(1996; 157 pages)
1.1 Background to the injection practices research
In many countries health workers are confronted with patients who prefer injections to oral medications. The historical background of this popularity of injections may be the spectacular cures achieved with injections such as quinine to treat malaria, and penicillin to treat jaws. However, apart from their reputed efficacy, economic factors may also determine their widespread use. It is evident that healers can demand a higher fee for administering an injection than for prescribing tablets. The unnecessary and overuse of injections has prompted increasing concern among international agencies such as the World Health Organization (WHO) and national health officials and policy makers, doctors and other health workers in the field. From a health point of view, administering injections without adequate medical knowledge or proper sterilization procedures leads to the risk of transmitting serious diseases such as hepatitis, poliomyelitis and possibly AIDS. In addition, the drug that is injected is often medically unnecessary, and potentially dangerous. From an economic point of view, the non-essential use of injections is undesirable as it imposes an unnecessary burden on household and health centre budgets that are often already limited - this is particularly the case in Africa - and are, in fact, still diminishing due to economic crises.
In many different cultures the belief in injections as a very powerful method of restoring or maintaining health is shared by providers and lay people alike. In fact, the problem of injection use seems to be so complex that it cannot be solved by training alone. Knowledge of the potential risks of injections is often not put into practice. Popular demand for injections will encourage informal injection providers to administer injections to clients in their homes and at market places. Formal providers may also administer more injections as a result of patient demand.
Essential Drug Programmes in developing countries want to diminish both the overuse and the non-essential use of injections. In order to improve the use of injections, programme managers need to know who is injecting, how often they give injections and for what purposes, if injections are given without medical justification, why injections are the preferred route of treatment, and under what hygienic conditions they are given. Acknowledging this, in 1990 the Action Programme on Essential Drugs of the World Health Organization, in consultation with the Expanded Programme on Immunization and the Global Programme on AIDS, initiated a research project in three developing countries where the misuse of injections is reportedly a problem. The research focuses on two, largely unanswered, questions: what is the extent of injection use? and why are injections so popular? To answer this last question, the causal and contextual factors behind the popular demand for injections need to be explored. This was seen to require anthropological research methods including participant observation, in-depth interviewing and focus group discussions. Data on the actual use of injections both at the household level, and at the level of the health services, is needed in order to explore the extent of the problem, the indications for which injections are used and also to locate the most important sources of injections. This requires epidemiological research methods, including household surveys and interviews with providers and users of injections. The development of simple and rapid methods to estimate the prevalence of injection use was one important objective in the initiation of this research.
At the same time, similar research into injection practices in Thailand was supported by the WHO Action Programme on Essential Drugs1 and recently published by WHO (Reeler & Hematorn, WHO/DAP/94.8). Similar methods and indicators were used, and many results are complementary to those of the injection practices research reported here.
1This research was carried out by researchers from the Institute of Anthropology of the University of Copenhagen (Denmark) and the Department of Public Health of Mahidol University (Thailand), and formed part of a larger in-depth study.