You are here: Home → What We Do → Operations Research and Evaluation → Quality Improvement → QI Program Examples → Program Evaluation for the Implementation of the Revised Syndromic Management Algorithms for Sexually Transmitted Infections in Two Districts in Botswana
 

Program Evaluation for the Implementation of the Revised Syndromic Management Algorithms for Sexually Transmitted Infections in Two Districts in Botswana

Background

In the early 1990s, Botswana's Ministry of Health (MOH) adopted syndromic management for sexually transmitted infections (STIs) as part of its STI and HIV prevention and comprehensive reproductive health strategies. The MOH reviews and updates its national syndromic management protocols based on periodic etiological studies and other developments in health care.

Following an etiological study in 2002, the STI subunit of the MOH's National STI Research and Training Center, with support from I-TECH, created training materials for a three-day training to introduce the revised STI management algorithms to health care professionals nationwide. The revised algorithms included treating genital ulcer disease with antiviral therapy. At the same time, the national government put in place the policy of routine HIV testing for STI patients, which was also included in the revised algorithm. Further, material on how to deliver routine HIV testing was integrated into the training curriculum. Prior to scale-up of the training program, the MOH asked I-TECH to evaluate the effectiveness of the training program in two health districts—Chobe and Lobatse.

The objectives of this program evaluation were to assess:

  • The user-friendliness of the revised STI syndromic management algorithms.
  • Health care professionals' ability to perform appropriate STI case management after training using the revised national training curriculum.
  • The acceptability and use of routine HIV-testing procedures by health care professionals after training in the context of STI care.
  • Health care professionals' ability after training to perform appropriate patient education and counseling about STI management, risk reduction, and partner notification. 
  • Returning patients' adherence to treatment and improvements in their STI-related conditions that were treated under the revised STI syndromic management guidelines.
  • The availability, distribution, and appropriate prescription of acyclovir.

Methods

The evaluation included post-training data collection in the two intervention districts and data collection in one comparison district (South East District). Nine health facilities in the training districts and seven facilities in the comparison district participated in the evaluation. In total, 145 patient visits were observed, 350 patients were interviewed and had data abstracted from their outpatient records, and 18 key informant interviews were conducted. Two hundred and twenty five health care professionals were trained.

Findings

  • Participants' self-assessed level of knowledge and skills in key areas of the training course increased. The largest self-assessed improvements in knowledge and skills were in risk reduction, patient-centered care, and integrating STI risk assessment, risk reduction, and routine HIV testing into a primary care visit.
  • As rated by patients, health care professionals in the training districts delivered more patient-centered care than their colleagues in the comparison district.
  • Significantly more patients in the training districts reported that a health care professional physically examined them during their visit than in the comparison district.
  • Patients at the training sites were significantly more likely to be offered routine HIV testing than at the comparison site.
  • A significantly higher percentage of patients in training districts were able to cite information that the health care professionals told them about STIs than in the comparison site.
  • Health care professionals observed after training performed most steps related to history taking, but often failed to complete risk assessment steps integral to the STI syndromic management algorithms without prompting by observers.
  • Health care professionals observed after training performed most steps of the physical exam without prompting.
  • Observers prompted the health care professionals to reconsider their prescriptions for patients during 19% of visits. Observers were significantly more likely to prompt them to reconsider prescriptions for patients with vaginal discharge and/or lower abdominal pain, and less  likely to prompt for patients with urethral discharge.
  • Treatment was appropriately prescribed in 89% of the cases observed.
  • Treatments for observed patients were compared to projected treatments for the patients in an HIV prevalence study (2002), which showed evidence of under-treatment with acyclovir for patients with genital ulcer disease (GUD) and over-treatment for chlamydia and gonorrhea or pelvic inflammatory disease among patients with vaginal discharge and/or lower abdominal pain.
  • Health care professionals who attended training made good progress in providing patient-centered care, but some aspects, such as helping patients develop a risk-reduction plan and set realistic behavior-change goals, could be strengthened.
  • Some health care facilities did not have supplies needed to provide STI care, such as patient education materials, condoms, and contact slips.
  • Acyclovir was dispensed in the correct dosage 96% of the times that it was prescribed, and it was dispensed for treatment of GUD or genital herpes 94% of the times that it was prescribed.
  • The percentage of visits with contact slips did not differ significantly between training and comparison sites.

For an article based on these findings, refer to: Weaver MR, Myaya M, Disasi K, Regoeng M, Matumo HN, Madisa M, Puttkammer N, Speilberg F, Kilmarx PH, Marrazzo JM. “Routine HIV Testing in the Context of Syndromic Management of Sexually Transmitted Infections: Outcomes of the First Phase of a Training Program in Botswana.” Sexually Transmitted Infections 2008; 84(4): 259–64. The article can be accessed at http://sti.bmj.com/cgi/reprint/84/4/259.

Document Actions