Among respondents who reported receiving at least 1 injection in the previous 12 months, 96.3% (95% CI: 95.5 to 97.1) were administered by health care providers, 4.6% (95% CI: 3.5 to 5.7) were self-administered, and 0.4% (95% CI: 0.2 to 0.7) were administered by traditional practitioners. Injectable contraceptives accounted for 42.2% (95% CI: 40.0 to 44.4) of all medical injections administered to women (data not shown). The vast majority of respondents (95.9%, 95% CI: 95.2 to 96.7) reported that the last time they received an injection from a health care provider, the needle came from a new, unopened package. Half (50.2%, 95% CI: 48.4 to 52.0) preferred injections as medication, 36.5% (95% CI: 34.8 to 38.3) preferred pills, and 13.3% (95% CI: 12.1 to 14.4) had no treatment preference. Seven percent of injection recipients (7.4%, 95% CI: 6.4 to 8.4) had seen a used needle or syringe near their home or community in the past 12 months compared with 6.3% (95% CI: 5.5 to 7.0) of all survey respondents. In total, 14,982 injections received by participants were administered by health care providers in the previous 12 months, corresponding to an average of 3.6 injections per person among those that received at least 1 injection in the past year. When applied to the survey population, the per capita medical injection rate for adults and adolescents aged 15–64 years was 1.1 injections per person per year.
In multivariate analyses, factors independently associated with increased odds of receiving a medical injection in the previous 12 months were being a woman (aOR, 2.1; 95% CI: 1.8 to 2.3); being currently or previously married or cohabiting compared with being never married or cohabiting [married or cohabiting (aOR, 2.2; 95% CI: 1.9 to 2.5); ever widowed (aOR, 1.7; 95% CI: 1.4 to 2.2); and separated/divorced (aOR, 1.7; 95% CI: 1.3 to 2.2)]; living in Nyanza (aOR, 1.6; 95% CI: 1.2 to 2.0) and Western (aOR, 1.4; 95% CI: 1.1 to 1.8) regions compared with Nairobi region; increasing education levels compared with having no primary education [incomplete primary (aOR, 1.7; 95% CI: 1.2 to 2.2); complete primary (aOR, 1.5; 95% CI: 1.2 to 1.9); and secondary or higher level of education (aOR, 1.4; 95% CI: 1.1 to 1.8)]; and being in the middle (aOR, 1.3; 95% CI: 1.1 to 1.6) or fourth highest (aOR, 1.3; 95% CI: 1.1 to 1.6) wealth quintile compared with being in the poorest wealth quintile (Table 2). Compared with persons aged 15–24 years, persons aged 35–64 years had significantly lower odds of receiving an injection in the past 12 months [aged 35–44 years (aOR, 0.7; 95% CI: 0.6 to 0.8), aged 45–54 years (aOR, 0.6; 95% CI: 0.5 to 0.7), and aged 55–64 years (aOR, 0.5; 95% CI: 0.4 to 0.7)]. We also examined these associations separately for men and women and found similar results (data not shown).
Overall, 51.2% (95% CI: 49.7 to 52.8) of survey participants preferred an injection to a pill as medication (Table 3). Preference for injection was higher among women (56.7%, 95% CI: 54.9 to 58.5) than men (45.3%, 95% CI: 43.4 to 47.2). Preference for injection was highest among persons aged 25–34 years, at 56.2% (95% CI: 54.0 to 58.4) and decreased with increasing age to a low of 45.4% (95% CI: 41.4 to 49.4) for persons aged 55–64 years. Over half of those who preferred injections resided in rural areas (51.6%, 95% CI: 49.8 to 53.4), were married or cohabiting (54.6%, 95% CI: 52.9 to 56.3), and had completed primary education (52.2%, 95% CI: 50.1 to 54.3). Preference for injection was higher among those who had received at least 1 injection in the previous 12 months (57.9%, 95% CI: 55.9 to 59.8) compared with those who had received no injection during the same time period (47.3%, 95% CI: 45.6 to 49.0).
In multivariate analyses, older respondents aged 35–44 years (aOR, 0.8; 95% CI: 0.7 to 0.9), 45–54 years (aOR, 0.7, 95% CI: 0.6 to 0.8), and 55–64 years (aOR, 0.6, 95% CI: 0.5 to 0.7) had lower odds of preferring an injection to a pill for medication than younger respondents aged 15–24 years. Female sex (aOR, 1.5; 95% CI: 1.3 to 1.6), residing in urban areas (aOR, 1.2; 95% CI: 1.1 to 1.4), and receiving an injection in the previous 12 months (aOR, 1.4; 95% CI: 1.3 to 1.5) were associated with a higher odds of preferring an injection to a pill.
Medication Injection and Associations With HIV Infection
HIV prevalence was 6.3% (95% CI: 5.1 to 7.4) among individuals who received at least 1 injection in the past 12 months compared with 5.3% (95% CI: 4.6 to 5.9) among those who had not (data not shown). Among those who had received an injection from a traditional practitioner in the past 12 months, HIV prevalence was 20.6% (95% CI: 0 to 44.4). In contrast, HIV prevalence among persons who had self-administered an injection in the past 12 months was 3.5% (95% CI: 0.4 to 6.6).
Among men, HIV prevalence among those who received a medical injection in the past 12 months (5.8%, 95% CI: 4.2 to 7.3) was significantly higher than those who did not receive an injection (3.8%, 95% CI: 3.1 to 4.5) (Table 4). Men who had self-administered an injection in the past 12 months had low HIV prevalence at 2.6% (95% CI: 0 to 6.3). Although men who reported receiving 2 to 3 (6.0%, 95% CI: 3.6 to 8.3) and 4 or more (6.6%, 95% CI: 3.0 to 10.2) medical injections from a health care provider in the past 12 months had higher HIV prevalence than men who had received no injections from health care providers (3.9%, 95% CI: 3.2 to 4.6), these differences were not statistically significant. After adjusting for age and number of injections received in the previous 12 months, men who had received a medical injection in the previous 12 months were 3 times more likely to be HIV infected than men who did not receive injections in the same time period (aOR, 3.2; 95% CI: 1.2 to 8.9).
Among women, HIV prevalence was 7.1% (95% CI: 6.2 to 8.1) among those who had not received a medical injection in the past 12 months, 5.5% (95% CI: 4.1 to 7.0) among women who received injectable contraceptives, and 7.4% (95% CI: 5.8 to 8.9) among women who received medical injections for reasons other than family planning (Table 5). Women who self-administered a medical injection in the past 12 months had an HIV prevalence of 4.8% (95% CI: 0 to 10.0). No associations were observed between the number of injections received by a health care provider and HIV infection among women. After controlling for age and the number of injections administered by a health care worker in the past 12 months, women who received injections for reasons other than family planning purposes were 3 times more likely to be HIV infected compared with women who received no injections in the past 12 months (aOR, 2.6; 95% CI: 1.2 to 5.5).
In this nationally representative survey, we found that approximately one-third of adults aged 15–64 years had received a medical injection in the 12 months preceding the survey, and the vast majority of these had received injections from a health care provider. Those who received injections were mainly women, currently or previously married, with higher wealth and education, and residents of Nyanza and Western regions. The estimated number of injections from health care providers per person per year was 1.1 injections. A global average of 3.4 medical injections per person per year among children and adults has been reported elsewhere, with Africa reporting an average of 2.2 medical injections per person per year.1 The proportion of medical injection recipients in our study, however, remained similar to what was reported in KAIS 2007, where 1 in every 3 persons aged 15–64 years received at least 1 medical injection in the previous 12 months.13
We found that 1 in 15 participants had seen a used syringe or needle near their home or in their community in the past 12 months. This finding corroborates 2 recent studies reporting improper medical waste disposal in the community. Mazrui and colleagues16 found that 11% of private health facilities in Nairobi disposed of medical waste in open dump sites, and a United Nations Environmental Program study team reported seeing used needles in the general waste disposal site in Dandora, Nairobi.17
Given a choice, half of Kenyan adults and adolescents preferred an injection to a pill for medication purposes, similar to what was reported in KAIS 2007.13 Furthermore, this rate was also similar to findings from a program evaluation of safe medical injections in Kenya, which showed that 5 out of 10 persons in Western and Nyanza regions preferred medical injections to pills.18 We also found that individuals who received an injection in the previous 12 months had significantly higher odds of preferring medical injections to pills compared with those who had no medication preference. These findings indicate that injection preference can influence injection use which could potentially lead to unnecessary and unsafe injections. Women were more likely than men to prefer injections over pills and accounted for 70% of medical injections that were administered by health care providers, with at least 40% for contraceptive purposes. This was consistent with findings from the Kenya Demographic and Health Survey of 2008–09, which reported that injectable contraceptives were the most widely used family planning method, with 1 in 5 women aged 15–49 years reporting that they were currently using this method.19
Individuals who had received higher number of injections from a health care provider in the previous 12 months had similar odds of HIV infection compared with individuals who had received no injections from a health care provider in the same time frame. Both men and women who received medical injections in the 12 months preceding the survey (not for contraceptive purposes among women) were more likely to have been HIV infected than those who had not received any injections in the previous 12 months. High HIV prevalence was noted among persons who had received injections from traditional practitioners, though the number reporting this practice was small. There is a possibility of re-use of injection devices in traditional medicine settings, potentially increasing the risk of HIV transmission and acquisition. We were encouraged to find that over 95% of those who received injections from health care providers observed a new, unopened needle package being opened. Patient-observed sterile treatment is a national strategy that has been adopted in Kenya since 2004 to ensure sterile care and reduction in HIV transmission risk in health care settings.20
This study had several limitations. The analysis relied on self-reported data that may have been limited by recall bias. To minimize this bias, we restricted the recall period to the preceding 12 months from the survey. Second, variables on medical waste in the community were dependent on correct knowledge of a used syringe or needle, but no informational material was provided to survey participants to confirm visual understanding of medical waste. Therefore, our reported estimates on medical waste could be either an overestimate or underestimate of true values in the population. Because KAIS 2012 was a cross-sectional survey where potential predictors and outcomes were measured at the same time, we were not able to determine causality in associations observed, such as those reported for injection status and HIV infection. In addition, we did not collect information on whether medical injections received were curative or preventative, both of which may have impacted our estimates of injection history and injection preference. Finally, the number of self-administered injections and number of injections received from traditional practitioners were not quantified, which may have contributed to lower injection totals.
Despite these limitations, this study provides important nationally representative population-based data that can be used to inform the national program on targeted strategies for the prevention of medical transmission of HIV and other blood-borne pathogens. Efforts to improve health communication, particularly to those who are more likely to receive medical injections, are needed to reduce the risks of unsafe injections, to address the hazards of medical waste disposal in the community, and to educate traditional practitioners on safe injection practices. In addition, medical waste management programs need to support waste disposal at the health facility and the community. Finally, given the wide use of injectable contraceptives among women, we recommend that the national reproductive health program integrate injection safety practices in reproductive health services. These recommendations can form the basis for policy makers to support injection safety interventions for patients, health care providers, and the community as part of comprehensive infection prevention and control programs.
The authors thank the KAIS 2012 field teams and all the individuals who participated in this national survey. They would like to thank George Rutherford, Kevin DeCock, Amanda Viitenen, and Anthony Waruru for reviewing and providing input on the article, and the KAIS Study Group for their contribution to the design of the survey and collection of the data set: Willis Akhwale, Sehin Birhanu, John Bore, Angela Broad, Robert Buluma, Thomas Gachuki, Jennifer Galbraith, Anthony Gichangi, Beth Gikonyo, Margaret Gitau, Joshua Gitonga, Mike Grasso, Malayah Harper, Andrew Imbwaga, Muthoni Junghae, Mutua Kakinyi, Samuel Mwangi Kamiru, Nicholas Owenje Kandege, Lucy Kanyara, Yasuyo Kawamura, Timothy Kellogg, George Kichamu, Andrea Kim, Lucy Kimondo, Davies Kimanga, Elija Kinyanjui, Stephen Kipkerich, Danson Kimutai Koske, Boniface O. K'Oyugi, Veronica Lee, Serenita Lewis, William Maina, Ernest Makokha, Agneta Mbithi, Joy Mirjahangir, Ibrahim Mohamed, Rex Mpazanje, Silas Mulwa, Nicolas Muraguri, Patrick Murithi, Lilly Muthoni, James Muttunga, Jane Mwangi, Mary Mwangi, Sophie Mwanyumba, Francis Ndichu, Anne Ng'ang'a, James Ng'ang'a, John Gitahi Ng'ang'a, Lucy Ng'ang'a, Carol Ngare, Bernadette Ng'eno, Inviolata Njeri, David Njogu, Bernard Obasi, Macdonald Obudho, Edwin Ochieng, Linus Odawo, James Odek, Jacob Odhiambo, Caleb Ogada, Samuel Ogola, David Ojakaa, James Kwach Ojwang, George Okumu, Patricia Oluoch, Tom Oluoch, Kenneth Ochieng Omondi, Osborn Otieno, Yakubu Owolabi, Bharat Parekh, George Rutherford, Sandra Schwarcz, Shahnaaz Sharrif, Victor Ssempijja, Lydia Tabuke, Yuko Takenaka, Mamo Umuro, Brian Eugene Wakhutu, Wanjiru Waruiru, Celia Wandera, John Wanyungu, Anthony Waruru, Paul Waweru, Larry Westerman, and Kelly Winter.
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Keywords:© 2014 by Lippincott Williams & Wilkins
HIV; injection safety; Kenya; medical waste management; population-based survey