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The AINAR game app helps you overcome your fear of needles

Neuroscientist Elisabeth Huis in 't Veld saw blood donors faint and discovered that this phenomenon is often caused by a fear of needles rather than blood loss. Now she is working on game app AINAR that helps people control their fear of needles.

The coronavirus pandemic put her research on hold for over a year, but it also had a positive effect. It sparked broad interest in needle phobia, a problem that neuroscientist Elisabeth Huis in 't Veld at Tilburg University hopes to solve with the AINAR game app. It is estimated that about thirty percent of all people suffer from this phobia to a greater or lesser degree. A considerable number are so afraid that they avoid any situation in which a needle might be inserted into their body. This means that they decide against getting the coronavirus vaccination, even though they might actually want to. Or, for example, that they avoid going to the doctor because they are terrified that a blood test may be required. So the phobia can have serious consequences. Another example that is perhaps less likely to come to mind: women with fertility problems who decide against an IVF treatment because it would involve hormone injections. Or people who want to donate blood, but who are afraid of needles and therefore cannot become donors, or who feel so ill while donating blood that they never come back.

Elisabeth actually saw this happen when she spent a few days working at a blood collection location shortly after joining the Donor Studies department at Sanquin blood bank. People who fainted when the needle went into their arm. “I was pretty shaken when I saw this for the first time”, she says. “But I also felt intrigued. Because these people say that they are fine one minute and the next minute they either faint or start vomiting. I wondered why they had no inkling of what was going to happen.”

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Doctors have very different ideas

While Sanquin seems an unlikely employer for a neuroscientist, it was the impact of this problem that led to the idea for a game app to help people control their needle phobia, Elisabeth tells us. “Until then, only doctors had looked at this phenomenon, and they had very different ideas about how to address it.” Most doctors believe that you faint after your donation because you have lost half a litre of blood. This is also the main assumption behind most interventions. Despite the prevalence of this problem, little was known about it. So Elisabeth starts spending hours reading the neuroscientific literature on this subject and discovers that the brain can react very violently to the mere sight of needles. She combines the scarce information she finds with the knowledge she obtained during her PhD research into the changes emotions can cause in your face, body and brain. Based on those resources, she comes up with a new hypothesis: unconscious processes in the brain and autonomic nervous system cause people to become unwell when a needle is inserted into their arm. Elisabeth: “Because this occurs at a subconscious level, you can’t uncover sensible information when you talk to people about it. If you want to address this problem, you need to develop something that can measure someone's anxiety and predict that they will faint or feel very unwell before they realize it themselves. Because that is generally too late.”

Influencing what happens in your body with biofeedback

Elisabeth quickly decides to use a thermal imaging camera to study the changes that occur in the face when a blood donor becomes unwell. Her intention is to use the data from this research to develop the algorithm for an app. “If people can see what is going on in their bodies, they can learn to influence the process”, she explains. This well-known neuroscientific technique is generally referred to as biofeedback. “You can try this at home. Simply by clearing your mind, focusing on your breathing and thinking of a pleasant experience or emotion. If something works, you experience the beneficial effect immediately. So you can quickly find out what works for you personally, because everybody is different in this respect.” Furthermore, this approach tackles the problem at its root. “Other common interventions such as ‘applied muscle tension’ simply address the symptoms. People are instructed to tighten their muscles to prevent a drop in blood pressure and avoid fainting. This technique is also by no means effective for everyone.”

She also decides to include her intention of creating an app in her research request from the start: if I really want to create an app, what do I need to do? And how do I get funding? Elisabeth: “I was taking an MBA course at the time and that helped me immensely. Your training as a scientist does not really prepare you for formulating requests like this.”

“This problem has only been considered by doctors until recently, and they look at things from a completely different perspective”

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Photo: Fotoburo Bolsius

Tilburg University: unique combination of Cognitive Science and AI

The money for her research came in the form of a Veni grant, which is part of the Talent Programme run by the Dutch Research Council (NWO). Elisabeth chose the Tilburg School of Humanities and Digital Sciences as the location for her research. “The combination of Cognitive Science and Artificial Intelligence that you find here is unique in the Netherlands and a key success factor for AINAR.”

In Tilburg, the app and AINAR start-up (AI for Needle Anxiety Reduction) start to physically take shape. In line with the lean start-up method, she starts small by making drawings together with people who are afraid of needles, building a simple prototype and continuously improving it based on user feedback. Work to create the algorithm takes place in parallel. The latter is a time-consuming task because a great deal of data is required, which she collects at both Tilburg University and at Sanquin. Testing in hospitals is the next step. Elisabeth: “The fact that people with needle phobia react very differently makes this problem even more complex. Some stop talking altogether and lose all their colour, whereas others become hectic, go red in the face and start sweating. This meant that we had to look at a wide range of personality traits, physical and brain responses and constantly adjust the algorithm to new findings.” A further complication is that healthcare is a sector with its own specific challenges. “Things happen slowly and there is a great deal of bureaucracy. As our work involves video, we were bombarded with questions, which is perfectly understandable.”

Academic entrepreneurship

“Fortunately, I collaborate with people who are very good at doing things that I can’t”, Elizabeth says with a hearty laugh. Like PhD student Judita Rudokaité, who is as technical as you can get and responsible for writing the algorithm. Or co-promotor, Sharon Ong, who specialises in extracting the data and patterns required for the algorithm from the biomedical images. And co-founder Cindy van Goor, who has years of experience in the healthcare sector and knows exactly how to approach technological innovations on a project basis. She is also the person who liaises with the hospitals. Access to IQONIC is also important for AINAR: this incubator promotes all aspects of entrepreneurship at Tilburg University, with the specific support of Dirk van den Berg as IQONIC's business developer. “Having a sparring partner who knows from experience how to make a start-up successful is immensely helpful.”

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“If you want to address this problem, you need to develop something that can measure someone's anxiety and predict that they will faint or feel very unwell before they realize it themselves.”

Making an impact

AINAR is still under development. The game developers are using player feedback to make the game more effective and more fun. In addition, the app will soon be tested on patients in a hospital environment at the Elisabeth-TweeSteden Ziekenhuis (ETZ) in Tilburg and other facilities. Elisabeth’s research (which will help constantly improve the algorithm) will continue until at least 2023. And after that date? “Then I want to start creating an app for children, because they suffer from this problem even more acutely. And hopefully we will soon be able to use the algorithm to tackle other problems as well. I still have lots of ideas about how I can make an impact as an academic entrepreneur.”

How the AINAR game app works

AINAR is a relatively simple puzzle game where you colour in boxes by tapping your smartphone's screen. As you do so, the app analyses your face using the phone's selfie camera. If the algorithm detects incipient signs of anxiety or stress, the puzzle squares turn red. If you are calm and collected, they are blue. The objective is to try to change the colour of as many squares as possible from red to blue.

Tackling the problem in the waiting room

Research conducted at Sanquin indicates that the donors’ fear of needles increases enormously while they sit in the waiting room and then spikes when the needle goes into their arm. So the waiting room is the place where you should tackle the problem, Elisabeth says. “The nurses do their best to calm people down, but they are actually too late as the fear experienced by the donors overpowers everything else at that stage. Even so, that positive interaction between the nurses and donors is clearly still needed. After playing AINAR, people will hopefully be more receptive to the nurses’ efforts.”  

Want to try AINAR yourself? You can download the game here.

Collaboration between Tilburg University and ETZ 

Within the WeCare partnership, Tilburg University (TiU) and the Elisabeth-TweeSteden Ziekenhuis (ETZ) have jointly carried out research in the field of data science and other areas for several years. The AINAR team collaborates with the neurosurgery department of the ETZ and has also received a WeCare grant from TiU/ETZ. The initiator is Peter van Dun. As an anaesthetic nurse, he immediately contacted Elisabeth when he heard that she was developing an app to help alleviate needle phobia. After 40 years of working in nursing, he is intimately familiar with this problem. Not only what it does to the patient, but also all the challenges it creates for the healthcare providers.

Listening to professionals in the workplace

Peter tells us about an oncology patient who had been living on tenterhooks for days because of the injection he was about to be given. In fact, the patient was much more afraid of the injection than the possible consequences of his illness. And another patient with acute abdominal pain, who, after hours of soothing persuasion in the emergency room, finally agreed to being given an injection under inhalation sedation in the anaesthesiology department. Peter is convinced that you can only effectively tackle needle phobia if you can respond to the needs of the individual patient and combine innovative techniques with information provided by experienced nurses. When the game app testing programme starts in the ETZ in the near future, his main goal is to make sure that the professionals in the workplace will be given the opportunity of providing input. 

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