Parenteral Medication Prescriptions, Dispensing and Administration Habits in Mongolia
Parenteral Medication Prescriptions, Dispensing and Administration Habits in Mongolia
Gereltuya Dorj * 0
Bruce Sunderland 0
Delia Hendrie 1
Richard Parsons 0
0 School of Pharmacy, Bentley, Curtin University , Perth, Western Australia , Australia,
1 School of Public Health Curtin University , Perth, Western Australia , Australia
High levels of injection prescribing were reported in Mongolia. Understanding the factors influencing the injection prescribing is essential to reduce their inappropriate use. The study evaluated the views, experiences and attitudes of community members associated with the prescribing of injections in Mongolia. A structured questionnaire focusing on respondents' characteristics, experiences and views OPEN ACCESS about injections was developed and administered face-to-face to community Citation: Dorj G, Sunderland B, Hendrie D, members in Ulaanbaatar, Mongolia. Standard descriptive statistics were used to PPraersscornipstiRon(s2,0D1i4s)pePnasrienngtearanldMAeddmicinaitsiotrnation summarize demographic data and responses to the questionnaires. Dependant dHoaib:1it0s.1in37M1/ojonugronlaial..pPoLnoeS.01O1N53E849(12): e115384. variables were compared using Kruskal-Wallis Tests for independence. Statistical Editor: Alfonso Carvajal, Universidad de analyses were performed using SPSS Version 21.0. Six hundred participants were Valladolid, Spain approached and the response rate was 79% (n5474). Almost half of the Received: July 7, 2014 respondents were aged between 31 and 50 (n5228, 48.1%) and 40.9% of Accepted: November 22, 2014 respondents were male (n5194). Most respondents were from Ulaanbaatar city Published: December 22, 2014 (n5407, 85.7%). All respondents had received injections in the past and 268 Copyright: 2014 Dorj et al. This is an open- (56.5%) had received injection in the past year. The most common reason for access article distributed under the terms of the having an injection in the past year was reported as treatment of a disease (n5163, pCerermatiitvseuCnroemstmricotnesd Autstreib,udtiisotnribLuictieonns,ea,nwdhriecphro- 60.8%), or for administration of vitamins (n570, 26.1%). Injections were prescribed adnucdtisoonuirnceanayremcerdeiudmite,dp.rovided the original author by a doctor (n5353, 74.9%), dispensed by a pharmacist (n5283, 59.7%) and Data Availability: The authors confirm that all data administered by a nurse (n5277, 54.9%). Only 16% of all respondents had the underlying the findings are fully available without expectation of receiving injections when they visited a doctor (n577). An important rPehsatrrimctaiocny., DCautratinaUreniavvearsiliatyb,leWfAromInstthituetioSncahloDolatoaf perception regarding injections was that they hastened the recovery process Access/Ethics Committee for researchers who (n5269, 56.8%). When asked their opinion about therapeutic injections, 40% of all meet the criteria for access to confidential data. respondents agreed that injections were a better medicine (n5190) than oral fFuunnddinigngto: Trehpeosret.authors have no support or medications, with older respondents strongly agreeing (p,0.001). Based on this Competing Interests: The authors have declared total sample, approximately 1891 injections per 1000 patients were administered. that no competing interests exist.
The excessive injection use seems to be promoted by inappropriate prescribing,
dispensing and administration of medication by doctors and others.
Injection medicines are commonly used in healthcare settings for the prevention,
diagnosis, and treatment of various illnesses. Unsafe injection practises including
the re-use of equipment in the absence of sterilization can place community
members and healthcare providers at risk of infectious and non-infectious adverse
events . Factors giving rise to unnecessary parenteral medication prescribing in
developing countries include socio-cultural, economic and structural factors.
Studies from developing countries suggest that injections are overused particularly
because of health practitioners prescribing practises and community members
preference for injections over oral medications . The belief in an injection as
a strong tool for restoring and maintaining health is mutually supported by health
professionals and community members in some developing countries .
Previous findings have suggested that patient demand may cause prescribers to
prescribe and administer injections for patient satisfaction  , whereas in
contrast others have indicated that community members were more open to
alternatives to injections . A study in Uganda and Indonesia which questioned
the causes for injection prescribing reported that local belief about illness,
concepts of efficacy, economic incentives for private or informal providers and
lack of patient-provider communication were the main reasons . A systematic
review of studies from 13 developing countries regarding injection use and safety
reported that in eight of those countries, 2596% of outpatients visits resulted in
at least one injection being prescribed, and for five countries a majority of the
administered injections were unnecessary. Commonly administered parenteral
injections included vitamins, antibiotics, analgesics and quinine . Previous
studies have reported inappropriate use of injections with respect to standard
treatment guidelines in Mongolia [13, 14]. A later study has observed a reduction
reporting eight injections per person per year (p,0.001)  however the small
sample size (200) limits generalisation. Worldwide studies on hepatitis C
prevalence reported wide range of estimates including 0.9% in India , 3.2% in
China  to 22% in Egypt . Substantial association between prevalent
hepatitis C infection and unsafe therapeutic injections has been reported in
previous studies . The World Health Organization (WHO) has estimated
that unsafe injections accounted almost two million of hepatitis C infections in
2000 . Given the high prevalence of antibody hepatitis C (anti-hepatitis C) in
Mongolia (16%24%) , it is important to minimise unnecessary injection
practises in the country especially on public health grounds.
In Mongolia, the pharmaceutical procurement sector is 100% privatized. Drugs
are distributed through organizations such as drug wholesalers and retail drug
outlets (community pharmacies and revolving drug funds). Recent statistics show
there were 703 community pharmacies, 75% of which had one to two branches in
Mongolia . The Health Insurance Fund a single national fund with 80% of the
population insured, finances a wide range of hospital care and outpatient medical
expenses including 107 drugs in the Essential Drugs List of Mongolia .
To evaluate community views, knowledge, attitudes and experiences of
community members associated with prescribing injections in Mongolia and to
assess other factors that may promote injection overuse in Mongolia
Development of the questionnaire
The development of a questionnaire was based on the World Health Organization
(WHO) developed guide: Injection Practises: Rapid Assessment and Response
Guide  and other research findings [1, 2, 10, 11, 26, 27].
A 33-item structured questionnaire asked general questions regarding
frequencies of injections use, use of injections in the past, experiences and views
about a consultation in the past year and previous ones, knowledge about safe
injection use and attitudes about injections versus other administration routes.
However, all specific injection use data were focused on community members
encounter with a health care provider in the past year.
Validation of the questionnaires
Two actively working professional translators with more than 15 years of
experience and whose native language was Mongolian completed the English to
Mongolian, and back translations to assure accuracy and minimize any possible
bias. These translators were unknown to each other . The author made
adjustments resulting from any inconsistencies. For content and construct validity
of the questionnaire, a pilot study was completed. Forty community members in a
selected hospital waiting area were requested to complete the questionnaire of
which 25 agreed. These were analysed for validity and clarity. Modifications
regarding some wording terms and sequencing of the questions were made after
the pilot study, in order to improve the completeness and clarity of questions. No
major omissions were identified. These responses were not used further in the
Selection of respondents
As recommended in the guide , a sample of community members, who were
confirmed to be at least 18 years of age, was selected by administering the
questionnaire face-to-face at pre-determined public locations to obtain samples
from different socio-economic groups. Questionnaires were administered at 55
different locations. These included three public central hospitals in urban and five
district hospitals in semi-urban districts; five Family Group Practices (FGPs)
located in urban and 15 semi-urban districts; three private hospitals in urban and
semi-urban districts; one university in urban and two in semi-urban districts;
three supermarkets in the city centre and 19 small shops in the semi-urban areas.
A community member information sheet, written in Mongolian, was issued to
potential respondents and the nature of the questionnaire was explained by the
researcher. Prior to administering the questionnaire, a verbal consent was
obtained because the participation was on a volunteer basis and all participants
were de-identified. Most of the questionnaires were completed by participants. In
some cases, however, the researcher administered the questionnaire to the
participant verbally and completed the questionnaire based on their responses.
The survey took place in public quiet areas, for example hallways of hospitals,
universities or waiting areas in supermarkets, whenever possible. All
questionnaires were administered during the winter period associated with a high
prevalence of acute respiratory infections (January-March), 2010 in Ulaanbaatar,
Data from the questionnaires were entered into Microsoft Excel for basic
analysis. The statistical analysis was completed using the Statistical Package for
Social Sciences (SPSS Version 21.0). Standard descriptive statistics were used to
summarize demographic data and responses to the questionnaires (frequencies for
categorical variables, means and standard deviations for variables measured on a
continuous scale). Questions were coded as 1- Yes, 2- Sometimes, 3 No.
Dependant variables were compared by a Kruskal-Wallis Test for independence.
The differences between individual groups were identified by performing a
pairwise comparison. A p value of ,0.05 was considered to be statistically
The Human Research Ethics Committee of Curtin University, Western Australia
approved the study protocol, including the consent procedure (PH-11-2010).
Six hundred community members aged over 18 years were contacted at various
locations (pharmacies, shopping centres, hospitals and universities) in
Ulaanbaatar, Mongolia. Of these 474 agreed to complete the questionnaire, giving
a response rate of usable questionnaires of 79%. Non-respondents included
mostly people from the younger age group (1830 years), who refused to
participate when asked and those who agreed but were unable to complete the
questionnaire. Almost half of the respondents were aged between 31 and 50 years
(n5228, 48.1%), 40.9% were male (n5194), and their average income converted
into US dollars was US$193 per month (n599, 20.9%). In addition, for
comparison purposes, relevant census data are provided for Mongolia (Table 1).
A comparison of the sample of community members with population data 
indicated statistically significant differences with respondents being younger and
the sample comprising more females, more singles and separated people and
having higher education levels than the Mongolian population. Most respondents
were from the Ulaanbaatar region (n5407, 85.7%) where the survey was
Data collected on the nature and prevalence of injection use revealed that all
respondents had received at least one injection in the past and 268 (56.5%) had
received injections in the past twelve months.
All respondents reported that the most common reason for having an injection
in the past twelve months was for treatment of a disease (n5163, 60.8%), for
administration of vitamins (n570, 26.1%), and some had injections for
vaccinations and contraception (Fig. 1).
Injections were commonly reported for the management of symptoms of
weakness, respiratory symptoms, which included cough, sore throat or
To further explore the extent of received injections, respondents were asked to
indicate the number of injections they had for their last treatment. Of the 163
participants, who had injections for treatment of a disease, over 80% (n5137) had
between one and four injections and almost 16% (n526) reported five or more
injections. A single injection was usually given for vaccination and always for
contraception (Table 2).
Quality of care
In terms of using new needles and syringes, a majority of all respondents was
aware of these requirements and only 39 respondents (8.2%) said they did not
Questions regarding unwanted effects of injections in the past were presented
and about 20% of all respondents (n591) had one of the proffered side effects
after previous injections. Of this group, similar proportions experienced a warm
feeling under the skin (n523, 20.9%) or a swollen or hard lump under the skin
(n526, 23.6%). Less common was extravasation and experiencing fainting after
having an injection.
Study, N5474, n (%)
When presented with reasons regarding side effects from injections, several
possible options were put forward in the questionnaire. About one-third (n531,
34.1%) did not know that these effects could occur from an injection whereas
others attributed them to the injection or the injection techniques employed
Fig. 1. Community members stated reasons for being given an injection.
Of those experiencing side effects from injections approximately one-third
consulted a doctor (n530, 32.9%) and others went to hospital (n515, 16.7%) or
consulted a pharmacist (n56, 6.3%). However, almost one-half of respondents
did not do anything (n540, 44.0%), which may be due to respondents not
recognizing that those symptoms were side effects related to an injection or
considering them minor.
Characteristics of prescribers, suppliers and administrators of
Injection prescribers and suppliers
The current guidelines for ambulatory care specify that patients who need an
injection should be referred to a hospital . In Mongolia, most drugs can be
purchased, including injections over-the-counter (OTC) [14, 30]. Therefore, all
participants were asked about prescribers and suppliers of the last injections
administered to gain an insight to this practice. The main prescribers were doctors
(75% to 92%), who were legal prescribers. Other practitioners were less frequently
sought for prescribing/selling injections and such provision is illegal under current
regulations . Of the 474 respondents, most (n5353, 74.9%) obtained their
injections on prescription with most being dispensed from pharmacies (n5283,
59.7%). Pharmacists occasionally prescribed and supplied OTC injections
aRespondents could select more than one option.
Injection exposure per 1000 of all
respondents per year
according to 5 to 22% of respondents. It is noteworthy that nurses prescribed at a
similar frequency. Doctors illegally supplied injections to between 25 and 40% of
respondents which is an illegal practise, except in an emergency situation or as an
inpatient (Table 3).
It was evident that pharmacists dispensed/supplied the majority of injections
with or without a prescription. Approximately 15% of respondents stated that
injections were supplied each by nurses and traditional practitioners (Table 3).
Administration of therapeutic injections
In compliance with guidelines , most respondents engaged nurses as the main
health professional for the administration of injections, followed by doctors. Of all
respondents, 17 people stated traditional practitioners administered injections.
About 15% of respondents reported that injections were administered by friends
or relatives (Fig. 3).
Responses across different groups were significant by Kruskal- Wallis test
[H511.1, df52, p50.004], administration of injections by nurses was more likely
to have been to the older age group (more than 51 years) (Group 3: [M51.4,
SD50.7]) than younger ones (range: 1830 years) (Group 1: [M51.8, SD50.9]),
Respondents attitude towards therapeutic injectable medicines
When all respondents were presented with questions regarding their attitudes
toward injections, only seventy-seven respondents (16.2%) had an expectation of
receiving injections in their mind when they visited a doctor. A significant
difference was found using the Kruskal-Wallis test of the expectation of an
aSome responses were missing for each category.
injection across respondents in different age groups [H56.1, df52, p50.048],
with respondents aged over 51 (Group 3: [M52.1, SD50.8]) being more
supportive of the expectation than younger ones (range: 1830 years) (Group 1:
[M52.4, SD50.7]), p50.018. When respondents stated they preferred not to have
injections prescribed, approximately one-third reported that doctors prescribed
injections to them (n5137, 29.0%).
When asked their opinion about therapeutic injections, 40% of all respondents
agreed that injections were a better medicine (n5190) than oral medications, and
this was statistically significant between age groups [Kruskal- Wallis test, H518.5,
df52, p,0.001]. Significantly older respondents (over 51 years) (Group 3:
[M51.4, SD50.5]), agreed more with this statement when compared to younger
respondents (Group 1: [M51.8, SD50.7, p,0.001] and (Group 2: [M51.7,
SD50.7], p50.001). There were 63 (13.3%) of all respondents indicated injections
were a better medicine with 221 (46.6%) who disagreed with this statement.
However, when all participants were asked for their opinions regarding
treatment with injectable medicines, having an injection was not a personal
preference for most respondents (n5392, 82.7%) (Table 4).
An important perception regarding injections was that they hastened the
recovery process (n5269, 56.8%) and a Kruskal-Wallis test yielded a statistically
Fig. 3. Distribution of individuals who administered injections to respondents.
aSome responses were missing for each category.
significant difference between age groups [H517.5, df52, p,0.001]. In
particular, older respondents (over 51 years) (Group 3: [M51.2, SD50.5]) agreed
with this statement more strongly when compared with respondents aged less
than 51 years (Group 1: [M51.7, SD50.7]), p,0.001; (Group 2: [M51.6,
However, more than half of the respondents agreed that treatment with oral
medication was more or sometimes more effective than injections (n5280,
59.1%). In general, most respondents did not support the statement that
treatment cost was less with injections (n5291, 61.4%) with younger respondents
being significantly stronger in their disagreement than respondents older than 51
years [Kruskal- Wallis test, H512.4, df52, p50.002], (Group 1: [M52.5,
SD50.7]), (Group 3: [M52.1, SD50.9]), p50.002.
Respondents also reported that when an injection was not prescribed that only
69 respondents (14.6%) would be disappointed and older respondents aged over
51 years [Kruskal-Wallis test, H520.8, df52, p,0.001] (Group 3: [M52.1,
SD50.8]) were more likely to be disappointed if an injection was not received
(p,0.001), (Group 1: [M52.6, SD50.7]), p,0.001; (Group 2: [M52.5,
The questionnaire also asked if respondents would refuse therapeutic injections
and 39.4% respondents (n5187) answered they would refuse an injection if
prescribed. Several reasons were proffered for refusing or rejecting injectable
medicines (Table 5).
Of all participants only 22 males (11.3% of male cohort) and 19 females (6.8%
of female cohort) had refused injections in the past. As the data in Table 5
demonstrate, the main reason for possible refusal was being scared of needles and
injections (n5180, 38.1%) and acknowledging the availability of other dosage
forms than injections.
In particular, respondents aged between 18 and 30 years stated being scared
[Kruskal-Wallis test, H58.7, df52, p50.013], (Group 1: [M52.1, SD50.9])
compared with those aged over than years 51 (Group 3: [M52.5, SD50.7],
p50.013). Similarly, younger respondents [Kruskal-Wallis test, H512.1, df52,
aSome responses were missing for each category.
p50.002] were likely to accept that other dosage forms, including tablets, capsules
and other administration forms were available (Group 1: [M52.1, SD50.8]);
(Group 3: [M52.5, SD50.8]), p50.002.
In general, most respondents trusted their doctors and pharmacists. In
addition, most did not support that after a period of time a disease would be
cured by itself (n5302, 63.5%).
This is a part of a larger study that has assessed the prescribing practice of
antibiotics, including injections for mild/moderate community-acquired
pneumonia (CAP) in Mongolia . Community members views, attitudes,
knowledge and experiences regarding the prescribing of injections were analysed
in this study.
A high level of injection prescribing was evident in this study. More than half
(56.7%) of the respondents, which were an ambulatory cohort of the public, had
received injection(s) almost always for the treatment of an illness in the past 12
months. Their injection exposure amounted to 1891 per 1000 of the total sample
or almost 2 injections per person per year. Additionally this cohort was younger
and presumably therefore healthier and also less predisposed towards injections
than would be a population representative sample. Complying with current
regulations, injections were frequently prescribed by a doctor and supplied from a
pharmacy. However, doctors were found to be both prescribing and supplying
injections in Mongolia. This indicates that doctors are a major contributor to the
high level of injection use in Mongolia. The high number of doctors in Mongolia
 may be a contributing factor since the prescribing of injections can provide
repeated consultations. Some the prescribing and supply of injections was also
carried out by individuals other than specified in the regulations. Inappropriate
prescribing of injections by nurses and pharmacists should be ceased. Some
countries with comparable health systems have also reported high levels of
inappropriate prescribing and injection use [4, 10, 26, 33]. The high numbers of
doctors with respect to the population is however unique to Mongolia.
In the past decade, little has been reported regarding the perceptions and
attitudes of patients towards injections. Past literature has suggested that patients
are often one of the main drivers that fuel the inappropriate use of injections
[10, 26, 3438]. In contrast, this study found that only a minority of community
members (16%) always/often expected injections to be prescribed. From those
who expected injections, older people tended to expect injections for common
medical conditions and this reflects other findings . It is unknown whether
the younger age groups dislike of injections is a preference that changes with
ageing or the current younger generation will become a long standing barrier to
injection prescribing. There is clear evidence of the respondents understanding of
the need for clean needles and syringes predicated by HCV which maybe a
contributing factor to their dislike. Other studies, have also reported a high level
of awareness of using new syringes and needles for injection use [37, 42].
However, it is also possible that a high awareness of the associated risks of unsafe
injection practises can be a cause for an increased utilization of disposable syringes
and needles instead of alternative forms of treatment.
In Mongolia, community members indicated injections hastened the recovery
process and this was consistent with other findings [26, 37, 38]. In addition, some
community members in this study indicated that injections were a better medicine
than oral medications (n5190, 40%) and this confirmed a previous finding from
Health workers in developing countries have reported that community
members compliance was improved with injections than with oral medication
[2, 11] and similarly, doctors and pharmacists in a questionnaire study
administered as part of this overall study indicated choosing an injection was to
often avoid non-compliance problems [32, 37, 38]. It is clear that the respondents
in this study would not choose an injection as an option to improve compliance.
In addition to the formal administrators (for example: nurses and doctors),
pharmacists and friends/relatives were identified by the respondents as injection
administrators. Similarly, studies in Egypt and India reported that unqualified
medical providers, including relatives, housekeepers of government clinics and
assistants of private medical doctors often administered injections . Reasons
for choosing unqualified medical providers were explained by their availability
and accessibility at low or without any extra cost  . There are public health
issues with unqualified practitioners administering injections.
The selection of community members was not random, however the response rate
of community members was high (79%). The study aimed to recruit community
members from various socioeconomic groups, by administering the questionnaire
at 55 different regions of Ulaanbaatar, shopping centres, hospitals and pharmacies
that were located in the central and semi-rural parts and different socioeconomic
areas. However, some differences were apparent in demographic characteristics of
respondents compared with the general population. It is also possible that the
responses from community members could be influenced by issues of social
desirability. The questionnaires were however, anonymous and confidentiality was
emphasized encouraging honesty. Some of the questions were based on recall of
events which may not always be complete. Factual questions however related to
injections administered in the last year to limit this factor. Forms were assessed for
completion by the researcher to improve completion. It is possible that those who
did not volunteer may have had different views. Although the respondents were
not the same as the population the main underrepresented group was the older
age cohort and more likely to support the administration injections. Some caution
must be exercised in generalising the findings to the whole population.
These findings suggest high levels of inappropriate use of injections occurred in
Mongolia. The current high level of medical prescribing and supply of injections is
a significant potential public health hazard in Mongolia. Illegal provision of
injections by pharmacists and other health practitioners should be eliminated.
Intervention campaigns addressing issues regarding appropriate prescribing and
use of injections should be implemented for prescribers. Further research is
needed to assess the proportion of administered injections that are unnecessary
and hence could reduce the public health hazard in Mongolia.
The authors would like to acknowledge that the work presented in this paper was
a part of a Doctor of Philosophy thesis conducted at the School of Pharmacy,
Curtin University, Western Australia.
Conceived and designed the experiments: GD BS DH. Performed the experiments:
GD BS. Analyzed the data: GD BS DH RP. Contributed reagents/materials/
analysis tools: GD BS DH RP. Wrote the paper: GD BS DH RP.
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