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Indian Journal of Community Medicine

Injection Safety Awareness and Knowlege Among Slum Population

Author(s): Puneet Misra, Anil Goswami, C.S. Pandav

Vol. 28, No. 3 (2003-07 - 2003-09)

Centre for Community Medicine (CCM), All India Institute of Medical Sciences (AIIMS), New Delhi-110029


Research question: What is the level of awareness of a slum community regarding injection safety.

Objectives: To study the awareness and knowledge of the community regarding safe injection use.

Study design: Cross-sectional, community-based.

Participants: Adults above 18 years of age in a slum community of Delhi.

Sample size: 363 families.

Statistical analysis: Done using Epi info 6. X2 test of proportions was used to find the difference between the two proportions.

Results: A total of 363 families were interviewed. About l 1.4% received one injection in the last three months. In children below 5 years. 72.8% of injections were preventive. The major proportion (66%) of therapeutic injections was provided by unqualified practitioners. In 52% of injection use, disposable syringes were used. Average cost per injection was found to be Rs. 22.60.

Conclusion: It is important to create awareness among the slum dwellers and the local practitioners about the importance of disposable syringes and injectables.

Key Words: Injection, Syringes, HIV/AIDS, Urban slum


The use of unsterilised needles and other skin piercing instruments for medical or other purposes has potential for (HIV) and (HBV) transmission, more so in intravenous (UV) drug user transmission. For instance, in Romania 57% of AIDS cases among children living in institutions were attributed to the use of contaminated needles and syringes1.

Transmission of blood borne pathogens through contaminated needles and syringes has long been recognised. However, the extent of this problem in developing countries has been poorly quantified.

It was estimated by Kane et al2 that approximately 8 to 16 million HBV, 2.3 to 4.7 million (HIV) and 80,000 to 1,60,000 HIV infections may result every year from unsafe injection practices.

Immunizations given in formal and informal health care settings are probably the most common percutaneous procedures worldwide. WHO estimates that currently 12 billion injections are administered annually. For each vaccination injection, nine therapeutic injections are given3.

In a study conducted in rural India4, the authors reported high use of injections in the area. None of the Private Medical Practitioners were qualified in modern medicine and they were using injections without following correct techniques.

The present study was planned to know about the status of injection use in a slum, along with awareness and knowledge of community towards disposable syringes and risk involved in use of unsterilised needles. The proportion of injections given by unqualified practitioners and average cost per injection were also studied.

Material and Methods:

The present study was conducted in an urban slum (Ambedkar camp) located near Nehru Place in South Delhi, India. This slum is covered by the Mobile Health Clinic and Health Workers belonging to Urban Health Programme of Centre for Community Medicine (CCM), All India Institute of Medical Sciences (AIIMS), New Delhi. The study was undertaken by a batch of 12 medical students from August 2001 to October 2001, as a part of their field epidemiological training exercise.

An interview schedule was prepared by the investigators with the help of an anthropologist and social scientist. The schedule was translated in local language i.e. in Hindi and again back translated independently in English by a third person. The responses were standardized. The interview schedule, which took about 15 minutes per respondent, was pre-tested in a slum, which was not included into the study. Before initiating the field work, all the 12 investigators, together participated in the exercise of administering interview schedule so as to minimize inter observer variations.

Any member of the family above 18 years of age and who was, residing in the area for more than 6 months and present at the time of visit was interviewed. The questions included whether any family member visited health care provider in the last 3 months, if yes, did they receive any injection and about type of syringes used. Questions were asked to determine their knowledge regarding safety of the injection and the diseases transmitted by unsafe injections.

The urban slum has over 1,200 houses with an estimated population of 6,000. There were 12 unqualified medical practitioners in the area. It was estimated that roughly 380 houses could be interviewed in the time available. Therefore, one in every third house was selected by systematic random sampling. The data were entered in D-base and analyzed using EPI info6.


A total of 363 families were enrolled. 65% of the respondents were females and 63% of the respondents were in 18-30 years age group. Information was available for 2,016 family members out of which 334 were under 5 years. 58% of the respondents were illiterate. There were 1,062 person-visits to the health care providers in the last 3 months and they received 501 injections, which came out to be 0.25 injection/person/three months. If it assumed that the incidence throughout the year was uniform, it came out to be 1.0 injection/person/year. About 11.4% of persons received at least one injection in last 3 months.

In children below 5 years, the incidence was 0.52 injections/child/three months, and assuming it uniform throughout the year, it Games 2.08 injections/child/year. The ratio of preventive injections to curative injections in children below 5 years was injections in under 5 years population were preventive i.e, used for immunization purposes.

Almost half (47%) of the visits to health care providers resulted in injection administration.

About 66% of the injections were given by local practitioners and all of them were unqualified. A total of 74% injections were given at private settings. In 72% of the cases injections were given at deltoid region. Most of the injections were given for fever. In half (52%) of cases disposable syringes were used.

About 51 % of the respondents were aware about the transmission of some diseases through unclean syringes, (among these 48% knew that AIDS can be transmitted by it, while only 2% were aware that jaundice can spread due to unclean syringes).

49% of the population was aware about the disposable syringes and 73% were willing to buy even after knowing about the cost involved.

Awareness about disposable syringes was considerably high in literates (67% compared to 37% in illiterate, p<0.001). Awareness of HIV/AIDS transmission through unsafe injections was high in literates (41% compared to 12%, p<0.001). The use of disposable syringes was more prevalent in the household of the respondents who were aware about disposable syringes (62% compared to 25%, p<0.001). Prevalence of use of disposable syringes in households, whose respondents were literate was 73%, compared to 29% in households whose respondents were illiterate (p<0.001).

72% of respondents preferred oral medications to injections, if the cost and the efficacy was the same. In case of efficacy being the same but cost of injection was more; even then 18% preferred injections.

Pain (59%) and abscesses (44%) were the most common adverse effects perceived by these respondents.

Average cost to patient per injection (including Mobile Health Clinic, AIIMS and Govt. Hospital) was Rs. 22.60/- while excluding Mobile Health Clinic and Govt. it was Rs. 39.60.


This study was conducted in a slum area of South Delhi. Due to time constraints during field training practice, we could cover only 363 families. History about injection use was taken from an adult of the same family and not from individuals, assuming that an injection would be discussed in the family and respondent would know the actual injection use in the family.

In a rural study from Haryana4, the incidence of injection use was 2.46 injection/person/year. While in the present study it was 1.0 injection/person/year. Based on different reports, it was concluded that about a thousand million injections per year are administered for the immunization purposes and 8 to 12 curative injections are given for each immunization injections. Thus, it is assumed that 8-12 billion injections are given worldwide each year i.e. 1.5 to 2 injections per person/year. While Simenson et al6, reported average incidence of injections as 1.5 injections/person/year with a range of 0.9 to 7.5. In the present study the results were on the lower side.

The incidence of injection use for children below five years was 2.1, while in a rural Haryana study4 it was 3.1

11.4% of population in this study had received at least one injection in last 3 months i.e. 22.8% in six months assuming incidence as uniform throughout year, as compared to 35% in last 6 months in rural India4. The possible reason for this difference could be due to a different study setting, since a demand for injectables was more.

In a review by Simenson et a1 6 it was found that 33% to 50% visits to doctor resulted in injection. Our data also supported their observations as 47.2% visits resulted in use of injections. While in rural India it was 55%. So it is very clear that about half of visits resulted in injection. Although most of the people preferred oral medication, if the efficacy was same. In the present study, it was 73% as compared to 54% in rural areas. In a rural setting 70% respondents were aware about disposable syringes, while it was 49% in this study. This may be because, in rural study the village is one of the prosperous and literate village of Haryana, whereas, most of population living in this slum has migrated from the undeveloped and most backward villages, mostly from the states of Uttar Pradesh, Bihar and Rajasthan.

Those who were literate had better knowledge regarding injection use through disposable syringes, in terms of both awareness and prevalence of use of disposable syringe, along with awareness regarding transmission of HIV/AIDS through syringes. This may be the result of various awareness campaigns of HIV/AIDS through various mass media.


The incidence of injection use in this study population was 1 injection per person per year, and about three quarters of the injections received by under-five children were preventive i.e. for immunization. Only half of the respondents were aware of the transmission of some diseases through unclean syringes. Therefore, it is important to increase the awareness among the slum dwellers about the need and importance of disposable syringes. It should also be emphasized that all illnesses do not require injections. Efforts should also be made to educate local practitioners about the use of disposable syringes and appropriateness of injectables.


  1. Hersch BS, Popovici F, Apettei RC et al. AIDS in Romania. Lancet 1991; 338: 645-9.
  2. Kane A, Lloyd J, Zaffran M, Simonsen L, Kane M. Transmission of hepatitis B, hepatitis C and human immunodeficiency viruses through unsafe injection in the developing world, model based regional estimates. Bulletin of the World Health Organization 1999; 77(10): 801-7.
  3. Hutin YJF, Chen RT. Injection safety: A global challenge. Bulletin of the World Health Organization 1999; 77(10): 787-8.
  4. Undergraduate study team, Anand K, Pandav CS, Kapoor SK. Injection use in a village in North India. National Medical Journal of India 2001;14(3):143-4.
  5. State of the world's vaccine and immunization. Geneva, World Health Organization/United Nations Children's Fund, 1996 (Unpublished document WHO/GPV/96.04: available on request from Vaccines and other Biologicals, World Health Organization 1211 Geneva 27, Switzerland).
  6. Simonsen L, Kane A, Lloyd J, Zaffran M, and Kane M. Unsafe injections in the developing world and transmission of blood borne pathogens: A review. Bulletin of the World Health Organization 1999; 77(10): 789-800.
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