Mubina Agboatwalla (1) Yvan Hutin (2) Steve Luby (3) Asim Mussarrat (1) Asif Ahmed (1) H

1. A Pilot Intervention To Improve Injection Practices In The Informal Private Sector in Karachi, Pakistan Mubina Agboatwalla (1) Yvan Hutin (2) Steve Luby (3) Asim Mussarrat (1) Asif Ahmed (1) • H Health Oriented Preventive Education (HOPE), Pakistan. World Health Organization, Geneva, Switzerland. Center for Disease Control (CDC), Atlanta.

2. Abstract Problem Statement: Health Care Providers in Pakistan practicing as General Practitioners (GPs) over prescribe injections and reuse syringes commonly. Since 80% of the general population visits these GPs, they contribute significantly to poor injection practices in Pakistan. Objectives: We conducted a pilot intervention among GPs in the informal private sector in a densely populated part of Karachi with the objective of reducing injection overuse and improving injection practices. Study Design: For this 12 months intervention we assigned 20 GP’s to an intervention and selected 20 others as a control group. An initial survey assessed baseline knowledge and practices using qualitative and quantitative methods. The intervention consisted in (1) Interactive Group Discussions (IGDs) between patients and GP’s on the topic of the use of injections to treat common ailments (using methods proposed by the International Network for the Rational Use of Drugs [INRUD] in Indonesia) and (2) Health education using pamphlets and posters. Exit interviews monitored injection use and injection safety before and after the intervention in both groups. Results: Pre-Intervention information indicated that the proportion of visits followed by an injection was 88.3% among patients in the control group and 84.4% among patients in the intervention group. Following intervention this proportion remained stable (87.3%) in the control group but decreased to 51% in the intervention group (P<0.05). At baseline, 91.9% patients in the intervention and 85% in the control group were given an injection using a new single use syringe. Following the intervention, a newly packed syringe was used for 64.7% patients in the control group as opposed to 92% in the intervention group. After the intervention, 89% patients in the intervention group mentioned that the packed syringe was opened in front of them as compared to 55.6% in the control group (P<0.05) Conclusion: The combination of IGD and Health education was effective in decreasing injection overuse and achieving safer practices in the informal private sector of Karachi, Pakistan. Other interventions, including the introduction of syringes with re-use prevention feature, need to be evaluated so that injection practices can be further improved in this setting.

3. Project Background • In Pakistan poor injection practices are common. • Reuse of syringes is common amongst Health Care Providers (HCPs) practicing in the private sector. • In 1993 a community based study in Hafizabad found the prevalence of HCV antibody to be 6.5%. These patients had received more than 10 injections per year in the last 10 years. • Prescribers believe that patients prefer injections. • Patients feel HCPs over prescribe injections. • Patient prescriber Interactive Group Discussions (IGDs) can help in clarifying this misunderstanding and reduce injection over use.

4. Objectives • Reduce injection overuse and improve injection practices in the informal sector of Karachi • Identify intervention strategies that could be scaled up nationally for the safe and appropriate use of injections in the informal sector in Pakistan

5. Methodology • A 12 month intervention study. • Middle to lower socio-economic areas, with congested buildings. • Intervention and control areas at a distance of 5 km from each other. • HCPs operating clinics in congested lanes in strong competition with one another. • At Baseline 21 GP’s and 4 Quacks enrolled in Intervention Group. In Control Group 17 GP’s and 3 Quacks enrolled. • During study 3 GP’s and 2 Quacks dropped out from the intervention group. • Baseline information collected from intervention and control groups. • Exit interviews conducted on every fourth patient leaving the HCPs clinic, monitoring injection use and safety. • Intervention conducted over a period of 6 Months. • Interactive Group Discussions (IGDs) between patients and HCPs using methods proposed by International Network for Rational Use of Drugs (INRUD), Indonesia. • Health education using IEC Material including patient booklets, doctors booklets, posters and Focus Group Discussions. • Post Intervention survey of patients after 6 months of intervention.

6. Injection Therapy During Visit to HCP (Baseline Data) 93-98% patients said the doctor advised the injection

7. Injection Therapy During Present Visit 36%

8. Whether Syringe was New or Packed

9. Patients Perception of Advantages and Disadvantages of Injections

10. Patients Satisfaction with Injection Therapy

11. Disposal of Syringes and Needle by HCPs

12. Summary • Injection Therapy is very common for patients visiting private practitioners. 76 – 84% patients receive injections during a visit to HCPs. • Nearly 93 – 98% patients said that injection therapy was advised by HCPs. • Advocacy was done in from of Focus Group Discussions with patients, Interactive Group Discussions (IGDs) with prescribers and patients and distribution of IEC Material. • A 36% reduction in injection therapy was seen in the intervention group (51%) after advocacy as compared to the Control Group (84%). • New and packed syringes were used for injections in 92% patients in the intervention and 64.7% in the control group. • However, in only 55.6% patients in the control group, the packed syringe was opened in front of the patient as opposed to 89% in the intervention group (p < 0.05) • Early recovery was cited as the main reason for preference of injection therapy (91 – 97% patients ). Post health education only 74% patients felt early recovery was the main advantage of injections. • Prior to health education patients did not associate Hepatitis and HIV/AIDs with unsafe injections. Nearly 20% patients after advocacy could relate HIV/AIDs and Hepatitis with unsafe injection.

13. Conclusion And Recommendations • Interactive Group Discussions (IGDs) provide an opportunity for patients and HCPs to exchange views on injection overuse and clarify perceptions of both HCPs and patients. • IEC Material was effective in improving patient’s knowledge about hazards of unsafe injections. • Patients do not associate unsafe injections with the hazards of HIV/AIDs and Hepatitis. • HCPs need to spend more time providing health education to patients. • Both the Media and the Health Community need to educate patients on hazards of injection overuse. • Sharp waste disposal is of low priority amongst HCPs and more efforts need to be directed towards this. • Introduction of syringes with re-use prevention needs to be evaluated to further improve safe injection practices. • The SIGN Network should intensify efforts in developing countries and target patients to increase consumer demand for safe injections.

14. Acknowledgements This study was supported by the Safe Injection Global Network (SIGN), World Health Organization (WHO), Geneva.