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Indian Pediatr 2010;47: 3 99-400 |
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Injections: Need for Reduction, Safety and
Appropriateness |
Atul Kotwal
Department of Community Medicine (PSM), Armed Forces
Medical College, Pune 411 040, India.
Email: [email protected]
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At present, doctors and needles seem to go
together. The needle signifies the power to heal through hurting and
condenses the notions of active practitioner and passive patient. Like the
hollow fangs of the snake, which curls around the staff of Aesculapius,
the needle penetrates and perpetuates our power(1). However, in recent
years there has been an increasing concern over the widespread misuse of
injections(2). The alarming extent to which unnecessary and unsafe
injections are administered has been studied extensively. Mathematical
models have been created suggesting a large proportion of HBV, HCV and HIV
infections might result annually from unsafe injections(3).
The transition to safe injection practices i.e. reduced
frequency, increased safety and appropriate sharps waste management needs
to be undertaken immediately, to reduce further transmission of blood
borne infections and avoid cases of abscesses, paralysis and other
complications(2). A broad, multi disciplinary approach addressing
policies, standards, systems, behavior and technology may ensure injection
safety(4).
The number of injections can be reduced by efforts to
wean populations away from injection overuse and encourage towards oral
medications. This involves behavioral change of clients and prescribers/injection-givers
through a combination of a supportive environment and information,
education and communication (IEC) activities. Efforts are currently on
worldwide to coordinate activity, advocacy for changes in policy, define
standards for safe injections, develop new behavior, take advantage of
health care reforms, increase the availability of safer injection
technologies, promote appropriate waste disposal and define adapted IEC
strategies(4).
Studies have shown that health workers seem to be
convinced about the superiority of injections and therefore administer far
too many injections than are medically justified; additionally, injections
were given to meet the desired needs of the patients(5). This need might
be either perceived by the provider or made explicit by the client by a
nonverbal cue like positioning of their body, rolling up of sleeve etc.
Few patients were even found to be giving a verbal request. This situation
could be the result of misunderstanding between health staff and patients
when the former simply assumed that the latter desired an injection and
the latter are accepting the injections because refusal would indicate non
- compliance or lack of faith(6). This cognitive dissonance has been
clearly demonstrated in a study in Indonesia. The knowledge, attitude,
practices and perceptions of prescribers/providers need to be influenced
by training and communication to enable them in choosing treatment wisely
on evidence, increased awareness regarding unsafe injection practices, and
their risks, and consequences and provide all medication by safest and
most appropriate route. Workshops, interactional group discussions and
health education campaigns have been shown to be effective(7).
In this issue of Indian Pediatrics, a well
designed randomized controlled trial showing the effective-ness of
interactional group discussion approach in reducing the frequency of
injections has been published(8). The limitations in the conduct of the
study have been aptly mentioned by the authors. The foremost being
contamination as the control arm too showed reduction in the number of
injections, the other limitations being issues of sustainability and
Hawthorne Effect. Similar studies in different settings and with designs
incorporating follow up need to be carried out to strengthen the evidence
for interactional group discussions in reducing the number of injections.
Even then, there is enough evidence from various settings, for
Interactional Group Discussions to be included as one of the components of
the overall strategy to reduce injections.
In addition, we must not forget the need to make the
injections being given as ‘safe’. The cultural meaning of injections,
their place in medical practice, their influence upon human relations,
financial gains/expenses involved and many other issues make the
injections a very complex issue which has to be tackled by a multi
dimensional and multi disciplinary approach. Locally relevant research
into various aspects of injection practices should provide quantitative
and qualitative information on injection practices. Ultimately, global
demand for injections is fuelled by the perceived therapeutic effects. The
risks are also linked to issues of lack of equity in health care. Thus, to
succeed, strategies to reduce injections and to make them safe have to
address the disparities and divides in accessibility and affordability of
health care and international pressures of drugs and technology; otherwise
unnecessary, unsafe and improperly disposed injections will continue to
spread infectious diseases and possibly create new ones, throughout the
21st century.
Funding: None.
Competing Interests: None stated.
References
1. Brokensha G. The hollow needle: inappropriate
injection in practice. Australian Prescriber 1999; 22: 145-147.
2. Kotwal A. Innovation, diffusion and safety of
medical technology: injection practices through a review of literature.
Social Sci Med 2005; 60: 1133-1147.
3. Hauri AM, Armstrong GL, Hutin YJF. Int J STD AIDS
2004; 15: 7-16.
4. Hutin YJF, Chen RT. Injection safety: a global
challenge. Bull WHO 1999; 77: 787-788.
5. Kotwal A, Priya R, Thakur R, Gupta V, Kotwal J, Seth
T. Injection practices in a metropolis of North India: perceptions,
determinants and issues of safety. Indian J Med Sci 2004; 58: 334-344.
6. Reeler AV. Anthropological perspectives on
injections: a review. Bull WHO 2000; 78: 135-143.
7. Hadiyono JEP, Suryawati S, Danu SS, Sunartono,
Santoso B. Interactional Group Discussion: Results of a controlled trial
using a behavioral intervention to reduce the use of injections in public
health facilities. Social Sci Med 1996; 42: 1177-1183.
8. Bhunia R, Hutin YJF, Ramkrishnan R, Ghosh PK, Dey S,
Murhekar M. Reducing use of injections through "Interactional Group
Discussions": A randomized controlled trial. Indian Pediatr 2009: 46;
409-414.
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