Reuse of injection devices to give healthcare injections decreased from 39.8 to 5.5% between 2000 and 2010, but trends since 2011 have not been described. We reviewed results of Demographic and Health Surveys (DHS) to describe injection practices worldwide from 2011 to 2015.

We searched the DHS Internet site for data published on injection practices conducted in countries from 2011 to 2015, extracted information on frequency (number of healthcare injections per person in the last 12 months) and safety (proportion of syringes and needles taken from a new, unopened package). We compared gender groups and WHO regions in terms of frequency and safety. For countries with data available, we compared injection practices 2004–2010 and 2011–2015.

Since 2011, 40 of 92 countries (43%) that conducted DHS surveys reported on injection practices. On average, the frequency of injection was 1.64 per person per year (from 3.84 in WHO Eastern Mediterranean region to 1.18 in WHO African region). Among those, 96.1% of injections reportedly used new injection devices (from 90.2% in the WHO Eastern Mediterranean region to 98.8% in the WHO Western Pacific region). On average, women received more injections per year (1.85) than men (1.41). Among 16 (40%) countries with data in 2004–2010 and 2011–2015, 69% improved in terms of safety. The annual number of unsafe injections reduced in 81% of countries. In Pakistan, the number of unsafe injections was the highest and did not decrease between 2006 and 2012.

Injection practices have continued to improve in most countries worldwide, although the Eastern Mediterranean region in particular still faces unsafe practices that are not improving. Further efforts are needed to eliminate unsafe injection practices in health care settings, including through the use of reuse-prevention devices. Despite some limitations, DHS is an easily available method to measure progress over time.

• DHS
• Demographic and health surveys
• Healthcare injection
• Injection device
• Injection practice
• Needle
• Syringe
• Unsafe injection

• Adolescent
• Adult
• Child
• Child, Preschool
• Communicable Diseases/epidemiology
• Communicable Diseases/mortality
• Cost of Illness
• Delivery of Health Care/methods
• Female
• Gastroenterology/organization & administration
• Global Health/economics
• Global Health/standards
• HIV Infections/mortality
• Health Services Accessibility
• Hepacivirus/isolation & purification
• Hepatitis/epidemiology
• Hepatitis/mortality
• Hepatitis/prevention & control
• Hepatitis/virology
• Hepatitis B/epidemiology
• Hepatitis B/mortality
• Hepatitis B/prevention & control
• Hepatitis B/transmission
• Hepatitis B virus/isolation & purification
• Hepatitis C/epidemiology
• Hepatitis C/mortality
• Hepatitis C/prevention & control
• Hepatitis C/transmission
• Humans
• Incidence
• Male
• Middle Aged
• Prevalence
• Tuberculosis/mortality
• Vaccination/standards
• World Health Organization
• Young Adult

• RP-2016-07-012 Department of Health
• EME/14/02/17 Department of Health
• MR/L002086/1 Medical Research Council
• MR/R011117/1 Medical Research Council
• MR/R015600/1 Medical Research Council
• MR/P025064/1 Medical Research Council

• Ramadan
• Type 2 diabetes
• fasting
• pharmacist
• type 2 diabetes patients

• Adult
• Attitude to Health/ethnology
• Australia/epidemiology
• Cultural Competency
• Cultural Diversity
• Diabetes Mellitus, Type 2/ethnology
• Diabetes Mellitus, Type 2/psychology
• Fasting/psychology
• Feeding Behavior/ethnology
• Feeding Behavior/psychology
• Female
• Humans
• Islam
• Male
• Medication Adherence
• Middle Aged
• Needs Assessment
• Patient Care Management/standards
• Pharmacists/standards
• Professional Role
• Qualitative Research
• Religion

AIM: To summarize the available information about injection use and its determinants in the South Asian region.

METHODS: We searched published and unpublished literature on injection safety in South Asia published during 1995-2016 using the keywords “injection”“unsafe injection” and “immunization injection” and combined these with each of the countries and/or their respective states or provinces in South Asia. We used a standardized questionnaire to abstract the following data from the articles: the annual number of injections per capita, the proportion of injections administered with a reused syringe or needle, the distribution of injections with respect to prescribers and providers and determinants of injection use.

RESULTS: Although information is very limited for certain countries (i.e., Bhutan, Maldives and Sri Lanka), healthcare injection use is very common across South Asia, with cross-country rates ranging from 2.4 to 13.6 injections/person/year. Furthermore, recent studies show that 5% to 50% of these injections are provided with reused syringes, thus creating potential to transmission of blood-borne pathogens. Qualified and unqualified practitioners, especially in the private sector, are the major drivers behind injection use, but patients also prefer injections, especially among the rural, poor or uneducated in certain countries. According to available data, Pakistan and India have recently taken steps towards achieving safe injection. Potential interventions include the introduction of reuse prevention devices, and patient-, community- and patient/community and provider-centered interventions to change population and practitioner behavior.

CONCLUSION: Injection use is common in South Asian countries. Multilevel interventions aiming at patients, providers and the healthcare system are needed to reduce injection use and reuse.

• Unsafe injections
• Hepatitis C
• Hepatitis B
• South Asia
• Prescription practices

• Bangladesh
• Bhutan
• Clinical Competence
• Equipment Contamination/prevention & control
• Equipment Contamination/statistics & numerical data
• Health Personnel
• Hepatitis B/transmission
• Hepatitis C/transmission
• Humans
• Immunization/statistics & numerical data
• India
• Indian Ocean Islands
• Injections/statistics & numerical data
• Needle Sharing/statistics & numerical data
• Nepal
• Pakistan
• Sri Lanka
• Sterilization/statistics & numerical data

• Acute HCV
• Co-infection
• HCV epidemiology
• Incidence
• Prevalence

• gender
• norms
• community intervention
• india
• impact

• Adolescent
• Adult
• Aged
• Attitude
• Community Participation
• Cooperative Behavior
• Cross-Sectional Studies
• Female
• Gender Identity
• HIV Infections/prevention & control
• Humans
• India
• Islam
• Longitudinal Studies
• Male
• Middle Aged
• Poverty
• Reproductive Health
• Sexually Transmitted Diseases/prevention & control
• Social Norms
• Spouses
• Young Adult

• R01 MH075678 NIMH NIH HHS
• R01MH075678 NIMH NIH HHS

Previous studies have shown that unsafe injection practice is a major public health problem in Nepal but did not quantify the problem. The present community-based study was planned to: 1) quantify injection usage, 2) identify injection providers, 3) explore differences, if any, in injection usage and injection providers, and 4) study and compare people’s knowledge and perception about injections between the urban and rural areas of Kaski district.

A descriptive, cross-sectional mixed-methods study was conducted from July to November 2012, using a questionnaire based survey and focus group discussions (FGDs). A semi-structured questionnaire advocated by the World Health Organization was modified and administered to household heads and injection receivers in selected households and the FGDs were conducted using a topic guide. The district was divided into urban and rural areas and 300 households from each area were selected. Twenty FGDs were held.

In 218 households (36.33%) [99 in urban and 119 in rural] one or more members received at least one injection. During the three month recall period, 258 subjects (10.44%) reported receiving injection(s) with a median of two injections. The average number of injections per person per year was calculated to be 2.37. Health care workers (34.8%), staff of medical dispensaries (37.7%), physicians (25.2%), and traditional healers (2.3%) were consulted by the respondents for their basic health care needs and for injections. Compared to urban respondents, more rural respondents preferred injections for fever (p < 0.001). People preferred injections due to injections being perceived by them as being powerful, fast-acting, and longer lasting than oral pills. More than 82% of respondents were aware of, and named, at least one disease transmitted by using unsterile syringes during injection administration or when syringes are shared between people.

Less preference for injections and high awareness about the association between injections and injection-borne infections among the general population is encouraging for safe injection practice. However, respondents were not aware of the importance of having qualified injection providers for safe injections and were receiving injections from unqualified personnel.

The online version of this article (doi:10.1186/s12889-015-1775-5) contains supplementary material, which is available to authorized users.

The unnecessary and unsafe use of injections is common in developing countries like Nepal. Policymakers have an important role in promoting rational and safe injection use. Hence, the present study was carried out to explore the perception of health policymakers regarding safe injection practice in Nepal.

An exploratory qualitative study design was used in this study. Key policymakers from both the central and regional level were selected using purposive sampling. A semi-structured questionnaire advocated by the World Health Organization (WHO) was used after modifying the context. Interviews were conducted to clarify doubts and obtain additional information. The data was analyzed manually using deductive content analysis technique.

In total, eleven policymakers participated. All unanimously agreed that injection safety is a problem and seven participants reported that injections are overused. They shared the opinion that injections are administered by various providers, including formal and informal health providers, and also quacks. Almost half the respondents reported that the National Drug Policy discourages injection overuse, while others reported that the policy contains no provisions regarding injection overuse. Most policymakers stated that only single-use disposable injection equipment is used to provide injection, while others thought that sterilizable glass syringe is also used. More than half of the participants believed that the quality of injection equipment available in the Nepalese market is not regulated by any government institution. Almost two-third of the policymakers stated that syringes and needles are not reused, while the rest thought syringes might be reused without sterilization in some parts of the country. Almost half of the respondents stated that illegal commercialization of used syringes exists in Nepal. Almost all respondents thought that health care institutions have a waste management plan, while more than half of them opined that such plans are limited to tertiary care hospitals located in the capital.

The result of this study revealed a divergence of views among policymakers, even among those in the same ministry. Though there has been some effort from the government to increase the safety of injection practices, greater efforts are required, especially with regard to standardization of policies and procedures related to injection practice.