The Drum Beat 138 - Perspectives on Injections

Something as apparently simple as the injection component of the immunisation process raises difficult issues that require focus and action by communicators. Take, for example, the different cultural perspectives on skin puncturing, the value attached to children and women in a community and the limitations of logistical strategies. These - and a range of other concerns - both highlight the value of the communication perspective and challenge our ability to respond effectively.

THE INJECTION CONTEXT

1.Key facts include:

• Total number of injections per year: 12 billion
• Ratio of therapeutic to vaccination injections: 20:1
• Diseases most frequently contracted through unsafe injection practices: Hepatitis B, Hepatitis C, HIV/AIDS.

Problems

2. The Safe Injection Global Network [SIGN] highlights 4 major problems:

• OVERUSE of therapeutic injections
• RE-USE of injection equipment without sterilization
• UNSAFE COLLECTION of sharps
• UNSAFE MANAGEMENT of contaminated waste

Targets

3. SIGN stresses the importance of 3 key participant groups for positive change:

• Injection PRESCRIBERS
• PATIENTS
• Injection PROVIDERS

Actions

4. 6 key actions are advocated:

1. Injection PRESCRIBERS to prescribe oral medication wherever possible.
2. If prescribed an injection, PATIENTS to ask if medication can be given orally instead.
3. PATIENTS to demand that a syringe and needle be taken from a new, sealed and undamaged package.
4. Injection PROVIDERS to use a syringe and needle taken from a new, sealed and undamaged package for EVERY injection.
5. Injection PROVIDERS to place syringes and needles in a safety box IMMEDIATELY after use, WITHOUT RECAPPING.
6. Injection PROVIDERS to manage waste safely and appropriately.

COMMUNICATION RELATED ISSUES and INITIATIVES

5. Anthropological perspectives on injections: A review. [PDF]

Reeler reviewed anthropological studies conducted on the social and individual determinants of poor injection practices. The findings highlight some core safe injection challenges, with major communication strategy implications, for all health interventions. These include:

"Most cultures...have their own explanations for the occurrence of disease, which may involve supernatural forces or ideas about balance between different elements." (p. 136 )

"Injections are seen as the outstanding symbol of biomedicine...portrayed as such in health and vaccination campaigns... However, injections are often classified and used in ways that are markedly at variance with biomedical intentions, and may even be irrational from the biomedical point of view...because injections have been introduced into cultural contexts where other explanatory models for illness prevail." (p. 136 )

"In many countries, body-piercing rituals are seen as a way of manipulating the body and intervening in its processes, and injections fit well into this explanatory framework. Examples include putting things under the skin (Indonesia), scarification (parts of Africa), and different forms of acupuncture (Bhutan, China, Thailand). The pain associated with inserting a needle...direct entry into the bloodstream; [and] [perception that injections are] 'hotter' than other types of medicine, are examples of the differing cultural contexts]." (p. 136 )

"In each setting, injection is associated with specific meanings and interpretations depending on medical traditions and ideas about contamination, causes of disease, perceptions of providers and their institutions, and local responses to the advice and behaviour of biomedical practitioners." (p. 141)

6. Safety of immunisation injections in Africa: Not just logistics.

Dicko et al review difficulties in reaching immunisation injection safety in Africa and propose a holistic approach to injection safety that goes beyond the problem of logistics.

"The results of this assessment of immunization injection practices suggest that the study countries [study published in 2000] have not made any progress with regard to safety over the last 10 years." (p. 166)

"The logistic approach to immunization injections...has rarely involved medical epidemiologists...most indicators used to measure progress in injection safety were related to logistics. While there cannot be safe injections without the logistics...health care workers require knowledge and skills to engage in safer injection practices. First, the injection must be justified. Second, the appropriate medication must be prepared correctly. Third, sterile techniques must be used to administer the injection through the appropriate route. Fourth, providers and recipients must know the benefits and potential adverse effects of injections." (p. 166)

7. Unsafe injections and the transmission of hepatitis B and C in a periurban community in Pakistan [PDF]

Khan et al in a study conducted in healthcare facilities of Darsano Channo, Pakistan provide evidence that injections are overused to administer medications and that most injections are given with syringes re-used in the absence of sterilization. Communication relevant excerpts from that study include:

"If oral and injectable medicines were equally effective in the treatment of a given illness...44% said they would prefer an injectable. 14% said they always insisted on receiving injectable drugs when visiting health care practitioners...Only 24% reported ever having asked their practitioners for oral medication in preference to an injectable drug that had been prescribed." (p. 958)

"Patients in Darsano Channo actively sought injections. 73% of the patients had received more than 10 injections in the preceding year...Practitioners, unaware of many of the specific risks of bloodborne pathogen transmission through injections, were providing a service that people wanted at a modest price. Complete medical evaluation was not part of this study; nevertheless, the fact that 81% of the patients visiting primary care clinics received a parenteral injection in the absence of laboratory or radiological evaluation pointed to unnecessary parenteral therapy." (p. 960)

8. Community-Based Safe Injection Initiatives - Nepal

This is a 2 year programme designed by Children's Vaccine Program (PATH) and General Welfare Pratistan. Advocacy efforts will involve a close working relationship with local partners to increase understanding of injection safety issues and to facilitate their active involvement in problem-solving and action related to those issues. Educational outreach and service provider training initiatives will build on already high levels of awareness of injection safety problems, but with a special focus on ways in which relatively simple changes in behavior can dramatically reduce risk to providers, consumers, and the general community.

RELEVANT RESOURCES

9. Safe Injection Global Network - SIGN has comprehensive information on these issues including a toolbox that allows visitors to choose their specific interests from:

• Type - Policy Aide, Research Tool, Training Module, IEC Template, Supervision Tools, Articles/Reports, Image Bank.
• Audience - Doctor, Nursing Supervisor, Nurse, Health Volunteer, Patient/Community, Policy Maker, General audience, Logistician.

10. Events

3rd World Congress on Vaccines & Immunisation - June 4-9

Global Health in Times of Crisis Conference - May 28-31

Association of Health Care Journalists - April 6-9

11. Training

Public Health in Emergencies - April 19-27

Radio Programming for Health Promotion - June 5-28

12. Materials

Public Health Fact Sheets

Communication Bibliography

Immunization Focus - e-magasine published by the Global Alliance for Vaccines & Immunisation. Contact gavi@unicef.org

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