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Adherence to national
guidelines in the syndromic
management of sexually
transmitted infections in
Botswana’s primary health
care
Boonstra E1, Lindbæk M1, Klouman E1,
Ngome E2,Romøren M1, Sundby J1
1
2
Department of General Practice and Community
Medicine, University of Oslo, Norway
Health Research Unit, Ministry of Health, Gaborone,
Botswana
Publ. in: In Tropical Medicine and International Health
2003,Vol 8:604-14.
Abstract
Adherence to National Guidelines on Syndromic
Management of Sexually Transmitted Infections
in Botswana’s Primary health care
Design: Cross-sectional prospective field survey
Sampling: This is a substudy of a prospective Drug utilization study
(N=2294 encounters), which includes 224 consecutive encounters of patients
with a STI. The sampling method of the Drug study was multistage: in each of
3 purposely chosen health districts - each representing an urban, semi-urban,
and rural setting - 10 primary healthcare facilities were randomly selected.
The number of encounters in each health facility was relative to the number of
outpatients in 1996.
Outcome Measures: Proportion of consultations meeting set criteria for
acceptable history taking, physical examination and appropriate treatment;
percentage of consultations with advice on partner notification and
counseling on the use of condoms; availability of antibiotics, STI algorithms,
condoms and essential equipment by health facility.
Results: In women (n=135), the criteria for acceptable history taking
were met in 34(25%), and for physical examination in 31(23%); and in men
(n=89), in 48(54%) and 51(57%) respectively. Appropriate treatment was
given to 73(65%) of the women (n=112) and to 56(81%) of the men (n=69).
Underprescription was found in 38(21%), overprescription in 12(7%), and
incorrect prescription in 2(1%) of all consultations (n=181). Advice on
partner notification was provided to 79(66%) of the women (n=120) and
71(86%) of the men (n=83). Counseling on the use of condoms was
provided to 90(75%) of the women and 74(89%) of the men. In half of the
health facilities, the lack of a fixed light source was the main constraint in
carrying out a vaginal speculum examination. In all health facilities essential
antibiotics and condoms were available. In 40% of the health facilities all
STI algorithms were displayed in the consultation room.
Conclusions: Adherence to national guidelines on diagnostic
management of STIs was relatively poor, especially in women with STIs.
One-third of the women and one-fifth of the men did not receive appropriate
treatment for their STI, in spite of excellent availability of drugs. Nurses
perform well on partner notification and counseling. Emphasis should be given
to training of nurses in clinical examinations, particularly pelvic examinations.
Background, design and
sampling
Background
Syndromic management of sexually
transmitted infections (STIs) is not ideal, and
the weakness of the health services in many
developing countries is a major drawback to
achieving high coverage of STIs with
efficacious treatment.
Design and sampling
This is a substudy of a cross-sectional
prospective Drug utilization study (N=2294
consecutive encounters), which includes 224
encounters of patients with a STI.
The sampling method of the Drug study was
multistage: in each of 3 purposely chosen
health districts - each representing an urban,
semi-urban, and rural setting - 10 primary
healthcare facilities were randomly selected.
The number of encounters in each health
facility was relative to the number of
outpatients in 1996. The survey was carried
out June-November 1998 by two nurses and a
pharmacy technician.
Study Aims
Main objective
To evaluate health worker’s adherence to
national guidelines on syndromic
management of sexually transmitted
infections.
Specific objectives
To assess:
- the quality of history taking and physical
examination
- the appropriateness of treatment
- the provision of advice on partner
notification and counseling on the use
of condoms
- the availability of essential antibiotics,
equipment and STI-algorithms
Methods 1 - Outcome measures
Outcome measures:
1. Diagnosis: proportion of consultations
meeting criteria for acceptable history taking
and physical examination.
2. Treatment:
- Appropriate: % of consultations with full
adherence to national guidelines.
- Inappropriate:
a) % unnecessary/wrong antibiotics
prescribed
b) % recommended antibiotics not
prescribed
c) % dose/duration of prescription incorrect
3. Partner notification and counseling on
condom use: % of consultations with partner
notification and counseling on use of
condoms.
4. Availability of antibiotics, STI-algorithms
and equipment: % of facilities with excellent,
fair or poor availability of antibiotics, STI
algorithms and equipment.
Methods 2
Criteria for acceptable history
taking and physical examination
History taking
Examination
Women:
Women:
• Abnormal vaginal
Vaginal
discharge and/or
speculum
genital ulcer and/or
examination
lower abdominal pain
• Pregnancy and/or
missed period and/or
recent delivery/abortion
• Recent partner change
Men:
• Urethral discharge
• Genital ulcer
• Dysuria
• Recent partner change
Men:
Physical
examination of
the affected
site
Results 1 - Materials
Number of consultations:
By district:
Gaborone (10 Cl2)
Kgalagadi (2 Cl2, 8 Hp3)
Ngami
(2 Cl2, 8 Hp3)
N= 2241
By health facilility:
Clinics (n=14)
Health posts (n=16)
102
60
62
167
57
Gender: males 40%, females 60%
Mean age: 30 years
Staff: Nurses
Enrolled nurse
Family Welfare Educators
1
86%
13%
1%
Sexually transmitted infections comprised 7.5% of the
total number of consultations (Botswana as a whole
6.5%); 2 Clinics; 3 Health post
Results 2
STI -syndrome diagnoses
FEMALES n(%)
Vaginal discharge syndrome
Lower abdominal pain
Genital ulcer syndrome
Inguinal bubo
Other
Subtotal
66 (49)
35 (26)
11 (8)
0
23 (17)
135
MALES n(%)
Urethral discharge syndrome
Genital ulcer syndrome
Inguinal bubo
Other
Subtotal
32 (36)
36 (42)
2 (2)
19 (21)
89
Total
224
Results 3
Acceptable quality of
history taking and
physical examination
(N=224)
History taking:
Examination:
Both
Women
n=135
n%
34 (25)
31 (23)
14 (10)
Men
n=89
n%
48 (54)
51 (57)
22 (25)
p
0.005
0.003
0.02
Results 4
Adherence to national
treatment guidelines
STD diagnosis group
Appropriate
n(%)
Inappropriate
n%)
Women
Vaginal discharge syndrome (n=66) 43 (65)
Lower abdominal pain (n=35)
23 (66)
Genital ulcer syndrome (n=11)
7 (64)
Subtotal (n=112)
73 (65)
Men
Urethral discharge syndrome (n=32) 29 (91)
Genital ulcer syndrome (n=35)
25 (71)
Inguinal bubo (n=2)
2 (100)
Subtotal (n=69)
56 (81)
Total (n=181)
129 (71)
23 (35)
12 (34)
4 (57)
39 (35)
3 (9)
10 (29)
0
13 (19)
52 (29)
Results 5
Availability of essential drugs,
STI algorithms and equipment
1. All essential antibiotics for treatment of STIs
at clinics and health posts were in stock
2. Supplies of condoms were adequate at all
facilities
3. All 5 STI-algorithms were displayed in 40%
of the facilities; in 50% none were displayed
4. 50% of the facilities lacked a fixed light
source, which made vaginal speculum
examination difficult or impossible
5. In 9 of 14 clinics and 2 of 16 health posts a
gynaecological examination couch was
available. In 29 of 30 health facilities an
ordinary examination couch was available.
Discussion
The loss of STI patients to the
health care system
STIs
Healthy population
Individuals with STIs in the population
Symptomatic infections
Seek health care:n(Fem)=135;nMale)=89
M
Adequate history: Fem=25%; Male=54%
F
Our
study
M
F
Adequate exam.: Fem=23%; Male=57%
Correct treatment: Fem=65%; Male=81%
STI identified and correct treatment prescribed
Partner notified:( F 66%, M 86%), but treated ?
% compliant with drug regimen
% cured STI patients
Conclusions
1.
2.
3.
4.
5.
6.
Adherence to national guidelines on
diagnostic management of STIs was
relatively poor, especially in women
One third of the women and one fifth
of the men did not get appropriate
treatment, despite excellent
availability of STI drugs
Nurses perform well with regard to
partner notification and counseling on
the use of condoms
Provision of antibiotics and condoms
was excellent
Display of STI algorithms at health
facilities was fair
Availability of essential equipment was
poor.