Why are injections so popular? / Anita Hardon

18 World Health • March-Aprill992 Why are iniections so popular? Anita Hardon Prescribing malaria pills in Sudan. Oral therapy is ;ust as effective as in;ections ... and costs less. ''I want an injection" is a request commonly heard by health workers in many countries, where patients prefer injections to oral medications. The reason for this popularity of the syringe may be the spectacular cures very often achieved with injections, such as quinine to treat malaria and penicillin to treat yaws. However, apart from their reputed efficacy, economic factors may also determine their widespread use. It is evident that healers can ask for a higher fee after administering an injection than after prescribing some tablets. The overuse and unnecessary use of injections is a problem because it adds an extra burden to household and health centre budgets that are often already limited and, especially in Africa, are diminishing because of the economic crisis. In addition, patients may risk getting infections such as AIDS or hepatitis, which can be spread by unhygienically prepared needles . Essential drugs programmes in developing countries want to reduce the overuse of injections. So programme administrators need to know who does the injecting; how often they give injections and for what purpose; whether these are used when there is no medical justification; and what hygienic measures are taken. Only then can an intervention strategy be developed that focuses on the main areas of misuse. WHO's Drug Action Programme, in consultation with the Expanded Programme on Immunization and the Global Programme on AIDS, initiated an Injection Practices research project in three developing countries (Indonesia, Senegal, Uganda) where the misuse of injections is considered to be a problem. The studies started in Overuse of injections adds an extra burden to household and health centre budgets May 1990 and will be completed in the summer of 1992. Some preliminary findings reported at an interim workshop of the multicountry study pointed to serious problems concerning both the medical rationality of injection use and the hygienic conditions under which injections are administered. Shortage of syringes and needles The Ugandan researchers observed that drug kits supplied to the government health clinics under the essential drugs programme contain six injectables. Penicillin and chloroquine are the most commonly prescribed. The kits contain reusable syringes and needles. However, shortages in kerosene supply (needed to boil the water to sterilize needles and syringes) are one of the problems confronting health workers, who often are not aware of and trained in the need for absolute hygiene when giving injections. Moreover, syringes are in high demand. During the AIDS campaign, patients became worried about infection through needles; many doctors advised them to keep their own equipment at home. So health workers sold them or gave away syringes and needles which patients World Heolth • Morch-Aprill992 kept for their own individual use. This led to acute shortage at the government health centres. The Indonesian research team studied drug management and distribution in government health centres, and found that nearly 50% of children under five and 75% of patients aged five and over receive one or more injections when visiting a health centre; this suggests widespread overuse. Preliminary results of the studies in all three countries show how complicated the provision of injections is: needles, syringes and the pharmaceutical substance may all come from different sources. In Senegal, for example, a doctor commonly prescribes an injection, then leaves it to the nurse in the health centre to administer it. In some cases the injectable drug is out of stock, and the patient has to go to the pharmacy to buy the drug, then return to the health centre to have it injected. If an essential drugs programme wants to improve this practice, it will need to address the prescribing practices of the doctor and the injection practices of the nurse; it will also need to educate the consumer and explain that in many cases an injection is not needed for recovery. In all three countries, health workers with minimal training (and sometimes even untrained guards and cleaning staff of the health centre!) tend to administer injections more often than doctors. By doing so these workers are considered better health workers by the patients and can at the same time earn some extra income. The patients' viewpoints People often credit the power of injections to their belief that the medicine is injected directly into the blood. In Uganda the researchers found that people relate the risk of getting an abscess from an unhygienic injection to the person who delivers it. They would rather be injected by someone they trust (members of their own family, relatives or neighbours) than by a health worker with whom they have no specific relationship. Another reason suggested for choosing such informal injection practitioners is the confidentiality they can provide in treating sexually transmitted diseases. The health centre would require the patient to inform his or her sexual partners about such diseases. 19 Final results of the research projects will certainly challenge the essential drugs programmes in Indonesia, Senegal and Uganda to undertake a campaign on the rational use of injections. Such a campaign will need to tackle the inappropriate use of injections by a variety of health care personnel, including doctors, nurses and untrained health centre staff. It will also have to reach consumers whose demand for this method of treatment is one of the main reasons for its abuse. In educating consumers, health educators should acknowledge that people are increasingly worried about the adverse effects of injections, particularly the risk of abscesses. If people's own concerns are at the core of the public education campaign, such a campaign is more likely to succeed. • Or Anita Hardon works in the medical anthropology unit of the University of Amsterdam, Oudezijds Achterburgwal 185, 1 0 12 OK Amsterdam, Netherlands. She was a consultant to WHO's Drug Action Programme for the multicountry Injection Practices research project. Immunizing children in Mexico. Injections can save lives, but should be administered only when needed.