Overview of injection practices in two governorates in Egypt

Authors


Summary

objective  To describe the extent and characteristics of injection use and injection providers in Egypt, given that unsafe injections are associated with blood-borne pathogen transmission.

methods  Household surveys of a population-based sample of residents in the Nile Delta and in Upper Egypt; focus group discussions and in-depth interviews with community target groups, formal and informal medical providers.

results  Of 4197 persons interviewed, 26.2% reported receiving an injection in the past 3 months. Of these, 77% reported it was for therapeutic indications. The age-sex specific prevalence of injections was highest among children 0–2 years of age and among older adults. Women were more likely to report having an injection than men, particularly at the age above 20 years. Overall, respondents reported receiving on average 4.2 injections per year, indicating that up to 281 million injections are provided per year in Egypt. Injection administrators were public and private sector physicians, pharmacists, barbers, doctor assistants, housekeepers, relatives and friends. Injection prescribers were mostly private and public sector physicians. Of the 1101 respondents who received an injection in the past 3 months, 92 (8.4%) reported that the provider did not use a syringe taken from a closed sealed packet.

conclusion  The frequency of therapeutic injection use is high in Egypt and may contribute to blood-borne pathogen transmission. The Ministry of Health and Population (MOHP) is developing interventions targeted towards promotion of injection safety and reduction of injection overuse on community basis as part of a comprehensive strategy to prevent blood-borne pathogen transmission in Egypt.

Introduction

Numerous studies indicate that unsafe injections contribute to the transmission of blood-borne pathogens throughout the world (Hersh et al. 1991; Luby et al. 1997; Singh et al. 1998; Vos et al. 1998; Frank et al. 2000). Several epidemiologic investigations suggest that unsafe injections are a significant risk factor for hepatitis C virus (HCV) infection in Egypt (Darwish et al. 1993; Mohamed et al. 1996; Habib et al. 2001). Additional studies have reported that unsafe medical, surgical, dental and transfusion procedures, as well as poor sterilization of medical equipment, also contribute to the transmission of HCV infection in Egypt (Tibbs 1997; El-Zayadi et al. 1999).

As part of a comprehensive strategy to prevent blood-borne pathogen transmission in Egypt, the Ministry of Health and Population (MOHP) has implemented a national programme to promote infection control, safe transfusion practices, and safe injection practices. This report provides results from a survey to evaluate the frequency and safety of injections in two governorates. The objectives of the survey were to determine the frequency and type of injections in a population-based sample of the community; identify persons who prescribe and administer injections; evaluate the safety of injections; and to explore socio-cultural beliefs of the population and health providers to injections and gain deep insight into the role of injection administrators in the society. This is the first study that describes the extent and characteristics of injection use and injection providers in Egypt. The data is being used to design and evaluate interventions to promote safe injections in Egypt.

Methods

The study used both quantitative and qualitative data collection methods.

Study governorates and target populations

Egypt is classified administratively into 27 governorates. The study was conducted in one governorate in the Nile Delta (Lower Egypt) and one in Upper Egypt. The Lower Egypt governorate, located about 80 km north of Cairo, has a population of 4 million. It has 13 administrative districts, each with 11–36 villages and an urban district capital. Most inhabitants live in rural areas. The governorate in Upper Egypt is located 640 km south of Cairo and has a population of 2.5 million. It includes 11 administrative districts with four to 33 villages per district. The economy in the community of Upper Egypt is less well developed than the governorate in Lower Egypt. Most residents in both governorates are involved in agriculture.

The study included residents from eight randomly selected study sites including four villages and one urban area in Lower Egypt governorate and two villages and one urban area in Upper Egypt governorate. All households were enumerated in each of the eight selected sites to serve as the sampling frame for each site. Household prevalence rate of injections was determined by any household who included at least one member who received an injection within the period of 3 months prior to the survey. Sample size calculations on the number of households to include in each study site were based on an estimated 30% household injection prevalence rate with confidence limits of 22–38%. All individuals in the selected households were invited to participate in the survey.

Survey methods

Persons participating in the survey were invited for interview using a structured questionnaire. For children younger than 10 years, the head of the household was interviewed. Information was collected on age, sex, education, occupation and detailed history of injections over the past 3 months, including the number and type of injections received, the provider and prescriber of the last injection, and the safety of the last injection including data on type and source of syringe used. Injections were defined as any skin puncturing procedure performed with a syringe and needle to introduce a substance. Safety of injections was assessed by asking about the source of syringe used for the last injection. Injections were classified as ‘safe’ if respondents replied the injection was provided by means of a plastic syringe obtained from a closed sealed packet. Injections were classified as unsafe if the respondent indicated the injection was provided by a previously opened plastic syringe. It was assumed that injections provided by opened plastic syringes were reused syringes. Nobody reported receiving injections from a glass syringe that is designed for reprocessing. Participants were also questioned regarding their lifetime history of having an injection-associated abscess.

Providers of injections were classified as formal and informal medical providers. Formal medical providers include health care professionals with formal medical training to administer injections. Persons who have not received training on providing injections and who are not licensed or officially recognized as injection providers were classified as informal providers.

Survey teams included Ministry of Health and local public health workers trained to standardize data collection methods.

Qualitative research methods and tools

The qualitative study was undertaken in the same villages and cities where the quantitative assessment has been undertaken. It started after completion of the quantitative assessment for further intensive investigations to explore reasons behind certain findings.

We conducted 18 focus group discussions in each governorate. Community target groups were adult men and women, and four focus group discussions were held for each target group. In each governorate five focus group discussions were held with doctors and five with nurses. Twenty in-depth interviews were conducted with informal injection administrators in each governorate. Focus group discussions with community members were conducted to ascertain the perception of community members regarding their preference of injections and reasons behind that, reuse of syringes, health-seeking behaviour and the use of formal and informal injection providers. For doctors and nurses, measuring their beliefs in injections and understanding their motives for prescribing injections were explored. We interviewed 20 informal injection administrators in each governorate. Perception on injection preference and risks associated with injections were measured. Data collected in the focus group discussions were tape recorded and notes were taken during the sessions. Content analysis was performed by coding of segments of text related to various topics and categories. Segments of the same topics were sorted and compared across all the interviews.

Data analysis

Survey questionnaires were entered into a computerized database. Household and individual based prevalence rates of injections in the past 3 months were calculated as indicators to describe the extent of injection use in the population. Estimates on the annual number of injections a person received was estimated by multiplying the number of injections a person received by four in the past 3 months. The total number of injections provided each year in Egypt was calculated by multiplying the mean number of injections per person per year by the census data for the year 2001. Data was presented for type of injections, injection administrators, prescribers and their characteristics, and socio-cultural beliefs on injections. Cluster analysis was used to adjust for the effect of household clustering on injection practices. It was performed with software that uses the Taylor Linearized Deviation approach (Sullivan et al. 1994). Each household was assigned a unique number that served as a field to identify households as the primary sampling unit.

Results

Injection prevalence rate

Based on sample size calculations, a total of 470 and 250 households were included in the survey from Lower and Upper Egypt, respectively. Although all households participated in the study, individuals absent at the time of the survey were not included in the survey. Of 4813 eligible household members, 87% completed the interview (n = 4197), including 85% of residents in Lower Egypt and 91% of residents in Upper Egypt. The male to female ratio in the sample was 1:1.

Overall, 72% of households in both governorates had at least one member who received an injection in the past 3 months. Individual based prevalence rate of injections was significantly higher among residents of Lower Egypt governorate than those of Upper Egypt governorate (P = 0.005). No consistency in the pattern of household prevalence rate of injections was observed in rural and urban areas in both governorates. For the Lower Egypt governorate, the household prevalence rate of injections was significantly higher in rural than urban areas (Prevalence ratio 1.2, P = 0.02). For the Upper Egypt governorate, the household prevalence rate of injections did not vary among residents in rural areas compared with residents in the urban community (P > 0.05) (Table 1).

Table 1.  Household and Individual-based prevalence rate of injections in Lower and Upper Egypt governorates in the past 3 months
 Households with members
receiving injections in the past 3 months
Individuals receiving injections
in the past 3 months
Estimated
annual
no. of
injections
per
person
Total no.
of house
holds
No. of
households
with at least
one member
receiving an
injection
Household
prevalence
rate of
injections
Total no.
of persons
interviewed
No. of
persons
who
received
injections
Individual-
based
prevalence
rate of
injections
95%
confidence
intervals
  •  Estimated annual number of injections per person was calculated based on multiplying by 4 the number of injections a person received in the past 3 months.

Lower Egypt
 Rural36927574.5205859228.827.7–29.84.8
 Urban1016362.454112823.720.1–274
 Total47033871.9259972027.726.6–28.84.8
Upper Egypt
 Rural15810667.1103425724.824.8–24.93.2
 Urban927480.456412421.921.9–21.94.8
 Total25018072.0159838123.823.8–23.83.6

Among the 4197 household residents who completed the interview, 1101 (26.2%) reported receiving an injection in the past 3 months. The design effect of household clustering on the individual prevalence of injections was minimal (0.9). The age–sex specific injection prevalence of persons receiving an injection over the past 3 months peaked in the 0–2-year-old age group, where most compulsory vaccines are provided. When analysed by gender, women were more likely to receive injections than men at most age groups, but statistical significance was only observed above the age of 50 years (Prevalence ratio 1.6, P = 0.03) (Figure 1).

Figure 1.

Age–sex specific prevalence rate of injections in Lower and Upper Egypt.

Types of injections

When questioned about the indications for their most recent injection, the majority of participants (77.2%) reported receiving a therapeutic injection vs. immunizations (15.7%) or other injections (7.1%) such as infusions or contraceptive injections. Residents of the Lower Egypt governorate were more likely to receive therapeutic injections compared with residents of Upper Egypt (80.3% and 71.3%, respectively, Figure 2).

Figure 2.

Types of injections in Lower and Upper Egypt governorates. Others include intravenous infusions and contraceptive injections.

Of the 1101 persons who had had an injection in the last 3 months, 1009 (91.6%) received a safe one (i.e. from a syringe that was opened from a new packet), against 92 (8.4%) participants who had been injected with a previously opened plastic syringe. Of the 92 unsafe injections, 52 (56.5%) were administered by a governmental source, 25 (27.2%) by informal practitioners and 15 (16.3%) by other providers. When asked about adverse events associated with injections, 69 (1.6%) respondents reported a lifetime history of having an abscess caused by an injection.

Injection administrators and their characteristics

There was remarkable variability in the characteristics of persons providing injections: 475 (43.1%) people received it from the governmental health workers, 375 (34.1%) from informal medical providers, 164 (14.9%) from private sector physicians or nurses, 48 (4.4%) from pharmacists, and 39 (3.5%) were not able to identify the source. Residents in Upper Egypt were given injections more frequently in governmental facilities, while participants in Lower Egypt received most of theirs from both informal and governmental providers (Figure 3).

Figure 3.

Injection administrators in Lower and Upper Egypt governorates.

Informal injection providers included relatives, housekeepers of local governmental clinics, tamargi (assistants of private medical doctors) and so-called health barbers (Table 2). Almost half (48.3%) of the 375 injections administered by informal practitioners were provided by relatives, neighbours and friends; 43.9% were administered by housekeepers and tamargi. A very small proportion (5.9%) was administered by barbers. Residents in the Lower Egypt governorate were more likely to use housekeepers and tamargi than residents in Upper Egypt who reported receiving injections from their household relatives. Health barbers exist only in Lower Egypt.

Table 2.  Characteristics of the group of informal injection administrators
 TotalHealth
Barber
Relatives/
friends
Housekeepers/
tamargi
No.%No.%No.%
Lower Egypt
 Rural244114.510442.612952.9
 Urban511121.62345.11733.4
 Total295227.512743.114649.5
Upper Egypt
 Rural59003661.02339.0
 Urban21001885.7314.3
 Total80005467.52632.5

Injection prescribers

Of the 1101 persons who received an injection in the past 3 months, 947 (86%) reported that either a public or private sector clinician prescribed it. In both governorates private sector clinicians prescribed injections slightly more often than government health workers; there was little difference between urban and rural areas (Table 3).

Table 3.  Prescribers of injections in Lower and Upper Egypt governorates
 TotalPrescribers of last injection
Self-
medication
Public
doctor
Private
doctor
PharmacistRelatives Others
No.%No.%No.%No.%No.%No.%
  •  Others include doctors in their working sites as factories or military hospitals.

Lower Egypt
 Rural592284.724942.127446.3315.2101.7  
 Urban128107.83829.76046.91612.510.832.3
 Total712385.328739.333446.4476.5111.530.4
Upper Egypt
 Rural257103.910239.711544.762.310.4238.9
 Urban12443.23830.67157.3    118.9
 Total381143.714036.718648.861.610.3348.9

Socio-cultural beliefs on injections

The quantitative assessment revealed high injection rates among the general population. Most men and women explained that they prefer injections as a way of treatment, because they are powerful and cure faster, circumvent the problems of having to swallow bad tasting tablets and stomach upsets caused by pills, and because they are particularly useful for children who are always reluctant to swallow medicine. The efficacy of injections in cases of serious illness was especially stressed. Few respondents recognized adverse events and difficulty in the administration of injections. These included pain of the prick of the needle, the need to store ampoules in the refrigerator and lack of access to an injection provider.

By discussing with community members the criteria upon which they choose injection administrators, the majority explained that an injection is not a sophisticated process and it just needs a trustful experienced person who does not require special skills or training. Using formal providers is appreciated as they are more trained, however, they are not readily accessible to all the population. The alternative is the informal group of injection administrators who are more accessible, move from house to house and provide their services in an easy, comfortable way. Also, domestic providers who are friends, relatives and neighbours are important providers as they may be available day and night without any expected cost. The most important criteria identified for an injection provider is ‘trust’. Using health barbers as injection providers in Lower Egypt governorate was very much appreciated as residents consider that they are experienced in providing injections and other medical services. In addition, barbers have a good reputation for administering injections without visible side-effects and they provide injections for a lower cost than formal providers. Payment is according to the patient's financial capability.

Interviews with medical staff indicated that doctors and nurses had similar perceptions of the strong effect of injections vs. oral medications, particularly for treatment of serious diseases. Physicians also reported that part of the motivation to prescribe injections was a desire to please their patients who often request injections, particularly elderly women. They also reported that if they refuse to prescribe injections, many patients return for further treatment that is considered a burden or seek care in other facility. Interviews with informal health providers revealed similar perceptions regarding the effectiveness of injections as the population and the formal group. They believed in the rapid effect of injections and the efficacy in case of serious disease. They did not recognize any risks related to injections, whether self risk or consumer risk. Rarely, exposure to needle sticks was expressed as a risk for transmission of diseases. However, risk to the recipient of the injection was only mentioned if syringes were reused.

Discussion

Findings in this study indicate that there is a high frequency of therapeutic injections among the general population, that many injections are prescribed and administered by untrained medical providers and that reuse of syringes occurs which is likely to contribute to blood-borne pathogen transmission in Egypt.

Numerous epidemiologic investigations demonstrate that an increased number of injections is associated with blood-borne pathogen infection (Hyams et al. 1987; Anonymous 1997; Luby et al. 1997; Hutin et al. 1999). The frequency of exposure to injections in Egypt (4.2 injections/person/year) is higher than those reported from Tanzania, Uganda, Indonesia, and Thailand (Reeler & Hematorn 1994; Gumodoka et al. 1996; Van Staa & Hardon 1996) but lower than what has been reported in Pakistan where it is estimated that residents receive 8.5 injections a year (Raglow et al. 2001). Using current estimates for the population of Egypt (67 000 000), and assuming that the figure of 4.2 injections per person per year is representative of the country as a whole, this study indicates approximately 281 million injections are administered yearly.

Similar to studies in other countries, qualitative findings in the study indicate that consumers prefer injections because of strong belief that injections cure faster and provide ‘stronger medicine’. Clinicians, particularly private sector providers, may contribute to this increased frequency of injections by meeting patients' demand for injections and receiving indirect financial benefit for prescribing injections by keeping their patients. Focus group discussions among clinicians and in-depth interviews with informal providers also suggest that providers believe that injections are more effective than oral medications in treating many different diseases similar to what is reported in other countries (Staa & Hardon 1996). The finding that the bulk of injections provided in Egypt are therapeutic and administered by a diverse group of trained and untrained providers presents a challenge for behaviour change strategies to reduce overuse of injections and promote injection safety.

Developing a behaviour change strategy will be challenging, particularly when targeting informal medical providers who administer injections at the community level in diverse locations and times. The motivation for using informal providers seems to include trust, convenience and cultural factors. Health barbers, who traditionally were a primary source of medical care in the past, provided a minority of injections in the Lower Egypt governorate but at a much lower cost than formal medical providers. Overall, the survey indicates that injection practices are embedded in diverse ways in Upper and Lower Egypt and emphasizes the importance of quantitative assessments of injection practices in different populations to better target behaviour change strategies.

One of the limitations of this study is that the administration and safety of the injections was not directly observed and information on injection safety was obtained through patient recall. It may be difficult for a consumer to determine whether a syringe has been previously used on another patient, thus using a previously opened plastic syringe was the only indicator for unsafe injections, although in some cases, the provider might have opened the packet out of the patient's sight. The finding that health barbers offered injections at much lower cost, sometimes even lower than the cost of a new syringe, also suggests that reuse of syringes does occur, although precise measures of the extent of reuse is difficult to measure. A second limitation of the study is the inability to extrapolate the findings of this study to all of Egypt. In particular, the study did not include residents from large urban areas who represent a considerable proportion of the population.

In Egypt, prevention of blood-borne pathogen transmission is a leading public health priority because of the high prevalence of HCV infection in the general population. HCV infection is a leading cause of chronic liver disease and hepatocellular carcinoma in Egypt (Mohamed et al. 1996). The epidemiology of HCV transmission in Egypt is complex. It is hypothesized that parenteral exposure to schistosomiasis treatment through mass campaigns before the 1980s was responsible for widespread HCV transmission and the creation of a large reservoir of persons with chronic HCV infection (Frank et al. 2000). Epidemiologic studies have reported additional diverse risk factors including unsafe injections and poor infection control practices (Darwish et al. 1993; El-Sayed et al. 1996; Mohamed et al. 1996; Angelico et al. 1997; Habib et al. 2001). It is apparent that a comprehensive programme to address all aspects of blood-borne pathogen transmission is urgently needed. Promoting safe injections is part of strategy that also includes efforts to promote infection control in the health care setting and improve the safety of transfusion practices. Promotion of injection safety is challenging because the adverse outcome associated with unsafe injections, such as acute hepatitis, may occur several months later or may be clinically inapparent. Thus, providers may not associate behaviours that promote blood-borne pathogen transmission with adverse events. A communication strategy targeting providers to promote safe injections must include both knowledge base and behaviour change components. The finding that persons can receive injections from practically anyone emphasizes the importance of educating the community as well as the formal medical sector. At the community level, reducing consumer demand for injections and creating public demand for safe injections and safe medical procedures is essential.

Acknowledgements

The authors thank the support of all health officials in Lower Egypt and Upper Egypt governorates, particularly Dr Mohamed Khairy, Undersecretary General, Dr Abdel-Raouf Zoheiri, Undersecretary General, Dr Abdel-Hamid Youssef, Director General, Dr Hosni Youssef, Director General and Dr Mohamed Rabei.

This work was supported by USAID, Work Unit no. 80000.000.000.E0022. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, the U.S. Government, nor the Egyptian Ministry of Health and Population.

Authors
Wafa Abu-Rabei, Ministry of Health and Population, 3 Magles El-Shaab Str., 11451, Egypt. E-mail: jessy@link.net
Caroline Bodenschatz, Infection Control Unit, Namru-3, 4 Latin America Str., Osiris building, Apt. 21, Garden City, 11461, Egypt. E-mail: cbodenschatz@hotmail.com
Said El-Oun, Ministry of Health and Population, 3 Magles El-Shaab Str., 11451, Egypt. E-mail: El_Ouns@yahoo.com
Zoheir Hallaj, Eastern Mediterranean Regional Office, World Health Organization, Nasr City, 7608, Egypt. E-mail: wregypt@link.net
Amr Kandeel, Ministry of Health and Population, 3 Magles El-Shaab Str., 11451, Egypt. E-mail: Kandeela@hotmail.com
Anna-Lena Lohiniva, Infection Control Unit, Namru-3, 4 Latin America Str., Osiris building, Apt. 21, Garden City, 11461, Egypt. E-mail: lohinivaAL@namru3.med.navy.mil
Frank J. Mahoney, US Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA. E-mail: mahoneyf@namru3.med.navy.mil
Dr Maha Talaat, Infection Control Unit, Namru-3, 4 Latin America Str., Osiris building, Apt. 21, Garden City, 11461, Egypt. E-mail: talaatm20@yahoo.com or talaatm@namru3.med.navy.mil (corresponding author).

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