Sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection and STD-related female reproductive tract infections, are a leading cause of morbidity and mortality worldwide (1-3). The consequences of unchecked STD transmission are particularly severe in developing nations. Good STD case management is a promising strategy for HIV prevention (4); this includes prompt recognition, effective treatment, and provision of education and counselling to STD patients about how to prevent further infection. Experience in STD control and family planning programmes indicates that the assessment and improvement of service quality is an essential part of programme management, leading to more effective and efficient use of resources (5-7). Recent efforts to assess the quality of STD services in the USA have relied on reviews of patient records (8) and simulated patients (9) as data sources. These sources are unavailable in most less-developed countries which need valid, reliable, and cost-effective methods for the assessment of STD service quality.
One popular approach to programme assessment is the use of indicators (10). Indicators, which are quantitative measurements of programme processes, outcomes or impact on health status, should be:
-- valid, i.e., giving a true and accurate measure of
the phenomenon under study (11, 12);
-- reliable, i.e., the measurement is consistent and
dependable across applications or time (11, 12);
-- directly related to programme activities and
anticipated outcomes, such that a change in the
indicator can be attributed to programme interventions
Indicators should be limited in number, readily interpretable, and operationally useful (14).(a) Their selection and use promote standardization of measures, permitting both tracking of the programme's progress over time and comparisons of programme strategies. Limitations in the use of indicators include the danger that programme resources will be directed to activities likely to drive indicator levels to the exclusion of other programme needs, and that the data needed to report on indicators will supplant the more complete information necessary for effective health programme management.
This paper reports on an effort to identify a limited number of indicators that can be used by programme managers and international technical assistance agencies to monitor public-sector STD control programmes, and to develop and field test a quality assurance method for the measurement of those indicators. This field test was part of a larger collaborative effort to develop comprehensive HIV/STD programme indicators involving the United States Agency for International Development, the Global Programme on AIDS of the World Health Organization, the U.S. Centers for Disease Control and Prevention (CDC), the AIDSCOM project of the Academy for Educational Development, the AIDSTECH project of Family Health International, and The Futures Group, and was carried out in collaboration with the Ministry of Health in Kingston, Jamaica.
Materials and methods
The method of clinic-based assessment (CBA) combines observations of health care service provision with an inventory of clinic resources in a representative sample of service sites. These methods have been used for health programme monitoring in both developed (e.g., 15) and less-developed (e.g., 16-18) countries.
We established a working group of experienced STD and international health professionals (epidemiologists, trainers, public health advisers, and social scientists) who drafted the assessment instruments by abstracting key elements of STD case management from the clinical practice guidelines of both CDC and VMO (4, 7, 16).(b,c) Draft instruments were pretested in STD clinics in Atlanta (GA, USA) and in Kingston, and revised as needed. …