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- Materials and methods
Summaryobjective To investigate the behaviour, knowledge of risks, and attitudes towards injections among patients at a clinic in Karachi.
methods In March 1995, trained staff administered a structured questionnaire to 198 consecutive new adult patients attending a university clinic in Karachi, Pakistan.
results Half (97; 49%) of the patients received injections at their last visit to a health care provider. 35% had received 10 or more injections in the last year. 64% felt that injections were more powerful and were willing to pay more for them than for pills. 84% preferred pills or advice over injections if told they were equally effective, 83% believed that a used needle could transmit a fatal disease, and 86% believed that it is usually possible to get better without an injection. 91% reported that the doctor always recommends an injection; few patients (9%) ever asked for one. Injections were given without much regard for the chief complaint of the patient. Some needles (n = 21) for the injection came from bowls of water: of those from closed packets (n = 116), 68 were ‘cleaned’ by wiping or placing them in water. 91% of patients (180) knew at least one risk of reuse of needles. Patients who knew three or more risks of using unclean needles were 0.14 times as likely to have had more than five injections per year in the last 5 years but only if the patients had 8 or more years of education.
conclusion Patients receive injections from doctors in Pakistan frequently, indiscriminately and often without proper safety precautions. They are aware of both positive and negative aspects of injections but are likely to do what the doctor suggests. Interventions to reduce risky overuse of injections should focus on patients' general education and knowledge of the risks of injections to empower them to choose healthier therapies.
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- Materials and methods
This study confirms that adults in Karachi were put at substantial risk for infection with blood-borne pathogens when they visited their general practitioner. Injections were vastly overused, 30% of patients having received 10 or more injections in the last year. Poorer and less educated patients tended to get more injections and to know less about the risks of injections with unclean needles. Injections were used indiscriminately – half of all visits included an injection regardless of the presenting complaint. This lack of discretion suggests that they were not dispensed on the basis of good medical practice. Injections in this study were often given without proper infection control practices. Although not directly proven by this study design, it is strongly suggested that the needles coming from bowls of water were re-used and/or contaminated and other studies in Pakistan bear this out (Gumodoka et al. 1996; Khan et al. 2000). The result is a situation where injections carry a real risk in the face of little or no benefit.
Two major public health consequences of this mode of transmission are crossover and amplification. Reuse of needles creates a situation where the health practitioner's clinic can become the point of crossover of disease transmission from groups at high risk of acquiring bloodborne viruses (e.g. people with multiple sexual partners, prostitutes, men who have sex with men, and intravenous drug users) to those who may otherwise be characterized as low risk groups in the general population. In this way, the general practitioner and community hospitals also easily become the means for the amplification (that is, the rapid exponential increase in the number of infected individuals) of bloodborne epidemics as occurred via the hospital with Ebola virus in Sudan (Baron et al. 1983). Although the numbers of people in Pakistan infected with HIV in 1995 were low (HIV Seroprevalence Study Group of Pakistan 1996), the epidemic will likely rise rapidly in the general population once a critical number of infected patients visit their local doctor. HCV and HBV rates are already quite high (Mujeeb & Mehmood 1996; Luby et al. 1997). This puts an immense number of patients in Pakistan at risk for HCV, HBV and potentially HIV and other diseases.
Despite a mean education level of six years, patients had reasonable knowledge that re-used needles were risky. This knowledge declined but was not extinguished in those with less education. Knowledge of specific risks of injections, however, was not enough – it had to be coupled with general education, that is, schooling, in order to influence behaviour and reduce the number of risky injections. This has important public health implications for interventions designed to reduce these behaviours. Such programs should consider the educational level of the population they hope to impact, strive for providing at least a minimal general education whenever possible, and consider starting with a relatively educated cohort when introducing new strategies.
Despite knowledge of these risks, few patients (16%) ever refused injections. Unlike the situation described in Uganda (Birungi 1998) there have been no massive anti-AIDS education campaigns in Pakistan to warn people against the dangers of sharing needles. Methods designed to empower patients to take a more active role in the decisions regarding their health care might be tried to overcome patient reluctance to question the doctor's treatment plan.
The attitude of patients regarding injections was rather balanced and open. An injection was regarded neither as a panacea nor as the only viable treatment. Although they value injections more in terms of paying a higher price and thinking that injections are more powerful, patients do not think injections last as long as pills and they prefer pills and advice five to one over injections if told they are equally effective. This view may prove an ally to future public health messages. Patients stated that they would rarely avoid the practitioner who refuses them an injection, nor shop for another doctor who would provide one. Although their behaviour may differ significantly when actually confronted with a refusal of an injection, it seems to reflect a trust of the doctor's recommendation over the perceived value of the injection itself. This information may be useful in educating health practitioners and mitigating their concerns about the economic consequences of decreasing injection use in their clinics. Information similar to this was used successfully in an intervention to reduce use of injections at public health facilities in Indonesia (Prawitasari et al. 1996).
The effect of the health practitioner has been to promote the use of injections in the climate of a moderate patient inclination toward their use. Practitioners recommend most injections and give them in 50% of visits. The reason for this may, in part, be economic. There is a substantial body of evidence that practitioners decide therapies based upon their own financial interest (Volinn et al. 1992). Practitioners typically keep a number of multi-use vials of injectable medications in their office. An injection can be included in the cost of the visit, whereas prescription of oral medication involves additional cost to the patient. Prescribing medications that can be obtained outside the doctor's office and usually without a prescription may be financially risky to the doctor in that the patient may bypass them with the next illness and go straight to the chemist. Another reason why injections may be overused by doctors is the inability to definitively diagnose an illness due to multiple factors including financial restraints against diagnostic services, poor training of doctors, a population burdened with a host of complicated acute and chronic illnesses, and too little time spent with patients. An injection, beyond its power as a placebo, can serve as a definitive procedure, cover up a lack of knowledge, be provided quickly from materials readily at hand, and conform to what doctors perceive as the patient's expectations.
Patients in many cases observed practitioners using improper infection control practices when administering injections – most importantly by re-use of plastic, disposable equipment. This is similar to findings of a study conducted outside Karachi by medical students doing observations during unannounced visits to general practitioners' offices (Khan et al. 2000). This again may have economic causes: a disposable needle and syringe set cost US$ 0.06 at the time of the study. This vanishingly small amount, when multiplied by re-using the set approximately 10–30 times, still seems small, but considering the US$ 0.96 per visit and incomes for doctors often less than US$ 200 per month, re-use could amount to appreciable financial benefit over time. It is not uncommon to find that the doctor has a dispenser actually giving the injection – sometimes a young boy with on-the-job training. Thus economic reasons and poor training may play a significant role in both the overuse as well as the improper handling of injections.
A potential limitation of this study is that the study population was university facility-based and does not necessarily represent the typical experience of Karachi residents. Aga Khan University Community Health Center clinic users are somewhat better educated and had higher household incomes than the general population which might affect the exact percentages of various practices and attitudes. However, our study did include a substantial number of poor, uneducated patients and our results correlate roughly with a study in a peri-urban area outside Karachi. 81% of patients exiting from general practitioners' offices there had received an injection, and almost none of these injections were judged by reviewers to be medically necessary (Khan et al., 2000). This suggests that the frequent and indiscriminate use of needles seen in our study also occurs in other settings in Pakistan.
Recall bias may have played a role in the results of this study. Extending the time of recollection from 1 to 5 years resulted in the disappearance, for example, of male/female differences in annual injection rates. It may be that injections over the 5 years were even more frequent than stated. On the other hand, since people were sick enough to come to the university clinic, their recent injection history may overestimate their total number of injections.
Another limitation is that the questionnaire assessing patient knowledge of needle risks used leading questions without distracters (intentionally incorrect answers presented as a choice in a multiple-choice question). Nonetheless, a large number of patients – both those with and without much education – admitted that they did not know and we consider it unlikely that the lack of distracters affected the trend in the results. The study relied on patient observation to get some evaluation of the safety of the injections they had received. This may actually underestimate the danger because needles observed to be taken from packages (and presumably sterile) may not have been – they may have come from the reused and repackaged needle black market or they could have been replaced in the packets by the practitioner. Direct observation by medical students in the study by Khan revealed an extremely high re-use rate (Khan et al. 2000).
Efforts to reduce the high-risk behaviours surrounding needle use could target general practitioners, medical equipment, or patients. Regulation of general practitioners by government or medical societies is not very likely to be effective, given the current state of these bureaucracies in Pakistan. Vos et al. (1998) successfully decreased the use of injections and improved the knowledge regarding sterilization through the development of guidelines and the education of healthcare personnel. Educational interventions exclusively in healthcare personnel, however, are not likely to completely overcome the economic incentives contributing to the problem.
Studies of needle/syringe sets which are specifically designed to prevent re-use by locking have shown them to be feasible to use for certain types of immunization injections, difficult but not impossible to re-use, and more expensive than conventional disposable syringes (Steinglass et al. 1995). Even if instituted widely in Expanded Program of Immunization (EPI) programs, they are unlikely to completely replace the billions of conventional disposable syringes being misused in other settings today.
Safe injections require healthcare workers to have a knowledge of sterilization, injection and disposal procedures, the motivation and supervision to properly perform these procedures, and an adequate supply of appropriate injection equipment (Aylward et al. 1995). Given Pakistan's current healthcare system, accomplishing improvements among healthcare workers in all of these prerequisites would be exceedingly difficult. It is therefore important to develop effective strategies to work on the knowledge and expectations of the general public as well.
The patients' balanced view of injections should be used to educate and empower them to be more informed and assertive consumers. Pilot studies examining the effect of educational interventions among patients are needed. Relatively educated people are more likely to respond to such messages, thus this calls for improvements in the general education of the population as a whole, and consideration of the education level in designing such pilot studies. Public health messages must be carefully constructed to avoid unforeseen side-effects such as in Uganda, where people distrusted needles from governmental hospitals and clinics but not from family members and neighbours (Birungi 1998). More work is needed focusing on understanding the specifics of where and why people seek injections. Further investigation of medical waste management is needed to ascertain the scope of the repackaging problem, and to insure sterility of packaged injection equipment.
Needles must be used less frequently and only with proper sterilization and hygiene. The lives of literally millions are at risk. Although improving literacy and access to general education and reducing poverty will likely be helpful, intense interventions which increase specific knowledge of the risks of needle use are also needed. National and worldwide effort should be aimed at decreasing this iatrogenic cause of widespread morbidity and mortality.