The Current Situation Of Safe Injection And Experimental Intervention Among Primary Care Providers In Hunan Province

Background Safe injection refers to the injection that is harmless to the recipient, protects the health workers from any avoidable risks and does not result in waste which is dangerous for the comunity. In contrast, unsafe injection practices are detrimental not only to patients, but also to health workers and environment. At present, injection abuse and unsafe injection practices occur routinely all over the world, especially in developing countries. According to WHO reports, in developing countries, 30%of immunization injections and 50%of non-immunization injections given to children were unsafe. Unsafe injection is the main way of transmitting Hepatitis B virus (HBV) and Hepatitis C virus (HCV), which can also lead to the spreading of human immunodeficiency virus (HIV), abscesses, septicemia, malaria and viral hemorrhagic fever. Furthermore, injection abuse can result in toxic and side effects of drugs and waste of health care resources. Currently, injection safety has become the focus of global public health in the 21st century.In order to reduce unsafe injection practices, a lot of researches have been implemented all over the world. The level of knowledge, attitude and practices of injection provider are the key reasons for current status of unsafe injection. However, most of the current studies focused on the areas of vaccination, the knowledge and attitude of injection providers. Furthermore, not all injection-related groups were included, and the evaluation index was limited to the knowledge difference of the target population. It is becoming an urgent need to evaluate the current status of safe injection comprehensively and objectively so as to take effective measures to reduce unsafe injection behaviors.Objectives To investigate the status quo of safe injection in primary medical institutions of Hunan province, from both the medical staff and the hospital managers; To give the experimental intervention through lectures, brochures and guidance, evaluate the immediate and long-term effects of the intervention, so as to provide evidences for developing safe injection policies and effective strategies for reducing unsafe injection practices.Methods The project consists of two parts. The first part is a sample survey of the status of safe injection; the second is the experimental intervention.Part One Sample survey of the status of safe injection1 The sample and sampling It has two phases.The first phase aimed to select primary health care units. The cities and states of Hunan province were divided into four different levels according to the Gross Domestic Product (GDP) per capita, per capita energy consumption, and proportion of rural population, life expectancy, neonatal mortality and literacy. Changsha, Yiyang, Hengyang and Western Hunan Autonomous Prefecture were randomly selected from each level and 8 counties were selected from the 4 cities. Lastly,1 county hospital and 4 rural health centers were selected from every county. Totally,8 county hospitals and 32 township hospitals were chosen as samples of this study.The second phase aimed at selecting the doctors, nurses and managers of safe injection form the sampling primary health units. The pre-survey revealed that rate of unsafe injection practices of medical staff was 29.3%, which was expected to reduce by 10%with intervention. According to epidemiological formula, combined with other factors, such as the possibility of attrition, the total sample size of medical staff was 664.17 doctors and 34 nurses were selected form each county hospital,4 doctors and 4 nurses were selected from each township hospital respectively, additionally,1 manager of safe injection was selected from each primary health care unit. Totally,264 doctors,400 nurses and 40 managers participated the survey. (Due to the different questionnaires, the managers were not included in calculation of sample size).2 Contents(1) The incidence and distribution of unsafe injection among primary medical staff;(2) The knowledge level of safe injection and attitude of primary medical staff;(3) The reality of management of safe injection in primary health care units:the relevant rules and regulations of safe injection, the supply of injection equipments, the disposal process of medical waste and so on;(4) The impact factors of safe injection.3 Instruments(1) Medical staff safe injection questionnaire The questionnaire was developed based on Wang fan's original questionnaire and modified by 7 experts, the test-retest reliability of the questionnaire was 0.895 (P <0.01). It included four sub-scales:①general information;②safe injection knowledge, consisting of 13 items, the test-retest reliability was 0.811 (P<0.01);③safe injection attitude, including 8 items, the test-retest reliability was 0.692 (P<0.01);④safe injection behavior, including 13 items, test-retest reliability was 0.925 (P<0.01).(2) Safe injection field observation questionnaire The questionnaire was translated from WHO safe injection field observations questionnaire, and modified according to the national conditions in China. It included the following:the supply of related equipments, sharp boxes available in injection site and disposal of sharp boxes; used sharps; the way of handling most of the sharps waste. We also observed the injection scenery, such as environment, the type of syringes, the process of injection and the management of medical waste.(3) The safe injection questionnaire for hospital managers It aimed to investigate the supply of injection and protective equipments, the policies of medical waste collection and management.4 Procedures In November 2008,8 investigators divided into 4 groups went to all the selected hospitals to observe and investigate the status of safe injection. Informed verbal consent was taken from each eligible participant before administration.664 medical staff safe injection questionnaires were administered and 610 were valid (response rate was 91.9%),40 safe injection questionnaires for hospital managers were handed and 36 were valid (response rate was 90.0%).5 Statistical methods SPSS statistical package was used in the analysis of safe injection of primary medical staff, including statistical description, chi-square test, analysis of variance, linear correlation analysis, and multiple linear regression.Part two The experimental intervention of safe injection1 Sample According to the results of the survey and in order to avoid cross-effects, the primary health care units were randomly divided into experimental and control groups, each group has four county hospitals and 16 rural hospitals.2 Intervention methods The intervention included safe injection knowledge and skills training, injection safety guidline, the guidance of injection fields and practices, and the interviews of managers.(1) Injection safety training①Safe injection training for the medical staff in Hunan Province:we invited experts to compile the curriculum of injection safety, and give lectures on management of hospital infection and medical waste, injection overuse, how to deal with needle injection injuries and prevent blood born diseases, related policies and laws. The course was held in October 2008 and lasted 3 days. The participants were managers from sampled and non-sampled hospitals.②Special training for intervention units:8 trained investigators went to the intervention hospitals and trained the staff. Only the staffs of intervention groups were trained. The workshop was held from November 10 to 17 in 2008. Multimedia was used to give lesson, and each module lasted 2 hours.(2) Injection safety guideline We compiled the guideline based on the curriculum of the workshop, and the guideline were designed as portable booklet. All the staff of intervention group got the guideline to guide their practices. The hospital organized them to study the guideline. The researchers assessed their knowledge during field observation.(3) Injection-site practice guidance After class teaching, the investigators went to the injection sites to observe and guide the practices of injection. They observed the procedures of injection, corrected the unsafe injection practices and demonstrated the right procedure. They observed and guided every participant. They had been to the hospitals for 3 times. Each time, they assessed participants'understanding of guideline and told them to refer to the guideline or consult researchers by telephone when they were confused.(4) Managers interview It aimed to know about the establishment and implementation of the policies, the training of injection safety, the awareness of safe injection, the evaluation of safe injection, as well as the supply of safe injection equipments and medical waste disposal process, etc, and discuss the related laws and regulations. After injection field observation, the researchers gave the managers feedback and recommendations for improvement.3 Evaluation The performance evaluation was given respectively after 1 month and 6 months. The evaluation methods included questionnaire, field observation and interview. The following aspects were evaluated:(1) The safe injection knowledge, attitude and practices of medical staff:it was evaluated by self-administered questionnaire.(2) The on-site evaluation of safe injection practices:it was evaluated by the field observation questionnaire and the Observation results from the investigators who went to the hospitals.(3) The management of safe injection sites:based on the questionnaire, and the observation results from the investigators who evaluated the supply of the safe injection devices and the disposal of injection waste and the relevant policies.4 Statistics methods Statistical package SPSS was to collect and analyze data. Two sample t test, chi-square test and nonparametric test were used to compare the safe injection knowledge and behavior of intervention and control group. The same test were used to compare the difference between pre-and post intervention (intervention group).Results1 The status of safe injection1.1 Safe injection status of primary medical staff1.1.1 The incidence of unsafe injection practices was 26.94%. There were differences between different levels of hospitals, the county medical staff had the lower incidence of unsafe injection practices(22.7%) than that of township hospitals(33.63%); there were no differences between different kinds of medical workers; the score of safe injection practices were 9.50±1.987, and there were statistical differences between different hospitals. The medical staff of county had the higher score (10.10±1.799) than those of township hospitals (8.62±1.922), and there were no statistical differences between different occupations. The incidence of unsafe injection behavior in order were:59.2%of the medical staff did not dispose needles correctly,57.7%of the medical staff did not wear gloves when drawing blood and giving intravenous infusion,46.9%of the medical staff did not check the disinfection and sterilization of the equipments before injection,11.8%(17.1%field observation) of the medical staff shared needles or syringes.1.1.2 The accuracy rate of safe injection knowledge was 73.62%. The knowledge score was 9.57±1.63. There were significantly differences between different levels of hospitals, the medical staff of county hospitals were better than those of rural township hospitals. There were differences between different occupations, the nurses were better than doctors. The accuracy rate of safe injection less than 60%were:the range of safe injection (21.0%), whether to separate syringes with hands (36.6%), the consequences of unsafe injections (54.3%), and whether to recap the needles (55.4%).1.1.3 The attitude of safe injection 98.5%of medical staff agreed that safe injection was very important to patients and medical staff, 16.4%believed that injection or infusion was necessary for ordinary cold, and the conception of standard precaution was not optimistic.1.1.4 The correlation analysis of safe injection knowledge, attitude, and behavior The safe injection knowledge showed a low positive correlation to attitude and behaviors, the correlation coefficient was 0.200 and 0.195 respectively and there were significances in statistics; but the correlation coefficient of safe injection attitudes and behaviors did not have statistical sense.1.1.5 Using total score of safe injection behaviors as dependent variable, the basic information, knowledge scores and attitudes as independent variables, stepwise multiple linear regression analysis was used to determine the impact factors. Eventually 11 statistically significant factors entered the stepwise regression model:hospital type, regular training, thinking of rare injection abuse, the protective attitude towards AIDS patients, continuous education, occupations, knowledge score, training courses, providing injections in ENT and epidemiology department, and whether minding what diseases patients got.1.2 The status of management of safe injection The interview with managers from 36 hospitals suggested that all the hospitals used disposable syringes.41.7% had the guideline of safe injection and 19.4% had safe injection protocol.6 hospitals(16.7%) reported disputes caused by safe injection,4 hospitals (11.1%) were not clear, and the others(26) never had such issues.75.0% of the medical institutions did not have spare puncture-resistant sharps boxes,19.4% of the medical institutions' sharps boxes were overfull, broken or open; 83.3% of medical institutions disposed sharp waste in plastic bottles or open containers; used sharps were found around the medical institutions(22.2%),80.6% of medical institutions collected and destroyed most sharp waste centrally, but some disposable syringes were not completely burned or buried deep enough.2 The results of intervention2.1 Unsafe injection practices One month later, the incidence of unsafe injection practices was 21.7%, significantly lower than pre-intervention(26.94%) and control group (27.9%) (P<0.01). Six month later, the incidence of unsafe injection practices was 18.4%, significantly lower than itself(one month later) and control group(P< 0.01). One month later, the practices score of intervention group was 10.17±1.66; there were significantly differences between pre-intervention and control group. The intervention group was better than control group in disposing used syringes and needles, using sharp boxes. Six month later, the intervention group got higher practices score(10.61±1.80), compared with control group. The intervention group was better than control group in disposing used syringes and needles, using sharp boxes and wearing gloves when drawing blood. But we also observed a lot of unsafe injection behavior, which was-worse than self-administered questionnaire.2.2 The score of safe injection knowledge One month later, the knowledge score of intervention group was 10.18±1.46. There were significantly differences compared with control group and pre-intervention; Six month later, the knowledge score of intervention group was 10.32±1.49, which was significantly different from pre-intervention. However, there was no significantly difference between intervention group and control group.2.3 Safe injection attitudes One month later,99.3%of intervention group believed that safe injection was very important to patients and health care workers.93.0%would give injection for people with AIDS, but they would enhance self-protection. Compared with control group, these differences were statistically significant. Intervention group had better attitude on common cold both 1 month and 6 month later.Conclusions1 The incidence of unsafe injection practices of primary medical staff were 26.94%, the main unsafe injection practices included different patients sharing needles or syringes, protective measures applied incorrectly, excessive occupational exposure and incorrect disposal of injection waste.2 The primary medical staff did not fully grasp the knowledge of safe injection, the weakness were:the range of safe injection, separating syringes by hand, the consequences of unsafe injections, and recap the needle.3 The primary medical staff agreed the importance of safe injection, but the safe injection attitude was somewhat dependent on injection by supporting that injection was necessary for common cold.4 The safe injection practices of primary medical staff were influenced by following factors:hospital type, regular training, thinking of rare injection abuse, the protective attitude towards AIDS patients, continuous education, occupations, knowledge score, training courses, providing injections in ENT and epidemiology department, and whether minding patients'disease.5 There was a big flaw on the management of safe injection in primary hospitals:causally disposal of medical waste and inadequate supply of safe injection equipments.6 The incidence of unsafe injection practices reduced after intervention, their safe injection practices and the score of safe injection knowledge improved greatly. The intervention consisting of combination of the knowledge with skills training, practices guidance and managers interview can significantly change the unsafe injection practices and improve the safe injection knowledge.