Building Behavior Change Strategies for Injection safety

1
Building Behavior Change Strategies for
Injection safety

• Rebecca Fields, Lonna Shafritz, Joy Pritchett
• Academy for Educational Development (AED)
• Mike Favin, The Manoff Group
• Entebbe, Uganda
• April 28, 2004

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Why Behavior Change?

• Needles and syringes can be
• ?A safe and effective means to treat and prevent
  disease
• OR
• ? A hazard in spreading disease

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Goals for Injection Safety

• Reduce unnecessary injections
• Improve the safety of those injections that are
  necessary
• Ensure safe management of sharps waste
• All require certain people to carry out
  certain desired actions or ideal behaviors.

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What is an Ideal Behavior?

• An ACTION
• Observable and measurable
• Specific
• Do-able
• Directly linked to improved health outcome

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Basis of the StrategyThe Behavioral Analysis

• (1) Specify Who needs to do What to work toward
  a particular objective
• (2) Identify the Obstacles and Enabling factors
  affecting their ability to carry out the
  behavior

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Example Health worker administers safe and
sterile injection

• WHO
• Doctor
• Registered nurse
• Enrolled community nurse
• Medical assistant
• Midwife
• Custodian??

• WHAT
• Clean the work area
• Prepare the skin
• Use sterile needle/syringe of right size/gauge
• Hold it only by certain parts
• Load correctly
• Use correct route of administration (e.g. IM)
• Dispose of needle/syringe correctly

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Obstacles Must come from perspective of those
expected to carry out actions!

• Illustrative examples--health worker
• Doesnt know all the steps
• Doesnt believe they are all important
• Is too hurried to carry them out
• Lacks necessary supplies and hasnt been able to
  obtain them in past
• Is uncomfortable doing new/different steps

8
Enabling Factors also from perspective of those
expected to carry out actions!

• Illustrative examples--health worker
• Truly desires to do right by her patients
• Finds that A-D syringes are easier and faster to
  use

9
Design of Program Strategies flow from Behavioral
Analysis

• Policies, norms, and standards issued officially
  by government, clearly stating needed steps
• Improved provision and management of injection
  supplies
• Feedback, Supervision, Motivation
• Training to build competence knowledge, skills,
  and attitudes

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Behavioral considerations inform design of
program activities and are integrated

• Changes in behavior result from coordinated set
  of complementary, mutually reinforcing activities

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Example Reducing unnecessary injections

• Start by defining the epidemiology of
  injections
• Who gives them?
• Which medications?
• Why do people want them?
• When and where do they get them?

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Studies show that patients

• May be used to getting injections
• View them as more powerful than pills
• View them as both magical and modern
• May not want to settle for less
• May get them from multiple providers

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Reducing Unnecessary InjectionsWHO needs to do
WHAT is complex

• First find out who are the most significant
  sources of injections

• WHO
• Different cadres of health staff
• Drug sellers
• Pharmacists
• Traditional healers
• Family members
• Barbers
• Quacks

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Example Health workers provide, and promote
the use of, oral medications

• WHO
• Public sector prescribers
• Public sector providers

• WHAT
• - Prescribe and provide oral presentations
  according to norms and standards that minimize
  use of injections
• - Explain reasons to patients

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Hypothetical Obstacles Needs to be based on
real data

• Injections have been the norm
• Patients desire injections may go elsewhere if
  refused
• Patient compliance with orals may be harder to
  assure
• Too rushed to give explanations to patients
• Unreliable or insufficient supply of orals

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Hypothetical Enabling FactorsNeed to be based on
real data

• Less expensive to use orals
• Lower need for injection equipment
• Less sharps waste to manage
• Concerns about risks of injections
• Responsive to current literature and advice of
  professional peers

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Possible Program Strategies, based on Behavioral
Analysis

• Official MOH policies and norms
• Training and orientation, from both MOH and
  professional societies
• Improved supply management of orals
• Communication materials to help improve patients
  acceptance
• Other innovative approaches interactional group
  discussion

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Behavior Change tools and materials for injection
safety

• Background and General
• - Anthropological perspectives on injections An
  Overview
• - SIGN Behavior Change Strategy

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Behavior Change tools and materials for injection
safety

• Assessment Tools
• SIGN Tool A on Determinants of Behavior
• SIGN Rapid Assessment and Response Guide
• Studies in Nepal (PATH CVP)

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Behavior Change tools and materials for injection
safety

• Interventions and Approaches
• Guide to Managing an Injection Safety Policy and
  Plan
• Guide to Supervising Injection Providers
• Interactional Group Discussion Guide
• SIGN Sample IEC materials

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Behavior Change tools and materials for injection
safety

• Experience from Countries
• Indonesia Interactional Group Discussion
• Pakistan Interactional Group Discussion
• Nepal Study on Perceptions of Private Providers
• Sample materials from Mongolia
• Study from Egypt
• SIGN files and archives great resource

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Applying Behavior Change in our Projects

• Obstacles
• Complex
• Takes time
• Requires research phase
• Involves multiple stakeholders
• No magic bullet

• Enabling Factors
• Tools and experience are available to build on
• Participatory approach leads to long-term changes
• Need and potential benefits are great
• BC helps unify activities
• Project provides great opportunities!