Percent of STI patients appropriately diagnosed and treated
The percent of patients with sexually transmitted infections (STIs) at selected health care facilities who are appropriately diagnosed and treated according to national guidelines, of all STI patients at those centers
Evaluators collect data through observing and interviewing providers at selected health care facilities offering 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.
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 œ that is, trained assessors posing as clients.
“Appropriate” diagnosis and treatment is assessed according to national guidelines governing STI services. In developing countries, these guidelines will most commonly include protocols for the syndromic management of locally common sexually transmitted pathogens, including treatment with drugs specified in national drug lists. Some countries recognize both syndromic and etiological management as appropriate, according to the diagnostic capacity of the service provider. Where national guidelines are unavailable, WHO guidelines on the syndromic management of STIs may be used to guide assessment of appropriate treatment.
This indicator is calculated as:
(Number of patients with STIs who are appropriately diagnosed and treated / Total number of patients with STIs) x 100
Assessment of an external expert
WHO/UNAIDS revised guidelines on evaluating STI services; MEASURE Service Provision Assessment (SPA)
STI programs 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 such management poses fewer bottlenecks in diagnosis. Training nurses and other health care providers new to the approach and often to STI care in general has required a huge investment.
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 applied primarily to public sector STI clinics, because most of the early training in syndromic management was of public sector employees. However, people with STIs often seek treatment in other sectors œ either at private sector clinics, from pharmacies or from traditional healers. Some countries have begun to include these sectors in training programs 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.
This indicator, measured through observation but including provider interviews in the process of data collection for validation purposes, has been widely used and proven 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 over-report “correct” diagnosis and treatment, falsely diminishing the gap between knowledge and practice. However, client exit interviews and mystery patient methodologies, as well as proving feasible, have demonstrated that the biases are smaller than was assumed. The gap between knowledge and practice in the area of treatment often shaped results because service providers do not follow “correct” protocols simply because they know drugs are unavailable or unaffordable. We thus recommend that evaluators present this indicator with indicators of drug availability.
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. Program managers need scores reported separately by area of knowledge and performance so that they may identify areas of weakness and may improve program performance.
quality, sexually transmitted infection (STI), cervical cancer