1. Public Perceptions about Injections and Private Sector Injection Practices in Central Nepal Mahesh Bhattarai and Scott Wittet

2. Study Objectives Use a qualitative, exploratory research approach to: Investigate the attitudes and knowledge of the general public and of private injection providers regarding injections. Observe and document injection practices of private providers.

3. Study Methods Timing: March-July, 2000 Location:Seven districts of Nepal’s Central region Methods: Focus group discussions, In-depth interviews, Direct Observation, and “Secret Shopper” interactions Respondents: Total of 204 private sector injection providers and consumers The respondents are diverse in terms of ethnicity, hill or Terai location, urban/rural lifestyle, educational level, gender, age, and experience.

4. Findings: The Good News The vast majority of providers and customers are well aware that injections can cause health problems. Many providers and consumers say that injections should not be used for “common illness.” Disposable syringes are commonly available (and used) in the study area.

5. Findings: More Good News Most providers and consumers know that needles and syringes should not be shared among people without “cleaning.” Most providers and consumers know that medical waste can be dangerous. They say that it should be either buried or burned to reduce problems. Many providers and some consumers are critical of unqualified injection providers in the community and would like to see the situation improved.

6. Findings: Troubling News Observed and reported consequences of poor injection practices: Providers and consumers commonly report adverse consequences following injection (including abscesses, amputation, and death). They also report needle prick incidents resulting from poorly disposed waste.

7. Findings: More Troubling News Practices that put providers at risk: Unsafe handling of injection equipment and other sharps is common. Storage of contaminated waste in easily accessible, open containers is common. Reuse is also common. Adverse consequences of injections could result in decreased business and even violence against the provider.

8. Findings: More Troubling News Practices that put consumers at risk: Medical services are being provided by unqualified personnel. Reuse of non-sterile injection equipment with the same patient is common. Use of non-sterile injection equipment among more than one patient was observed.

9. Findings: More Troubling News Practices that put the community at risk: Disposal of contaminated medical waste in public areas, including needles and syringes, is common. Selling used injection equipment may be a problem.

10. Findings: More Troubling News Unnecessary injections: Injections are valued by consumers and providers as fast acting and necessary for a variety of complaints. Injections of vitamins, antibiotics, and painkillers are common in spite of widespread acknowledgement that oral medications should be used for less serious complaints.

11. Recommendations There is a serious gap between provider knowledge about injection safety and provider behavior. Policy initiatives, infrastructure development, and provider and consumer behavior change strategies should be considered.

12. Recommendations Research which might be useful: Conduct an assessment of public sector practices. Gain a better understanding of hospital and municipal handling and disposal of medical waste. Investigate attitudes towards and practices related to intravenous infusions and minor surgery. Assess the safety of disposable syringes in the market. Investigate syringe (and needle) sales practices and the economics of recycling. Determine whether providers support TT and vaccination of pregnant women (and others) or not.

13. What’s Next Early 2001 Dissemination meeting with SIGN partners in Kathmandu to discuss findings and brainstorm future research and interventions. Late 2001 Report to SIGN on new plans and progress.