Improved injection practices after the introduction of treatment and sterility guidelines in Tanzania
Dr J Vos, Health Centre Filmwijk, Greta Garboplantsoen 1, 1325 HE Almere, The Netherlands. E-mail Martien.Borgdorff@wxs.nl
Summaryobjective To evaluate the effect of introduction of treatment and sterilization guidelines on the number of avoidable injections and on the sterility of needles and syringes.
methods In 1991, 66 randomly selected health units in Mwanza Region, Tanzania, were visited and factors were determined that might contribute to HIV transmission by injections. In a workshop with all senior health workers from the region, findings were presented and treatment and sterilization guidelines developed. Thereafter, seminars were held at each health centre of the region. Four months after the intervention, data were collected at the same health facilities in order to assess changes in prescribing practices, sterilization procedures, and sterility of needles and syringes.
results The knowledge on indications for injections improved markedly for paramedical staff. The proportion of outpatients receiving an injection dropped from 23% to 10% and the proportion of patients receiving an avoidable injection dropped from 16% to 6%. Procedures for sterilization, keeping sterilized equipment, and administration of injections improved. A smaller proportion of sterilized needles and syringes tended to be contaminated in dispensaries, but this reduction from 44% to 22% was not significant.
conclusion Considerable improvement in knowledge, prescription practices and sterility procedures was observed at dispensary level after carrying out a training programme.
HIV can be transmitted by contaminated or unsterilized needles and syringes; in particular by needle-sharing among intravenous drug users (Friedland & Klein 1987, Des Jarlais et al. 1989), but also by health care-related (iatrogenic) transmission. For instance in Romania, 57% of AIDS cases among children living in institutions were attributed to the use of unsterilized needles and syringes (Hersch et al. 1991), and in a recent study in Tanzania, 0.4% of new HIV infections were estimated to be attributable to medical injections (Hoelscher et al. 1994). Association between injections and HIV-1 infection has been shown in various studies (Mann et al. 1986b, McCarthy et al. 1989, Killewo et al. 1990, N'galy et al. 1988, Berkley 1991, Van de Perre et al. 1987, Konde-Lule et al. 1989), though not in all (Lepage et al. 1986). Reducing the number of injections and improving the sterility of syringes and needles is useful, not only to prevent HIV transmission but also for the prevention of hepatitis B and C (Narendranathan & Philip 1993), abscesses (Soeters & Aus 1989), paralysis due to trauma of the ischiadic nerve and other complications.
Mwanza Region is situated on the shores of Lake Victoria in North-west Tanzania and has a population of 2 million. There are 9 hospitals, 23 health centres and 191 registered dispensaries. A seroprevalence survey in 1991 showed that the prevalence of HIV infection was 2.5% in rural, 7.3% in road side settlements and 11.8% in urban areas (Barongo et al. 1992). A study on injection practices (baseline study) conducted between October 1991 and February 1992 in 66 health units of Mwanza Region showed that one in every four outpatients received an injection, and that of all injections given 70% could have been avoided (Gumodoka et al. 1996) Most avoidable injections were given for respiratory infections, skin infections and urinary tract infections. Forty percent of supposedly sterilized needles and syringes were bacterially contaminated. The baseline study also showed that patients preferred to have injections over oral drugs for almost all conditions, as appears to be the case in most parts of Africa and other continents (Reeler 1990, Wyatt 1984, Michel 1985, Gitanjali 1993). Health care workers felt that patient demand for injections was a big problem and led to over-prescription of injectables (Gumodoka et al. 1996).
This paper reports the results of an evaluation carried out from December 1992 to February 1993 in order to assess changes in injection and sterilization practices after the development and implementation of interventions to reduce the HIV transmission by injections.
After the baseline study (Gumodoka et al. 1996), results were presented in a workshop to all senior health workers and consensus was reached which patients would need an injection for specified conditions. Based on the estimated percentage of patients requiring injections for various conditions (Table 2), the proportion of avoidable injections was calculated.
Proportion of patients receiving an injection for various conditions in government health facilities at baseline and at evaluation
At the workshop, treatment guidelines were developed for the conditions listed in Tables 1 and 2, and sterilization guidelines were prepared. Copies of the guidelines can be obtained from the first author (in print or through e-mail). A health education programme was formulated to raise community awareness about the effectiveness of oral drugs and possible side effects of injections. It included communication with the Village Primary Health Care Committees, designing, pre-testing, producing and distributing posters and leaflets, and carrying out health education sessions for inpatients and outpatients. Thereafter, one-day seminars were held by regional and district supervisors in each health centre of the region in which all staff members from surrounding dispensaries participated as well as four staff members from each health centre and each hospital. At these seminars the research results were presented and participants were taken through the treatment guidelines and sterilization procedures step by step.
Percentage of health workers with adequate knowledge on indications for injections at baseline and at evaluation
For the baseline study, health facilities had been randomly selected; the same were used for the evaluation: all 9 hospitals, 11 of 23 health centres and 46 of 191 dispensaries. Of the 66 health facilities selected, 49 were administered by the government, 12 by a mission, and 5 were private. At evaluation, all centres were visited in the morning and the same research tools were used (Gumodoka et al. 1996). In the analysis, data are presented from those facilities which provided data both at baseline and at evaluation.
To assess the changes in knowledge on indications for injections, an anonymous self-administered questionnaire with 64 closed questions was handed to all health workers who were prescribing on the day of the visit. Knowledge was defined as adequate if 75% or more of the questions were answered correctly. Adequacy of knowledge was rated separately in the analysis for each of the following; nine parts (36 questions) on the treatment of common diseases (Table 1), 10 questions on side-effects of drugs, and 8 questions on which diseases may be transmitted through injections. The proportion of health workers with adequate knowledge before and after the intervention were compared.
At baseline, diagnoses and treatment were recorded of all outpatients at 45 of 57 (79%) dispensaries and health centres, at evaluation in 42 centres. In hospitals and in most of the mission and private health units, no records were kept on diagnosis and treatment of outpatients. For the baseline study, the number of patients seen and the number of injections given for specified conditions were counted for the first week of January and July 1991 and for the evaluation for the first week of October and November 1992. The first weeks were selected because drug kits are received early in the month and later in the month prescribing practices may be influenced by shortage of drugs. The availability of drugs was assessed by recording the quantity of drugs received and the time span in which those drugs were finished.
Patients and health care workers were interviewed in semi-structured interviews using open-ended questions about their opinion on the health education sessions, regarding injection practices and sterility, and on the posters and leaflets developed and distributed as part of the health education programme.
A checklist was used to record the available equipment. Samples were taken for aerobic microbiological cultures from sterilized needles and syringes and forceps containers. Equipment was considered contaminated if aerobic bacteria were cultured on a McConkey or blood agar plate. Controls of unused bottles with medium were taken from each batch on returning from data collection.
Procedures related to sterility were subdivided into three major components: the sterilization process, the storage of sterilized equipment and sterility during the administration of injections. To assess the process of sterilization, we used the following criteria: needles and syringes should be cleaned, taken apart and boiled in water for 20 minutes; used needles and syringes should not be mixed with sterile ones. To assess the storage of sterilized equipment the following criteria were applied: needles and syringes should be kept dry and covered and picked up with a sterile forceps: the forceps should be kept dry or in 1:20 lysol solution. For the administration of injections the following steps should be observed: no touching of sterile needles or plungers with the hands; the stopper of the ampoule should be cleaned; the drawing needle should not be the one used for giving the injection and a separate needle and a separate syringe should be used for each patient. Structured observations were made of each of those steps.
The available equipment used for sterilization and the number of needles and syringes were counted. The supply of syringes and needles was defined as adequate if twice the number of syringes that were on average used in one day was present. The number of supervisory visits from district supervisors was counted for the past year at baseline and for the preceding four months (ie the time elapsed since the baseline visit) at evaluation using the visitors book at the health facility.
All data were double-entered and verified using dBase IV, and range and consistency were checked. A paired comparison was made between health facilities in 1991 (baseline) and 1992 (evaluation). The Mantel-Haenszel χ2 test was used for paired comparisons and adjustment for confounders. The Mantel-Haenszel odds ratio (ORMH) was used as an overall measure of change after the intervention, summarizing over levels of health workers or health facilities.
Questionnaires to determine the knowledge of health workers were completed by 111 respondents in 1991 and by 123 in 1992. The distribution by level of health care workers was similar for both years. Overall, the proportion of health staff having an adequate knowledge on indications for injections improved, with most improvement among those with less education. The proportion increased from 4% (1/25) to 58% (18/31) among nurse aids, and from 19%(9/48) to 66% (29/44) among rural medical aids. No significant change was seen for medical assistants, assistant medical officers, and medical officers, where the proportion was 37% (14/38) at baseline and 50% (24/48) at evaluation (Table 1). Knowledge on indication for injections in the treatment of eye diseases, malaria, and pneumonia showed little change. However, for otitis, pelvic inflammatory disease (PID), skin infections, tonsillitis, upper respiratory tract infection (URTI), and urinary tract infection (UIT) there was a substantial improvement in knowledge (Table 1). The knowledge scores on side effects of injections and on transmission of diseases by injection did not change (data not shown).
At evaluation there were fewer cases of eye disease, malaria, pneumonia, and skin infection and more cases with ear disease, URTI, and UTI than at baseline. The total number of patients tested for all specified conditions combined in the 2 weeks recorded was similar for 1991 and 1992. In government health facilities, the proportion of patients receiving an injection dropped from 23% in 1991 to 10% in 1992 and the proportion of all patients receiving an avoidable injection dropped from 1813/11680 (16%) to 673/11036 (6%) (ORMH 0.39, 95% CI 0.36–0.42) (Table 2). The largest reductions in injections given were observed for ear infection, PID, and UTI. In non-government health facilities the proportion of avoidable injections was much higher at baseline (72%) and showed a limited reduction at evaluation to 58% (P < 0.05). There were no changes in availability of non-injectable drugs. Oral antibiotics, penicillin V, cotrimoxazole syrup and tetracycline tablets were not finished more quickly in 1992 than in 1991 (data not shown).
Interviews with 50 medical assistants and rural medical aids showed that in all centres the treatment guidelines, developed at the consensus workshop, were thought to be very useful and all said to have changed prescription practices. In all centres the guidelines were readily available and reported to be used for reference.
Contamination of sterilized syringes and needles at dispensaries had decreased from 16/36 (44%) in 1991 to 8/36 (22%) at evaluation (ORMH 0.34, 95% CI 0.11–1.11). This reduction was not significant. There was no improvement in the contamination rate of the forceps containers, nor of the rates of contamination at health centres and hospitals (data not shown). All controls were negative.
There was a significant improvement for each of the three major components of procedures related to sterility: sterilization, storage of sterilized equipment, and administration of injections. These improvements were seen in particular at dispensary level (Table 3). Of 47 nurses responsible for sterilization who were interviewed, 42 (89%) reported that they had become more strict about the time of boiling, 40 (85%) that they were now keeping the sterilized needles and syringes dry and 33 (70%) that they were now using a separate syringe and needle for each patient. At baseline, the number of syringes available was inadequate in 6 of 50 (12%) health facilities, and at evaluation in 7 of 54 (12.9%). For the number of needles these proportions were 6% and 2%, respectively. Though in the intervention period needles and syringes had been ordered, they had not yet been received and distribution at the time of evaluation.
Proportion of health facilities with adequate sterilization and storage of equipment and administration of injections at baseline and at evaluation
At baseline, the District Medical Officer had visited 48% (29/60) health facilities during the last year; the District Nursing Officer, 32%; and the Mother-Child Health-Coordinator, 45%. At evaluation these proportions over the past four months were 33%, 20% , and 58%, respectively. In 1991 sterilization procedures had been supervised at least once in the past year in 36 out of 62 (58%) health facilities, in 1992 in the past four months 34/60 (57%). The treatment guidelines had been discussed in 24/60 (40%), and the health education programme in 25/60 (42%) of health facilities.
The posters and leaflets for the health education programme aiming at reduction of patient demand for injections were thought to be clear and very useful by all health workers interviewed. The posters were found posted in all health units and health education sessions were reported to be held 1 to 3 times a week. In 38 of 48 health facilities patient demand was reported to have diminished; in 10 facilities no change was reported. In 38 of 50 health units the medical assistant or rural medical aid in charge had attended the local health committee meeting and explained about the posters and the leaflets.
In all but one health facilities two patients were interviewed about their preference for injections or oral drugs as treatment, independent of the condition. Of 123 patients, 72 (59%) preferred oral medication, 24 (20%) preferred an injection and 27 (22%) wanted both. Reasons for patients preferring injections over oral drugs were described in the paper on the baseline study (Gumodoka et al. 1996). The message of the posters was unclear for 10 of 123 patients, the leaflet was understood by all patients. There were 21 (17%) patients who reported not believing the message. The main reasons were: I have never seen any harm of injections (9), injections are better treatment (5) especially for old people (3), in hospital sterilization is good (3), and I have paid for it (1).
We saw considerable improvement in knowledge, prescription practices and sterility procedures after a training programme at health centre and dispensary level. Reducing the number of injections and improving the sterility of syringes and needles is particularly important for reducing transmission of bloodborne disease such as HIV and hepatitis B and C. For the replication of the intervention in other areas, we consider the following steps as essential.
Steps for the development of an intervention programme to reduce avoidable injections
•Determine injection practices for common conditions, describe sterilization practices, and identify health staff carrying out prescription and sterilisation (they may be different from those supposed to be doing it according to job descriptions); assess patients' perspectives on getting injections.
•Obtain consensus among medical supervisors on the role of injections in the treatment of common conditions.
•Develop treatment and sterilization guidelines and a health education programme.
•Carry out ‘on the job’ training, targeting those who prescribe treatment and sterilize equipment and implement a locally relevant health education programme.
Knowledge on indications for injections improved markedly, in particular for lower cadres such as nurse aids and mother & child aids. These cadres are prescribing in dispensaries if the rural medical aids are absent, but have no formal training in prescribing. The training workshop did not cover specific side-effects of injectables and transmission of diseases by injection and the knowledge on these questions had not improved. Therefore, it seems reasonable to attribute the improvement in knowledge on indications for injections to training at the workshop, rather than to the possible effect of administering repeat questionnaires on the same topic.
The choice of a 75% score as a cut-off point for the definition of adequate knowledge was somewhat arbitrary. As the knowledge questions were closed with yes-no-don’t know categories, a 50% score could be obtained by random guessing. A score of 75% or more suggested that the answer was known to 50% of the question or more. However, in the present study the definition of ‘adequate’ is not of major importance, as the main aim of the study was to determine changes in knowledge levels.
Overall, a large reduction in the proportion of avoidable injections was observed in government dispensaries. The number of cases seen for various conditions differed between baseline and evaluation, which might influence overall results. However, the reduction in avoidable injections was also significant for each of the specified conditions separately. In dispensaries, lower cadres of staff commonly give prescriptions. For these cadres the workshop and the introduction of the treatment guidelines appear to have been effective in changing prescription practices.
At hospitals and in most of the non-government dispensaries and health centres, diagnosis and treatment were not recorded routinely. It would be advisable for all non-government health units to start recording diagnoses and treatment to make supervision easier and quality control possible. The non-government health units, which did keep these records, were found to give many injections. As non-government health facilities usually depend partly on patient fees for survival, there is an economic incentive to prescribe the treatment liked best by the patients. In addition, drug supply to non-government facilities may be less restricted, creating less need for rationing injections.
Contamination rates of medical equipment dropped in dispensaries after the intervention, though this reduction was not significant. A significant improvement was observed in sterilization, storage and administration of injections. As the supply of equipment did not change, the improvement in sterilization practices can probably be attributed to the training intervention. This intervention was particularly successful for dispensaries. An important factor in the success of the training may have been participation of the lowest cadres, who were mostly untrained and usually responsible for sterilization of equipment.
Storage of the forceps was still a problem. In most districts there was no lysol; 67% of forceps stored in chlorxylenol (Dettol®) and 44% of those kept in cold boiled water were contaminated. It seems that procurement of lysol 1:20 solution is a priority. If this is not possible, it might be better to keep the sterilized forceps dry in a sterile dry container.
The number of supervisory visits appears to have increased after the baseline visits and may have contributed to the improvements observed. Regular supervision, preferably in the framework of a continuing programme of quality assessment, on issues related to prescribing practices and sterility, is likely to be essential to sustain the achievements made.
We thank the Principal Secretary, Ministry of Health and the Director General, National Institute for Medical Research for permission to conduct this study and to publish the results. We also thank the regional medical officer and the district medical officers of Mwanza region for their cooperation. Our special thanks go to Mrs S Joshua, regional nursing officer and all district nursing officers and district Mother and Child Health Care coordinators for their contribution to the district seminars. This study was financed by the Netherlands' Minister for Development Cooperation, Section for Research and Technology, The Hague, The Netherlands, as part of the Tanzania-Netherlands Research Project Aids and HIV Infection (TANERA).