Respondents in the household questionnaires were asked which treatment they would prefer if the tracer condition occurred.

Uganda

From the results of the household survey it can be inferred that a significant proportion of the respondents would use injections and/or an indicated combination of injection and oral therapy should a tracer condition occur. Comparing the results for both regions, fever was the condition for which injections were most commonly mentioned while they were mentioned least for intestinal worms.

In-depth interviews with a limited number of households in Busoga from both remote and urban settings indicated that it is rather intricate to use the idea of a scale of illness to evaluate the appropriateness of injection use. The medical construction of what constituted a mild and serious illness was not coherent with the lay people's perception. At the local level, most of the illnesses were regarded as mild or serious depending on the length of time the illness took to be cured, the response to oral therapy, and the role adopted by the sick person - admitting himself to hospital, taking to his bed at home or failing to perform normal duties. Informants indicated that any illness which persists, with or without treatment, is serious enough to justify the use of injection therapy, including a cough and common cold. Although mild in nature, a common cold was never taken for granted, as it is believed to be a prelude to a more serious disease such as malaria. Other informants expressed the view that nearly every illness appeared mild at its onset, hence no illness should be ignored. The people therefore justified the use of injection as a preventive measure.

Lay people also perceived serious illnesses as those which could cause anaemia and dehydration. They were also perceived to be those diseases that get to the bones. These diseases might render the patient restless, lead to a rise in body temperature, loss of strength, loss of appetite and general body weakness. Meanwhile all tracer conditions which were symptomatic of measles (there was an outbreak of measles in at least three communities in Busoga during the study) - such as diarrhoea in children, vomiting, unproductive cough and fever - were therefore also regarded as serious.

The study treated various tracer conditions as single disease entities. However, often people complain of a combination of symptoms. An injection is not always given to one isolated tracer condition, but sometimes to a patient with several symptoms. This poses complexities in applying hypothetical tracer conditions to evaluate the appropriateness of injection use.

Indonesia

The questions on hypothetical illness cases in the household survey confirm the overwhelming preference for injections. In Lombok, the respondents state a clear preference for a combination of injections and oral therapy in all tracer conditions. Second most popular is 'oral therapy alone' in a case of a cough & common cold; and 'other therapies' (notably ointments) are mentioned in a third of the households as the best therapy for skin diseases. In Lebak, treatment 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. Remarkable is the strong preference in the Lebak area for injectable therapy in case of skin diseases. With diarrhoea, in both regions some 50% of respondents state that a combination of oral and injection therapy is best. In Indonesia, all four tracer conditions can be seen as priority targets for health education campaigns aiming at reducing injection use.

During the focus group discussions, organized in Lebak, the participants - all women with children under five years of age - discussed the treatment of the tracer conditions. For most tracer conditions there is no clear cut agreement among participants on whether injections are required to effect a cure. For example: fever is treated at home (with application of compresses, herbs and self-medication), before the patient is taken to the puskesmas. Injections should not be administered during high fever, some participants remarked, but others are convinced that fever should be treated by injections. Cough & common cold (masuk angin) is not primarily treated with injections. Only if the condition does not remit within a week or so are injections deemed necessary. In addition, the combination of fever and cough & cold is an indication of the degree of seriousness. There is no consistent pattern in the answers on whether cough & common cold without fever requires injection treatment. Participants are acquainted with tuberculosis, a condition which in their opinion should be treated with injections. Diarrhoea is another tracer condition for which in the early stages other treatments are applied (such as herbs, self-medication with Western medicines and oral rehydration drinks). If the diarrhoea continues and cannot be halted, injections should be given. The only tracer condition for which all mothers agree that injections are required for faster cure is skin disease, but other treatments are also applied (such as ointments and herbs). Other indications for which injections are often used include headache, abdominal pains, toothache, convulsions and snakebites. Vitamin injections ("for the liver") are also popular for pregnant women and after childbirth.

The results of the focus group discussions in Lebak concur with other ethnographic research conducted in Java. Hagenbeek (1994) reports that the majority of his respondents consider diarrhoea, dysentery, influenza, vomiting and diarrhoea, skin diseases, and typhus to be disorders which should be taken seriously and need to be treated by an injection. On the other hand, there are also illnesses for which injections are not indicated: worms, many supernatural and mental disorders (such as possession), convulsions as well as measles (gabagen). According to many respondents, the cause of measles is quite obscure. It is thought to be caused by spirits or by a hot-cold imbalance. There are various traditional remedies, but injections are considered dangerous because the injection would not allow the spots to 'come out' and lock the heat or the spirit inside the body.

In Thailand, the relationship between injection use and self-limiting illnesses such as common cold, diarrhoea and tiredness was also studied (WHO/DAP/94.8: 43). Although the numbers were small, it can be concluded that injections are often used for trivial complaints.