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A behaviour change strategy to promote the safe ... - digicollection.or..

A behaviour changestrategy to promote thesafe and appropriateuse of injectionsSecr etari at of the Safe Inj ection Global Net work.Department of Blood Safet y and Clinical Technolog y, W orld Health Organization20 Avenue Appia, CH-1211, Geneva 27, Switzerl and. Fax: +41 22 791 4836. Email: sign@ who.int.


4 PROBLEMS 3 PARTICIPANT GROUPS 6 KEY ACTIONSTHERAPEUTIC INJECTIONSTHERAPEUTICINJECTION OVERUSEPRESCRIBERS1.Prescribe oral medicationwherever possible2. If prescribed an inject ion, ask ifmedication can be given orallyinst eadPATIENTSREUSE OF INJECTION EQUIPMENT WITHOUTSTERILIZATION3. Demand that a syringe andneedle be t aken from a new,sealed and undamaged packageIMMUNIZATION & THERAPEUTIC INJECTIONSUNSAFE SHARPSCOLLECTIONPROVIDERS4. Use a syringe and needle from anew, sealed and undamagedpacket for EVERY inject ion5. WITHOUT recapping, placesyringes and needles in a safetybox IMMEDIATELY after useUNSAFE M ANAGEM ENT OF INJECTIONWASTE6. Manage inject ion waste safelyand appropriately2


PROPOSEDBEHAVIOUR1. PRESCRIBERSto prescrib e oralmedication ratherthan an injectionwhen treatment isrequired.CURRENTBEHAVIOUROftenunnecess arilyprescribeinjectionsREASONS FORCURRENTBEHAVIOURLac k of clearprescription polic yPrescriberpreference forinjectionsPerception thatinjections givemore r apid r eliefReal or imaginedperception ofpatient prefer encefor injectionsFinancial inc entivefor prescribinginjectionsBARRIERSTO CHANGE‘Lock’No guidelinesStrong beliefinjections aremore effectiveFear thatpatients willgo elsewher eLoss ofincomeMOTIVATIONPositiveSimple, easy tofollow guidelinesBelief t hat oralmedicationswor k jus t as fastEvi denc e- Scientific- Anec dot alReassurancethat patients areopen t oprescription oforal medicationsSTRATEGY – ‘Key’s’ for CHANGEMOTIVATIONNegativePossibility thatprescriptionsmay beexaminedFear of diseasetransmission(especially HIV)from uns afeinjectionpracticesIf new socialnorm cr eat ed fororal medication,fear t hat patientswill go elsewhereif injections overprescribedINFLUENCEMOHPOLICY MAKERSMOHPROGRAMMES /NGOsSUPERVISORSPROFESSIONALASSOCIATIONSPROFESSIONALJOURNALSSATISFIEDACCEPTORSMOHPROGRAMMES /HEALTHEDUCATION /NGOsMASS MEDIAPATIENTSSATISFIEDACCEPTORSMOHPROGRAMMESRELIGIOU SLEADERS /OPINIONLEADERSMASS MEDIAPROPOSED ACTIONPOLICY MAKINGNational policy f or thesafe and appropriateuse of injec tionsBUDGETARYALLOC ATION forinjection safetyPOLICYIMPLEMENTATIONIssue of st andardtreat ment guidelinesSUPERVISION &MONITORINGof prescriptionsPEER GUIDANCEDirect mailingPEER GUIDANCEPublished articlesPERSONALTESTIMONIESPROGRAMMECOMMUNICATIONProduc tion &distribution of IECmat erialsMEDIA CAMPAIGNMessagesCONSUMERDEMANDCommunic ating apreference for or almedicationsPERSONALTESTIMONIESPRE & IN SERVICETRAININGto i mprove prescribercommunication skillsINFLUENTIAL TALKSTo enc ourage patient/prescriber di alogueBEHAVIOURMODELLING ofpositivepatient/ prescriberdialogueTOOLCODE1.-15.-14.-196.-16.-26.-44.-14.-84.-124.-134.-164.-64.-74.-104.-136.-43.-14.-14.-204.-124.-134.-16INDICATORSPOLICY1.Nationalpolicy for thesafe andappropriate u seof injectionsPOLICY2. Budgetaryallocation forinjection safetyEVALUATION3. Proportion ofinjectionsincluding atleast oneinjection(OT8 indicator)3


PROPOSEDBEHAVIOUR2. PATIENTS tocommunicat e apreference for oralmedicationCURRENTBEHAVIOURAcceptinjectionswithoutquestionRequestinjectionsREASONS FORCURRENTBEHAVIOURBelief thatprescriber knowsbestPreference forinjectionsBelief that they giverapid reliefBARRIERSTO CHANGE‘Lock’Difficulty oftalki ng toprescribers(‘mysti que’)Prescribermay notwelcomequestionsStrong beliefMOTIVATIONPositiveBelief that theyare protectingthemsel ves fromharmBelief t hat oralmedicationswor k jus t as fastwith benefit thatthey are muc hsafer‘STRATEGY - KEY’s for CHANGEMOTIVATIONNegativePersonalisedrisk-Fear of diseasetransmission(especially HIV)from uns afeinjectionpracticesFear of diseasetransmission(especially HIV)from uns afeinjectionpracticesINFLUENCEMASS MEDIASATISFIEDACCEPTORSPRESCRIBERSMASS MEDIAMOHPROGRAMMES /HEU UNITPROPOSED ACTIONBEHAVIOURMODELLINGdemons trating t hat itis bot h possible anddesirable to discusstreat ment options withyour doctorPERSONALTESTIMONIESINTERPERSONALCOMMUNICATION –Prescribers moreopen t o patient’sques tionsMEDIA CAMPAIGN topromote pref erenc efor oral medicationPROGRAMMECOMMUNICATIONIEC materials inhealt h f acilitiesTOOLCODE4.-124.-134.-164.-186.-43.-14.-14.-124.-134.-164.-184.-64.-7INDICATORSEVALUATION1. Proportion ofpatientsreporting apreference foran injectionsfor thetreatment of adefined tracercondition (eg.fever)PRESCRIBERSINTERPERSONALCOMMUNICATION –Gentl e persuasion t oaccept oralalternatives3.-14.-1RELIGIOU SLEADERS /OPINIONLEADERSMOH / NGOsCOMMUNITYSATISFIEDACCEPTORSINFLUENTIAL TALKSTo enc ourage patient/prescriber di alogueSERVICE DELIVERYVoluntary system ofaccreditation of ‘ Saf eInjection’ clinics whichoperate accordi ng t oa patient’s charterPEER PRESSURENew social nor m fororal medicationsINTERPERSONALCOMMUNICATION4.-204.-104.-114.-66.-44


PROPOSEDBEHAVIOUR3. Patients todemand thatsyringe andneedle be takenfrom a new,clean andundamagedpackageNB: Danger ofrepackedsyringes – avoidsuspicious orpoor qualitypackaging, andrefuse if syr ingebarrel is mo istinsideCURRENTBEHAVIOUROften acc eptsyringe andneedleregardless ofsourceREASONS FORCURRENTBEHAVIOURLac k ofunderstanding ofdiseas etransmissionLac k of awarenessof t he ris ks of dirtyneedles andsyringesTrust provider toprovide a s afeinjectionMay feel awkwardabout questioni nginjection providerabout sterility ofequipmentDifficulty ofobser ving source ofequipment duringtreat mentLow inc omeBARRIERSTO CHANGE‘Lock’Limitededuc ation andaccess toinformationRespect forhealt hprofessionalsProvi der maynot welcomequestionsForget tochec kSyringes andneedles mayseem (or be)too expensi veMOTIVATIONPositiveBelief they areprotecti ngthemsel ves fromharmBelief that theyare protectingthemsel ves fromharmBelief that theyare protectingthemsel ves fromharm‘STRATEGY - KEY’s for CHANGEMOTIVATIONNegativePersonalised ris kFear of diseasetransmission(especially HIV)from uns afeinjectionpracticesPersonalised ris kFear of diseasetransmission(especially HIV)from uns afeinjectionpracticesPersonalised ris kFear of diseasetransmission(especially HIV)from uns afeinjectionpracticesINFLUENCEMASS MEDIAMOHPROGRAMMES/ HE Adviser /NGOSCOMMUNITYSATISFIEDACCEPTORSRELIGIOU SLEADERS /OPINIONLEADERSCOMMUNITYPROVIDERMOH / NGOsMASS MEDIANGOsPROPOSED ACTIONMEDIA CAMPAIGNto raise awareness ofneed f or new pack etto be opened in frontof youPROGRAMMECOMMUNICATIONIEC materialsavailabl e in healthfacilitiesPEER PRESSURENew social nor m todemand s afe i njectionequi pmentINTERPERSONALCOMMUNICATION –to promote use ofsafe i njectionequi pmentINFLUENTIAL TALKSTo empower patientsto demand safeequi pmentNew social nor m toask for safe injectionequi pmentPOLICY – T o opennew packet in front ofpatientsINTERPERSONALCOMMUNICATIONto be more open topatients questionsSERVICE DELIVERYVoluntary system ofaccreditation of ‘ Saf eInjection’ clinics whichoperate accordi ng t oa patient’s charterMEDIA CAMPAIGNwith reasons t hatpaying for injectionequi pment is crucialto protect healthSOCIAL MARKETINGof affordable saf einjection equipmentTOOLCODE4.-144.-174.-184.-64.-94.-66.-44.-204.-14.-104.-114.-18INDICATORSEVALUATION1. Increase innumber ofpatientsrecalling thatsyringe andneedle for lastinjection weretaken from anew packageEVALUATION2. Increase innumber ofpatientsidentifying HIV(HBV, HCV) asa poten tialconsequenceof unsafeinjections.5


PROPOSEDBEHAVIOUR4. PROVIDERS touse a sterileneedle andsyringe forEVERY injectionNB: Danger ofrepackedsyringes – avoidsuspicious orpoor qualitypackaging, andrefuse if syr ingebarrel is mo istinsideCURRENTBEHAVIOUROften admi nisterinjections withdirty needles andsyringesREASONS FORCURRENTBEHAVIOURInsufficient suppliesLac k of f undsWish to recycleval uable equi pmentUnaware of highrisks of using dirtyneedles andsyringes-Compl acenc yBARRIERSTO CHANGE‘Lock’Pooravailability ofsafe i njectionequipmentCost ofsuppliesWast e ofpreciousresourcesLack of initialor in-servic etrainingPoorconditi ons ofservice &rewardsMOTIVATIONPositiveIncreas edavailability ofsupplies – noneed t o re-us eequipmentBelief they areprotecti ng bot hpatients &themsel ves fromharmBelief they areprotecti ng bot hpatients &themsel ves fromharmIncenti ves f orgoodprofessionalpractices‘STRATEGY - KEY’s for CHANGEMOTIVATIONNegativeFear they couldtransmitdiseas esPersonalisedrisk:Fear they couldtransmitdiseas es(especially HIV)to both patients& thems el vesPersonalisedrisk:Fear they couldtransmitdiseas es(especially HIV)to both patients& thems el vesFear ofreprimandINFLUENCEMOH POLICYMAKERSMOHPROGRAMMESPROPOSED ACTIONPOLICY – Nationalpolicy for the safe andappropriate us e ofinjectionsPOLICYIMPLEMENTATION –include on theessential drug listBUDGETARYALLOC ATION/ NGOs SUPPLY- sufficientsafe i njectionequi pment eg.bundlingPROVIDERSPOLICY – T o ref useto give injection if lackof safe s upplies- to open new packetin front of patientsNGOsSOCIAL MARKETING– Soci al marketing t oincrease access tosafe i njectionequi pmentPATIENTS SUPPLY – T opurchas e own safeinjection equipmentfrom tr ustworthysourceMARKET MARKET FORCES –increased consumerdemand will increaseavailability and reducecost of suppliesNGOsSOCIAL MARKETING– to provide safe &affordabl e injecti onequi pmentMOHPRE & IN SERVICEPROGRAMMES TRAININGPersuasiv eprofessional trainingand educationSUPERVISORS SUPERVISION –motiv ate all staff tofollow sterile practicesTOOLCODE1.-13.-24.-24.-63.-24.-24.-3INDICATORSPOLICY1. Nationalpolicy for thesafe andappropriate u seof injectionsPOLICY2. Safe injectionsuppliesincluded onessential druglistPOLICYIMPLEMEN-TATION3. Budgetaryallocation forsafe in jectionequipmentEVALUATION4. Proportion ofprovidersidentifying HIVas a potentialconsequen ce ofunsafeinjections6


PROPOSEDBEHAVIOUR5. PROVIDERS toplace syringesand needl es in asafety bo ximmediat ely afteruse WITHOUTRECAPPINGCURRENTBEHAVIOURProvi ders leavedirty needles andsyringes l yingaround clinicsProvi ders rec apneedlesREASONS FORCURRENTBEHAVIOURLac k of guidelinesfor safe sharpscollectionLac k of a saf et ybox or ot her safesharps c ont ainerSafe containerunavailable sorecappi ng ‘makesneedle s afe’Unaware of ris ks ofneedlestic kNatural reaction torecap needleBARRIERSTO CHANGE‘Lock’Unaware ofcorrectprocedureNo boxCost of safetyboxNo saf et y boxBelief they are‘immune’- Habit- Unconsciousrespons eMOTIVATIONPositiveAdhering toprofessionalpracticeIncenti ves f orgoodprofessionalpracticesAvailability ofsafet y box– easeof dis posalencourages us eBox (available s ono need t o rec apDesire to protec tthemsel ves fromharm‘STRATEGY - KEY’s for CHANGEMOTIVATIONNegativeFear ofreprimandFear ofneedlestic kinjury Possibilityof contracti ngHIVPersonalised ris k-Fear of HIV fromneedlestic k –conscious effortto changeINFLUENCEMOH POLICYMOHPROGRAMMESPRIVATEPROVIDERSPROPOSED ACTIONPOLICY – Nationalguidelines f or saf esharps c ollectionPRE & IN SERVICETRAININGSUPERVISORS SUPERVISION –ensure saf e collec tionof sharpsMOHMOHPROGRAMMES/ MANAGERSOF PRIVAT ECLINICSNGOsWHOPROVIDERSALLRESPONSIBLEPARTIESMOHPROGRAMMES/ MANAGERSOF PRIVAT ECLINICSPOLICY – Saf ety boxto be included onEssenti al Drug ListBUDGETARYALLOC ATIONSUPPLY – Safetyboxes to be providedin EVER Y healthfacilitySOCIAL MARKETINGof safety box es t oprivate clinicsTECHNOLOGYTRANSFER tofacilitate localmanuf acture of box esat low costIMPROVISAT IONof a saf e s harpscont ainer if box esunav ailableSUPPLY – of s afetybox or saf e sharpscont ainer (cut ter)PRE & IN SERVICETRAINING –Persuasiv eprofessionaleduc ation & IECcampaign(Personalise risk ofneedlestick)TOOLCODE1.-13.-23.-34.-44.-34.-34.-24.-44.-54.-24.-44.-56.-4INDICATORSPOLICY1. Inclusion ofsafety bo xes inEDLPOLICY2.Bundling ofsyringes w ithsafety bo xesPOLICYIMPLEMEN-TATION3. Budgetaryallocation forsafe in jectionequipmentEVALUATION4. Proportion offacilities withdirty sharp sobserved inunprotectedcontainersEVALUATION5. Annualincidence ofneedlestickinjuriesamongst heathcareworkers7


PROPOSEDBEHAVIOUR6. PROVIDERS tomanage injectionwaste safely andappropriatelyCURRENTBEHAVIOURInjection wastediscarded inopen andunguardedrubbish areasREASONS FORCURRENTBEHAVIOURInjection wastediscarded in openand unguardedrubbish areasDifficulty ofmanaging wasteproperl yBARRIERSTO CHANGE‘Lock’No guidelinesLac k offacilitiesCost offacilitiesLac k ofsystemCompl acenc yLow st atusMOTIVATIONPositiveAdhering toprofessionalpracticeIncenti ves f oradopting goodprofessionalpracticesFacilitiesavailabl eSys tem in placewhich is easy toimplementIncenti ves f orgoodprofessionalpracticesImprovedincenti ves andfinanci al rewards‘STRATEGY - KEY’s for CHANGEMOTIVATIONNegativeFear thatchildren mayplay withdiscardedsyringesFear thatdiscardedsyringes may bescavenged,repac kaged andresoldFear ofreprimandFear thatchildren mayplay withdiscardedsyringesFear thatdiscardedsyringes may bescavenged,repac kaged andresoldFear ofreprimandINFLUENCEMOH POLICYMOHPROGRAMMES/ MANAGERSOF PRIVAT ECLINICSPROPOSED ACTIONPOLICY – Nationalguidelines f or saf ehealt hcare wastemanagementBUDGETARYALLOC ATION forhealt hcare wastemanagementPRE & IN SERVICETRAINING –Persuasiv eprofessionaleduc ationSUPERVISORS SUPERVISION –motiv ate s taff tomanage was te s afelyMOH / NGOs /PRIVATEFACILITIESWHOMOH /LOCALGOVERNMENTNGOs /PRIVATEFACILITIESINFRASTRUCTUREDEVELOPMENTInstallation, operati onand supervision ofincinerat ors at l argerfacilitiesTECHNOLOGYTRANSFER ofappropriate low cos ttechnologiesCOLLECTIONSYSTEM for safetyboxes and othermedical waste toappropriate facilitiesfor bur ningSUPERVISORS SUPERVISION –ensure saf e collec tionof sharpsMANAGEMENT(MOH &PRIVATEFACILITIES)IMPROVEDCONDITIONS OFSERVICE for sanitaryworkersTOOLCODE1.-24.-24.-54.-154.-35.-34.-24.-35.-3INDICATORSPOLICY1. nationalPolicy for thesafe andappropriatemanagement ofhealthcarewastePOLICYIMPLEMEN-TATION2. Budgetaryallocation forsafe in jectionequipmentEVALUATION3. Proportion offacilities withdirty sharp sobserved in thesurroundings8


ANNEX 11. POLICY AIDES1.-1. Aide- memoire f or a nati onal s trat egy f or the s afe and appropriate us e of injecti ons Policy makers Leaflet1.-2. Aide- memoire f or a nati onal s trat egy f or healt hcare w aste management Policy makers Leaflet2. RESEARCH TOOLS2.-1. Rapid assess ment and respons e guide Health sys tems Research tool2.-2. Tool A (Foc us gr oup discussi on guide) Health sys tems Research tool2.-3. Interac tional group discussion guide Health sys tems Research tool3. TRAINING MODULES3.-1. Communication skills for healthcare providers Healthc are provi ders Slides / H andout3.-2. Safe injecti on practices Healthc are provi ders Slides / H andout3.-3. Safe sharps management Healthc are provi ders Slides / H andout4. IEC TEMPLATES4.-1. Good prescribers gui de Healthc are provi ders Leaflet4.-2. Good injecti on providers gui de Healthc are provi ders Leaflet4.-3. Good supervisors guide Supervisors Leaflet4.-4. Always use a s afety box Healthc are provi ders Poster4.-5. Safe wast e management Healthc are provi ders Poster4.-6. Your guide t o saf e medical treat ment (including patients charter) Community Leaflet4.-7. ‘Do I really need an injection?’ Community (schools) Leaflet4.-8. Choos e oral medicati on Community Leaflet4.-9. Make sure the syringe and needl e come from a new pack et Community Poster4.-10. The patients c harter for safe and appropriate injections Community Poster4.-11. Safe Injection Clinic (safe injections given here) Community Sticker4.-12. Talk to y our doct or Community Radio s pot4.-13. Choos e oral medicati on Community Radio s pot4.-14. Make sure the syringe is from a new packet Community Radio s pot4.-15. Don’t pl ay with syringes and needles Community Radio s pot4.-16. Choos e oral medicati on Community TV spot4.-17. Make sure the syringe is from a new packet Community TV spot4.-18. Safe and appropriat e us e of injec tions Broadc asters Resource pack4.-19. ‘Dear Colleague’ l etter Professional assoc. Templ ate4.-20. Health talks f or saf e injec tions Religious/O pinion leaders Templ ate5. SUPERVISION TOOLS5.-1. Prescription monitoring Supervisors5.-2. Monitoring use of saf e injec tion equipment Supervisors Checklist5.-3. Monitoring shar ps wast e management Supervisors Checklist6. RESOURCE CENTRE6.-1. Technical articles - professional journals Health prof essionals File6.-2. General articles - newspapers Community File6.-3. Injection safety back ground reports Health prof essionals File6.-4. Personal tes ti monies General Audio / video

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