Author(s): Stephen ED Nsimba [[dagger]â ] 1 , Amos Massele 2 , Edmund J Kayombo 3
focus group discussion; injection; interactional group discussion; malaria; prescriber; primary healthcare; public and private facility; standard treatment guidelines
Irrational prescribing, in many forms, is commonly seen in various healthcare facilities in developing countries such as Tanzania. A study conducted by the International Network for Rational Use of Drugs (INRUD) in Tanzania between 1999 and 2001, in public and church-owned primary healthcare (PHC) facilities, found frequent irrational use of drugs, including polypharmacy, and overuse of antibiotics and injections. It was observed that over 70% of patients studied received at least one injection when they visited a health facility/hospital  . It was obvious from this study that irrational use and overuse of injections is problematic at these facilities; this may increase the spread of HIV, hepatitis B and C, and precipitate paralysis in those suffering from acute polio infection [2-â6,101] . It has also been reported that use of unsafe injections contributes to 30% of hepatitis B virus infections worldwide  .
The WHO defines rational or appropriate prescribing as prescription of injections in less than 15% of cases, and anything above 15% is considered inappropriate injection  . Therefore, based on this definition, appropriate prescription of injections means prescribing injections that have a clear indication related to a particular or a specific disease. According to the Essential Drug List, any injections given where oral medications or topical drugs could be used, and where there are no clear contraindications for use of oral medications or incidence of adverse effects, such as vomiting or extensive burns, is also considered inappropriate. Overuse of injections is commonly seen in healthcare facilities in Tanzania, and is considered to be serious owing to the likelihood of adverse effects, such as pain at the site of injection, risks of abscesses, and risks of transmission of hepatitis B and C and HIV, as well as the economic impact [3,7,102] . Overuse of injections has also been reported in several other developing countries [8,9] , and has been implicated in the spread of hepatitis B and C, and HIV [3-â6,10,11,101,102] . Therefore, it is highly probable that unsafe injection practices are also prevalent in many other developing countries; however, so far no effective interventions have been conducted in Tanzania or other developing countries to prevent overuse of injections [3,4,7-â10,101] . Most of the interventions, which have been carried out by the Ministry of Health in Tanzania, are confined to formal educational approaches in the form of seminars or workshops. Experiences have demonstrated that such approaches have had little impact on the consumers, and may not have had any effect on the prescribing habits of clinicians. Many prescribers express that their motives for prescribing injection are mostly caused by the customers'â demands, but little or no evidence from formal studies supports this. By contrast, our experience based on focus group discussions (FGDs) with consumers demonstrated that the majority did not demand an injection, but clinicians in privately owned PHC facilities preferred to prescribe injections because...