Case management and patient reactions: a study of STD care in a province in Zambia

Three methods of delivering clinic-based training on syndromic management of sexually transmitted diseases in South Africa: a pilot study

Introduction

The South African National Department of Health sought to improve syndromic management of sexually transmitted infections (STIs). Continuing medical education on STIs was delivered at primary healthcare (PHC) clinics using one of three training methods: (1) lecture, (2) computer and (3) paper-based. Clinics with training were compared with control clinics.

Methods

Ten PHC clinics were randomly assigned to control and 10 to each training method arm. Clinicians participated in on-site training on six modules; two per week for three weeks. Each clinic was visited by three or four unannounced standardised patient (SP) actors pre-training and post-training. Male SPs reported symptoms of male urethritis syndrome and female SPs reported symptoms of vaginal discharge syndrome. Quality of healthcare was measured by whether or not clinicians completed five tasks: HIV test, genital exam, correct medications, condoms and partner notification.

Results

An average of 31% of clinicians from each PHC attended each module. Quality of STI care was low. Pre-training (n=128) clinicians completed an average of 1.63 tasks. Post-training (n=114) they completed 1.73. There was no change in the number of STI tasks completed in the control arm and an 11% increase overall in the training arms relative to the control (ratio of relative risk (RRR)=1.11, 95% CI 0.67 to 1.84). Across training arms, there was a 26% increase (RRR=1.26, 95% CI 0.77 to 2.06) associated with lecture, 17% increase (RRR=1.17, 95% CI 0.59 to 2.28) with paper-based and 13% decrease (RRR=0.87, 95% CI 0.40 to 1.90) with computer arm relative to the control.

Conclusions

Future interventions should address increasing training attendance and computer-based training effectiveness.

Trial registration number

AEARCTR-0000668.

Partner notification for sexually transmitted infections in developing countries: a systematic review

BACKGROUND

The feasibility and acceptability of partner notification (PN) for sexually transmitted infections (STIs) in developing countries was assessed through a comprehensive literature review, to help identify future intervention needs.

METHODS

The Medline, Embase, and Google Scholar databases were searched to identify studies published between January 1995 and December 2007 on STI PN in developing countries. A systematic review of the research extracted information on: (1) willingness of index patients to notify partners; (2) the proportion of partners notified or referred; (3) client-reported barriers in notifying partners; (4) infrastructure barriers in notifying partners; and (5) PN approaches that were evaluated in developing countries.

RESULTS

Out of 609 screened articles, 39 met our criteria. PN outcome varied widely and was implemented more often for spousal partners than for casual or commercial partners. Reported barriers included sociocultural factors such as stigma, fear of abuse for having an STI, and infrastructural factors related to the limited number of STD clinics, and trained providers and reliable diagnostic methods. Client-oriented counselling was found to be effective in improving partner referral outcomes.

CONCLUSIONS

STD clinics can improve PN with client-oriented counselling, which should help clients to overcome perceived barriers. The authors speculate that well-designed PN interventions to evaluate the impact on STI prevalence and incidence along with cost-effectiveness components will motivate policy makers in developing countries to allocate more resources towards STI management.

Routine HIV testing in the context of syndromic management of sexually transmitted infections: outcomes of the first phase of a training programme in Botswana

Objective:

In 2004, the Ministry of Health adopted revised protocols for the syndromic management of sexually transmitted infections (STI) that included routine HIV testing. A training programme for providers was developed on the revised protocols that featured interactive case studies and training videos. An objective of the first phase of the training programme was to test its effect on four measures of clinical practice: (1) routine HIV testing; (2) performance of physical examination; (3) risk-reduction counselling and (4) patient education.

Methods:

Clinical practice in a district where providers were trained was compared with a district without training. The measures of clinical practice were reported by 185 patients of providers who had been trained and compared with reports by 124 patients at comparison clinics.

Results:

Relative to patients at comparison clinics, a higher percentage of patients of trainees reported that the provider: (1) offered an HIV test (87% versus 29%; p<0.001); (2) conducted a physical examination (98% versus 64%; p<0.001); (3) helped them to make a plan to avoid future STI acquisition (95% versus 76%; p<0.001) and (4) provided patient-specific information about HIV risk (65% versus 32%; p<0.001). Among patients offered HIV testing, the percentage who accepted did not differ between groups (38% of 161 patients of trainees versus 50% of 36 comparison patients; p = 0.260). Overall, 33% of patients of trainees and 14% of comparison patients were tested (p<0.001).

Conclusion:

A multifaceted training programme was associated with higher rates of HIV testing, physical examination, risk-reduction counselling and better HIV risk education.

Evaluation of the Quality of Care for Sexually Transmitted Infections in Primary Health Care Centres in South Africa

Sexually transmitted infections (STIs) are one of the most common illnesses among adolescents and adults in developing countries. While research from other countries indicates that a lack of financial, infra-structural and human resources are central determinants of the quality of care for STIs, South African studies suggest that there are also problems in health workers' interactions with STI patients. This study investigates the quality of care for STIs at 24 primary health care (PHC) centres in four provinces of South Africa (SA). Semi-structured interviews were conducted with STI patients and health providers. In addition, in-depth interviews were conducted with a sample of STI patients, and focus group discussions were held with diverse community groupings. Simulated patients also completed questionnaires on the care they received at the centres. Frequencies were computed on close-ended questions in order to describe patterns and trends in the data. Cross-tabulations were calculated to check for gender, provincial and urban-rural differences. Composite scores were also generated for the purpose of comparing quality of care across the different participating groups. Finally, the depth interviews and focus groups were analysed thematically. The results show that PHC centres in SA are relatively well-resourced. However, problems were found in the actual encounter between health workers and STI patients, which severely undermines the quality and effectiveness of treatment. It is strongly recommended that attention be given to health providers, in particular through the provision of further training and support in relation to effective STI management.

The syndromic approach to treatment of sexually transmitted diseases in low-income countries: issues, challenges, and future directions

BACKGROUND

Sexually transmitted diseases (STDs) are a major cause of adult morbidity worldwide. In 1991, the World Health Organization (WHO) introduced the concept of the "syndromic approach" to managing sexually transmitted diseases in low-income countries, however, there has been some controversy regarding the ongoing use of this approach.

OBJECTIVES

(1) To understand the use of the syndromic approach to managing sexually transmitted diseases in low-income countries, and to determine if evidence supports its continued use. (2) To help Canadian doctors understand the past STD management of immigrant patients from low-income countries, and evaluate the direct effect (if any) of such medical practices to the patient's health and perception of health in Canada.

METHODS

Medline was searched under the key words "sexually transmitted diseases," "developing nations," and "syndrome," as well as "algorithms," "prevention and control," and "WHO." Research articles and data were also accessed from the Web sites of WHO, UNAIDS, Reproductive Health Online (JHSPH), and the Centers for Disease Control and Prevention (USA). Data were selected based on the relevance to the topic, and research articles assessed from a methodological perspective. Most research articles were of Level II-2 evidence or lower as described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam.

RESULTS

In resource-poor countries, the use of the syndromic approach is appropriate for high-risk groups and for symptomatic individuals. However, it is still a poor screening approach when applied to asymptomatic cases, particularly in women. Risk scoring and simple laboratory tests help to increase the algorithmic sensitivity of the syndromic approach.

CONCLUSION

Syndromic management involves making clinical decisions based on a patient's symptoms and signs. Until inexpensive, simple, and accurate STD diagnostics are developed and made available for use in low-income countries, a modified syndromic approach is the most feasible method of STD management in these countries. It is useful for Canadian physicians to be aware of this approach especially when caring for women from these countries.

Quality of sexually transmitted disease case management in Nairobi, Kenya: a comparison among different types of healthcare facilities

BACKGROUND

In Nairobi, the prevalence for sexually transmitted diseases (STDs) among attenders at antenatal and family planning clinics is substantial, but knowledge about the quality of STD case management is scarce.

GOAL

To assess quality of STD case management in Nairobi healthcare facilities.

STUDY DESIGN

All the facilities in five sublocations were enumerated. In 142 facilities, 165 providers were interviewed, observed during 441 interactions with patients who had STDs, and visited by a simulated patient.

RESULTS

For observations of patients with STDs, correct history-taking ranged from 60% to 92% among the various types of facilities, correct examination from 31% to 66%, and correct treatment from 30% to 75%. The percentage of correctness for all three aspects (World Health Organization prevention indicator 6) varied between 14% and 48%. Public clinics equipped for STD care performed best in all aspects, whereas treatment was poorest in pharmacies and private clinics. The providers trained in STD management performed better than those without training.

CONCLUSIONS

Quality of STD case management was unsatisfactory except in public STD-equipped clinics. This indicates the need for improvement by interventions such as further training in syndromic management, improved supervision, and the introduction of prepackaged syndromic management kits.

Traditional healers and the treatment of sexually transmitted illnesses in rural Zambia

Lately there has been increasing interest regarding the practice of traditional healers and their use of indigenous plants to treat illnesses. Twenty-three local healers (n'ganga) in Chiawa, rural Zambia, were interviewed about knowledge, practices, and their use of indigenous plants in the diagnosis and treatment of sexually transmitted illnesses (STIs) among male clients. They were also asked about their perceptions of modern medicine. The study revealed that all the n'ganga diagnosed and treated three main types of STIs. They named them as: songeya, doroba and bola-bola. They treated the illnesses with Strychnos cocculoides; Musa species; Solanum delegoense; Ximenia caffra; Diplorynchus condylocarpon; and Croton megalobotrys. Ten of the n'ganga perceived modern medicine to be effective against STIs and five of them sometimes referred some of the clients to the local health centre. It is being argued that a scheme to incorporate the n'ganga into STD control activities in which they can be utilised to refer clients to modern medical facilities can be beneficial. Given the necessary health information and support, the n'ganga may effectively execute this scheme.

Syndromic management of sexually transmitted diseases: is it rational or scientific?

Control of sexually transmitted diseases improves the reproductive and sexual health of afflicted individuals and lowers the community burden of HIV. Preventing STDs or their complications requires health education, condom promotion and effective case management. Clinical diagnosis is frequently incorrect while laboratory-confirmed aetiological diagnosis is expensive. In resource-poor countries which lack trained personnel and laboratory facilities, syndromic management remains a rational approach to STD care. Although the approach is simplistic in design, its successful implementation requires regular monitoring and evaluation of protocols as well as supervision and training of clinicians.