A behaviour change
strategy to promote the
safe and appropriate
use of injections
Secr etariat of the Safe Injection Global Net work.
Department of Blood Safet y and Clinical Technolog y, W orld Health Organiz ation
20 Avenue Appia, CH-1211, Geneva 27, Switzerland. Fax: +41 22 791 4836. Email: sign@ who.int.
4 PROBLEMS
THERAPEUTIC INJECTIONS
THERAPEUTIC
INJECTION OVERUSE
3 PARTICIPANT GROUPS
6 KEY ACTIONS
PRESCRIBERS
1.Prescribe oral medicat io n
wherever possible
2. If prescribed an inje ct ion, ask if
medication can be giv en orally
inst ead
PATIENTS
3. Demand that a syringe and
needle be t aken from a new,
sealed and undamaged package
REUSE OF INJECTION EQUIPMENT WITHOUT
STERILIZATION
IMMUNIZATION & THERAPEUTIC INJECTIONS
4. Use a syringe and needle from a
new, seale d and undamaged
packet for EVERY inject ion
PROVIDERS
UNSAFE SHARPS
COLLECTION
5. WITHOUT recapping, place
syringes and needle s in a safety
box IMMEDIATELY after use
UNSAFE M ANAGEM ENT OF INJECTION
WASTE
6. Manage inject io n waste safely
and appropriately
2
PROPOSED
BEHAVIOUR
1. PRESCRIBERS
to prescrib e oral
medication rather
than an injection
when treatm ent is
required.
CURRENT
BEHAVIOUR
REASON S FOR
CURRENT
BEHAVIOUR
BARRIERS
TO CHANGE
‘Lock’
Often
unnecess arily
prescribe
injections
Lac k of clear
prescription polic y
No guidelines
STRATEGY – ‘Key’s’ for CH ANGE
MOTIVATION
Positive
Simple, eas y to
follow guidelines
MOTIVATION
Negative
Possibility that
prescriptions
may be
examined
INFLUENCE
MOH
POLICY MAKERS
MOH
PROGRAMMES /
NGOs
SUPERVISORS
Prescriber
preference for
injections
Strong belief
injections are
more effecti ve
Perception that
injections give
more r apid r elief
Real or imagined
perception of
patient prefer ence
for injections
Financial inc entive
for prescribing
injections
Belief that oral
medications
wor k jus t as fast
Evi denc e
Scientific
Anec dotal
Fear that
patients will
go elsewher e
Loss of
income
Reassurance
that patients are
open to
prescription of
oral medications
Fear of disease
transmission
(especiall y HIV)
from uns afe
injection
practices
If new social
norm cr eated for
oral medication,
fear that patients
will go elsewhere
if injections over
prescribed
PROFESSIONAL
ASSOCIATIONS
PROFESSIONAL
JOURNALS
SATISFIED
ACCEPTORS
MOH
PROGRAMMES /
HEALTH
EDUCATION /
NGOs
MASS MEDIA
PATIENTS
SATISFIED
ACCEPTORS
MOH
PROGRAMMES
RELIGIOU S
LEADERS /
OPINION
LEADERS
MASS MEDIA
PROPOSED ACTION
TOOL
CODE
POLICY MAKING
National policy for the
safe and appropriate
use of injec tions
BUDGETARY
ALLOC ATION for
injection safety
POLICY
IMPLEMENTATION
Issue of standard
treatment guidelines
SUPERVISION &
MONITORING
of prescriptions
PEER GUIDANCE
Direct mailing
PEER GUIDANCE
Published articles
PERSONAL
TESTIMONIES
PROGRAMME
COMMUNICATION
Produc tion &
distribution of IEC
materials
MEDIA CAMPAIGN
Messages
CONSUMER
DEMAND
Communic ating a
preference for or al
medications
PERSONAL
TESTIMONIES
PRE & IN SERVICE
TRAINING
to i mprove prescriber
communication skills
INFLUENTIAL T ALKS
To enc ourage patient
/prescriber di alogue
1.-1
BEHAVIOUR
MODELLING of
positive
patient/prescriber
dialogue
4.-12
4.-13
4.-16
INDICATORS
POLICY
1.National
policy for the
safe and
appropriate u se
of injections
POLICY
2. Budgetary
allocation for
injection safety
5.-1
4.-19
6.-1
6.-2
6.-4
EVALUATION
3. Proportion of
injections
including at
least one
injection
(OT8 indicator)
4.-1
4.-8
4.-12
4.-13
4.-16
4.-6
4.-7
4.-10
4.-13
6.-4
3.-1
4.-1
4.-20
3
PROPOSED
BEHAVIOUR
CURRENT
BEHAVIOUR
2. PATIENTS to
communicat e a
preference for oral
medication
Accept
injections
without
question
REASON S FOR
CURRENT
BEHAVIOUR
Belief that
prescriber knows
best
BARRIERS
TO CHANGE
‘Lock’
Difficulty of
talki ng to
prescribers
(‘mysti que’)
‘STRATEGY - KEY’s for CHANGE
MOTIVATION
Positive
Belief that they
are protecting
themsel ves from
harm
MOTIVATION
Negative
Personalised
riskFear of disease
transmission
(especiall y HIV)
from uns afe
injection
practices
Prescriber
may not
welcome
questions
Request
injections
Preference for
injections
Belief that they give
rapid relief
Strong belief
Belief that oral
medications
wor k jus t as fast
with benefit that
they are muc h
safer
Fear of disease
transmission
(especiall y HIV)
from uns afe
injection
practices
INFLUENCE
MASS MEDIA
SATISFIED
ACCEPTORS
PRESCRIBERS
MASS MEDIA
PROPOSED ACTION
BEHAVIOUR
MODELLING
demons trating that it
is both possible and
desirable to discuss
treatment options with
your doctor
PERSONAL
TESTIMONIES
INTERPERSONAL
COMMUNICATION –
Prescribers more
open to patient’s
ques tions
MEDIA CAMPAIGN to
promote preferenc e
for oral medication
TOOL
CODE
4.-12
4.-13
4.-16
4.-18
6.-4
3.-1
4.-1
PROGRAMME
COMMUNICATION
IEC materials in
health facilities
PRESCRIBERS
INTERPERSONAL
COMMUNICATION –
Gentl e persuasion to
accept oral
alternatives
3.-1
4.-1
RELIGIOU S
LEADERS /
OPINION
LEADERS
MOH / NGOs
INFLUENTIAL T ALKS
To enc ourage patient
/prescriber di alogue
4.-20
SERVICE DELIVERY
Voluntary system of
accreditation of ‘ Safe
Injection’ clinics which
operate accordi ng to
a patient’s charter
PEER PRESSURE
New social nor m for
oral medications
INTERPERSONAL
COMMUNICATION
4.-10
4.-11
SATISFIED
ACCEPTORS
EVALUATION
1. Proportion of
patients
reporting a
preference for
an injections
for the
treatment of a
defined tracer
condition (eg.
fever)
4.-12
4.-13
4.-16
4.-18
4.-6
4.-7
MOH
PROGRAMMES /
HEU UNIT
COMMUNITY
INDICATORS
4.-6
6.-4
4
PROPOSED
BEHAVIOUR
3. Patients to
demand that
syringe and
needle be taken
from a new,
clean and
undamaged
package
CURRENT
BEHAVIOUR
Often acc ept
syringe and
needle
regardless of
source
REASON S FOR
CURRENT
BEHAVIOUR
Lac k of
understanding of
diseas e
transmission
BARRIERS
TO CHANGE
‘Lock’
Limited
educ ation and
access to
information
‘STRATEGY - KEY’s for CHANGE
MOTIVATION
Positive
Belief they are
protecti ng
themsel ves from
harm
Lac k of awareness
of the ris ks of dirty
needles and
syringes
MOTIVATION
Negative
Personalised ris k
Fear of disease
transmission
(especiall y HIV)
from uns afe
injection
practices
INFLUENCE
MASS MEDIA
MOH
PROGRAMMES
/ HE Adviser /
NGOS
COMMUNITY
NB: Danger of
repacked
syringes – avoid
suspicious or
poor quality
packaging, and
refuse if syr inge
barrel is mo ist
inside
SATISFIED
ACCEPTORS
Trust provider to
provide a s afe
injection
Respect for
health
professionals
May feel awkward
about questioni ng
injection provider
about sterility of
equipment
Provi der may
not welcome
questions
Difficulty of
obser ving source of
equipment during
treatment
Forget to
chec k
Low inc ome
Syringes and
needles may
seem (or be)
too expensi ve
Belief that they
are protecting
themsel ves from
harm
Belief that they
are protecting
themsel ves from
harm
Personalised ris k
Fear of disease
transmission
(especiall y HIV)
from uns afe
injection
practices
Personalised ris k
Fear of disease
transmission
(especiall y HIV)
from uns afe
injection
practices
RELIGIOU S
LEADERS /
OPINION
LEADERS
COMMUNITY
PROVIDER
MOH / NGOs
MASS MEDIA
NGOs
PROPOSED ACTION
MEDIA CAMPAIGN
to raise awareness of
need for new pack et
to be opened in front
of you
PROGRAMME
COMMUNICATION
IEC materials
availabl e in health
facilities
PEER PRESSURE
New social nor m to
demand s afe i njection
equi pment
INTERPERSONAL
COMMUNICATION –
to promote use of
safe i njection
equi pment
INFLUENTIAL T ALKS
To empower patients
to demand safe
equi pment
New social nor m to
ask for s afe injection
equi pment
POLICY – T o open
new packet in front of
patients
INTERPERSONAL
COMMUNICATION
to be more open to
patients questions
SERVICE DELIVERY
Voluntary system of
accreditation of ‘ Safe
Injection’ clinics which
operate accordi ng to
a patient’s charter
MEDIA CAMPAIGN
with reasons that
paying for i njection
equi pment is crucial
to protect health
SOCIAL MARKETING
of affordable safe
injection equipment
TOOL
CODE
4.-14
4.-17
4.-18
4.-6
4.-9
4.-6
6.-4
4.-20
INDICATORS
EVALUATION
1. Increase in
number of
patients
recalling that
syringe and
needle for last
injection were
taken from a
new package
EVALUATION
2. Increase in
number of
patients
identifying HIV
(HBV, HCV) as
a poten tial
consequence
of unsafe
injections.
4.-1
4.-10
4.-11
4.-18
5
PROPOSED
BEHAVIOUR
4. PROVIDERS to
use a sterile
needle and
syringe for
EVERY injection
CURRENT
BEHAVIOUR
REASON S FOR
CURRENT
BEHAVIOUR
Often admi nister
injections with
dirty needles and
syringes
Insufficient s upplies
BARRIERS
TO CHANGE
‘Lock’
Poor
availability of
safe i njection
equipment
‘STRATEGY - KEY’s for CHANGE
MOTIVATION
Positive
Increas ed
availability of
supplies – no
need to re-us e
equipment
MOTIVATION
Negative
Fear they could
transmit
diseas es
INFLUENCE
MOH POLICY
MAKERS
MOH
PROGRAMMES
/ NGOs
NB: Danger of
repacked
syringes – avoid
suspicious or
poor quality
packaging, and
refuse if syr inge
barrel is mo ist
inside
Belief they are
protecti ng both
patients &
themsel ves from
harm
Personalised
risk:
Fear they could
transmit
diseas es
(especiall y HIV)
to both patients
& thems el ves
PROVIDERS
NGOs
PATIENTS
Lac k of funds
Cost of
supplies
Wish to rec ycle
val uable equi pment
Waste of
precious
resources
Unaware of high
risks of using dirty
needles and
syringes
Compl acenc y
Lac k of initial
or in-servic e
training
Poor
conditi ons of
service &
rewards
Belief they are
protecti ng both
patients &
themsel ves from
harm
Personalised
risk:
Fear they could
transmit
diseas es
(especiall y HIV)
to both patients
& thems el ves
MARKET
NGOs
MOH
PROGRAMMES
Incenti ves for
good
professional
practices
Fear of
reprimand
SUPERVISORS
PROPOSED ACTION
POLICY – National
policy for the safe and
appropriate us e of
injections
POLICY
IMPLEMENTATION –
include on the
essential drug list
BUDGETARY
ALLOC ATION
SUPPLY- sufficient
safe i njection
equi pment eg.
bundling
POLICY – T o refuse
to giv e injecti on if lack
of safe s upplies
- to open new packet
in front of patients
SOCIAL MARKETING
– Soci al marketing to
increase access to
safe i njection
equi pment
SUPPLY – T o
purchas e own safe
injection equipment
from tr ustworthy
source
MARKET FORCES –
increased consumer
demand will increas e
availability and reduce
cost of supplies
SOCIAL MARKETING
– to provide safe &
affordabl e injecti on
equi pment
PRE & IN SERVICE
TRAINING
Persuasiv e
professional training
and education
SUPERVISION –
motiv ate all staff to
follow sterile practices
TOOL
CODE
1.-1
3.-2
4.-2
INDICATORS
POLICY
1. National
policy for the
safe and
appropriate u se
of injections
POLICY
2. Safe injection
supplies
included on
essential drug
list
POLICY
IMPLEMENTATION
3. Budgetary
allocation for
safe in jection
equipment
4.-6
EVALUATION
4. Proportion of
providers
identifying HIV
as a potential
consequen ce of
unsafe
injections
3.-2
4.-2
4.-3
6
PROPOSED
BEHAVIOUR
5. PROVIDERS to
place syringes
and needles in a
safety bo x
immediat ely after
use WITHOUT
RECAPPING
CURRENT
BEHAVIOUR
Provi ders leave
dirty needles and
syringes l ying
around clinics
REASON S FOR
CURRENT
BEHAVIOUR
Lac k of guidelines
for safe sharps
collection
Lac k of a safety
box or other safe
sharps c ontainer
BARRIERS
TO CHANGE
‘Lock’
Unaware of
correct
procedure
No box
‘STRATEGY - KEY’s for CHANGE
MOTIVATION
Positive
Adhering to
professional
practice
Incenti ves for
good
professional
practices
Availability of
safety box– ease
of dis posal
encourages us e
MOTIVATION
Negative
INFLUENCE
MOH POLICY
Fear of
reprimand
Fear of
needlestic k
injury Possibility
of contracti ng
HIV
Cost of safety
box
MOH
PROGRAMMES
PRIVATE
PROVIDERS
SUPERVISORS
Belief they are
‘immune’
Habit
Unconsci
ous
respons e
Box (available s o
no need to rec ap
Desire to protec t
themsel ves from
harm
4.-3
4.-3
BUDGETARY
ALLOC ATION
SUPPLY – Safety
boxes to be provided
in EVER Y health
facility
SOCIAL MARKETING
of safety box es to
private clinics
TECHNOLOGY
TRANSFER to
facilitate local
manufacture of box es
at low c ost
IMPROVISAT ION
of a safe s harps
container if box es
unav ailable
SUPPLY – of s afety
box or safe sharps
container (cutter)
ALL
RESPONSIBLE
PARTIES
Personalised ris k
Fear of HIV from
needlestic k –
conscious effort
to change
SUPERVISION –
ensure safe collec tion
of sharps
MOH
PROGRAMMES
/ MANAGERS
OF PRIVAT E
CLINICS
PROVIDERS
No safety box
1.-1
POLICY – Safety box
to be included on
Essenti al Drug List
WHO
Safe container
unavailable so
recappi ng ‘makes
needle s afe’
Unaware of ris ks of
needlestic k
Natural reaction to
recap needle
POLICY – National
guidelines for safe
sharps c ollection
PRE & IN SERVICE
TRAINING
MOH
NGOs
Provi ders rec ap
needles
PROPOSED ACTION
MOH
PROGRAMMES
/ MANAGERS
OF PRIVAT E
CLINICS
TOOL
CODE
PRE & IN SERVICE
TRAINING –
Persuasiv e
professional
educ ation & IEC
campaign
(Personalise risk of
needlestick)
3.-2
3.-3
4.-4
INDICATORS
POLICY
1. Inclusion of
safety bo xes in
EDL
POLICY
2.Bundling of
syringes with
safety bo xes
POLICY
IMPLEMENTATION
3. Budgetary
allocation for
safe in jection
equipment
EVALUATION
4. Proportion of
facilities with
dirty sharp s
observed in
unprotected
containers
4.-2
4.-4
4.-5
EVALUATION
5. Annual
incidence of
needlestick
injuries
amongst heathcare workers
4.-2
4.-4
4.-5
6.-4
7
PROPOSED
BEHAVIOUR
6. PROVIDERS to
manage injection
waste safely and
appropriately
CURRENT
BEHAVIOUR
REASON S FOR
CURRENT
BEHAVIOUR
BARRIERS
TO CHANGE
‘Lock’
Injection waste
discarded in
open and
unguarded
rubbish areas
Injection waste
discarded in open
and unguarded
rubbish areas
No guidelines
‘STRATEGY - KEY’s for CHANGE
MOTIVATION
Positive
Adhering to
professional
practice
MOTIVATION
Negative
Fear that
children may
play with
discarded
syringes
Fear that
discarded
syringes may be
scavenged,
repac kaged and
resold
Difficulty of
managing waste
properl y
Lac k of
facilities
Incenti ves for
adopting good
professional
practices
Facilities
availabl e
Cost of
facilities
Lac k of
system
Sys tem in place
which is eas y to
implement
Compl acenc y
Incenti ves for
good
professional
practices
Improved
incenti ves and
financi al rewards
Low status
INFLUENCE
MOH POLICY
MOH
PROGRAMMES
/ MANAGERS
OF PRIVAT E
CLINICS
Fear of
reprimand
SUPERVISORS
Fear that
children may
play with
discarded
syringes
MOH / NGOs /
PRIVATE
FACILITIES
Fear that
discarded
syringes may be
scavenged,
repac kaged and
resold
WHO
MOH /LOCAL
GOVERNMENT
NGOs /
PRIVATE
FACILITIES
Fear of
reprimand
SUPERVISORS
MANAGEMENT
(MOH &
PRIVATE
FACILITIES)
PROPOSED ACTION
POLICY – National
guidelines for safe
healthcare waste
management
BUDGETARY
ALLOC ATION for
healthcare waste
management
PRE & IN SERVICE
TRAINING –
Persuasiv e
professional
educ ation
SUPERVISION –
motiv ate s taff to
manage was te s afely
TOOL
CODE
1.-2
4.-2
4.-5
4.-15
4.-3
5.-3
INFRASTRUCTURE
DEVELOPMENT
Installation, operati on
and supervision of
incinerators at l arger
facilities
TECHNOLOGY
TRANSFER of
appropriate low cos t
technologies
COLLECTION
SYSTEM for safety
boxes and other
medical waste to
appropriate facilities
for bur ning
SUPERVISION –
ensure safe collec tion
of sharps
INDICATORS
POLICY
1. national
Policy for the
safe and
appropriate
managem ent of
healthcare
waste
POLICY
IMPLEMENTATION
2. Budgetary
allocation for
safe in jection
equipment
EVALUATION
3. Proportion of
facilities with
dirty sharp s
observed in the
surroundings
4.-2
4.-3
5.-3
IMPROVED
CONDITIONS OF
SERVICE for sanitary
workers
8
ANNEX 1
1.-1.
1.-2.
1. POLICY AIDES
Aide- memoire for a nati onal s trategy for the s afe and appropriate us e of injecti ons
Aide- memoire for a nati onal s trategy for healthcare w aste management
2.-1.
2.-2.
2.-3.
Rapid assess ment and respons e guide
Tool A (Foc us gr oup discussi on guide)
Interac tional group discussion guide
3.-1.
3.-2.
3.-3.
Communic ation skills for healthcare providers
Safe injecti on practices
Safe sharps management
4.-1.
4.-2.
4.-3.
4.-4.
4.-5.
4.-6.
4.-7.
4.-8.
4.-9.
4.-10.
4.-11.
4.-12.
4.-13.
4.-14.
4.-15.
4.-16.
4.-17.
4.-18.
4.-19.
4.-20.
Good prescribers gui de
Good injecti on providers gui de
Good supervisors guide
Always use a s afety box
Safe waste management
Your guide to safe medical treatment (including patients charter)
‘Do I really need an inj ection?’
Choos e oral medicati on
Make sure the syringe and needl e come from a new pack et
The patients c harter for safe and appropriate injections
Safe Inj ection Clinic (safe i njections given here)
Talk to y our doctor
Choos e oral medicati on
Make sure the syringe is from a new packet
Don’t pl ay with syringes and needles
Choos e oral medicati on
Make sure the syringe is from a new packet
Safe and appropriate us e of injec tions
‘Dear Colleague’ l etter
Health talks for safe injec tions
5.-1.
5.-2.
5.-3.
Prescription monitoring
Monitoring use of safe injec tion equipment
Monitoring shar ps waste management
6.-1.
6.-2.
6.-3.
6.-4.
Technical articles - professional journals
General articles - newspapers
Injection safety back ground reports
Personal tes ti monies
2.
3.
6.
Leaflet
Leaflet
Health sys tems
Health sys tems
Health sys tems
Research tool
Research tool
Research tool
Healthc are provi ders
Healthc are provi ders
Healthc are provi ders
Slides / H andout
Slides / H andout
Slides / H andout
Healthc are provi ders
Healthc are provi ders
Supervisors
Healthc are provi ders
Healthc are provi ders
Community
Community (schools)
Community
Community
Community
Community
Community
Community
Community
Community
Community
Community
Broadc asters
Professional assoc.
Religious/Opinion leaders
Leaflet
Leaflet
Leaflet
Poster
Poster
Leaflet
Leaflet
Leaflet
Poster
Poster
Sticker
Radio s pot
Radio s pot
Radio s pot
Radio s pot
TV spot
TV spot
Resource pack
Templ ate
Templ ate
Supervisors
Supervisors
Supervisors
Checklist
Checklist
Health professionals
Community
Health professionals
General
File
File
File
Audio / video
RESEARCH TOOLS
TRAINING MODULES
4.
5.
Policy makers
Policy makers
IEC TE MPLATES
SUPERVISION TOOLS
RESOURCE CENTRE
10