivery.

View Figure 1, Table 1.

Ethics

Ethical approval was provided by the New Zealand Health and Disability Ethics Committee (11094). The study was also endorsed by Health New Zealand – Te Whatu Ora Capital, Coast and Hutt Valley, including review by the Māori Research Advisory Group (RAG-M #916).

Results

Ten participants aged 9–20 years participated in the study. Four were female; five identified as Māori and five as Pacific people. Participants reported lower pain scores during the SCIP procedure when using VR, with mean pain scores decreasing from five out of 10 for prior injections to three out of 10 during the VR-assisted injection. Anxiety scores also decreased, from a mean of three out of 10 before the injection to one out of 10 after the procedure (Table 1).

All participants expressed willingness to use VR again and recommend it to others. In response to the statement “Overall, using the VR helped make the injection feel less painful, less scary and more manageable”, six participants strongly agreed and four agreed.

Nurses and caregivers also described positive impacts on the overall procedure experience. Nurses reported smoother and, in some cases, faster procedures, particularly among participants with higher anxiety or lower familiarity with SCIP.

One nurse noted:

“They were much more relaxed today, not flinching or tense and was calmly breathing. So, less stopping during the procedure.”

Another observed:

“Only said ‘ow’ once, seemed to be in less pain. So much more relaxed. Way quicker and easier for me as usually takes 45 minutes as we stop and start but today took around 30 minutes.”

Another highlighted that the VR headset gave them a conversation starter:

“It gave me something to talk to the patient about, usually it’s just hard, but this made the appointment easier for both of us.”

Caregiver feedback was similarly positive. One whānau member said:

“Much better, a lot less ows. This one was real easy.”

Participants described the experience as calming, engaging, a bit weird and a welcome distraction. One participant’s comments reinforced these observations:

“I’m pretty distracted, can't really feel anything ... ocean pretty cool, made fish appear.”

Overall, VR was widely seen as a low-effort, high-impact addition that improved the procedure experience for tamariki, rangatahi (youth), whānau and nurses.

Broader implications

Reducing the pain and anxiety of regular injections may have important implications for long-term adherence. For tamariki requiring years of ongoing treatment, interventions that make injections less distressing may help reduce missed doses and treatment fatigue.²³ In this pilot, immersive VR was well received and created moments of calm, focus and even enjoyment during a procedure that can be anticipated with fear, suggesting it may help improve the overall experience of care.²⁴

By investing in tools that support comfort and emotional wellbeing, we demonstrate respect for the child’s experience and show whānau that the system values their participation. These shifts, however modest, can support trust, increase engagement and improve equity. VR is not a silver bullet, but it is a relatively low-cost intervention with potential to be scaled up across clinical and community settings. The Meta Quest headset and VR applications used in the study cost under NZ$700, and nurses reported the technology was straightforward to incorporate into routine SCIP delivery following brief orientation and setup support. Wider implementation would require consideration of equipment cleaning, maintenance, storage and replacement if devices were damaged. Following this pilot, the headset has also been used within paediatric services for other procedures, including oncology treatments and sexual assault assessments. It complements other efforts to improve care— such as new injection regimens like SCIP—culturally safe practice and whānau-centred service design. Together, these innovations can make painful procedures more tolerable and care more inclusive.

Limitations

This study was limited by a small sample size, and findings about effectiveness should therefore be treated as preliminary. Participants were aware they were using VR, and positive responses may have been influenced by novelty effects. Feedback was collected immediately after the procedure and in the presence of the researcher, which may have contributed to more favourable responses. In addition, VR was evaluated only during SCIP procedures, where participants lie on their backs; its feasibility during other procedures, such as intramuscular injections, requires further investigation. Practical considerations, including equipment costs, staff training and ongoing maintenance, may also influence wider implementation.

Conclusions

Immersive VR distraction was highly acceptable and associated with lower reported pain and anxiety during the SCIP procedure. VR also appeared to improve the overall procedural experience for tamariki, rangatahi, whānau and nurses. The use of VR may improve the experience of injectable treatments, including intramuscular BPG, and warrants further exploration in both clinical and community settings.