Appropriate diagnosis and treatment of STIs
STI programmes are focusing on syndromic management of STIs as the most practical approach in high prevalence, low resource situations. The shift to syndromic management has increased the potential coverage of care, since there are fewer bottlenecks in diagnosis. It has required a huge investment in training for nurses and other health care providers who were new to the approach and often to STI care in general.
This indicator reflects the success of that training, combined with efforts to ensure adequate supplies of drugs and other necessary materials to care provision points. It tracks changes in the provision of adequate care to patients seeking care for STIs.
Choosing which STI service delivery points to survey is important. Traditionally, this indicator has been constructed primarily for public sector STI clinics. This is largely because most of the early training in syndromic management was of public sector employees. However it is widely recognised that people with STIs often seek treatment in other sectors – either at private sector clinics, from pharmacies or from traditional healers. Some countries have begun to include these sectors in training programmes for syndromic management, and evaluations using this indicator have successfully been carried out in these sectors. Service delivery points surveyed should include representative service providers from any sector that has received training in syndromic management of STIs.
Number of patients with STIs at selected health care facilities who are appropriately diagnosed and treated according to national guidelines
All STI patients at those centres
Data are collected in observations and interviews with providers at selected health care facilities providing STI care. Providers are assessed on history taking, examination and treatment of patients. A provider must score positively on all three items in an interaction with a client for that client to enter the numerator of the indicator.
Since the development of WHO/GPA Prevention Indicators 6 and 7 (PI6 & 7) protocol researchers have tried several alternative data collection methodologies. Instead of, or in some cases in addition to, observation and provider interviews, data have also been collected through exit interviews with clients and interactions with “mystery” clients – that is, trained assessors posing as clients.
“Appropriate” diagnosis and treatment is assessed according to national guidelines governing STI services. In developing countries these will most commonly include protocols for the syndromic management of locally common sexually transmitted pathogens, including treatment with drugs specified in national drug lists. In some countries, both syndromic and aetiological management are recognised as appropriate, according to the diagnostic capacity of the service provider. Where national guidelines are not available, WHO guidelines on the syndromic management of STIs may be used to guide assessment of appropriate treatment.
Geographic location: N/A
Pregnancy status: N/A
Time period: N/A
Type of orphan: N/A
Vulnerability status: N/A
This indicator, measured through observation but including provider interviews in the process of data collection for validation purposes, has been widely used and proved to be feasible. There has been discussion of the extent to which the direct observation and provider interview methodologies bias data. It is thought that service providers perform better under observation than they normally would, or overreport “correct” diagnosis and treatment, diminishing the gap between knowledge and practice. The application of client exit interviews and mystery patient methodologies, as well as proving feasible, has demonstrated that the biases are not as great as was assumed. The gap between knowledge and practice in the area of treatment is often shaped by the service provider’s not following “correct” protocols simply because they know drugs are unavailable or unaffordable. Because of this, it is recommended that this indicator be presented together with indicators of drug availability such as that proposed in STI Service Indicator 3.
As with all composite indicators, improvements in some areas may mask deterioration in others. If service in one area is poor, the facility will score poorly on the indicator, even if service provision in other areas has progressed significantly. Programme managers need scores reported separately by area of knowledge and performance in order to identify areas of weakness and to improve training programmes.