Improving quality of sexually transmitted disease case management in rural South Africa

Abstract

Objective: To measure quality of sexually transmitted disease (STD) syndromic case management and aspects of health-seeking behaviour at baseline in an intervention trial.

Setting: Ten rural primary care clinics, Hlabisa district, South Africa.

Design: Simulated patients (fieldworkers trained to present with STD syndromes) made a total of 44 clinic visits; 49 STD patients were interviewed when exiting clinics; facilities were assessed for availability of necessary equipment and drugs; 10 focus group discussions were held with staff; and STD syndrome surveillance was performed in all 10 clinics.

Results: A total of 9% of simulated patients were correctly managed (given correct drugs, plus condoms and partner notification cards), recommended drug treatment was given in only 41% of visits, and appropriate counselling was given in 48% of visits. Among patients leaving the clinic, although 39% waited over an hour to be seen and only 37% were consulted in private, all reported staff attitudes as satisfactory or good. Only six clinics had syndromic management protocols available, three reported intermittent drug shortages, and seven lacked partner notification cards. Focus group discussions revealed good staff knowledge about STD, but showed lack of training in syndromic management and low morale. Surveillance data showed that while 75% of those presenting for care did so within 1 week of symptom onset, 27% had been treated for an STD in the preceding 3 months, and only 6% of those treated were contacts.

Conclusions: Quality of STD case management was poor despite good staff knowledge and availability of most essential resources. An intervention comprising staff training and STD syndrome packets has been designed to improve quality of case management.

PIP: The effectiveness of syndromic management of sexually transmitted disease (STD) patients--a strategy that has been proposed for introduction to South Africa's public health sector--depends on both the quality of case management and health-seeking behavior patterns. These issues were assessed in 10 rural primary care clinics in South Africa's Hlabisa district. Field workers trained to present with STD syndromes (simulation patients) made a total of 44 clinic visits. In addition, 49 actual STD patients were interviewed when exiting clinics, facilities were checked for availability of essential drugs and equipment, 10 focus group discussions were held with staff, and STD syndrome surveillance was performed. Among simulated patients, only 9% were correctly managed (i.e., given correct drugs, condoms, and partner notification cards); appropriate counseling was provided in just 48% of visits. All clients interviewed as they left the clinic reported satisfactory or good staff attitudes, even though 39% waited over 1 hour to be seen and only 37% were seen in privacy. Only 6 clinics had syndromic management cards available, 3 reported intermittent drug shortages, and 7 lacked partner notification cards. In focus groups, staff demonstrated adequate knowledge of STDs, but poor morale and a lack of training in syndromic management. Finally, surveillance data revealed that, although 75% of patients presented within 1 week of symptom onset, 27% had been treated for an STD in the past 3 months and only 6% of those treated were contacts. An intervention comprised of staff training and STD syndrome packets has been designed to improve the quality of STD case management in South Africa.