Injection safety practices in primary health care hospitals in Bangladesh: a mixed methods exploration of their public health impacts

A K Azad Chowdhury1, Tapash Roy2, A B M Faroque1, Sitesh C Bachar1, A K M Shahidur Rahman1, Sheikh Zahir Raihan1, Manik Chandra Shill1, Raushanara Akter1, Muntasir Mamun Majumder1, Abdullah Al Muid1, Muhammad Asaduzzaman1, Nishat Nasrin1, Nahid Akter1, Hamidur Rahman Gazi1, Anirban Sarker1, Abul Kalam Mohammad Yousuf1, Ali Tanweer Siddiqi1, Abul Kalam Lutful Kabir1, Claire Anderson2*
1 2

Department of Clinical Pharmacy & Pharmacology, University of Dhaka, Bangladesh The Centre for Social Research in Medicine and Health, School of Pharmacy, University of

Nottingham, UK

*Corresponding author Dr. Claire Anderson Professor of Social Pharmacy Division of Social Research in Medicines and Health School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, United Kingdom Email: Claire.Anderson@nottingham.ac.uk Tel: 0044 115 951 5389

Other authors email:

AKAC: akchowdhury2003@yahoo.com TR: tapash_68@hotmail.com ABMF: abmfaroque@yahoo.com SCB: sitesh@squarehospital.com AKMSR: drshaheen20032003@yahoo.com SZR: sheikhzahir_du@yahoo.com MCS: manik_all@yahoo.com

RA: raushanarabd@yahoo.com MMM: muntasirju@yahoo.com AAM: beh_shuvo@yahoo.com MA: asad@ewubd.edu NN: nishat@ewubd.edu NA: naj047@yahoo.com HRG: rony671@yahoo.com AS: anirban.126@gmail.com AKMY: dr.yousuf2008@yahoo.com ATS: dr.alitanweer@yahoo.com AKLK: lkabir81@yahoo.com

Abstract

Background: Unsafe injection use is a serious public health concern in South Asian countries including Bangladesh. Understanding injection safety practices in hospitals of Bangladesh is crucially needed for evidence-based development of intervention initiatives. This study explored the extent of injection uses and injection safety practices in Upazila Health Complex (UHC) hospitals of Bangladesh.

Methods: The study employed both quantitative and qualitative methods of research. The methods used were a retrospective prescription survey (n=4320), focus group discussions (n=6), in-depth interviews (n=24) with service providers, and observation of the activities of direct service providers (n=120), waste handlers (n=48) and hospital facilities (n=24). Quantitative and qualitative data were assessed with statistical and thematic analysis, respectively, and then combined.

Results: High levels of injections use by the clinicians were found (between 60.15% and 94.18%; average 77.9%) with no significance deference observed in injection over-use in UHCs of each division except Dhaka division. Qualitative data further confirmed that both providers and patients preferred injections, believing that they provide quick relief. The doctors perceived injection use as their prescribing norm that enabled them to prove their professional credibility to remain popular in a competitive health care market. Patients believed that injections were necessary for a good prescription. Additionally, a persistent pressure from hospital administration to use up injections before their expiry dates also influenced doctors to prescribe injections regardless of actual indications. The injection safety practices were largely poor. Needle-stick injuries were fairly common among service providers. The disposal of injection needles, syringes and other materials were not properly done in most of the UHCs. Health providers safety concerns were not addressed properly, despite the fact that risk of getting infections during injection procedures may increase. Moreover, most of the health providers and waste handlers were not trained on injection safety practices and infection prevention. A very few of them were fully immunized against HBV and HCV.

Conclusions: As far as the patients and providers safety is concerned, this study demonstrates a need for further research exploring the dynamics of rational and safe injection uses in Bangladesh. In a context where high level of unsafe injection practices were reported, immediate prevention initiatives need to be operated through continued intervention efforts and health providers training in hospitals of Bangladesh.

Introduction

Unsafe injection practices have an inherent risk of spreading three primary blood borne pathogens human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) [12]. Available information suggests that unsafe injections use in South Asian countries is alarmingly high [3]. Recently, a small scale study conducted in few primary health care hospitals in Bangladesh has found very high levels of irrational and unsafe use of injections (60% to 100% of the encounters were irrational and/or unsafe) [4]. Such unsafe practices are clearly exposing a huge number of patients at the risk of HBV, HCV, HIV and malarial infections [5]. In addition, it drains out scarce financial resources of both from the private and public sectors. Very limited information is available to provide evidence-based understanding on the national picture of injection safety practices in Bangladesh.

Recently, a small intervention study using monitoring-training-planning (MTP) strategy (an intervention which combines managerial and educational strategies) showed that the intervention reduced the use injections in some health complexes in Bangladesh [6]. But the intervention results are only indicative rather than confirmatory owing to lack of proper expertise, trained personnel, sound methodology, small sample size in limited study areas. Therefore, it is imperative that a well designed intervention study be carried out at a big enough scale which can represent its applicability at the national level for its incorporation in the national health program as a preventive measure to promote rational use of injections with an aim to reduce the associated risk of HBV, HCV and HIV infections that transmitted through unsafe injection procedures [7].

The current study is proposed to undertake as formative study to assess the magnitude of irrational and unsafe use of injections in UHC hospitals in big enough samples that may represent the national scenario in this respect. It is a crucial need in a country where high prevalence of HBV (5.5%-10%) and HCV (2.8%-3.6%) is documented among general population [8-12]. Overuse of injection may possibly be compounding the problem further. The threat of HIV infection is looming in Bangladesh, as the country is surrounded by high HIV prevalence neighboring countries such as India, Myanmar and Thailand [13]. Epidemiologically, Bangladesh is currently moving towards a concentrated HIV epidemic state with an increasing prevalence of HIV (7.1%)

among injecting drug users in Dhaka [14]. Irrational and unsafe injection use may further facilitate epidemic spread of these infections. The formative phase of this study has explored the extent of injection use and context of injection safety practices in UHCs in Bangladesh. Findings of the this study provides evidence-base for MTP intervention in UHCs with high levels of unsafe injection use in order to reduce their use and thereby cut down the risk of HBV, HCV and HIV infections.

Methods

The study employed both quantitative and qualitative methods of research. A total of 4320 (180 from each UHC) prescription-data were retrospectively collected from a random sample of hospital records of 24 UHCs using a structured questionnaire. Qualitative data was obtained through focus group discussions (FGDs), in-depth interviews and health providers/ facilities observations to complement quantitative data.

Study design and setting: The results reported here were part of a mixed methods study that was conducted in 24 UHCs in Bangladesh. Both quantitative and qualitative methods were used for investigation. The overall study consisted of three components: i) a baseline survey of injection use patterns. ii) Six FGDs with medical officers and 24 in-depth interviews with doctors (n=12), nurses (n=8), and waste handlers (n=4) on injection safety practices; and iii) observation of UHCs facilities (n=24) and direct service providers (n=120) and waste handlers (n=48) to access how injection safety measures were followed.

Sampling and data collection: The study was conducted in 24 primary health care centers (known as UHC) of six divisions in Bangladesh between September 2007 and February 2008. The UHCs were purposively selected on the basis of accessibility, non ongoing interventions and maximum scattering across the country.

Retrospective survey of injection use: Retrospective prescribing data were collected from hospital records. We randomly selected 180 prescriptions from the list of each hospital record (prescribed between January 2005 and January

2007) with an aim to investigate a total of 4320 prescriptions from 24 UHCs. Information on sociodemographic characteristics and injection prescribing pattern (i.e. percentage of patients received injection, number of injections received by each patient, health conditions where most injections were prescribed) were collected using a pre-validated structured questionnaire [6].

Observation of injection safety practices: Prospective data were collected through observing the activities of the providers and waste handlers using pre-validated SIGN indicators [15]. Unobtrusive observations of health complexes were separately made following same indicators. We observed the activities of 120 direct service providers, 48 waste handlers and 24 hospital facilities to access how safety measures were followed and to look for evidence of poor injection practices. To assess injection recipients safety we observed a total of 480 injections being administered by 120 direct service providers. Injection safety practices indicators were observed under four sub-categories, such as safety measures for: i) health facilities, ii) direct injection providers, iii) patients/injection recipients, and iv) waste handlers.

In each health complex observation was made in terms of injection preparation, administration of injection to the patients and disposal of syringe/medical waste to have a clear picture whether the health providers followed standard guidelines or not.

In-depth interviews and focus group discussions: The qualitative study involves in-depth interviews with the doctors, nurses and waste handlers, and FGDs with doctors of 24-UHCs to explore the providers perspectives on injection uses and their understanding of injection safety practices and risk perception. A total of 24 in-depth interviews with doctors (n=12), nurses/medical assistants (n=8) and waste handlers (n=4) of UHCs and six FGDs (with 5-7 doctors in each group) were conducted in local language.

Both the qualitative and quantitative data were collected by 05 trained postgraduate research students. Monitoring and supervision was provided by the principal investigator and other members of investigation team. All in-depth interviews and focus groups were conducted in a semi-structured manner with some interview guidelines and a list of questions. Two persons

conducted each interview/FGD - a facilitator and a note-taker. Informed consent was requested from each participant and those who agreed were included in the study. The study protocol was reviewed and approved by the experts and review committees at the University of Dhaka, Bangladesh and the University of Nottingham, UK.

Data analysis:

All statistical analyses were conducted using SPSS version 15 (SPSS Inc., Chicago). Calculations of frequencies, proportions, and tests were used to assess the significance of relationships between outcomes and explanatory indicators. Qualitative data sources (narrative interviews, focus groups, field observation notes) were assembled and extensive discussions were held between the researchers to explore the key themes. On the basis of this discussion, we developed coding matrices for thematic analysis based on Ritchie and Spencer's framework approach [16] and entered data from all sources into these. This allowed us to identify key themes, explore discourses, and compare these across data and/or respondents. Results were then compared and discrepancies discussed with the wider group, and concepts were further refined.

Finally, qualitative data was organized, and the central themes/ findings were constantly compared and combined with results of quantitative data to see how findings complemented each other. The key findings from both data sets was then analyzed in relation to wider perspectives of injection uses and injection safety practices (locally and where applicable internationally).

Results

The extent of injection uses: Table 1 shows the extent of injection use pattern in six divisions of Bangladesh. The analysis for injection use pattern in six divisions revealed that it was the highest in the UHCs of Chittagong division (94.2%) and lowest in the UHCs of Dhaka division (60.2%). The average number of injections used per patient per prescription was 2.66 (range 1.04-4.26). The number of injection use per patient was also the lowest in UHCs of Dhaka division (average 1.04) and the highest in UHCs of Khulna division (average 4.26).

[Enter Table 1 here]

The findings also revealed that the injections were mostly used to treat acute watery diarrhea and dehydration (29.3%) and respiratory infection/pneumonia (16.2%) followed by traumatic injury resulting from assaults (11.8%), full-term pregnancy with labor pain (7.7%) and acute abdominal pain (5.2%). Further analysis reveal that injection use rate was significantly higher for treating diarrheal diseases (p<0.01), where more than 2 injections per prescription were used and in UHCs of Chittagong division (Table 2).

[Enter Table 2 here]

Injection safety practices: Table 3 demonstrated injection safety practices according to SIGN indicators in the UHCs of Bangladesh. In general injections safety practices were poor. In most of the UHCs the indicators score were very low highlighting that injection safety practices were not followed properly. Further, providers were not trained in injection safety practices and waste disposal process was not safe (Table 3). It was noted that the providers in the health facilities of Dhaka division (87.5%) and Rajshahi division (75%) have received some sort of training on injection safety practices, but almost none of the providers in the UHCs of all other study sites in Khulna, Chittagong, Barisal and Sylhet division were trained on injection safety practices. The injection syringe and needles were not disposed-off properly in most of the facilities.

Immediate disposal of used needle and syringe in a puncture proof sharps container or use of a needle remover was not observed in many health facilities studied. Disposal of waste both inside and outside the facilities was also not satisfactory - during observations we saw used syringes and drips lying around, not only at health facilitys waste sites but inside the hospital buildings (including consultation sites and wards) as well. Overflowing sharps containers were found in most of the health complexes. In few sites we found children playing with used syringes.

In terms of injection recipients safety findings demonstrated that none of the health providers washed their hands properly with antiseptic soap or used alcohol based rub in health complexes in

Chittagong, Rajshahi, Khulna, Sylhet and Barisal division. In contrast, when we asked individually almost all providers in the health complexes reported that they have washed their hands properly with antiseptic soap or used alcohol based rub.

All service providers in the health complexes of Dhaka division reported to clean or wipe the injection place with rectified spirit before providing injection but this practice was very poor in all other divisions (ranged from 8.8% in Rajshahi division to 30% in Sylhet division). Although in most cases the health care providers used a new syringe and new needle, sometimes nurses used each syringe twice for the very poor patients or they did not always prepare the injections on a clean table or tray.

The needle-stick injury was common with 67.5% of the health providers in Rajshahi, 46.3% in Dhaka and 32.5% in Chittagong and Barisal division reported to have this injury in the last 6 months before the survey. This may be a potential cause of transmission of viral infection like HBV, HCV and HIV from patients to providers. On the other hand, none reported such injury in Khulna and Sylhet division. Most of the reported needle stick injury occurred before and/or during the use or during disposal. Only 8.8% of the health professionals interviewed in Dhaka and Sylhet were fully immunized against hepatitis B virus (3 doses). The rest of the health providers from all other study sites were not immunized against hepatitis B and C virus (3 doses).

Determinants of high injection use and unsafe injection practices: Qualitative data revealed that injections were prescribed to most patients. Most doctors reported treating 50-60 patients on an average day (including patients in their private practice). Common conditions for which an injection was prescribed include watery diarrhea/dehydration, pain/ trauma due to assault, fever, unconsciousness, respiratory infections/ pneumonia, abdominal colic and general weakness. Routinely injected medicines included antibiotics, painkillers, multivitamins, anti-malarials, IV infusions and antihistamines.

In most of cases the diagnosis were made based on clinical presentation and rarely supported by laboratory investigations. Hence providers often have made decisions for prescribing antibiotic injections based on their clinical judgments and perceived seriousness of the diseases. It appeared

10

during in-depth interviews and FGDs with doctors and in some cases with health assistants that their perception of the seriousness of the disease may not be correct as they were hardly ever supported by standardized, evidence-based treatment protocols for the treatment of common illnesses.

The reason behind such indiscriminate and/or excessive injections uses is fairly complex. Box 1 illustrates a summary of the key qualitative findings. Both in-depth interviews and FGDs identified multiple reasons that shape the final decision to use injections by the physicians/medical assistants. Doctors as well as patients believed that injections work better than oral medications. In many cases injections use were predominantly influenced by doctors belief that injections are more effective than oral medications and their perceived seriousness of the diseases often motivated them to use injection. Doctors own quest to prove their superiority over other doctors also shaped their prescribing behavior and instigates them to use so called high-cost powerful medications based on their own belief that medication by injection is more effective than oral medications. In few cases the sensitivity of the patients condition influenced doctors to prescribe injections e.g. if the patient was an influential family member of the community, doctors prescribed them injection to show that the patient was taking care of seriously.

In many cases patients demands also have crucial influence towards prescribing injections. Patients demands mostly emanating from their desire to get quick relief and/or a notion to justify strong police cases against the offenders (in case of accident/assault incidences the persons responsible for the offences). In most of these doctors and providers highlighted that such demand from patients were mostly derived from the perceptions that injections are the sure way to quick relief. Most of the providers highlighted that the communities also consider injections in a prescription as a standard practice. They have a tendency to relate good treatment to receiving injections or any treatment that can give them quick cure. Doctors further mentioned patients believe that injections are necessary in a good prescription. Hence a prescription without injections was not considered as a good prescription. In few cases an intention for better compensation and/or litigation aspects to justify documentary seriousness of the incidences motivated patients to demand for injections.

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Further, pressure from the health/hospital administration to use up the injections before their expiry dates, sometimes influenced the doctors to prescribe injections regardless of actual indications. The doctors mentioned that there was also a persistent pressure from the hospital administration to release inpatients from the hospitals as quickly as possible to clear the beds for allocating them to new patients. Such pressure often affected doctors prescribing behavior to treat patients more aggressively with injections to apparently cure them as quickly as possible.

It was revealed that in absence of the doctors the medical assistants need to take responsibility to prescribe for many cases. The doctors highlighted that the medical assistants tended to over prescribe injections and that frequently happens when some of the doctors remain absent from the health complexes for long lime.

It was also noted that aggressive marketing or promotional activities of injection products by the medical representatives of the pharmaceutical companies has significant influence on prescribing behavior of the doctors. In many cases, the pharmaceutical companies offered attractive gifts to the doctors and paramedics to prescribe their medicines and such aggressive marketing techniques have significant influence on irrational use of injections by the doctors and medical assistants.

[Insert Box 1 here]

Discussion

As in many other cultures, injections were popular in Bangladesh. Injections were overused in UHCs of Bangladesh as both providers and patients prefer them, believing that they provide quick relief. In fact prescription of injections is usually the doctors initiative. In many countries, however, the use of injection remains high due to false assumption of prescribers that injections will improve patient satisfaction and that they are always expected by the patients [17-19]. The doctors perceived injection use as their prescribing norms that enable them to establish their goodwill and to prove their professional credibility. Supporting findings from previous research in Pakistan, most of the providers highlighted that the communities also consider injections in a prescription as a standard practice [17].

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In our survey, very high levels of injections use by the clinicians/medical assistants in the hospitals in Bangladesh were observed. The percentage of patients receiving injection and also the number of injections per patient were very high in most of the UHCs hospitals. No significant difference was found in terms of injection uses in UHCs of each division except Dhaka division.

Consistent with findings from other settings, our observation suggests that injections safety practices were not satisfactory in general [20-22]. Sharps injuries happened frequently among injection providers and medical waste handlers. Providers were not aware of the risks associated with unsafe injection practices. There was no culture to promote self-protection or train providers in terms of safety practices [20]. In addition, puncture-proof containers were lacking and medical wastes were not disposed properly. From the view point of safety of patients, health providers, waste handlers and community - the injection safety practices in all of the study health areas were poor. Thus, it increases the risk to needle-stick injury and hence increasing the risk of infection like HBV, HCV and HIV transmission through contaminated needles. Similar findings were reported in previous studies in different settings [21-22]. The presence of sharp waste in the environment also shows that Bangladeshs medical waste management infrastructure needs to be strengthened.

The injection safety practices indicators were also somewhat better in many respects in Dhaka. This may be due to that fact that there had been few previous interventions implemented to promote rational use of injection, and also to promote the safe injection practices in the selected UHCs of Dhaka [6]. In fact the authors of the study with the funding support from the SIGN WHO project implemented MTP intervention in 4 UHCs to reduce the use of avoidable injections and promote injection safety practices. It is interesting to see that the impact of that intervention still persists, which is an encouraging finding to plan and introduce similar interventions in other UHCs in Bangladesh. This indicates the need for a well designed intervention study involving both patients and health care providers in order to ensure rational injection use and promote injection safety practices. In doing so, such intervention should include components like proper monitoring, adequate training of the health professionals and safe management of sharps medical waste. These practices if followed may even lower the emerging threat of Bangladesh. HBV, HCV and HIV infection in

13

In our in-depth interviews and FGDs, most physicians and medical assistants reported that patients particularly older persons in rural areas prefer injections for common medical conditions. This finding is consistent with result of other studies in different settings [6, 17-19]. However, a number of elements suggested that health care workers significantly contribute to injection overuse. These include: a tendency of physicians to provide rationalized and scientific explanations to justify their overuse; economic incentives from pharmaceutical companies; limitation of standardized and evidence-based treatment protocols for common illnesses; and the persistence of inappropriate policies and pressure from hospital authorities. Practitioners think patients want injections. This prompts them to administer more injections than they deem necessary to remain popular in a competitive health care market [18-19]. As a result, patients think that far more injections are required than are actually needed.

A lack of awareness on the part of health care workers of the risk of HBV, HCV and HIV transmission in health care settings even with or without reuse of non-sterile equipment may explain a number of practices allowing for cross contamination that expose both injection providers and recipients to infections. In the Bangladeshi setting where HBV and HCV infection has a high endemic profile and where injections are overused, the observed breaks in infection control practices may be sufficient to transmit HBV and HCV from patient to patient through injections. Further, poor immunization against HBV and HCV, and lack of training on injection safety and waste disposal has precipitated risk of infection [6, 20]. The absence of a culture to promote health care workers protection may explain the practices that expose injection providers to needle-stick injuries.

The data presented here reflects the present situation in injection prescribing in hospitals of Bangladesh. At this stage, we do not know what is ideal or gold standard. No data are available regarding the association between injections and infections in Bangladesh or elsewhere. Given that high levels of unsafe injection use in Bangladeshi hospitals, the study demonstrates a need for more research to explore the dynamics of injection safety practices and relationships between injections and infections in different hospital contexts, and suggests a need for prevention efforts to promote safe and rational injection use in hospitals in Bangladesh.

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Finally, a lack of concern for the management of health care waste associated with an absence of a waste treatment infrastructure may explain the practices that result in the presence of sharps waste in the environment. Supportive supervision for health workers will strength the injection safety and related waste management, which depends on the training, retraining and helping the process of transforming the attitude of the health workers, patients and communities [20].

Conclusion

Health care providers and patients are two important groups that should be addressed to minimize poor injection practices. As far as the patients and providers safety is concerned, this study demonstrates a need for further research exploring the dynamics of rational and safe injection use in Bangladesh. In a context where high level of unsafe injection practices are reported, immediate prevention initiatives need to be operated through continued intervention efforts in hospitals in Bangladesh to (1) promote safer injection practices and behaviour change, (2) ensure appropriate training of health care providers on injection safety and (3) ascertain safe health care waste management.

Competing interests

We declare that we have no competing interests.

Authors' contributions

AKAC and CA designed the study. TR conducted the statistical and thematic analyses. AKAC and TR drafted the manuscript and incorporated all suggestions from other authors. All authors made significant contributions to the conception and design of the analyses, interpretation of the data, and drafting of the manuscript, and all authors approved the final manuscript.

Acknowledgements

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We express our gratitude to all doctors and service providers who participated in this study. Funding for this study came from the British Council funded Higher Education Links Program.

References

1. Hauri AM: Armstrong GL, Hutin YJ: The global burden of disease attributable to contaminated injections given in health care settings. Int J STD AIDS 2004, 15(1): 7-16. 2. Lanphear BP: Trends and patterns in the transmission of blood borne pathogens to health care workers. Epidemiol Rev 1994, 16:437-50. 3. Hutin YJ, Hauri AM, Armstrong GL: Use of injections in healthcare settings worldwide, 2000: literature review and regional estimates. BMJ 2003, 327(7423):1075 4. Chowdhury AKA, Rahman SM, Faroque ABM, Hasan GA, Zahir Raihan SZ: Wide spread injection use in the hospitals of the upazila health complexes of Bangladesh, Mymensingh Medical Journal 2007. 5. Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M: Unsafe injections in the developing world and transmission of blood borne pathogens: a review. Bull World Health Organ 1999, 77(10):789800. 6. Chowdhury AKA, Rahman MS, Faroque ABM: Studying and implementing the monitoringtraining-planning strategy to ensure the rational use of injections in the hospitals of the Upazila Health Complexes of Bangladesh [abstract]. In Safe Injection Global Network Report of the Global Injection Safety and Infection Control meeting , 23-25 October 2007, Geneva, World Health Organization 2007: 13-14. http://infocooperation.org/hss/documents/s15920e/s15920e.pdf (accessed on 20 August 2010). 7. Suryawati S: A practical guide: MTP intervention to improve medicine use in health facilities. Centre for Clinical Pharmacology and Medicine Policy Studies, Gadjah Mada University, Yogyakarta, Indonesia 2005. 8. Ashraf H, Alam NH, Rothermunddt C, Brooks A, Bardhin P, Hossain L, et al: Prevalence and risk factors of hepatitis B and C virus infections in an impoverished urban community in Dhaka, Bangladesh. BMC Infectious Disease 2010, 10: 208.

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9. Mahtab M, Rahman S, Karim MF, Khan M, Foster G, Solaiman S, Afroz S: Epidemiology of hepatitis B virus in Bangladeshi general population. Hepatobiliary Pancreat Dis Int 2008, 7(6): 595-600. 10. Sabin KM, Rahman M, Hawkes S, Ahsan K, Begum L, Black RE, Baqui AH: Sexually transmitted infections prevalence rates in slum communities of Dhaka, Bangladesh. Int J STD AIDS 2003, 14: 614-21. 11. Akbar SMF, Hossain M, Hossain M.F., Sarkar S, Hossain, SAS, Tanimoto S, et al: Seroepidemiology of hepatitis viruses of chronic liver diseases in Bangladesh: high prevalence of HCV among blood donors and healthy person. Hepatology Research 1997; 7(2): 113-120. 12. Khan M Ahmad N: Seroepidemiology of HBV and HCV in Bangladesh. International Hepatology Communications 1996, 5 (1): 27-29. 13. UNAIDS: 2007-Report on the global AIDS epidemic. Geneva: UNAIDS. Available at: http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf (Accessed on 27 July 2010) 14. Ministry of Health and Family Welfare, Bangladesh: National AIDS/STD program. 2008 UNGASS country progress report Bangladesh; reporting period: January 2006 - December 2007. Dhaka: National AIDS/STD Programme, Directorate General of Health Services Ministry of Health and Family Welfare, Government of Bangladesh 2008. 15. World Health Organization: Safe Injection Global Network Report of the Global Injection Safety and Infection Control meeting (23-25 October 2007), WHO; Geneva, 2007: 35. http://infocooperation.org/hss/documents/s15920e/s15920e.pdf (accessed on 15 September 2010) 16. Ritchie A & Spencer L: Qualitative data analysis for applied policy research. In: A Bryman and RG Burgess (eds), Analyzing qualitative data. Routledge, London 2001. 17. Altaf A: Focus group discussions with the public in Sindh, Pakistan. In Gisselquist D & Hutin YJF (eds) Pilot-testing the WHO tools to assess and evaluate injection practices: A Summary of 10 assessments coordinated by WHO in Seven Countries ( 2000 - 2001 ) 2001, 42-46. 18. Altaf A, Agha A, Agboatwalla M: In-depth interviews regarding injection practices in Sindh, Pakistan. In Gisselquist D & Hutin YJF (eds) Pilot-testing the WHO tools to assess and evaluate injection practices: A Summary of 10 assessments coordinated by WHO in Seven Countries (2000 - 2001 ) 2001, 47-52. 19. Hutin YJF: Injection practices in Albania: Rapid assessment and proposed action plan. In Gisselquist D & Hutin YJF (eds) Pilot-testing the WHO tools to assess and evaluate injection

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practices: A Summary of 10 assessments coordinated by WHO in Seven Countries ( 2000 - 2001 ) 2000, 10-21. 20. Moro PL, Moore A, Balcacer P, Montero A, Diaz D, Gmez V, Garib Z, Weniger BG: Epidemiology of needle-sticks and other sharps injuries and injection safety practices in the Dominican Republic. Am J Infect Contro 2007, 35(8): 552-559. 21. Musa OI. Injection safety practice among health workers in static immunization centres in a Nigerian urban community. Trop Doct. 2006, 36: 185-186. 22. Ernest SK. Injection safety: knowledge and practice among health workers. West Afr J Med. 2002, 21(1):70-73.

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Table 1: The extent of injection uses pattern in selected UHCs of six divisions of Bangladesh Location Injection use rate (%) 60.14 61.90 70.39 57.80 50.47 94.18 93.89 92.83 91.67 98.33 70.92 76.99 74.19 65.00 67.50 82.92 69.44 77.22 90.00 95.00 82.36 72.77 86.66 73.33 96.67 75.42 81.67 93.89 46.66 79.44 77.65 No. of injection /person (SD) 1.04 ( 0.03) 1.07 ( 0.02) 1.47 ( 0.05) 0.98 ( 0.01) 0.62 ( 0.05) 3.92 ( 0.12) 2.33 ( 0.09) 3.30 ( 0.11) 4.34 ( 0.14) 5.72 ( 0.16) 2.26 ( 0.08) 2.80 ( 0.10) 2.67 ( 0.09) 1.88 ( 0.07) 1.69 ( 0.06) 4.26 ( 0.13) 2.36 ( 0.09) 2.45 ( 0.09) 5.48 ( 0.16) 6.75 ( 0.18) 2.15 ( 0.08) 1.90 ( 0.07) 2.70 ( 0.10) 1.60 ( 0.06) 2.40 ( 0.09) 2.32 ( 0.76) 3.27 ( 0.11) 2.56 ( 0.09) 1.16 ( 0.03) 2.27 ( 0.08) 2.66 ( 0.08)

Dhaka Division (n =720) Kaliakoir UHC Mirzapur UHC Gazaria UHC Bondor UHC Chittagong Division (n =720) Sitakunda UHC Manikchari UHC Rangunia UHC Anoara UHC Rajshahi Division (n =720) Durgapur UHC Bagmara UHC Puthia UHC Godagari UHC Khulna Division (n =720) Batiaghata UHC Fultala UHC Avoynagar UHC Tala UHC Sylhet Division (n =720) Golapgonj UHC Fenchugonj UHC Bianibazar UHC Chatak UHC Barisal Division (n =720) Uzirpur UHC Gournadi UHC Babugonj UHC Nalchiti UHC Total (n= 4320)

Figure 1

Table 2: The association between injection uses rate and selected explanatory variables
Variables Injection use rate (%) P value

Division Dhaka Chittagong Khulna Rajshahi Barisal Sylhet Type of illness for what injection prescribed Diarrhea Respiratory infection Road traffic accident Traumatic injury due to assault Acute abdominal pain Pregnancy with labor pain Peptic ulcer Pyrexia of unknown origin Others Number of injections prescribed 1-2 >2 32.8 67.2 29.3 16.2 02.6 11.8 05.2 07.7 02.1 01.9 23.2 60.14 94.18 82.92 70.92 75.42 82.36

0.01

0.05

0.001

Table 2: Division-wise injection safety practices in the UHCs in Bangladesh

Indicators Division** Total

1 A. General safely for facilities (n=24) Average no. of injections per patient (number) Syringe, needle disposed in puncture proof box (%) Facilities with no loose sharps/needles overflowing (%) Facilities with no loose injection materials scattered (%) Facilities with safe final waste disposal methods (%) B. Injection providers safety (n=120) Reported needle stick injuries in last 6 months (%) Trained in injection safety practices (%) Immunized against HBV [all 3 doses] (%) C. Safety of the recipients (n=480) Providers washed hands with antiseptic soap/rub (%) Patients whose injection site sterilized by spirit (%) Used new syringe- needles for reconstitution (%) Injection was prepared on clean table (%) Followed adverse events after injection (%) 0.9 55.0* 36.5 23.8 31.5

2 3.8 36.3 48.3* 40.0* 12.5

3 02.3 20.0 47.5 26.5 21.5

4 02.3 0.0 0.0 0.0 10.12

5 02.31 0.0 0.0 11.2 0.0

6 04.3 0.0 0.0 15 21.3 2.7 18.5 22.0 19.4 16.2

46.3 87.5* 02.5

32.5 0.0 25.0

67.5* 75.0 12.5

0.0 0.0 52.5*

32.5 0.0 45.0

0.0 0.0 0.0

29.8 27.1 22.9

33.5* 100.0* 100.0 56.5 13.8

0.0 0.0 100.0 0.0 0.0

0.0 08.8 100.0 05.0 0.0

0.0 30.0 90.0 50.0 0.0

0.0 20.0 0.0 80.0* 30.0*

0.0 12.5 100.0 18.8 0.0

05.6 28.5 81.7 35.0 07.3

D. Safety of the waste handlers (n=48) Trained in healthcare waste management (%) 50.0* 0.0 Immunized with HBV vaccine [3 dose] (%) 08.8 0.0 Used protective measures during waste handling (%) 62.5* 0.0 Reported needle stick injury in last 6 months (%) 46.5* 20.5 **1= Dhaka, 2= Chittagong, 3= Rajshahi, 4 = Sylhet, 5= Barishal, 6= Khulna. * p<0.01

0.0 0.0 0.0 27.5

12.5 08.8 0.0 16.3

0.0 0.0 0.0 30.6

0.0 0.0 0.0 10.8

10.4 2.9 10.4 25.4

Box 1: Key findings from qualitative data

Disease conditions where injections were frequently used Watery diarrhea/dehydration Malaria Acute pneumonia Unconscious patients Abdominal pain Road traffic accidents and assault cases Pyrexia of unknown origin, and General weakness.

Reasons behind high levels of injections use Perceived severity of the disease (doctors perspective): Doctors belief that injections are more effective than oral medications Perceived seriousness of the diseases by the often motivated them to use injection A perception that serious conditions need serious and powerful medication Doctors own quest to prove their superiority over other doctors through prescribing so called high-cost powerful medications. The sensitivity of the patients condition Patients demand A desire to get quick relief: mostly derived from the perceptions that injections are the sure way to quick relief A prescription that injections are necessary in a good prescription A notion to justify strong police cases against the offenders (in case accident/assault incidences the persons responsible for the offences) Pressure from hospital authority To use up the injectables before their expiry dates To release indoor patients from the hospitals as quickly as possibly (affecting doctors prescribing behavior to treat patients more aggressively with injections) Prescribing and dispensing by the medical assistants/paramedics A tendency to over-prescribe injections Prolonged absence of doctors from hospitals Emergency case management in absence of doctors Promotional activities by the pharmaceutical companies Aggressive marketing Attractive gifts offer to the doctors and paramedics/ medical assistants