Glove Puppet as a Distraction Method: Reducing Hospitalization Response in Preschool Children During Injections
Abstract
Introduction: Hospitalization and medical procedures such as injections are common causes of anxiety and behavioral distress in preschool children. Non-pharmacological, atraumatic care such as distraction technique is an imperative to reverse such reactions. This study aimed to analyse the effectiveness of glove puppets as a distraction method in reducing hospitalization-related behavioural responses in preschool children undergoing injection procedures.
Methods: This quasi-experimental pretest–post-test non-equivalent control group study was conducted among 32 preschool children aged 3–6 years hospitalized at Dr. Ramelan Naval Hospital, Surabaya, Indonesia. Participants were assigned to an intervention group (n = 16) and a control group (n = 16). Behavioural responses were assessed using a validated observational checklist before and after the injection procedure. Glove puppet distraction therapy was administered to the intervention group prior to the injection procedure. Data were analysed using the McNemar test to evaluate categorical changes and the Wilcoxon test to compare pre–post scores.
Results: Before the intervention, 87.5% of children in the intervention group and 75% in the control group exhibited high levels of behavioural distress. After the intervention, the proportion of high distress in the intervention group decreased significantly to 25%, while no meaningful change occurred in the control group (81.3%). A significant reduction in distress was observed in the intervention group (p < 0.001; Cohen’s d = 1.56).
Conclusion: Glove puppet distraction is a simple, cost-effective, and developmentally appropriate strategy that significantly reduces hospitalization-related behavioural distress among preschool children.
References
Pau K. Reducing trauma For Children in Healthcare. Starlight Children’s Foundation. London W67AU: Starlight Children’s Foundation; 2023 Jan.
Fox JK, Halpern LF, Dangman BC, Giramonti KM, Kogan BA. Children’s anxious reactions to an invasive medical procedure: The role of medical and non-medical fears. J Health Psychol. 2016 Aug;21(8):1587–96.
Berman AT, Snyder SJ, Frandsen G. Kozier & Erb’s Fundamentals of Nursing : Concepts, Process, and Practice 11th Edition. United Kingdom: Pearson Education Limited; 2022.
Hockenberry MJ, Wilson D, Cheryl C. Rodgers. Wong’s Essentials of Pediatric Nursing. 10th ed. St. Louis: Elsevier; 2019.
Lane JD, Ronfard S, Francioli SP, Harris PL. Children’s imagination and belief: Prone to flights of fancy or grounded in reality? Cognition. 2016 Jul;152:127–40.
Delvecchio E, Salcuni S, Lis A, Germani A, Di Riso D. Hospitalized Children: Anxiety, Coping Strategies, and Pretend Play. Front Public Heal. 2019 Sep;7(September):1–8.
Nada M, Bahgat R, Kafl R. Effect of a Distraction Method on Pain, Anxiety and Behavioral Distress among Children during Venipuncture. Menoufia Nurs J. 2024 Jan;9(1):55–69.
Suparno S, Estiani M, Aisyah A, Saputri K. Application Of Medical Play To Reduce The Level Of Hospitalization Anxiety In Preschool Children. J Matern Child Heal Sci. 2023 Jun;3(1):291–301.
Badan Pusat Statistik. Profil Anak Usia Dini 2023. Vol. 4, Badan Pusat Statistik. 2023.
Sillero Sillero A, Ayuso Margañon R, Marques-Sule E, Gil Poisa M. Child-Centered Care: A Qualitative Study Exploring Pediatric Hospitalization Through Children’s Perspectives. Nurs Reports. 2024 Oct;14(4):3138–49.
Signorelli C, Robertson EG, Valentin C, Alchin JE, Treadgold C. A Review of Creative Play Interventions to Improve Children’s Hospital Experience and Wellbeing. Hosp Pediatr. 2023 Nov;13(11):e355–64.
Choudhary R, Kumari A. Assess The Effectiveness of Play Activities on Anxiety during Therapeutic Interventions among Hospitalized children at selected Hospitals of Mohali, Punjab. Int J Adv Nurs Manag. 2025 May;125–33.
Hasinuddin M, Noviana U, Fitriah F. Family Support System as an Effort to Optimize Coping Mechanism of Preschool Children During Hospitalization. J Ners. 2020 Jan;14(2):199–204.
Uz?en H, Ba?bakkal Z. The Effect of Therapeutic Play on the Quality of Life and Symptom Control of Children with Cancer. ?nönü Üniversitesi Sa?l?k Hizmetleri Meslek Yüksekokulu Dergisi,. ?nönü Üniversitesi Sa?l?k Hizmetleri Mesl Yüksek Okulu Derg. 2025;13(2):294–312.
Lluesma-Vidal M, Carcelén González R, García-Garcés L, Sánchez-López MI, Peyro L, Ruiz-Zaldibar C. Effect of Virtual Reality on Pediatric Pain and Fear During Procedures Involving Needles: Systematic Review and Meta-analysis. JMIR Serious Games. 2022 Aug;10(3):e35008.
Kwon S, O’Neill ME, Foster CC. The Associations of Child’s Clinical Conditions and Behavioral Problems with Parenting Stress among Families of Preschool-Aged Children: 2018–2019 National Survey of Child Health. Children. 2022 Feb;9(2):241.
Frigerio A, Nettuno F, Nazzari S. Maternal mood moderates the trajectory of emotional and behavioural problems from pre- to during the COVID-19 lockdown in preschool children. Eur Child Adolesc Psychiatry. 2023;32(7):1189–99.
Compas BE, Jaser SS, Bettis AH, Watson KH, Gruhn MA, Dunbar JP, et al. Coping, emotion regulation, and psychopathology in childhood and adolescence: A meta-analysis and narrative review. Psychol Bull. 2017 Sep;143(9):939–91.
Mariscal P, Bravo L, Llorca-Torralba M, Razquin J, Miguelez C, Suárez-Pereira I, et al. Sexual differences in locus coeruleus neurons and related behavior in C57BL/6J mice. Biol Sex Differ. 2023;14(1):64.
Aly Hassan Essawy M, Mohamed Elarousy ELsaid W, Rashad Kotb M, Abdel-hameed Ramadan Gaffar H, Mohamed Mahmoud Abu Hadida, R. Effect of Play Activities Versus Passive Distraction Technique on Preoperative Anxiety and Fear Levels among Children Undergoing Surgeries. Alexandria Sci Nurs J. 2024 Jun;26(2):15–26.
Mesa NDK, Mutiah C, Aripa L, Muchsin W, Kurniawati K, Megasari AL. Anxiety Levels of Preschool Children on the Effect of Play Therapy Due to Hospitalization at Makassar City Hospital. Int J Health Sci (Qassim). 2024 Mar;2(1):394–403.
Halemani K, Issac A, Mishra P, Dhiraaj S, Mandelia A, Mathias E. Effectiveness of Preoperative Therapeutic Play on Anxiety Among Children Undergoing Invasive Procedure: a Systematic Review and Meta-analysis. Indian J Surg Oncol. 2022 Dec;13(4):858–67.
Meiri N, Ankri A, Hamad-Saied M, Konopnicki M, Pillar G. The effect of medical clowning on reducing pain, crying, and anxiety in children aged 2–10 years old undergoing venous blood drawing—a randomized controlled study. Eur J Pediatr. 2016 Mar;175(3):373–9.
Sánchez JC, Porras GL, Torres MA, Olaya JC, García AM, Muñoz L V, et al. Effects of clowning on anxiety, stress, pain, and hormonal markers in paediatric patients. 2024;1–9.
Birnie KA, Noel M, Parker JA, Chambers CT, Uman LS, Kisely SR, et al. Systematic Review and Meta-Analysis of Distraction and Hypnosis for Needle-Related Pain and Distress in Children and Adolescents. J Pediatr Psychol. 2014 Sep;39(8):783–808.
Anchala K, Tirumala V, Saikiran KV, Elicherla NR, Rahul S, Nuvvula S. Efficacy of kaleidoscope, virtual reality, and video games to alleviate dental anxiety during local anesthesia in children: a randomized clinical trial. J Dent Anesth Pain Med. 2024 Jun;24(3):195.
Campos MC, Rodrigues KCS, Pinto MCM. Evaluation of the behavior of the preschool one just admitted in the unit of pediatrics and the use of the therapeutic toy. Einstein (São Paulo). 2010 Mar;8(1):10–7.
Koukourikos K, Tzeha L, Pantelidou P, Tsaloglidou A. The Importance of Play During Hospitalization of Children. Mater Socio Medica. 2015 Dec;27(6):438.
Tas FQ, van Eijk CAM, Staals LM, Legerstee JS, Dierckx B. Virtual reality in pediatrics, effects on pain and anxiety: A systematic review and meta?analysis update. Pediatr Anesth. 2022 Dec;32(12):1292–304.
Schoonover T, and Perryman K. Child-Centered Play Therapy and Adverse Childhood Experiences: A Single-Case Research Design. J Child Adolesc Couns. 2023 Jan;9(1):1–20.
Javed T, Khan AS, Jarral NA, Taqi Z, Raza M, Shahid Z. Medical Clowning: A Cost-Effective Way to Reduce Stress Among Children Undergoing Invasive Procedures. Cureus. 2021 Oct;13(10):e18886.
Dewi NP, Utami IK, Gunawan A, Tahir MT, Alaydrus S, Polontalo NA. Study of Treatment in Heart Disease Patients Installation in Undata Hospital, Central Sulawesi. J Public Heal Pharm. 2024;4(1):38–45.
Copyright (c) 2025 Media Publikasi Promosi Kesehatan Indonesia (MPPKI)
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Authors who publish with Media Publikasi Promosi Kesehatan Indonesia retain the copyright of their work. The journal applies a Creative Commons Attribution-ShareAlike 4.0 International License (CC BY-SA 4.0), which grants the following rights:
-
Copyright Retention: Authors retain the copyright of their work, maintaining full control over their intellectual property without restrictions.
-
Right of First Publication: Authors grant the journal the right of first publication of their work. This ensures that the work is initially published and credited in Media Publikasi Promosi Kesehatan Indonesia.
-
License to Share and Reuse: The work is licensed under CC BY-SA 4.0, allowing others to copy, distribute, remix, and build upon the work for any purpose, even commercially, as long as proper credit is given to the authors, and any new creations are licensed under the same terms.
