Subcutaneous (S.C.), intramuscular (I.M.) and intravenous (I.V.) injections were observed. Intravenous infusions are only provided at hospitals and limited number of private clinics. S.C. and I.M. injections are given on the buttocks. The patient is allowed to choose which side to be injected. In repeated injections the buttocks are alternated at each injection. The prescriptions do not indicate route of administration; therefore the injection method is up to the provider’s judgement. All nursing aids, informal providers and nurses inject intramuscular. They explain that this route is less prone to abscess formation than the subcutaneous route. The (rare) intravenous injections are mainly provided by nurses and physicians. This is mostly given in life threatening conditions, such as shock, asthmatic attacks, and post partum haemorrhage.
Prior to injecting, a majority of providers aspirate the syringe to ascertain that the needle tip is not lying in a blood vessel. Where the needle has pierced the vessel, blood would reach the syringe, thus potentially contaminating it with blood borne diseases like hepatitis and HIV.
Since most of the needles used are brought in by patients, providers could only discover that the equipment is blocked during injection or when adjusting the volume of drug prescribed. Providers indicate that old needles are rusty inside and almost fail to conduct thick drugs such as PPF unless they are diluted heavily. In fact, many of the providers are aware of the dangers of reused disposable needles, but only readjust their medicine to suit the anomalies of such dirty needles.
Biomedically trained providers do not apply their fingers to guide the needle into the skin, but this practice is very common among the non-biomedically trained providers who claim that many of the needles are blunt and could easily break if not guided with the assistance of their index finger. Others indicated that they had heard of cases where needles broke in the patient’s buttocks. Some patients avoid this potential source of contamination by presenting needles too short for sliding along the provider’s finger.
Use of the same equipment on multiple patients was observed in over 50% of the health facilities, especially those of the semi-rural and remote communities. The practice is most common among providers in government health units, informal facilities and home providers. Here the number of patients sometimes overwhelms the available syringes, needles, and fuel for sterilization. One of the aid posts in a remote community had only three syringes to treat an average of 15 patients daily and sterilization was carried out once daily only. Use of the same needle is a common practice among the home based providers and for family administered injections, but is restricted to siblings. Here the mother presented with only one set of injection equipment to use on more than one of her children who could have contracted malaria.