This study reveals that injections are widely used as a means of administering drugs. The household surveys in two regions in Uganda found a prevalence of respectively 25.3% and 30.0% of injection use at the household level during a confined two week recall period. Injections are popular with both providers and users. A highly receptive user population in combination with providers who try to rationalize the use of injections has gone a long way in making treatment by injection the most popular. To the providers, injections are popular because of economic gain, acceptance by society and patient’s demand. Therefore, injection prescription is high and most treatments given include injections. Seventy-two percent of prescriptions in Busoga and fifty nine percent in Ankole contained injections - far above the desired national level of fifteen percent. This practice characterizes most providers, both biomedically trained and unqualified ones and both those practising in formal health care settings and informal ones.
From the users’ point of view, the popularity of injections is influenced by local perceptions of illness and efficacy of treatment. The expectation of an injection at every visit to a health care setting has become part of the culture of health care in Uganda. Another factor supporting the popularity of injections is the easy access to injecting equipment. Government health facilities, private clinics, pharmacies, drugshops, and drug pedlars are the basic sources of needles and syringes, which are often kept at home by the patients and presented to providers at a subsequent visit. Personal appropriation and domestication of the injection technology is well established to the extent that 63% and 82.5% of the sampled households in Busoga and Ankole respectively, own needles and syringes. This process has been accepted, encouraged and facilitated by both users and providers.
The domestication of the injection of equipment is associated with the deterioration in the country’s health services, and was largely reinforced by the fear of AIDS/HIV transmission. The massive AIDS health education campaigns warned people about the dangers of sharing and using unsterile needles and syringes. In a population of almost nil intravenous drug users, mistrust is directed at the health workers, government health facilities, reusable equipment and sterilization procedures which are regarded as ‘communal’. The population has therefore resorted to disposables, ‘single use equipment’, and later to the acquisition of equipment. Personalization of the technology is seen as a means of avoiding AIDS. The phobia is also present among health workers who would seem to support this process by accepting the ‘private’ injection equipment brought in by the patients and who hand over disposables to them after use. The culture of ‘personal injections’ poses a growing threat as injection providers increase in numbers and as people develop more confidence in non-formal providers.
Providers fail to match these challenges with sufficient standard hygienic procedures. Patients bring their own equipment to health facilities, but home sterilization seldom meets minimum hygiene standards and sterilization of private equipment is not done at the facility. The sterile chain is interrupted as needles and syringes change hands and places. The study also indicates that even when communal equipment is used, hygienic procedures are rarely satisfactory. In Busoga and Ankole the majority of all providers do not meet the minimum hygienic standards to be observed before, during and after administration of an injection. It is therefore hardly surprising that many households have experienced injection complications, mainly abscesses. In Busoga, over 40% of the households reported injection complications. However, these are usually not related to poor hygiene but thought to be the result of the ‘bad hand’ of a provider.