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Table of Contents   
ORIGINAL ARTICLE  
Year : 2016  |  Volume : 9  |  Issue : 4  |  Page : 241-244
Perception of injections in semi-urban communities in Sokoto, northwest Nigeria


1 Department of Pharmacology and Therapeutics, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
2 Department of Internal Medicine, College of Health Sciences, Usmanu Danfodiyo University/Teaching Hospital, Sokoto, Nigeria
3 Epidemiology Unit, Department of Public Health, Sokoto State Ministry of Health, Sokoto, Nigeria

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Date of Web Publication28-Jun-2016
 

   Abstract 

Objective: The hazards associated with injections constitute a serious public health challenge worldwide, especially in the developing countries such as Nigeria. To adequately address this menace, there is a need for a survey to assess the perception of health-care seekers and providers on injections generally to provide a platform upon which targeted intervention can be made. This study aimed at evaluating the semi-urban community perception on injections and awareness of dangers associated with it. Materials and Methods: This was a cross-sectional using validated interviewer administered questionnaires. A total of 102 respondents were recruited using a multi-stage sampling technique from semi-urban area. The questionnaire sought their demographic profiles, awareness of hazards associated with injections use, and perceptions. Results: Out all the respondents, 96.1% had injections in the last 3 months. Only 47.1% seek medical help in government health facilities. Majority considered injections to be more effective than oral drugs [80.4%, odds 4.10 and 95% confidence interval (CI) 2.53-6.65]. Most of the respondents preferred injections (74.5%, odds 2.92 and 95% CI 1.88-4.55). Chloroquine injection was the most cited by injections the respondents (70.6%). And only, 29.4% (odds 0.42 and 95% CI 0.27-0.64) had adverse events following injections. Awareness of hazards associated with injections was not too good as (27.5%, odds 0.38 and 95% CI 0.25-0.58) admitted that injection carries no risks. Conclusion: Awareness on dangers associated with injections was poor with erroneous perception that injections generally were more effective than oral drugs. Chloroquine is still widely used as an anti-malaria drug in private settings despite its ban. Incidence of injection is high in semi-urban communities.

Keywords: Injections, perception, semi-urban communities

How to cite this article:
Umar MT, Bello SO, Jimoh AO, Sabeer AA, Ango UM. Perception of injections in semi-urban communities in Sokoto, northwest Nigeria. Ann Trop Med Public Health 2016;9:241-4

How to cite this URL:
Umar MT, Bello SO, Jimoh AO, Sabeer AA, Ango UM. Perception of injections in semi-urban communities in Sokoto, northwest Nigeria. Ann Trop Med Public Health [serial online] 2016 [cited 2019 Aug 19];9:241-4. Available from: http://www.atmph.org/text.asp?2016/9/4/241/184789

   Introduction Top


Injection remains one of the very vital routes of drug administration in clinical settings. It ensures rapid delivery of drug to the system directly and also useful in patients who cannot tolerate oral drugs. It is a global phenomenon though more common in developing climes as that of Nigeria. It is estimated that annually over 16 billion injections are administered, most (95%) of which are for therapeutic purposes, especially in the developing countries.[1] The World Health Organization (WHO) defines a safe injection as the one that is not harmful to the recipient, does not subject the giver to any avoidable risk, and does not result in any waste that is dangerous to the community.[2] Majority of these injections used for curative reasons are not necessary and are misplaced.[3]

The rampant misapplication of injections and choice of injections over oral drugs in many third world countries has become a source of concern not only to health-care professionals but also to the WHO. This worry prompted the WHO in 1990 through its action program on essential drugs to initiate a collaborative study on injection practices in three developing countries, namely Uganda, Senegal, and Indonesia.

In many parts of the world, health-care professionals encounter patients who prefer injections to orally administered drugs. In Ghana, 80% of the patients treated for malaria ended up with injections.[4] The historical perspective of this preference is not unconnected to the spectacular cures achieved with Penicillin injections in the control of yaws.[5] This is further amplified by the epitomization of allopathic medicine with syringes and needle.[6] The preference of injections to oral medications is influenced by sociocultural and economic factors. The health-care professionals in the private sector tend to administer injections more than those in public services.[7] This is because injections appear to involve a special technique that needs expertise and attracts more fees from the patient/clients than simple administration of oral drugs.

Globally inappropriate injection practice has been alarming,[2],[4] which included reuse and poor sterilization of injection materials and incessant use. This practice has produced a breeding ground for the transmission of Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS), viral hepatitis B and C, malaria, etc. and also results to sepsis, injection abscesses, and pain that may trigger paralytic poliomyelitis.[1],[8]

Another fundamental concern is also that of injection materials disposal. Improper disposal poses serious danger to the community.[9],[10]

Health-care professionals also in some instances contribute to the overuse of injections. They believe that patients always prefer injections to oral medications and the fear that they may seek alternatives, may make some of them to administer injections to win the confidence of the patients.[11],[12] In private practice setting as highlighted, injections may attract higher costs than orally administered drugs. All these factors may contribute toward the mis- and overuse of injections. The study aims at assessing background perception and knowledge of respondents toward injections as a preliminary upon which further surveys can be carried out involving population as well as health-care providers.

Settings, study design, and sample selection

Sokoto is the seat of the famous Sokoto Caliphate. It is bordered in the north by Niger Republic, Zamfara state to the east, and Kebbi state to the south and west. It houses two local government areas (LGAs) Sokoto north and south and parts of Wamakko, Dange-Shuni, Kware LGAs as peri-urban areas that constitute parts of the metropolis. The health-services needs are provided by the primary health-care centers in the peri-urban areas. However, teaching and specialist hospitals along with Noma and Maryam Abacha women and children hospitals provide referral health services.

The study was cross-sectional and descriptive in design using interviewer administered questionnaires to respondents in peri-urban communities in Sokoto. The 102 participants recruited in the survey were selected by multistage sampling technique. Stage 1 involved identification of peri-urban settlements around Sokoto metropolis from neighboring LGAs of Wamakko, Kware, and Dange-Shuni LGAs from which a list was drawn (Kaura, Yar' Abba, Gagi, Kwannawa, Arkilla, More, Tamaje, Bado village, and Kwalkwalawa). Stage 2 involved selection of the study area by simple random sampling from the list in stage 1 (Arkilla). Stage 3 concerned the selection of actual participants in the survey. Taking into account the house of the community head which was central, houses on four cardinal directions was counted and marked. The number of houses in a particular direction divided by the total number of houses in the area multiplied by sample size gives the actual number to be recruited in the survey in that direction. Only one participant was drawn from each household at the sampling interval of 5. Individual respondents were contacted with expressed permission of the district head. Participation in the study was strictly voluntary and only those respondents who expressed their willingness to join were involved.

Questionnaire, validation, and data collection

The questionnaire was adapted from validated questionnaires of previous studies that assessed determinants of preference of injection to oral medications with modifications to suit our context.[7],[13] The questionnaire was structured to generate information on demographics of respondents, and information on knowledge and perception on injections. A free space for comments on issues not addressed in the questionnaire was provided. A pilot survey to assess test–retest reliability was carried out before on set of data collection. Community entry permit was obtained from the district head. The questionnaires were distributed and administered by trained assistants.

Statistics

The data was analyzed with GraphPad InStat Software (GraphPad InStat Software Inc., La Jolla, CA) for proportions, standard error of mean, odds, and 95% confidence intervals (CI).


   Result Top


Out of 120 questionnaires administered, 102 were considered for data analysis (85%) after data cleaning. The remaining 15% was not analyzed either due to incomplete information or not properly filled. The mean age of respondents was 34.5 ± 4 years. Majority of the patients are males 92 (90.2%). All were Muslims and significant number was Hausa by tribe 78 (76.5%). Thirty-one percent were not gainfully employed. A total of 29.4% had no formal education but attended Qur'anic school. Only 47.1% attended government health facility when they are sick while 45.1% go to chemists and the remaining 7.8% to the private hospitals. On adverse events following injections, 30 (29.4%) had reported encounter. Responses of respondents on aspects of injections perceptions were depicted in [Table 1]. The commonest complications mentioned were generalized body itching, abscesses, swelling, and limping in 19.6%, 3.9%, 3.9%, and 2.0%, respectively as shown in [Table 2]. On the awareness of dangers associated with injections, 27.5% of respondents held that injections had no risks. However, 59.8% and 33.3% admitted that HIV/AIDS and liver diseases, respectively, could be transmitted [Table 3].
Table 1: Perception of the respondents on injection

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Table 2: Proportions of commonly encountered complications with injections

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Table 3: Awareness of respondents of hazards associated with injections

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   Discussion Top


The percentage of respondents who attained formal education observed in this study is close to the national figure of 73.6%.[14] This is however surprising considering the fact the study area is located within the educationally disadvantage zone of Nigeria. This may be explained by the fact that most of the academic institutions in the metropolis are located there. This study revealed high injection rate compared to 45.6% and 68% reported previously.[3],[15] Similar finding was reported in Indonesia in which 70-90% of the patients attending public health institutions received injections.[13] This is really disturbing more so that a significant number of respondents seek medical attention in government health-care facilities where best practices were expected. Economic, social, and cultural factors have been known to intertwine in influencing the perceptions of the patients as well as of the health-care providers in the choice of routes of drug administration.[11]

Respondents' preference for injections to oral formulation observed in the survey was quite high compared to the following rates reported elsewhere: 13%, 29%, 42%, and 44%.[3],[7],[16],[17] This may be attributed to wrong perception that drugs administered through injection are more effective than the oral forms, poor patient–health-care provider communication and in some instances economic benefits on the part of the health-care giver especially in the private settings.[13]

Overall respondents' knowledge of risks associated with injection administration was quite disturbing. Similar observation was noted in other studies.[7] However, it was reassuring that a good proportion of respondents were aware that some dangerous diseases could be transmitted via injection administration. This finding was supported by similar studies.[3],[16] This may not be unconnected to the robust health education campaigns in both print and electronic media by the health authorities especially on HIV/AIDS. More of these need to be carried out on other transmissible diseases such as hepatitis B and C as the awareness of the respondents regarding these diseases was worse. Proportion of respondents who have had complications arising from injection in our survey was quite significant and is close to 28.1% as reported in India.[3] And the most common encountered incident was that of itching. This is not surprising considering the fact that chloroquine injection was the most cited treatment by the respondents, and pruritus is a recognized side effect of chloroquine especially among the Black race.[18] This still brings to the fore the noncompliance to the WHO recommendation of using artemisinin-based combination therapy as first line in the treatment of uncomplicated plasmodium falciparum malaria. Previous study in the area documented widespread use of chloroquine in the treatment of uncomplicated plasmodium falciparum malaria despite its ban along with artesunate due to resistance.[19]

Less than half of the respondents in the survey indicated the cost of drugs as a predictor for preference for injection. This is similar though higher than 17% reported.[20] Efficacy appears to be the driving force for the choice of routes of drug administration. This finding agrees with the rate of 70% documented earlier.[21] Disturbingly, majority of the respondents in the index study believe that injection is more efficacious. There is urgent need to vigorously embark on public enlightenment on the risks associated with injections and also on targeted intervention on health-care providers at that cadre.


   Conclusion Top


In conclusion, this survey demonstrated high proportion of injection usage and preference among the respondents and poor awareness of hazards associated with injection administrations. It also showed inclination toward medicine stores when seeking medical help and widespread use of chloroquine for the treatment of plasmodium falciparum malaria despite its ban. This calls for intervention by the health authorities.

Limitation of the study

The study assessed only the health-care seekers. However, this can be broadened to include health-care professionals within the study area to give a wider perspective.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Hutin YJ, Hauri AM, Armstrong GL. Use of injections in healthcare settings worldwide, 2000: Literature review and regional estimates. BMJ 2003;327:1075.  Back to cited text no. 1
    
2.
Aide Memoire Injection Safety. Safe Injection Global Network Secretariat, Blood Safety and Clinical Technology. World Health Organization. Available from: . [Last accessed on 2014 May 20].  Back to cited text no. 2
    
3.
Kotwal A, Priya R, Thakur R, Gupta V, Kotwal J, Seth T. Injection practices in metropolis of North India: Perceptions, determinants, and issues of safety. Indian J Med Sci 2004;58:334-44.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
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Ofori-Adjei D, Arhinful DK. Impact of in-service training on clinical management of malaria by medical assistants in Ghana. In: Etkin Tan NL, editor. Medicines Meanings and Contexts. Vol. 4. Quezon City: HAIN; 1994. p. 225-40.  Back to cited text no. 4
    
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Nwakolo N, Parry EH. Injections and health. Trop Doct 1989;19:97-8.   Back to cited text no. 5
    
6.
Wyatt HV. The popularity of injections in third world: Origins and consequences for poliomyelitis. Soc Sci Med 1992;19:911-5.   Back to cited text no. 6
    
7.
Zewdie A, Wabe NT. The prevalence of therapeutic injections in Ethiopia: From the patients' and health care providers' perspectives. Gaziantep Med J 2012;18:21-6.  Back to cited text no. 7
    
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Reeler AV. Injections: A fatal attraction? Soc Sci Med 1990;31:1119-25.  Back to cited text no. 8
    
9.
Janjua NZ. Injection practices and sharp waste disposal by general practitioners of Murree, Pakistan. J Pak Med Assoc 2003;53:107-11.   Back to cited text no. 9
    
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Battersby A, Feilden R, Nelson C. Sterilizable syringes: Excessive risk or cost-effective option? Bull World Health Organ 1999;77:812-9.  Back to cited text no. 10
    
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Kermode M. Unsafe injections in low-income countries health setting: Need for injection safety promotion to prevent the spread of blood-borne viruses. Health Promot Int 2004;19:95-103.   Back to cited text no. 11
    
12.
Vong S, Perz JF, Sok S, Som S, Goldstein S, Hutin Y, et al. Rapid assessment of injection practices in Cambodia, 2002. BMC Public Health 2005;5:56.  Back to cited text no. 12
    
13.
Injection practices in the developing world. Results and recommendations from fields studies in Uganda and Indonesia. Available from: . [Last accessed on 2015 Jun 3].  Back to cited text no. 13
    
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National Bureau of Statistics. A report of the NBS: the national literacy survey. Nigeria: National Bureau of Statistics; 2010;20:20.  Back to cited text no. 14
    
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Janjua NZ, Akhbar S, Hutin YJ. Injection use in two districts of Pakistan: Implications for disease prevention. Int J Qual Health Care 2005;17:401-8.  Back to cited text no. 15
    
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Abdulebar S, Tesfaye F, Gedif T, Gebre-Mariam T. The Prevalence and community perception of therapeutic injection use in Meskan District, South Central Ethiopia. Ethio Pharm J 2007;25:63-71.  Back to cited text no. 16
    
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World Health Organization. Bulletin. World Health Organization; 2000;78:956-63.  Back to cited text no. 17
    
18.
Aghahowa SE, Obianwu HO, Isah AO, Arhewoh IM. Chloroquine-induced pruritus. Indian J Pharm Sci 2010;72:283-9.   Back to cited text no. 18
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World Health Organization. Roll Back Malaria. National Malaria Policy & Strategy. Anti malarial drug policy: World Health Organization; 2005. p. 193.  Back to cited text no. 19
    
20.
Secrest AM, Matinrazm A, Ferris LK. Efficacy, safety, and out-of-pocket costs are the most important factors to patients in choosing a psoriasis therapy. J Clin Aesthet Dermatol 2014;7:30-3.   Back to cited text no. 20
    
21.
Borner M, Scheithauer W, Twelves C, Maroun J, Wilke H. Answering patients' needs: Oral alternatives to intravenous therapy. Oncologist 2001;6(Suppl 4):12-6.  Back to cited text no. 21
    

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Correspondence Address:
Muhammad Tukur Umar
Department of Pharmacology and Therapeutics, College of Health Sciences, Usmanu Danfodiyo University, Sokoto
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.184789

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