The results of the injection practices research indicate that the high prevalence of injection use in the two countries included in the research cannot be biomedically justified, neither are these injections often provided in a safe, hygienic way.
Medical appropriateness of injection use
The medical appropriateness of injection use was researched by means of investigating actual and preferred practices in a few selected tracer conditions, representing uncomplicated, non-severe and self-limiting illnesses. In both countries, high rates of injection use were revealed. Most often injections were combined with oral medication. The presence of actual tracer conditions was recorded in the household questionnaires and in exit interviews at health facilities (Indonesia). Hypothetical illness cases were presented in the household questionnaires, and in focus group discussions (Indonesia) and in-depth interviews (Uganda).
In Uganda the most common tracer condition was fever. This condition was most often treated with injections - especially when the fever was accompanied by the presence of other symptoms. The percentages of tracer conditions treated in Busoga with injections (either alone or with oral medication) ranged from 0% (cough & common cold alone) to 77% (combination of fever and vomiting). In Ankole, injection use was highest in the case of fever (34%) and lowest in a cough & common cold (13%). With respect to the treatment prescribed, it is noteworthy that in both regions over 95% of all injections prescribed were chloroquine, Penicillin Procaine Fortified (PPF) and Crystalline Penicillin. Fever is invariably treated as malaria, resulting in chloroquine prescription in over 95% of the cases. Many providers prescribe a special combination of injectables (PPF and chloroquine) especially for patients with fever and cough. The popularity of this combination is basically the result of poor diagnostic capacity. In some health facilities, chloroquine is even used to reconstitute PPF or crystalline penicillin, resulting in a potentially dangerous, hypertonic solution.
When asked which treatment is preferred should one of the mentioned tracer conditions occur in the household, the answers of the respondents reflect the tendencies described for actual use of injections. Fever should be treated with injections according to 50-75% of the respondents, while 25% view injections as the preferred mode of treatment for vomiting. For acute diarrhoea and cough & common cold the injection preferences range from 17 to 38%. Therefore it can be concluded that in Uganda, fever, cough & common cold, vomiting and acute diarrhoea are priority conditions for health education campaigns aiming at reducing injection use. However, tracer conditions do not always appear as single disease entities. An injection may not be given to one isolated tracer condition, but could appear indicated for a patient with a combination of symptoms.
In Indonesia, actual use of injections was recorded both in the household questionnaire and in an exit interview at health facilities. In the tracer conditions recorded in the households injections are given in over half of the cases. Comparing the two regions, the results again indicate that the overuse of injections is especially prevalent in Lombok. High injection rates in the treatment of skin diseases are particularly noteworthy (some 60% in both areas), in particular for pityriasis versicolour which is the most common skin disease in Indonesia. This is actually a fungal infection which is best treated by locally applied ointments. In the other tracer conditions, injection use varies from 33 to 56%.
Rates are even higher in the exit interviews at health facilities. The majority of the health facilities included in the Indonesian study belong to the formal government health services, confirming that injection overuse in Indonesia is very much a problem of the public sector. In Lombok injection rates are again consistently higher than in Lebak (an average of 85% of all patients with tracer conditions injected at the health facility in Lombok, while this is 64% in Lebak). A further breakdown of the rates in urban, suburban and rural facilities indicates that in Lebak, injection rates are highest in the suburban health facilities. A review of patient records at health facilities revealed that the most commonly used injectables include antibiotics, vitamins, analgesics and antihistamines. The popularity of oxytetracycline for the treatment of all tracer conditions is particularly striking. It is the most commonly used antibiotic in Lebak, and it comes second to penicillin in Lombok.
The immense popularity of injections, both with Indonesian providers and the public, is demonstrated clearly by the hypothetical case method. When asked which treatment is preferred should a tracer condition occur in the household, the respondents in Lombok state a clear preference for a combination of injections and oral therapy in all tracer conditions. In Lebak, this preference for injections is not as outspoken as in Lombok: some 60% of the respondents prefer 'oral medication only' for fever and almost 50% also prefer this for a cough and common cold. On the other hand, the Lebak respondents have a strong preference for injectable therapy in case skin diseases are present. In the case of diarrhoea, in both regions some 50% of respondents state that a combination of oral and injection therapy is best. In Indonesia, all four selected tracer conditions can be seen as priority targets for health education campaigns aiming at reducing injection use. However, in focus group discussions there was no clear cut agreement between participants as to whether injections are required to effect a cure for most tracer conditions. Mothers explained that injections are usually not the first resort of treatment. Drugs bought from local shops or home remedies are given first. Only if this does not achieve the desired effect, children are taken to the puskesmas' nurses and doctors. The only tracer condition for which all mothers agreed that injections are required for faster cure is skin disease, although other treatments are also applied.
It can be safely concluded that the indications for which injections are deemed necessary are seriously overestimated in both countries, both by the public and by the health providers. As a result, injection use in common, self-limiting conditions is very high. At the same time it is important to realize that popular conceptions of what constitutes a serious illness or a self-limiting disease may diverge from biomedical ideas. In-depth interviews in Busoga (Uganda) revealed that perceived seriousness is of great importance in the evaluation of the appropriateness of injection use. Prior to visiting a health provider, most patients have already attempted self-medication with tablets. Since tablets proved ineffective, they want an injection. This was also stated by the participants of the focus group discussions in Lebak (Indonesia). Here too, it is believed that any simple illness can turn into a serious disorder and therefore needs to be taken seriously.
Hygienic appropriateness of injection use
Hygienic conditions under which injections are administered were surveyed by means of a combination of observation and interviews in Uganda and through a questionnaire with providers in Indonesia. In both countries the research demonstrates that injections are often unsafe since the minimum hygienic requirements are not met.
With respect to sterilization, the Ugandan situation is rather unique. The Ugandan government recommends the use of reusable equipment only (mainly plastic). Sterilization of reusable equipment, however, is not confined to established biomedical institutions; instead the provider facilities normally require the users to sterilize their equipment at home before and after visiting the provider facility. Lay persons' standards of sterilization diverge from those stipulated by biomedical experts. Besides the general lack of concepts of hygiene and sterilization, many households, especially those in the remote and semi-rural areas, consider family control over the needles and syringes and personal knowledge of the users to be a more significant and determining factor in the safety of injection than actual sterilization procedures. In fact, it is understood that the locus of contamination is outside the household. As a consequence of the popular concern with the spread of HIV through communally shared needles and syringes in public health facilities, 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 in Uganda. In the health facilities it was observed that some 60% of the patients bring along their own syringe and needle. This finding is confirmed by data in the household questionnaire. In Busoga 63% and in Ankole 83% of all households keep needles and syringes at home. Only a limited number of households were in possession of injectables.
Complications of injections are well-known in Ugandan households. In Busoga, 43% of the households visited indicate that they experienced injection complications at some time, particularly injection abscesses (37%). Popular explanations of the causes of such complications do not blame the lack of hygiene or inappropriate injectable solutions, but rather the personal qualities ('bad hand') of the provider.
As a result of the widespread practice of keeping injection equipment at home it is rather impossible to meet optimum hygienic standards in Uganda. The domestication of injection technology breaks the sterile chain. At the same time, the results of the study also indicate that a high percentage of provider facilities in both regions do not meet the required minimum standards of hygiene at each stage of injection administration. In Ankole, out of the 14 provider facilities visited which administered injections at the time of the visit, 72% did not observe minimum hygienic conditions before injection administration, while 50% and 64% respectively did not observe minimum hygienic conditions during and after injection administration. In Busoga, the observations at 21 provider facilities show that 62% of the providers did not meet minimum hygienic standards before injecting, 48% did not meet minimum hygienic standards during injecting, while 81% did not meet minimum hygienic standards after injection. The poor hygienic practices include inadequate sterilization both at home and provider facilities, picking up the boiled syringes and touching the needles with bare hands, improper disposal of needles and syringes or giving the equipment to the patient to carry home. Furthermore, the same equipment is used on multiple patients, and the injection site is often not cleaned before injecting. It was noted in Uganda that a higher level of training of the health worker was not related to the provision of safer injections. Yet on the whole, NGO health facilities meet the highest hygienic standards.
In Indonesia, the majority of providers interviewed only used disposable syringes (in Lebak 26/27; in Lombok 10/15). Most disposable syringes are not discarded immediately after use. The majority of providers thus reuse disposable equipment, 'sterilizing' it by a variety of methods. With respect to the sterilization methods applied, more than half of the syringes are not washed before sterilization, only a few are stored in alcohol before reuse. Most injection providers then boil the equipment, but usually less than 20 minutes. There are also indications that the same equipment is sometimes used for more than one patient without sterilization.