Efficacy Comparison of Clown Care Therapy Versus Virtual Reality Distraction on Venipuncture-Induced Anxiety in Preschool Children: A retrospective cohort study

Yannan Cheng¹Chang-cui Chen²Jingfang Hong^1*

• ¹College of Nursing, First Affiliated Hospital of Anhui Medical University, Hefei, China
• ²Dongcheng Campus, First Affiliated Hospital of Anhui Medical University, Hefei, China

Background: Venous blood sampling is common in preschool children but often triggers marked anxiety, which can compromise procedural success and negatively influence later healthcare adaptation. Clown care therapy (CCT) and virtual reality distraction (VRD) are non-pharmacological strategies to reduce anxiety; however, evidence from Chinese clinical settings is limited, direct comparisons are scarce, and objective physiological indicators are underused. Objective: To compare the effectiveness of CCT versus VRD in reducing anxiety during venous blood sampling in preschool children using both subjective and objective outcomes, and to evaluate their clinical applicability. Methods: This single-center retrospective cohort study was conducted in the Dongcheng District of the First Affiliated Hospital of Anhui Medical University. Medical records of 220 children aged 3–6 years who underwent venous blood sampling between January 2022 and January 2025 were reviewed. According to the routine distraction method documented in the records, children were assigned to a CCT group (n=110; interactive play delivered by medical clowns) or a VRD group (n=110; virtual reality device used during the procedure). Outcomes included anxiety assessed by the modified Yale Preoperative Anxiety Scale (m-YPAS), physiological stress indicators (heart rate, crying duration, cortisol change), procedural indicators (cooperation level, first-attempt success rate, sampling time), and parental satisfaction. Between-group comparisons were performed, and multivariable analyses were used to identify factors associated with anxiety reduction. Results: Compared with VRD, CCT was associated with lower m-YPAS scores during sampling (t=4.128, P<0.001), a smaller increase in heart rate (t=5.217, P<0.001), shorter crying duration (t=6.384, P<0.001), and a smaller cortisol change (t=3.724, P<0.001). Cooperation was better in the CCT group (P<0.001), first-attempt success rate was higher (χ²=5.143, P=0.023), and sampling time was shorter (t=4.926, P<0.001). Parental satisfaction was also higher with CCT (P<0.001). In multivariable analysis, CCT remained independently associated with greater anxiety reduction (P<0.001). Conclusion: In this retrospective cohort, CCT outperformed VRD in reducing venipuncture-related anxiety in preschool children and improved physiological stress responses, procedural efficiency, and parental satisfaction. Prospective studies are needed to confirm causality and explore cultural acceptability and implementation pathways.