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Building Informed Trust: Injection Practices in Cambodia


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Dr Sachiko Ozawa from JHSPH presents recent findings from a study on trust in health systems and injection rates in Cambodia to the Health System Reform in Asia conference in Hong Kong in December 2012. She notes that the average Cambodian receives six injections/year, and that trained medical practitioners often feel pressure to give shots and IVs as patients will often turn to informal providers if they don't.

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Building Informed Trust: Injection Practices in Cambodia

  1. 1. Building informed trust: Injection practices in Cambodia Sachiko Ozawa 1 , Kenneth Shermock 2 , Sovuthikar Inuong 3 1 Johns Hopkins Bloomberg School of Public Health 2 The Johns Hopkins Hospital 3 Cambodia Heath Committee Social Science & Medicine Conference, December 11, 2011
  2. 2. What’s the Problem? <ul><li>Cambodia has one of the world’s highest rates of overall injection usage </li></ul><ul><ul><li>According to Vong et al (2005): </li></ul></ul><ul><ul><ul><li>Average injection rate is 5.9 injections per person-year among the general population in Cambodia </li></ul></ul></ul><ul><ul><ul><li>40% received ≥1 injections in previous 6 months </li></ul></ul></ul><ul><ul><ul><li>Reasons for injection include: 74% therapeutic, 16% intravenous infusions, and 10% immunizations </li></ul></ul></ul><ul><ul><ul><li>Prescribers reported that 47% of total prescriptions they wrote included a therapeutic injection or infusion </li></ul></ul></ul><ul><ul><ul><li>>85% of injections were received in the private sector </li></ul></ul></ul>Vong S, Perz JF, Sok S, Som S, Goldstein S, Hutin Y, Tulloch J. Rapid assessment of injection practices in Cambodia, 2002. BMC Public Health, 2005; 5:56.
  3. 3. <ul><li>People’s blind trust in injections are troubling : </li></ul><ul><ul><li>Injections increase the risk of bloodborne infections </li></ul></ul><ul><ul><ul><li>Vong et al. found that among injection providers, 58% recapped the syringe after use and 13% did not dispose of the used needle and syringe appropriately. </li></ul></ul></ul><ul><ul><ul><li>Anecdotal reports suggest that used needles and syringes might be repackaged and resold as new. </li></ul></ul></ul><ul><ul><li>Injection practices place both patients and health workers at risk </li></ul></ul><ul><ul><ul><li>The same study found that over half (53%) of the providers reported a needlestick injury during the previous 12 months. </li></ul></ul></ul><ul><ul><li>People may be paying out-of-pocket for unnecessary injections that can contribute to poverty </li></ul></ul><ul><ul><ul><li>Injections cost more than oral pills and are prescribed frequently. </li></ul></ul></ul>What’s the Problem?
  4. 4. Injection practices in Cambodia Why is injection use so common? What do people think about injections?
  5. 5. Qualitative Research <ul><li>To understand people’s trust and knowledge in injection practices </li></ul><ul><ul><li>8 focus groups </li></ul></ul><ul><ul><li>32 key-informant interviews - public providers, </li></ul></ul><ul><ul><li>- private providers, </li></ul></ul><ul><ul><li>- school teachers, and </li></ul></ul><ul><ul><li>- village chiefs </li></ul></ul><ul><ul><li>Conducted in 2 Operational Districts in Cambodia </li></ul></ul>Interview with Private Provider Focus group with villagers
  6. 6. Illnesses that call for injections Injection received Injection not necessary <ul><ul><li>“ Serious illness” </li></ul></ul><ul><ul><li>“ Pneumonia, serious diarrhea, lung infection, intestine infection” </li></ul></ul><ul><ul><li>Birth control </li></ul></ul><ul><ul><li>Immunizations </li></ul></ul><ul><ul><li>“ Headache, dizziness, fever” </li></ul></ul><ul><li>“ When we catch a cold” </li></ul><ul><li>“ Lung problem” </li></ul><ul><li>“ High blood pressure” </li></ul><ul><li>“ Stomach ache” </li></ul><ul><li>“ Common illness such as headache, fever” </li></ul>
  7. 7. Injection preference <ul><li>Some consider injections their preferred means of care over oral medications </li></ul><ul><li>[Interview with public provider] </li></ul><ul><li>“ People like getting injections compared with taking oral pills.” </li></ul><ul><li>[Focus group with villagers] </li></ul><ul><li>“ People think that if they have serious illness, they need injection because injection can cure their diseases fast” </li></ul><ul><li>“ I trust injections to cure me” </li></ul>
  8. 8. Injection preference “ Most people prefer injections” “ Some people prefer injection and some prefer oral medicine” “ Most people prefer oral pills” <ul><li>“ Because injections can cure their diseases fast” </li></ul><ul><li>“ People may vomit taking oral medicine and prefer injection” </li></ul><ul><li>“ The effect of injections last longer” </li></ul><ul><li>“ Some people get injections very often, some not that often” </li></ul><ul><li>“ Because they are afraid of needles” </li></ul><ul><li>“ Taking oral pill is easier” </li></ul><ul><li>“ Oral medicine is better because if applies to the illness. Injection may affect a lot” </li></ul>
  9. 9. Main injection benefits <ul><li>“ Injection cures diseases faster and enables me to go back to work” </li></ul><ul><ul><li>“ For example, when we have malaria, we take oral pill for 3 days but our body is still hot. But if we take injection it takes only 1 day to make our body warm.” </li></ul></ul><ul><li>“ It is easy for patients who cannot take oral medicine because of the taste and smell” </li></ul><ul><ul><li>“ It is difficult to take oral pill. Some people vomit.” </li></ul></ul>
  10. 10. Main injection risks <ul><li>Injection may cause: </li></ul><ul><li>“ medical reaction” </li></ul><ul><li>“ withered hands/legs” </li></ul><ul><li>“ the vein surface to go livid” </li></ul><ul><li>“ my thigh [to] become hollow” </li></ul><ul><li>“ infected wounds” </li></ul><ul><li>“ weight loss” </li></ul><ul><li>pain where it is injected </li></ul><ul><li>more spending than oral pills </li></ul>
  11. 11. Perception of injection risk <ul><li>[Focus group with villagers] </li></ul><ul><li>“ There is no side effect of injections” </li></ul><ul><li>“ Sometimes I ask doctor about the risk but he said that there is no problem” </li></ul><ul><li>“ People think that injection is like a two-sided weapon which can help and kill at the same time” </li></ul><ul><li>“ If we use the right dose, it can cure us but if we overdose it can destroy our health” </li></ul>
  12. 12. “ Medical reaction” <ul><li>[Focus group with villagers] </li></ul><ul><li>“ People think that injection cures faster and better but sometimes it turns worse when medicine reaction happens.” </li></ul><ul><li>“ My neighbor got reaction last time because private provider gave her serum injection and let her stay alone. With that experience, people are afraid of medical reaction now.” </li></ul><ul><li>“ Some people think that their children got fever after injections.” </li></ul>
  13. 13. Side effects <ul><li>[Interview with public provider] </li></ul><ul><li>Q: “What do people think about the side effect of injection?” </li></ul><ul><li>A: “Maybe they haven’t thought of it because if they have, they would be critical about it.” </li></ul><ul><li>“ They think there is no difference between oral medicine and injection because their understanding is limited.” </li></ul>
  14. 14. Demand for injections <ul><li>[Focus group with villagers] </li></ul><ul><li>“ The health center never uses serum injection so [I] don’t trust it” </li></ul><ul><li>“ When I go to public hospital, I really need injection but doctor never allows me to get it” </li></ul><ul><li>“ At public hospital we get oral medicine, but at private we get serum injection” </li></ul><ul><li>“ [At public] hospital, they only gave me oral medicine. I felt worse and asked to leave and then went to private provider for injection. ” </li></ul>
  15. 15. Providers catering to patient demand <ul><li>[Interview with public providers] </li></ul><ul><li>“ Most of the time people come to the health center, they are keen to get injections. When we deny, they will change to private provider.” </li></ul><ul><li>“ People don’t want to listen to doctors tell them that this kind of disease can be cured with oral pill. People prefer to have injection and will think that doctors are not skilled if they don’t provide any injection.” </li></ul>
  16. 16. High use of injections: systemic problem <ul><li>[Interview with public provider] </li></ul><ul><li>Q: “What are the risks of injection?” </li></ul><ul><li>A: “It makes it into a habit” </li></ul><ul><li>Q: “What habit?” </li></ul><ul><li>A: “The condition can be cured by oral medicine, but they prefer [to take] injection, so when it happens again, they need injection again to get healed.” </li></ul>
  17. 17. Diagnosis for injection <ul><li>[Interview with private provider] </li></ul><ul><li>“ Every time people request [injections] I don’t inject immediately as I worry about the impact. This is why I have to check them up first to know clearly about the type of disease.” </li></ul><ul><li>“ At first I would explain to them but if they keep on insisting for injection, I would [inject]. But it doesn’t mean that we just inject them without checking their type of disease beforehand .” </li></ul>
  18. 18. Conclusion <ul><li>Some people consider injections the preferred means of care over oral medications </li></ul><ul><li>Knowledge of side effects is limited </li></ul><ul><li>Private providers are catering to individuals who want to get injections </li></ul><ul><li>High use of injections is a health system problem: private providers give injections because they think that patients want them and patients want injections because private providers give them </li></ul>
  19. 19. Policy Implications <ul><li>Opportunities for: </li></ul><ul><li>Education & Communication </li></ul><ul><ul><li>Risks of injections </li></ul></ul><ul><ul><li>Mixed preference for injections </li></ul></ul><ul><li>Standards & Regulation </li></ul><ul><ul><li>Injection prescription practices </li></ul></ul><ul><ul><li>Injection markets for private providers </li></ul></ul>
  20. 20. Thank you! Sachiko Ozawa, We gratefully acknowledge financial support by the Johns Hopkins Center for Global Health for a Faculty Pilot Grant.