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close this bookInjection practices in the developing world: A comparative review of field studies in Uganda and Indonesia (WHO/DAP, 1996, 149 p.)
View the document(introductory text...)
View the documentExecutive summary
View the documentAcknowledgements
Open this folder and view contents1. Introduction
Open this folder and view contents2. Towards a rapid assessment methodology for injection practices research
Open this folder and view contents3. Background: the social and cultural context of injections
Open this folder and view contents4. The prevalence of injection use in Uganda and Indonesia
Open this folder and view contents5. The popularity of injections in Uganda and Indonesia
Open this folder and view contents6. The appropriateness of injection use in Uganda and Indonesia
Open this folder and view contents7. Conclusions and recommendations
View the documentReferences
Open this folder and view contentsAppendix 1: Indicators for injection use and for assessment of hygienic practices
Open this folder and view contentsAppendix 2: Methods applied in the injection practices research
Open this folder and view contentsAppendix 3: Tools used in the injection practices research
View the documentBack Cover

Executive summary

In the health centres (pukesmas) in Central Java, Indonesia, a patient’s treatment basically consists of the administering of an injection and the prescribing of several pills. It is foremost the nurses who are responsible for the diagnosis and treatment of patients. Often the consultations are very short and end with the rhetoric question: “Suntik, ya?” (“Injection, yes?”). As a consequence, about eighty to ninety percent of the patients leave the clinic with a new fluid in their bodies. (Sciortino 1993)

In a village in Northeastern Thailand injections are generally believed to be much more powerful and faster working than other forms of medicine administration, because injections ‘run in the blood’. A respondent quantified the effect of injections as compared with pills: “one ampoule equals ten pills!”. (Reeler 1993)

Widespread misuse of injections

Preference of injections to oral medications and widespread misuse of injections in many developing countries has long been of great concern to health professionals and the World Health Organization, but so far little systematic research has been conducted into this world-wide practice. Therefore, in 1990 the WHO Action Programme on Essential Drugs instigated a collaborative study on injection practices in three developing countries (Indonesia, Senegal and Uganda). Its purpose was: to examine the extent to which injections are used, the sources from which they are obtained, the way in which they are perceived, the indications for which they are given and the type and degree of improper and unsafe practices in the process of administration of injections. An additional objective was the development of a simple and rapid methodology to investigate injection use.

In this report the results and recommendations from the field studies in Uganda and Indonesia are presented and compared. In both countries, the high popularity of injections was confirmed: injection use was found to be very prevalent both at the household level and in health facilities. The results further indicate that this high prevalence of injection use cannot be biomedically justified. These injections are often not provided in a safe, hygienic way.

Rapid assessment methodology (RAM)

In the two countries the research used qualitative and quantitative methods to collect data from the point of view of users and providers. Injection use in the past two weeks was recorded through household surveys in two regions of each country. Preferences for injection therapy were investigated through in-depth interviews and focus group discussions. Provider-oriented methods included semi-structured interviews, reviews of prescriptions, patient exit interviews and observations in provider facilities. These included government and private medical clinics and various ‘non-formal’ sources of injections.

The strengths of this research project’s methodology are the combination of qualitative and quantitative data collection methods; and the flexible research design which allowed for modifications according to local conditions. At the same time, the formulation of common injection practices indicators helped to provide cross-country comparable data.

Key aspects of the rapid assessment methodology

· Identification of variables to be measured and key indicators.

· Standardized systematic sampling procedures to cover a variety of health care settings.

· User-oriented methods:

- household survey using a standardized questionnaire which includes local concerns,
- follow-up visits to households to improve quality of reporting,
- in-depth interviews,
- focus group discussions,
- use of standardized and local tracer conditions and “hypothetical” illness cases.

· Provider-oriented methods:

- identification of informal and private providers done through the household survey,
- semi-structured interviews,
- reviews of prescriptions,
- patient exit interviews,
- observation in provider facilities.

· Analysis using pre-defined indicators:

- to measure the prevalence of injection use,
- to measure the appropriateness of injection use.

· Strengths of research methodology:

- combination of qualitative and quantitative data collection methods,
- flexible research design to allow for cross-country comparisons and local concerns,

- formulation of common injection practices indicators and selection of universal tracer conditions.

Injection rates in countries

The prevalence of injection use, defined as the percentage of households in the surveys receiving one or more injections in the past two weeks, is high in both countries under study. It ranges from around four in ten households in Indonesia, to about three in ten in Uganda. There are no significant differences between the injection rates of the urban, suburban and rural households in both countries even though accessibility to modern health services varied between the various locations. The great majority of the injections reported in the two-weeks recall period in both countries had been given for therapeutic reasons (85-90%). Intravenous drips are not very common and immunizations are infrequently reported. In Indonesia it could be established that the very young constitute a high risk group for receiving injections. The percentage of children under five receiving an injection was twice as high as the percentage for the entire research population.

· 40% of households in Indonesia had received one or more injections.
· 30% of households in Uganda had received one or more injections.

There is a marked difference between the two countries with respect to the source of the injections received in the households. The bulk of the injections received in the Indonesian household survey originate from the public sector. Private practices of nurses, who also work in the public sector, and of doctors are also popular. In contrast, in Uganda only a minority of the last injections received in the household was given in the government health facilities. Private medical practices are far more popular. Most striking, however, is the fact that many injections are given by non-formal providers or at home by family members. This reflects the trend of informalization in Uganda where public facilities are often mistrusted and held responsible for the spread of the AIDS epidemic.

· The bulk of the injections received in Indonesia were given in the public sector.

· The majority of injections received in Uganda were given by private, often non-formal, providers.

Injection use in public health facilities

Injection use rates at public health facilities are fairly high in both regions in Uganda: an injection is given in between six to seven out of ten treatments. In Indonesia, of every ten patients treated in Lebak, seven received an injection. In Lombok, the mean injection rate is even higher: almost nine out of ten visits here end with the administration of one or more injections.

· 70-90% of all Indonesian patients in the public system received an injection.

· 60-70% of all Ugandan patients in the public system received an injection.

In both countries, high rates of injection use in uncomplicated, non-severe and self-limiting illnesses are found, indicating medical inappropriateness of injection use. In Uganda, fever is most often treated with injections - especially when accompanied by other symptoms. Over 95% of all injections prescribed are chloroquine, Penicillin Procaine Fortified (PPF) and Crystalline Penicillin. A very popular combination consists of PPF with chloroquine. In Indonesia, injections are given in half of the recorded illness cases in the households. The highest injection rates are found in the treatment of skin diseases (some 60%). The most commonly used injectables include antibiotics, vitamins, analgesics and antihistamines. Particularly striking is the popularity of oxytetracycline for the treatment of all recorded illnesses.

The enormous popularity of injections

In both countries the enormous popularity of injection therapy was confirmed. If self-medication with oral therapy brings no relief, or when a fast cure is desired, patients tend to solicit providers for an injection. This preference for injections is guided by local ideas and beliefs of illness and concepts of efficacy. It is further strengthened by the economic interests of private providers. In Indonesia, users stated that it is “customary” to receive injections in health facilities. Customers have little say over this routine treatment. When the providers are asked why they give injections, they usually claim that this is because of patient demand. This vicious circle (health workers give injections because they think patients expect them; patients want injections because health workers give them) and the lack of communication between both parties serves to continue the practice of routine administration of injections. The research confirms that communication between health workers and patients is unsatisfactory. Over half of the patients had not received any explanation from the health worker with regard to their treatment. Injections are popular because of:

· Local beliefs about illness and concepts of efficacy.
· Economic interests of private providers.
· Lack of patient-provider communication.

Hygiene problems and injections

Hygienic appropriateness of the injection administration was not adequate in both countries. The research demonstrates that injections in both countries are often unsafe since the minimum hygienic requirements are not being met. In Indonesia, the majority of providers interviewed used disposable syringes. However, most disposables are not discarded immediately after use but are reused after ‘sterilizing’. In Uganda, as a consequence of the popular concern about AIDS and the distribution of injection equipment to the users by private and non-formal providers, personal appropriation of needles and syringes is now very common. The majority of households keep injection equipment at home. In the health facilities, it was observed that some 60% of the patients bring along their own syringe and needle, making it rather difficult to meet hygienic standards. At the same time, a high percentage of provider facilities in both regions does not meet the required minimum standards of hygiene at each stage of injection administration.

· In Indonesia, disposable syringes were reused by providers.
· In Uganda, households brought their own injection equipment to health facilities.

A higher level of training of the health worker was not related to the provision of safer injections. Although many Ugandan households are familiar with complications due to injections, particularly injection abscesses, they do not explain them by lack of hygiene but rather by the personal qualities (‘bad hand’) of the provider.

Recommendations for interventions

The research teams recommended a number of managerial, educational and regulatory interventions.

Type of intervention proposed

Uganda

Indonesia

Regulatory

Improve control at the national level of the import, sale and use of injecting equipment

Enforce the rules

Establish clear rules and regulations for the use of injections in medical practice

Institute coercive measures and sanctions toward providers

Managerial

Supply disposables

Improve supervision of health facilities

Create incentives for providers with good practices

Supply disposables

Educational:
Training of providers

Carry out clean injection programme for providers, including in-service training, refresher courses, and guidelines

Make health personnel aware of the negative impact of their injection practice on the spread of HIV and hepatitis

Educational:
Training of the public

Train non-formal providers who operate from their homes

Carry out clean injection programme for users, including information, education and communication (IEC) about the need for hygienic practices, and posters

Undertake massive and intensive educational programme, sensitive to the meaning people ascribe to injections

However, the above interventions will only be successful if they consider the underlying reasons for injection misuse both for providers and for users. For example, while training of health providers is necessary and worthwhile, it does not ensure correct use of injections and drugs in general. Also, in many contexts it is no longer possible to eliminate injections from the arsenal of treatments available. Such intervention would be met with both incomprehension and opposition from providers and patients. Therefore, any policy to be adopted must be based upon good understanding of the cultural meaning of injections, their place in medical practices, and their influence upon human relations.