Popularity of injections in Uganda
The popularity of injections in Uganda was investigated through interviews with key informants in the research communities and informal conversations with health providers. In Busoga, the study formed part of a larger year-long ethnographic study of the use of injections (Birungi 1994b). As a result, there is more contextual data from that area.
The reasons why providers like injections in Uganda
In both regions it is evident that many providers, particularly private ones, besides providing a service, are strongly motivated by a desire to make money. In order to attract their clientele an injection has to be provided, because most patients who visit the private and other providers feel they only get their money's worth if an injection is included in the treatment. The provider survey findings reveal that the provider's profit motive favours injections which yield more than oral therapy. For instance, comparing malaria treatment at the various health facilities in Busoga, the study findings indicate that 84% of the antimalarial prescriptions at the profit-oriented health facilities are injections as compared to 66% at the non-profit oriented facilities. At one of the private clinics in an urban area, a full treatment course of chloroquine tablets earns a profit of 240 Ugandan shillings as contrasted with 2000 shillings from injection treatment; over 20% of the profits gained from injection treatment are obtained from the sale of needles and syringes.
In Busoga, some of the providers justify the prescription of injections in that it gives them greater control over the treatment and limits patient non-compliance. Unlike tablets or oral medications which are often administered by the patient, the injection is administered by a health specialist. Providers claim that the majority of patients do not observe times to take medicines and that many skip doses. According to them, there is also a danger of overdosage. This has become the justification of providers to prescribe an injection as a rule of medical practice in many communities.
The reasons why users like injections in Uganda
Although most sick Ugandans normally start their treatment by self-medicating with oral therapy, they believe strongly in the efficacy of injections. This conviction is based on local ideas of illness and the efficacy of various treatment options. Patients believe that medicine injected into the blood stream does not leave the body as quickly as it does when administered orally. Oral medicine is often compared to food which enters the digestive system and eventually leaves the body through defecation. For diseases that are transmitted through the blood system, the administration of the treatment into the blood stream is believed to attack the disease directly at the source. In the case of (suspected) malaria, injections are also preferred to chloroquine oral treatment because of the perceived side-effects of the latter form of medication. Chloroquine tablets are said to cause nausea and itching. The tablets are bitter and unpalatable and are therefore particularly difficult to administer to children. Other patients who had recurrent malarial attacks claimed that these do not respond to tablets. As a result, Ugandan patients often tend to solicit injections from providers. However, due to the fear of HIV transmission, it is common practice that many patients carry a personal needle and syringe, even on index visit24 to a provider facility.
24The index visit is the first time a health facility is visited for the present illness.
Popularity of injections in Indonesia
The belief in injections: health providers in Indonesia
Sciortino (1993:35-37) sees three reasons for the generous administering of injections in Indonesia:
• The providers themselves strongly believe in injections as the most effective way of treatment. In addition, the compliance of the patient is guaranteed with an injection, not with oral drugs.
• Health providers derive a certain status and power from administering injections. The essence of medical practice in their eyes is to supply treatment in the form of drugs. Their 'secret' knowledge of drugs distinguishes the professional from the lay person and increases the status of the administrator in the eyes of the receiver. Injections are even more effective than oral drugs to express this difference in knowledge and status. Health providers have control over them. Oral drugs are available in the drug-store but injections can only be obtained in the puskesmas or in the private practices.
• It is believed that injections are preferred by the patients and that patients would be disappointed if they did not receive an injection. They see it 'as a matter of suggestion'. Furthermore, the private interests of the nurses are involved. If they refused injections, then their private practices would not be visited any more either. Injections give popularity to the prescriber.
The injection practices research, although limited in scope and amount of providers interviewed25, confirms that many Indonesian health providers believe in the injection as a superior and indispensable treatment. Injections are routinely prescribed. Some 30-40% of all providers interviewed in the provider's survey believe that injections provide a more rapid cure. On the other hand, many health workers are also aware of the fact that the effect of injections is often the same as of oral medicine (30% in Lebak; 60% in Lombok). When asked what their reasons are for giving injections, the vast majority refers to patient demand as the driving force behind their action: "the patient would not be satisfied if not injected", and because of "the request of the family or patient". Some 50% of providers interviewed in Lebak claim that injections are "the most appropriate therapy". "Poor compliance" of patients is mentioned as a reason for giving injections by 15-20%.
25In Lebak 27 and in Lombok 15 providers were interviewed. In Lebak the majority worked in public health services; in Lombok all providers interviewed were engaged in private practice. No informal providers were included in the research. See Table 13, Appendix 2.B.
The belief in injections: the patients in Indonesia
A great majority of Indonesians believe in the benefits of injections, found Sciortino (1993:37-39), although the younger generation and mothers with small children are building some resistance to this kind of treatment.
• Supporters of injections believe that injections work faster and that serious diseases can only be permanently cured with an injection. Temporary relief can be found in pills and syrups, but to eliminate disease, an injection is needed. Thus after home treatment with traditional and modern remedies has failed, patients will go to the health centre for an injection.
• Public image of biomedicine further strengthens this idea: rapid results of neosalvarsan injections in Dutch colonial times in the combat of framboesia tropica have made people believe that an injection was crucial for all diseases. Biomedicine was 'injected' into the villages. Images in advertisements further strengthen this association as does the behaviour of health centre staff.
• It is the health providers who decide on the therapy and the role of the patient is to follow the advice of the specialist.
Objectors to injections are basically motivated by fear, according to Sciortino (1993:38). Besides fear of pain, people are frightened that if the medicine does not agree with them (tidak cocok: does not suit the body), the possibility of an allergic reaction arises. This fear is even greater concerning young children, who are less strong and thus believed to have less resistance against such an allergy (Sciortino 1993:39). This belief is partly shared by the health workers, but possible doubts by patients or health workers are often not expressed. Patients, in their role of passive receivers, hardly ever refuse injections.
During the focus group discussions organized in Lebak, the participants - all women with children under five years of age - discussed, among other things, the treatment of common health problems. There was general agreement among the mothers that injections are not usually the first resort for treatment. Drugs bought from local shops or home remedies are first given and if this does not achieve the desired effect, children are taken to the puskesmas' nurses and doctors. The mothers explained that whether injections are actually given or not is decided by the providers who are usually nurses in health centres. Although the participants generally like injections, mothers are sometimes reluctant to have their children injected. One participant of a focus group discussion mentioned that one of her children was taken to a doctor who did not inject the child. Since the condition did not improve, she brought her child to a nurse's private practice. The mother was in doubt whether to allow the child to be injected, but the nurse said that injections were all right.
Request for injections
Respondents in the Indonesian household questionnaire were asked whether the injection had been given on request of the patients or their family. The results show that popular demand for injections is enormous, especially in Lebak (the difference between the two regions is statistically significant (*p=0.01). Over half of the injections were given on explicit request of the patient or the family (Figure 12).
When asked why this request for injections had been made, over sixty percent of respondents stated that they preferred an injection because of its "fast action" and that it is "customary" to receive injections. This was followed by reasons such as "injections are more appropriate"; "they are cheaper" and "more effective" and "I forget to take medicine".
The fact that injections are frequently given on request of the patient was also confirmed in the study in health facilities. The majority of injections had been given on request in Lebak, while the reverse is true for Lombok (Figure 13). This difference is highly statistically significant (**p=0.001).
The question why injections are desired was also asked in exit interviews in health facilities in Indonesia. About a third of patients indicated that these provide "faster cure". Another important reason stated by some 10% of patients interviewed is that injections are "customary". In Lebak quite a few patients mention they like injections for family planning, a reason not stated in Lombok.
The research confirms that injections are very popular in Indonesia. Both providers and users of injections believe in them and have a strong preference for this form of treatment. The providers claim that they give most injections because of the demand of patients in the conviction that patients will not be satisfied if not injected. Indeed, data from the household questionnaire reveals that in about 50% of the cases in which injections were received, the patient did request this mode of treatment. However, in the focus group discussions, mothers claim that they usually have no say in deciding which therapy is chosen. This vicious circle (health workers give injections because they think patients expect them; patients want injections because health workers give them) keeps the practice of routine administration of injections going. The lack of communication between health worker and patient in many encounters in the health centre is demonstrated by the research finding that in Lebak 50% of all patients interviewed in the health facilities had received no explanation from the injection provider (in most cases a nurse) as to the rationale of this treatment. In Lombok, this percentage was even higher: 89% received no explanation (**p=0.001).
Figure 12. Request for injections (Percentage of patients who received an injection on request - Household survey - Indonesia) - Lebak
Figure 12. Request for injections (Percentage of patients who received an injection on request - Household survey - Indonesia) - Lombok
N = all patients in the households who received injections
Lebak n=234; Lombok n=239
Figure 13. Request for injections (Percentage of patiens who received an injection on request - Exit interviews - Indonesia) - Lebak
Figure 13. Request for injections (Percentage of patiens who received an injection on request - Exit interviews - Indonesia) - Lombok
N = all injected patients in health facilities
Lebak n=267 (inci. 2 patients injected in midwife's practice); Lombok n=341