MATERIALS AND METHODS

Choose of health centres for sampling was based on method described previously (Cheraghali et al., 2004). Briefly, in 2004 health centres in five provinces of Iran randomly selected according to their geographical distribution in these provinces. Thirty prescriptions of each physician working in these centres were randomly selected and prescription rate for injectable medicines was calculated simply by dividing total number of injectable medicines prescribed to total number of medicines in prescriptions and expressed as percentage. According to these value physicians were categorized in low and high prescription rates. The border line was 30% and doctors prescribing injections higher than 30% allocated in high rate prescribing. The borderline has been selected arbitrary and it is based on data obtained from previous surveys of pattern of prescribing medicines in Iran (Cheraghali et al., 2004). Then thirty physicians, regardless of their gender or prescribing pattern, were randomly selected for in depth interview. A questionnaire contains questions about reasons for prescribing injections has been developed and used for interview. Of these 30 physicians one declined the interview and 16 were in high rate (>30%) prescribing group and 13 in low rate prescribing injections group. Table 1 shows gender distribution of each group.

RESULTS

Seven identical questions were asked from all physicians. High rate physicians were asked for reasons why they prescribe injectable medicines and their responses are shown in Table 2. Majority of high rate group believe that patients’ belief has the major impact on their prescribing behaviour and they think they prescribe injections to ensure patients’ compliance. However, they do not believe an economical benefit is an important contributory factor in prescribing injections. They also believe that their training in university was fairly appropriate for their practice.

This group also stated following as major disadvantages of injectable medicines:

The physicians then asked about their opinion on effective interventions to improve situation. Responses from high rate group are summarized in Table 3. Although this group sees patients’ education about disadvantages of injections as the most important factor on improving the situation, they do not believe that explaining efficacy of oral dosage forms of medicines to the patients could help. However, they also suggested that managerial interventions such as restriction on prescription of injectables would be an improving factor.

Similar questions were asked from low rate physicians and their responses are summarized in Table 4. In contrary to high rate group 54% of this group believe that patients’ demand has a major impact on their prescribing habit.

Table 1:	Gender distribution of physicians interviewed

Table 2:	Reasons for prescribing injectable medicines by high rate physicians (n = 16)

Table 3:	Opinion of high rate physicians on effective interventions to improve irrational use of injectables (n = 16)

Table 4:	Reasons for prescribing injectable medicines by low rate physicians (n = 13)

They declare that they prescribe injections because it may provide better compliance or because oral dosage forms may not have sufficient quality. Suggestions from low rate group for effective interventions to improve situation are shown in Table 5. This group strongly believes that patients’ education including youngsters about disadvantages of injections would greatly improve the situation.

Table 5:	Opinion of low rate physicians on effective interventions to improve irrational use of injectables (n = 13)

They believe proper training of medical professionals and improving income are two major contributory factors on improving prescription behaviour of physicians. They also proposed managerial interventions such as auditing physicians’ prescribing pattern as an effective interventional tool.

Low rate group also stated following as major disadvantages of injectable medicines:

DISCUSSION

In many developing countries health workers are confronted with patients who prefer injections to oral medicines. The historical background of this popularity may be due to efficacy of these dosage forms to cure disease such as infectious disease. However, economic factors may also determine their widespread use in developing countries. The unnecessary and overuse of injections has created increasing concern among national and international health agencies. From a health prospective, administering injections without adequate medical knowledge or proper sterilization procedure leads to the risk of transmitting viral and/or microbial infections. From an economic point of view the nonessential use of injections imposes an unnecessary burden on patient and national health budgets.

In different cultures the belief in injections as a very powerful method of restoring or maintaining health is shared by some of the providers and patients and it seems it cannot be solved by training alone. Knowledge of the potential risks of injections is often not put into practice. Patient’s demand may also force providers administer more injections to please the patient (Reeler, 1990).

Of course in designing effective interventions it has to be borne in mind that some injections are very useful. Vaccination, for example, has saved the lives of many children. In some cases the injection of some antiinfectives may be the most rational way to treat certain conditions. If patients cannot swallow or are nauseated injections may be the best form of treatment. However, most injections given in developing countries are medically unjustified and may be even dangerous. Therefore, it is necessary to prevent and limit the administration of harmful and unnecessary injections without damaging public perception of useful injections. Although providers commonly emphasise patient’s demand as a major driver of injection overuse, studies indicate that patients are open to alternative to injections (Hutin et al., 2003). Prescribers overestimate patients’ preference for injections and have false perceptions about their effectiveness. Prescribers’ attitude also contributes to overuse of injections.

In this study 29 general practitioners working in public health care centres were interviewed for their attitude toward injections. According to extent of prescribing injections, physicians were categorized as high rate prescriber and low rate prescriber. Their responses to questions are summarized in Table 2-5. Eighty one percent of high rate prescribers and 54% of low rate prescribers believe patient’s demand is the major factor on driving them toward prescription of injections. This indicates that perception of prescribers toward patient’s demand is a main driving force on their prescribing habit and they do not rely on their medical knowledge about injections and their proper application. Equal percent (31%) of high and low rate prescribers prescribe injections to respond to patient’s request for faster treatment. Both groups believe the lower quality and efficacy of oral dosage forms compared to injections is a driving force for prescribing injections. Although previous studies reported economic benefits as an incentive for providers to prescribe more injection (WHO, 1996), physicians who work in health centres in Iran earn a fix salary and their income is independent of their prescription behaviour. Therefore they should not have any economic incentive to prescribe injections. Only 19% of the high rate prescribers declared financial incentives as an important factor for prescribing injections when they practice in private office. In contrary to low rate prescribers, 19% of high rate prescriber think improper university training is a factor on prescribing injections.

Results of this study clearly show that there is a substantial influence from gender on prescribing pattern. Although most of female physicians interviewed fell in low rate prescriber group, it seems that male doctors in low rate prescribers are more restricted on rational prescribing of injections (Table 2 and 4, gender distribution). Results in Table 2-5 also show substantial influences from gender of prescribers on their attitude toward causes of irrational prescribing of injections. Therefore, it is suggested that corrective interventions might provide different results in different genders and in order to maximize effectiveness of interventions they should be tailored according to gender of prescribers.

Physicians’ suggestions on effective interventions to improve rational prescribing of injections are summarized in Table 3 and 5. Both groups believe patients’ education is the most effective way of improving situation. This is mainly to the fact that prescribers believe patients’ demand is the major driving factor on prescribing injections (Reeler, 1990). However, it seems that low rate prescribers put more emphasise on this intervention.

The fact that both groups believe improving quality of oral dosage forms may improve rational use of injections indicates that attitude of the prescribers toward efficacy of the oral dosage forms should be improved. Since most of countries use same regulatory system for controlling quality of different dosage forms of the medicines, with exception of their inherent differences, it is unlikely that quality of injections would have superior quality.

When prescribers in both groups asked about their opinion on disadvantages of injections surprisingly both groups stated very similar items including higher adverse effects, higher costs and needs for extra trained staff and equipments for administration. This clearly indicates that both groups are aware of disadvantages of irrational prescribing of injection. However, it seems they do not put their knowledge into practice.

Although prescribers indicated educating of patients and training prescribers influences rational use of injections both groups suggested some managerial interventions such as restrictions on prescription of injections and auditing prescription pattern as useful tools for overcoming the problem. This emphasizes importance of implementing multi factorial interventions as effective corrective measures for irrational drug use (Laing et al., 2001).

Results of this study show that despite some common reasons for prescribing injections among prescribers, their attitude toward injections clearly differ. Therefore this should be in mind that before implementing any interventions to improve injections use attitude of prescribers should be investigated and the interventions should be tailored accordingly.