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
Why Behavior Change?
Needles and syringes can be:

A safe and effective means

to treat and prevent
disease
OR
 A hazard in spreading
disease
 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.
What is an Ideal Behavior?

An ACTION
Observable and measurable
Specific
Do-able
Directly linked to improved
health outcome
 Basis of the Strategy:
The 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
 Example:
“Health worker administers
safe and sterile injection”
WHO WHAT
- Doctor - Clean the work area
- Registered nurse - Prepare the skin
- Enrolled community - Use sterile needle/syringe of
nurse right size/gauge
- Medical assistant - Hold it only by certain parts
- Midwife - Load correctly
- Custodian?? - Use correct route of
administration (e.g. IM)
- Dispose of needle/syringe
correctly
 Obstacles –
Must come from perspective of
those expected to carry out actions!
Illustrative examples--health worker:
 Doesn’t know all the steps
 Doesn’t believe they are all important
 Is too hurried to carry them out
 Lacks necessary supplies and hasn’t been
able to obtain them in past
 Is uncomfortable doing new/different steps
 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
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
 Behavioral considerations
inform design of program
activities and are integrated
Changes in behavior
result from
coordinated set of
complementary,
mutually reinforcing
activities
 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?
 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
 Reducing Unnecessary Injections:
“WHO needs to do WHAT” is complex
WHO
- Different cadres of
health staff
First find out
- Drug sellers
who are the
- Pharmacists
most significant
- Traditional healers sources of
- Family members injections
- Barbers
- “Quacks”
 Example:
“Health workers provide, and promote
the use of, oral medications”

WHO WHAT
- Public sector - Prescribe and
prescribers provide oral
- Public sector presentations
providers according to norms
and standards that
minimize use of
injections
- Explain reasons to
patients
 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
 Hypothetical Enabling Factors
Need 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
 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
 Behavior Change tools and
materials for injection safety

Background and General

- “Anthropological perspectives on
injections: An Overview”
- SIGN Behavior Change Strategy
 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)
 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
 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
 Applying Behavior Change
in our Projects
Obstacles Enabling Factors
 Complex  Tools and experience are
 Takes time available to build on
 Requires research  Participatory approach leads
phase to long-term changes
 Involves multiple  Need and potential benefits
stakeholders are great
 No magic bullet  BC helps unify activities
 Project provides great
opportunities!