Evaluating STI - Health Systems Trust

Evaluating Quality of STI Management
at a Regional Level Using the
District STI Quality of Care Assessment Tool
DISCA
Reproductive Health Research Unit
1301 Maritime House
Salmon Grove
Durban 4001
Tel: (031) 304 8383
Fax: (031) 304 8468
Email: a.moys@rhru.co.za
Health Systems Trust
402 Maritime House
Salmon Grove
Durban 4001
Tel: 031-307 2954
Fax: 031-304 0775
Email: hst@healthlink.org.za
Developed by:
Anne Moys (RHRU) in conjunction with other
members of the Reproductive Health Research Unit
(RHRU), Health Systems Trust (HST) and district staff
in the Free State, Mpumalanga, Gauteng and the
Eastern Cape.
The National STI Initiative is funded by
The Henry J. Kaiser Family Foundation (USA)
This guide was developed through the work of the National STI
Initiative, based on the experience of using the DISCA in over 100
clinics across 5 different Provinces.
The National STI Initiative is a collaboration of:
The information contained in this publication may be freely distributed
and reproduced, as long as the source is acknowledged, and it is
used for non-commercial purposes.
August 2002
Reproductive Health Research Unit – University of Witwatersrand
Initiative for Sub-District Support – Health Systems Trust
Provincial Departments of Health (Free State, KwaZulu-Natal,
Mpumalanga, Gauteng, Eastern Cape, Northern Cape)
This publication is also available on the Internet
www.hst.org.za
Designed by The Press Gang Tel: 031 566 1024

Contents
Purpose of this booklet Page 1
Key steps in conducting a DISCA assessment Page 1
Providing immediate feedback Page 2
DISCA analysis at a district level Page 3
Summary sheets Page 3
Summary of DISCA results
◆ Data Page 5
◆ Partner management Page 6
◆ Safe examination and treatment Page 8
◆ Staff workload and training Page 11
◆ STI drugs Page 12
◆ Treatment of STI clients Page 15
◆ Knowledge of correct treatments Page 16
◆ General comments Page 17
Key step 11 – Identify strengths and weaknesses Page 18
Key step 12 – Write a report Page 19
Key step 13 - Feedback to clinics Page 23
Key step 14 – Decide on priorities Page 23
Key step 15 – Develop an action plan Page 24

Purpose of this booklet
This booklet is a step-by-step guide for monitoring and evaluating
some key aspects of quality of STI management at Primary Health
Care facilities in the public sector.
It is written for District Managers, Clinic Supervisors and STI
Coordinators to assist them in developing a plan to evaluate the quality
of care in the clinics for which they are responsible and to develop
action plans for improving this care.
It is based on the use of a quality improvement instrument, the District
STI Quality of Care Assessment (DISCA). The DISCA was developed
after extensive consultation with nurses, public health professionals
and health service managers, and measures key input, process and
output indicators related to management of people with sexually
transmissible infections (STI).
This booklet is part of a package of resources related to the DISCA.
The package includes – A Practical Guide to Using the DISCA, a
shorter guide to the DISCA, the DISCA form itself and a set of summary
sheets for analysing information from 6 clinics.
This booklet focuses mainly on analysing, interpreting and reporting
on the findings from several completed DISCA forms.
– 1 –
Key steps in conducting a
DISCA assessment
(This guide deals primarily with steps 10 – 15)
1. Identify the appropriate and relevant people concerned with
the quality of STI care in the clinics. At the District level,
these would include the District STI/HIV coordinator, the
Maternal and Child Health (MCH) coordinator, the Primary
Health Care trainer, the clinic supervisors and the District
medical officer. If possible it would be good to have
representation from local authority clinics, the private sector
(including occupational health sites) and any relevant NGOs
in the area.
2. Bring this team together to discuss the issue of quality of
care in the clinics and examine the DISCA tool as a method
for improving quality.
3. Discuss how the DISCA can be used in the District, including
suggestions on additional data to be collected, how the data
will be collected, analysed and used.
4. Discuss the importance of the quality and completeness of
data.
5. Compile a complete list of clinics in the district and decide
whether the DISCA will be used in every clinic or whether a
representative sample will be evaluated.
6. Allocate each clinic to be evaluated to a supervisor or STI
coordinator. Decide on the deadline for the completion of
the DISCAs.

7. Inform all clinics in the District of the plan for evaluating
STI quality of care.
8. Ensure that everyone who will be completing a DISCA
understands the purpose and the content of the DISCA. If
necessary go through the booklet ‘A Practical Guide to Using
the DISCA’ together.
9. Follow up any outstanding DISCAs after the agreed upon
deadline.
10. Analyse the information, either manually using the summary
sheets available, or using a computer programme such as
EPI-INFO.
11. Identify strengths and weaknesses revealed in the DISCA.
List all the issues that need addressing.
12. Write a report identifying the key issues that need
addressing. Putting some of the information in graph form
can be a very helpful way of presenting the information.
(See the examples in the DISCA report on pages 20-21)
13. Discuss the findings with district teams and ensure there is
feedback to individual clinics.
14. Decide which issues are a priority to address.
15. Develop an action plan to address problems and
shortcomings. Consider who should be included in the group
that develops this plan.
16. Follow up to ensure that actions are implemented. One way
of follow up is to repeat the DISCA after 6-9 months.
– 2 –
Providing immediate
feedback
Usually when the DISCA is being conducted at a clinic, it is part of a
District plan to evaluate the quality of STI care. It could be used by a
supervisor responsible for a group of clinics or a facility manager in
charge of one clinic. Some feedback should be given immediately to
clinic staff at the time the DISCA is conducted.
If it is part of a district plan, the findings also need to be evaluated
from a broader perspective, to identify whether problems need
addressing at a group of clinics, a district, or even a provincial level,
or whether they just relate to factors within one clinic.
The immediate feedback to the clinic should include the following:
◆
◆
◆
Compliment the staff on good work you have noticed.
Discuss with staff the problems that have been
identified and ways of overcoming these. There is space
to record this at Q27 and Q28 of the DISCA.
Evaluate your own performance in handling the
assessment and ask for feedback from the clinic staff.

DISCA analysis at a
district level
There are computer programmes available that could be used to
analyse the information from the DISCA reports, however the majority
of people who would be using the DISCA in their local clinics would
not have access to these programmes. This booklet will therefore
focus on manual analysis of the information.
Summary sheets are available on which the findings from 6 clinics
can be represented.
In using these summary sheets, clinics should be grouped according
to the District structure. For example, clinics that fall under one
supervisor should be analysed together.
Ensure that all the reports have been submitted and follow up on any
that are missing.
Summary sheets
– 3 –
Practical Task – Summarise the information from 4
DISCAs
The summary sheets have been reproduced in the following pages.
They are broken down into smaller units with comments on how to
record and interpret the information.
Information from 4 DISCA reports has been filled in to provide
examples and give some practice in interpreting the information.
Calculate the averages and percentages in the appropriate places.
The second column of the summary sheet gives guidance about where
to find the information requested.
From the information filled in on the summary sheets, list the various
issues that need addressing and record these on a sheet of paper.
Appendix 1 provides some comments on the information from the 4
DISCAs entered on the summary sheets.
Quality of Information
When summarising the information from the DISCA forms, you may
find that some of the information is clearly incorrect. For example,
the number of adult clients entered may exceed the total number of
clients. There may also be sections of the form that are not completed.
The summary sheets do not record every item on the DISCA. For
example, they do not reflect whether after hours services are available
in an area, nor whether privacy can be provided at the clinic. They
focus on the aspects of management that could be improved without
major policy changes or changes that would be costly e.g. creating
more space at a clinic to improve privacy.
The quality of the information itself tells you something about the
quality of care at the clinic.
It is usually not a cost effective use of time to try to get all the correct
information at this stage, but investigating these matters would be
part of the feedback that needs to be given to the clinic staff.
Obviously if figures are clearly incorrect, it does not make sense to
use them in calculating percentages.

– 4 –
If the people completing the DISCAs have not been properly oriented
about the information required and the value of gathering it, the quality
of information may well be unsatisfactory.
When analysing DISCAs
The information you get is
the information you use.
Key Step number 10 - Analyse the
information
The following pages give the summary sheets with a guide to using
them to analyse the information in the DISCAs.

– 5 –
SUMMARY OF DISCA RESULTS
Clinic name Clinic name Clinic name Clinic name Clinic name Clinic name
1. DATA
Clinic A Clinic B Clinic C Clinic D
This section gives information on the proportion of clients that are treated for an STI. Many clinicians have the impression that 10% or more of their
clients are treated for STIs. The records usually show a much lower figure.
The number of ANC and FP clients is included so that they can be compared with the number of clients treated for an STI. Often ANC and FP clients
are not asked whether they have any STI symptoms, nor are they made aware of their risk of STIs if they are not in a mutually monogamous
relationship or not using condoms. Unless FP clients are using dual protection – a method or methods that protect against both pregnancy and
STIs, they may well have STIs.
If the clinic is open 6 or 7 days a week the average number of STI clients per day needs to be calculated using the number of days the clinic was
open for the month in question.
Total number of clients in the last month Enter number from 6a Not entered 4127 Not entered 2089
Total number of adult clients Enter number from 6b 1330 3224 Not entered 1712
(over 5) (over 5)
Total family planning clients Enter number from 6c 433 426 Not entered 329
Number of first visit ante-natal clients Enter number from 18b 30 55 Not entered 40
Percentage antenatal clients with Answer from 18c x 100 30 x 100 55 x 100 40 x 100
positive RPR Answer from 18b 1 3 3
Percentages need to be calculated for the last row above using the figures given and multiplying by 100.
Where the numbers of first visit antenatal clients are small, as those above, the percentage of those with positive RPRs is not a reliable indication
of the level of syphilis in the community. However, if there were more than 100 first antenatal clients and 20% or more of them had positive RPR
results, this would be a point to take note of. A more reliable figure for ANC syphilis prevalence would be the results over a whole year.

– 6 –
Total antenatal clients Enter number from 6d 76 236 Not entered 149
Total STI clients Enter number from 6e 41 126 Not entered 14
Average number of STI clients
Total STI clients 6e
per day 20
Percentage of adults treated for STIs Total STI clients 6e x 100
Total adult clients 6b
STI clients as percentage of Total STI clients 6e x 100
FP + ANC clients
Total FP + ANC clients
The percentage of STI clients in relation to total adult clients as well as in relation to FP and ANC clients gives some indication as to whether
clinicians are screening for STIs amongst clients who may be at risk, but have come to the clinic for another reason.
To calculate the percentage of adults treated for an STI, take the number from 6e (STI clients), divide it by the number from 6b (total adult clients)
and multiply the answer by 100.
The percentage of STI clients in relation to FP and ANC clients involves adding the number of FP clients (6c) to the number of ANC clients (6d).
Divide the number of STI clients (6e) by this total and multiply the answer by 100.
Do these percentages reflect the expected prevalence of STIs in the community?
How do they compare with the HIV prevalence for the Province - or for the district (if you know this figure)?
PARTNER MANAGEMENT
Partner notification cards in all
consultation rooms? Enter answer from 16a Yes Yes Yes No
Notification cards in local language? Enter answer from 16b Yes No No No
Looking at the information entered in this example, the question arises as to how one clinic in the area has partner notification cards in a local
language and the others do not. Has the information been filled in correctly? Has one clinic designed their own partner notification card? Does one
clinic serve a community of a different language group from the others?

– 7 –
Why does one clinic not have partner notification cards at all? Have they just failed to order them? Do they feel it is not necessary to provide STI
clients with some sort of written communication for the partners?
Availability of partner notification cards does not necessarily mean that there is effective communication with STI clients about the importance of
partners being treated.
Number of partner cards issued Answer from16c 26 87 No record No record
Number of partners treated Answer from 16d 4 7 No record No record
Partners treated as percentage Answer from 16d x 100
of STI clients
Answer from 6e
Partners treated as percentage Partners treated 16d x 100
of cards issued
Partner cards issued 16c
Partner cards issued as No of cards issued 16c x 100
percentage of STI clients No of STI clients 6e
Although the partners of the index clients at a particular clinic may seek treatment from another service, the number of partners coming for
treatment can give an indication of the awareness of the need for partner treatment within the local community.
If the percentage of STI clients who come as partners is recorded over a period of time, this can give an indication of whether there is improved
communication about partner management.
How does the number of partner cards issued compare with the number of clients treated for STIs?
The number should be at least the same, if not more. Every client treated for an STI should be informed of the importance of the treatment of the
partner/s, so every client should be given one or more partner notification cards.
If the number of cards issued is much less than the number of clients, is this because:
◆
◆
◆
There is a shortage of cards
Clinicians don’t give cards to all clients
They give them but forget to record it?
Not all clinics record the information about partner management. As it is an aspect of STI management that remains a challenge, tracking the
number of partners treated each month provides a useful guide as to whether there is improving communication about the importance of partner
management.

– 8 –
2. SAFE EXAMINATION AND TREATMENT
This section looks at resources. Are they sufficient for providing good quality of care?
If speculum examinations are not done on most women, what is the reason for this? Is it due to inadequate resources, or is there a need to train in
the skill of doing the examination or the understanding of the importance?
Number of consultation rooms for
STI clients Enter number from 3 or 4b 6 6 4 5
Number of couches Enter number from 7a 7 4 4 5
Number of examination lights working Enter number from 7b (ii) 7 4 3 1
Number of specula Enter number from 7c Not entered Yes Yes Yes
(number not given)
Is there enough equipment for
proper examination?
Enter yes or no and
what is in short supply
In order to answer this last question, look at the number of consultation rooms recorded and then the number of couches, lights and specula. Does
it seem that an adequate genital examination could be conducted in all the consultation rooms? If not, which pieces of equipment are in short
supply? In the example above none of the clinics has entered the number of specula available. It is usually not an efficient use of time to follow up
each item that is not recorded as it should be. It is clear that in one of these clinics there are not enough functioning examination lights to do
speculum examinations in all consulting rooms – and this clinic records that only a few women are examined.
It is not always easy to know how many specula are enough. Some of the factors that influence this are:
◆
◆
◆
The method of sterilisation – do they have to be sent away for sterilisation? Do they have to be soaked in a biocide for 12 or more
hours?
Is there a policy about doing Pap smears? If so, about how many are done each day?
Are clients who are starting a method of contraception for the first time examined with a speculum? If so, about how many of these
clients are seen each day?

– 9 –
To what extent are speculum
examinations done? Enter answer from 8 Most Most Most A few
This answer is a subjective view obtained from clinicians at the clinic. However, it does give some insight into whether women with STIs are
examined with a speculum. Clinics may record that most women are examined and yet they may not have any functioning lights. Are they
recording what they think the answer should be?
If most women are not examined, the reason for this needs to be investigated. Is it due to:
◆
◆
◆
◆
◆
◆
Insufficient equipment (Even if there is insufficient equipment, it is not appropriate to assume that that is the only reason why more
examinations are not done.)
Lack of awareness that speculum examinations are part of comprehensive examination of women with STIs.
Lack of confidence in carrying out speculum examinations.
A perception that the clinic is too busy to have time to do speculum examinations.
Lack of motivation about providing quality care.
A combination of these factors?
Current syndromic protocols
in all consulting rooms? Enter answer from 9b Yes Yes Yes No
Are individual client education
materials available? Enter answer from 9c Yes Yes Yes Yes
Are education materials in
a local language? Enter answer from 9d Yes Yes No Yes
If most of the clinics in an area have protocols in all consultation rooms and appropriate client education leaflets available, what is the reason why
one or two clinics do not?
It is important to recognise that availability of resources does not automatically mean effective use of these resources. Quality of care needs to be
assessed on the actual management of clients and not just on the availability of all the necessary resources.

– 10 –
Turn-around time for RPR results Enter answer from 11b 2-3 days 2 weeks 3 days 2 days
Here too, it should be noted whether a delay in obtaining blood results is common to all the clinics in an area or only for one or two. In other words,
is it a problem relating to a particular clinic, or is it a problem affecting the whole area?
If most of the clinics have a turn around time of a week or more, further investigation is needed to find out the cause, and to explore ways of
speeding up obtaining the results. Often the delay relates to transport problems. In this case is it possible for test results to be faxed to clinics?
Condoms out of stock in last month? Enter answer from 12 No Yes No Yes
With this question it is important to try and establish whether it has been answered correctly. In this case a ‘No’ answer means that there has been
a constant supply of condoms.
In the example above, 2 clinics recorded shortage of condoms and the other two had sufficient. Is this what they actually meant in their answers?
Is there a problem with condom supply in the area? Are the clinics which run out of condoms more active in condom promotion than the others and
therefore use more condoms than the neighbouring clinics?
Is condom access both easy Check information in Easy and
and private? answer 13 private Easy Easy Easy
Where are condoms kept in this facility? Do clients have to get them from a clinician or can they easily help themselves? Are there places where
they can help themselves without anyone else seeing – e.g. the toilets? Are they in all consultation rooms where clinicians can provide them and
demonstrate how to use them if necessary? What impression does the answer to this question give about the attitude to condom promotion at this
clinic?
Is there a dildo available? Enter answer from 14b Yes Yes Yes Yes
As is the case with education materials, the presence of a dildo does not necessarily mean effective and appropriate communication about condom
use.

– 11 –
3. STAFF WORKLOAD AND TRAINING
This section gives information on the workload of clinicians as well as what proportion have undergone specific training in syndromic management
and HIV counselling. Have at least half of the clinicians been trained in syndromic management, and is there at least one clinician trained in HIV
counselling?
Total number of professional nurses Enter number from 21a 5 6 3 5
Average number of clients per day Total number clients 6a
Number of working days
Average number of clients per
clinician per day
Number of clients per day
Number of clinicians 21a
Calculating the average number of clients per clinician per day will give an indication of the workload at each clinic.
The total number of clients was the first figure recorded on the summary sheet – taken from 6a on the DISCA.
The number of working days depends how many days a week the clinic is open and how many working days there were in that month. This number
could range from 20 (clinics open 5 days a week ) to 30 (a clinic that offers a 7 day a week service).
Number trained in syndromic
management Enter number from 21b 4 6 3 1
Percentage trained in syndromic Number trained 21b x 100
management
Total number clinicians 21a
When looking at the percentage of clinicians who have been trained in syndromic management, it would be useful to compare this with the
percentage of clients given the correct treatment (The last item under Section 5 of the summary sheet). Are more clients receiving correct
treatment at those clinics where more clinicians have been trained? If not, (as in the examples of Clinic B) other factors also need to be considered.
Were all the drugs available for correct treatment? Did the incorrect treatments relate to the drugs that were out of stock?
Attending a training course does not always mean that what was presented during the training is being implemented in clinical practice.

– 12 –
Number trained in HIV counselling Enter number from 21c 1 6 1 0
Percentage trained in HIV counselling Number trained 21c x 100
Total number clinicians 21a
Are there sufficient staff trained in HIV counselling to be able to offer HIV counselling at that clinic to any client who might want to be tested? Are
other categories of staff trained in HIV counselling? Are they competent to do the counselling and if so, are they given the opportunity to do it?
Sometimes professional nurses are reluctant to trust assistant nurses or lay counsellors with the responsibility of counselling even if they are
competent. Part of effective STI management involves helping clients become aware of their HIV risk and being able to provide pre-test counselling.
Pre-test counselling may be of more value than the actual tests and its results, as effective counselling can contribute to behaviour change that
reduces risk of further STIs.
STI DRUGS
If there is a problem with drug supply, does it apply to all clinics? If not, why do some clinics have a problem and not others? Which of the drugs are
most often out of stock? Why is this?
Were all STI drugs in stock for
both months? Enter yes or no from 23 No No Yes No
Which drugs were out of stock? Enter drugs from 23 Ciprofloxacin Cipro, Erythro, Doxycycline
Flagyl
Shortage of any of the drugs is obviously an issue that needs resolving as soon as possible. Although several of the STI drugs have alternatives that
are available at clinics, these drugs are invariably more expensive than the recommended drug and may also have more side effects, resulting in
the client not completing the full treatment.
The DISCA does not provide information on the reasons for the drug shortages. Where all clinics have shortages, the problem usually lies outside
the clinic, but if only one or two clinics are short of drugs it could be related to the drug management at the clinic. Further investigation is needed
to establish why all the drugs are not always available. An appropriate strategy can then be developed to overcome the problem.
Clinic staff may feel that they cannot do anything about problems that are beyond the clinic, but that is not the case. The frustrated clinician who
cannot prescribe what is necessary for the client may be the most effective person to raise this problem with the department responsible for drug
supplies.

– 13 –
This page is taken from a completed DISCA. Indicate whether the treatment is correct using the 3 columns for correct drug, dosage, frequency and
duration. Then use the information to fill in one of the blank columns on the summary sheet on page 15 in order to practise transferring this
information into the summary. Comments on the exercise are on the following page. The assessment of correct treatment is based on the National
Protocols published in 1997 that were still in place in mid 2002.
24. Fill in the information below for the 10 most recent clients treated for an STI. Use the client cards, daily register or pharmacy records to obtain the information
STI clients Syndrome What type of drugs did the patient receive? Correct drug Correct dosage Correct RPR test
frequency & requested
See codes
duration
below State the type, dose and duration Yes/No Yes/No Yes/No Yes/No
1. 2 Cipro 500mg stat, Doxy 100mg bd
2. 6 (BOM) Cipro 500mg stat, Doxy 100mg bd
3. 6 (RPR) Benz Pen 2.4 mu imi weekly x 3
4. 3 Cipro 500mg stat, Doxy 100mg bd, Flagyl 400mg tds x 5 days
5. 2 Cipro 500mg stat, Doxy 100mg bd, Flagyl 2g stat
6. 4 Benz Pen 2.4 mu imi weekly x 3, Erythro 500mg tds x 7 days
7. 1 Cipro 500mg stat, Doxy 100 mg bd x 7
8. 2 and 3 Cipro 500mg stat, Doxy 100mg bd, Flagyl 400mg bd x 7 days
9. 6 (LGV) Doxycycline 100mg bd x 7 days
10. 1 and 4 Cipro 500mg stat, Doxy 100mg bd x 7 days, Benz. Pen 2.4mu stat
Syndromic Codes: (to be used in the 2 nd column above);
1 – Penile discharge 2 – Vaginal discharge 3 – Pelvic inflammatory disease (PID)
4 – Genital Ulcers 5 – Genital warts 6 – Other STI (specify)

– 14 –
Comments on the Client Record
1. The drugs and dosage are correct but the frequency and duration cannot be commented on as it is not recorded. It could be considered
to be a fully correct treatment.
2. This should have been entered as 1 (penile discharge). The treatment suggests this was a male (All clients in this DISCA diagnosed with
vaginal discharge or PID were given Metronidazole, so the staff here are clearly aware that this is part of the treatment for women.)
Burning on micturition in men who are at risk of STIs should be treated as urethral discharge.
3. This is the correct treatment for this diagnosis.
4. Some protocols recommend that Metronidazole should be given bd and others tds. Clinicians should follow the protocol for their area.
The duration should however be 7 days.
5. The duration of Metronidazole is not given for several of these clients. It can be assumed that the correct duration was prescribed as the
two that are recorded are correct.
6. Protocols also vary on the duration and frequency of Erythromycin. This should correspond with the protocol for this area. However only
one dose of Penicillin is needed to treat genital ulcers.
7. This treatment is correct.
8. If a woman is diagnosed as having PID it is not necessary to include a diagnosis of vaginal discharge. PID is a result of an untreated
cervicitis which may have been symptomatic or asymptomatic. See 4 above for the comment on Metronidazole.
9. In the National STI Protocol booklet of July 1997, the treatment for LGV is given on the inside of the back cover. The duration of
Doxycycline that is recommended is 14 days.
10. This client has been treated for urethral discharge with the addition of Penicillin. If chancroid infection is present it will remain untreated.
If Erythromycin 500mg qid was given for 7 days in place of the Doxycycline, it would be effective against both chlamydia and chancroid.

– 15 –
5. TREATMENT OF STI CLIENTS
This is a key section of the DISCA
Did every clinic fill in 10 clients? If not, is it because they diagnose so few? Were the recorded treatments correct in every respect? The column for
each clinic is divided in two so that the total number of clients treated can be recorded on the left side and the number correctly treated on the right
in the columns headed X. The total number of clients correctly treated will be the sum of the figures in the right hand columns.
Look at the numbers of clients with each syndrome. Is this what you would expect? Discharges are usually the most common syndrome. PID
means that this woman did not get effective treatment at the stage when she had cervicitis which may have been asymptomatic, but might have
caused a discharge that she did not consider abnormal. This is one of the reasons why it is important to look out for the possibility of STIs amongst
all clients who may be at risk – i.e. sexually active and not consistently using condoms if the relationship is not mutually monogamous.
On the basis of the information below, are there any issues that need investigating? What action needs to be taken?
X X X X X X
Number of treated clients recorded Enter number from chart 24 10 10 10 10
Number of clients with urethral discharge Enter number from chart 24 3 3 3 3 4 4 4 4
Number of clients with vaginal discharge Enter number from chart 24 3 2 3 0 3 2 4 4
Number of clients with PID Enter number from chart 24 2 1 3 0 0 0
Number of clients with genital ulcers Enter number from chart 24 1 1 1 0 3 3 1 0
Number of clients with warts Enter number from chart 24 1 1 0 0 0
Number of clients with other STI Enter number from chart 24 0 0 0 1 1
Number of clients (all STIs) correctly treated Enter number from chart 24
Percentage clients correctly treated Number correct X 100
Number recorded
There is more than one combination of drugs that can be used effectively to treat STIs syndromically.
Many provinces follow the protocol recommended by the National STI Directorate, but some provinces have chosen to use protocols that differ in
certain respects. Clinicians should follow the treatment recommended for that province. Where different clinicians follow different protocols within
the same area, this can lead to confusion resulting in some clinicians not providing correct treatment. If the treatment recorded would be effective

– 16 –
in treating that syndrome, it could be counted as correct treatment, even if it differs slightly from the local protocol. However, if it differs from the
recommended protocol and there is any uncertainty about whether it is effective, it should be considered incorrect. If clinicians are consistently
using a protocol that differs from the one recommended for their province, this should be addressed.
Sometimes there are a number of clients recorded as 6 (other STI). The treatment might give an indication what this ‘other’ STI is. Some clinicians
enter a diagnosis of BOM and provide the treatment for urethral discharge. This is an appropriate treatment for a man complaining of burning on
micturition who is at risk of STIs and where differential diagnoses have been excluded. This should be entered as urethral discharge.
Some clients have several STIs simultaneously and may be treated for both discharge and ulcers. The simplest way to enter this is probably as 6
(other STI). In deciding whether the client was treated correctly, the treatment should be effective for both syndromes. If only one syndrome is
effectively treated, this should be counted as an incorrect treatment.
Where there are incorrect treatments, do they mostly relate to the same syndrome? What aspects of diagnosis and drug management need to be
corrected? Are the errors common to several clinics? Are the incorrect treatments due to the correct drugs not being available at the clinic?
6. KNOWLEDGE OF CORRECT TREATMENTS
This section looks at whether clinicians know the correct treatments without consulting the protocol. Does this information correspond with the
treatments recorded in the client record section of the DISCA? Is their knowledge correct on all scores – drug, dosage and duration?
Correct urethral discharge treatment Enter from 25a (i) Yes Yes Yes Yes
Correct vaginal discharge treatment Enter from 25a (ii) Yes Yes Yes Yes
Correct genital ulcer treatment Enter from 25a (iii) Yes Yes Yes No
Correct treatment in pregnancy Enter from 25b Yes No No Yes
Correct alternative to Doxycycline Enter from 25c No Yes No Yes
In some provinces pregnant women are treated for vaginitis (Metronidazole if it is after the first trimester) and asked to return if the discharge has
not cleared within a week. They are then treated for cervicitis at the return visit (spectinomycin or ceftriaxone and Erythromycin). Spectinomycin
or ceftriaxone may not be available at all clinics.

– 17 –
Although most protocols do not specifically mention Erythromycin as an alternative drug to Doxycycline in the treatment of discharges, it is
apparent from the treatment recommended for pregnant women with an STI discharge that Erythromycin can be used instead of Doxycycline. The
recommended drug should always be the first choice. The alternative should only be given if the recommended drug is not available, or if there is
a reason why that particular client cannot take the recommended drug. Amoxycilline 500mg t.d.s. x 7 days can also be used to treat chlamydia,
but is not effective against other organisms that might be part of a non-gonococcal discharge.
7. GENERAL COMMENTS
Take note of the comments that are made in section 26. Do the problems relate mostly to clients, (e.g. partners refuse to come for treatment,
clients are promiscuous, clients don’t comply with the treatment) or do they also speak of the clinic situation (e.g. transport problems, insufficient
time to do effective health education, staff not trained in syndromic management)?
The way that this section is answered can give some insight into the attitude that clinicians have towards clients with STIs.
On the whole when clinicians do mention problems that relate to the clinic, they tend to be points about lack of resources – insufficient specula/
lights/staff etc. The implication is that if they had everything they needed, the quality of care would be good. Awareness sometimes needs to be
created about how the actual quality of the consultation could be improved.
Apart from recording the information given in the DISCA, it is important to ask several questions:
◆
◆
◆
What is the quality of the data? Were sections not completed? Is this because the records at the clinic are inadequate, or was the
person completing the DISCA not adequately skilled or not committed to doing the task properly?
Were the questions on the DISCA correctly interpreted? Sometimes the client record review is filled in with one case of each
syndrome, which suggests this person thought this section sought to find out if the correct treatment for each syndrome is known.
Feedback to the clinic on the findings is essential. Clinicians at the clinic should be involved in discussing how quality can be
improved, based on the information in this evaluation.

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Responding to DISCA findings
Once the DISCA information has been summarised and analysed,
note should be taken of those aspects of care that are functioning
well and those aspects that need attention.
Key Step number 11 – Identify
Strengths and Weaknesses
List of Strengths and Weaknesses from the 4 Examples
◆
◆
◆
◆
◆
List the strengths and weaknesses in care revealed in
the DISCA reports. Which of the problems are common
to several clinics, and which relate only to a specific
clinic?
Write a report on the DISCA findings and send copies
to the STI Coordinator, Regional Management team
and the individual clinics.
If there were problems relating only to a specific clinic,
arrange another visit to this clinic to discuss these
issues with the staff. Try to establish the reasons for
the problems and involve them in planning how they
can be remedied.
Meet with the district team to discuss the findings and
to explore the reasons for these problems.
Decide what the main problems are and discuss with
the team the action plans for addressing them.
Strengths
◆
◆
◆
At 3 out of the 4 clinics most women with STIs are
examined with a speculum.
All except 1 clinic have the current syndromic protocols
in all consultation rooms.
All clinics have client education materials, although at
one clinic these are not in the local language.
◆ The turn-around time for RPR results in all except 1
clinic is 3 days or less.
◆
◆
◆
All clinics have a dildo.
At 2 of the clinics all clinicians are trained in syndromic
management. At a third clinic only one person out of
5 has not attended a formal training.
Clinicians at all clinics were able to state the correct
drug treatment for urethral and vaginal discharge.
Weaknesses – most clinics
◆
◆
From the number of STI clients recorded, it seems as
though clinicians don’t look out for the possibility of
STIs in clients who attend the clinic for another reason.
Only 2 clinics record the number of partner cards issued
or the number of partners who come for treatment. In

– 19 –
both these cases less cards were issued than the
number of clients seen.
◆
Clinic D has only one clinician trained in syndromic
management.
◆
◆
Only one clinic has partner notification cards written
in a local language.
Only one clinic has a functioning examination light in
all consultation rooms.
◆
At clinic B only clients with urethral discharge received
the correct drug treatment, and 3 out of 10 STI clients
were diagnosed with PID.
◆
◆
◆
◆
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Two out of four clinics were short of condoms in the
previous month.
Only 1 clinic has condoms in an area where the client
can take them without being observed.
At two of the clinics only one person is trained in HIV
counselling and at one clinic no clinicians have this
training.
Three of the clinics have problems with drug shortages.
At only 1 clinic were all 10 clients given the correct
drug treatment.
Clinicians are not clear about the correct drug
management during pregnancy, nor are they aware
that Erythromycin can be used to treat chlamydia.
Key Step number 12 – Write a Report
This is a sample report on the 4 DISCAs entered in the summary
sheets of the preceding pages.
The list of strengths and weaknesses that was drawn up could be
attached to the report.
Where possible, use graphs, charts or tables to present the information
as this usually conveys a clearer message than a written description.
Even if you do not have access to a computer programme that will
produce graphs, some of the graphs used here could easily be done
by hand.
Weaknesses at one particular clinic
◆
◆
There seems to be a problem with record keeping at
Clinic C.
Clinic D does not have syndromic protocols or partner
notification cards in all consultation rooms.
Remember that a diagram or graph
will usually convey a message more
effectively than just a written sentence.
◆
At clinic B it takes 2 weeks to get RPR results.

Background
Report on the quality of
STI care at 4 clinics based
on the DISCA
During July quality of STI care was assessed at Clinics A, B, C and D
using the District STI Quality of Care Assessment tool (DISCA).
A meeting was held with the 4 facility managers at which the
completion of the DISCAs was discussed. Opportunity was provided
for the facility managers to ask any questions they had about the
tool.
Overall comment on the use of the DISCA
◆
All facility managers felt that the DISCA was a useful
tool to assess quality of STI care. They were surprised
to find how many aspects of STI management need
improving as most of the staff felt that they were
competent in managing clients with STIs.
– 20 –
◆
◆
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Three of the clinics do not have suitable lighting in all
consultation rooms to enable speculum examinations
to be done effectively.
Only two of the clinics keep a record of the number of
partner notification cards issued or the number of
partners treated. In both these clinics the number of
cards issued was considerably less than the number
of STI clients treated. (63% and 69%)
Three of the clinics do not have partner notification
cards written in a local language.
The number of STI clients in relation to the total number
of clients, as well as in relation to the number of clients
seeking reproductive health services, is quite low. This
is illustrated in Figure 1 and suggests that clients are
only treated for an STI if that was the primary reason
for attending the clinic.
◆
Despite the meeting before using the DISCA, it is
apparent that more support needs to be given if good
quality data is to be obtained.
General comments
◆
Not all the information required by the DISCA was
supplied.

– 21 –
◆
Three of the clinics were out of stock of at least one
drug in the previous month. The following table
illustrates the availability of drugs in the four clinics.
Figure 4 shows the number of clients treated for each syndrome and
the number that were correctly treated.
Figure 3 indicates the number of episodes of each syndrome amongst
the 40 clients recorded.
Knowledge of correct treatments
Clinicians knew the correct treatment for urethral and vaginal
discharge at all 4 clinics. At one clinic the treatment stated for genital
ulcers was incorrect, and at two clinics incorrect treatment was stated
both for STIs in pregnancy and the correct alternative to Doxycycline.

– 22 –
Additional Comments
The following points would not need to be included in the report, but
are given here in order to give a fuller comment on the information
from the 4 DISCAs. This provides a guide for identifying issues that
are reflected in the completed DISCA forms.
Comments on Specific Clinics
Clinic A
Clinic B
◆
◆
◆
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◆
Although the total number of clients is not recorded,
from the other figures, this clinic seems to have the
best client/provider ratio out of the 3 clinics that gave
client figures.
Not all staff are clear about the correct drug treatments.
The turn around time for RPR results is exceptionally
long, considering that the other 3 clinics in the area
receive them within a few days. This is also obviously
quite a big and busy clinic.
Condoms were out of stock during the previous month.
Despite the fact that all clinicians have undergone
training both in syndromic management and HIV
counselling, only 3 out of the 10 clients were correctly
treated. However, those clinicians who were asked
about treatment, knew the correct drugs (apart from
in pregnancy), so the problem may have been the
unavailability of drugs.
Clinic C
Clinic D
◆
◆
◆
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This clinic has more drugs out of stock than any of the
others, which suggests that part of the problem may
be at the clinic level.
Three out of 10 clients with PID suggests that clients
with vaginal discharges may not be seeking treatment,
and that clinicians may not be screening for STIs
among clients who come for other reasons.
Record keeping at this clinic appears to be poor.
On the other hand, this is the only clinic that does not
report having drug shortages.
Very few clients at this clinic are treated for STIs, despite
having quite high numbers of family planning clients.
Few women with STIs are examined with a speculum.
This may be because only one consultation room has
an examination light.
Although the syndromic guidelines are not in all
consultation rooms, correct treatment was given to all
10 clients apart from one (Warts or other STI).
Partner notification cards are not in all consultation
rooms.
Only 1 clinician has been trained in syndromic
management and none in HIV counselling.
This clinic appears to be male friendly as at least 6 out
of the 10 clients recorded were men.

– 23 –
Key Step number 13 – Feedback to Clinics
Key Step number 14 – Decide on Priorities
Feedback is an important part of the DISCA process. The manner in
which this will be done should be discussed when plans are first made
to conduct the DISCA evaluation.
A forum should be established to allow for feedback of findings to all
staff at the clinic.
Whatever feedback approach is used, it is ultimately the clinicians
who need to be aware of the strengths and weaknesses in the quality
of care of clients.
Ideally the clinicians should be involved in the next two steps of
deciding on priorities and developing action plans. They may have
some important insights into why some aspects of quality are deficient
and how they could be remedied.
Providing feedback to clinicians is valuable for a number of reasons.
◆
◆
◆
It enables them to see the relevance of the DISCA and
should increase their commitment to the correct use
of this tool.
It increases their awareness of aspects of quality that
need improving.
It enables them to be part of the decision making
process for improving quality of care. People will always
be more committed to carrying out action plans that
they have participated in developing.
Criteria for Selecting Priorities
There are three key questions to answer in deciding what the priorities are:
◆
◆
◆
How important is it to address this?
This would take into account the following factors:
- How serious is the problem? What impact does it
have on the quality of someone’s health?
- How common is this problem? Does it affect large
numbers of people?
Can we do something about it?
- Are there people with the necessary skills to be
able to address it?
- Are the necessary resources available? This
would include any materials needed as well as
the finances required.
- Is it something that could be done easily and soon,
or would it be a long term project?
Are there people who are willing/wanting to do
something about it?
- Do staff within the health services feel committed
to addressing this issue?
- Is there a level of concern in the community about it?
- Are there people in the community who could
play a role in resolving the problem?
- Are there people who might block the proposed
action?

– 24 –
Key Step number 15 – Develop an Action Plan
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When developing an action plan, invite all the key stakeholders who will play a role in carrying out the plan.
Try to get to the root of the problem in order to develop an appropriate plan.
Remember to make your plans SMART - Specific, Mearsurable, Attainable, Realistic and with a Time frame.
Ensure that the plan is communicated to all those who are expected to take some action.
Suggested action plan for Clinic B in order of priority
Problem Cause Action By whom? By when? Evaluation
Drug shortages Shortage in the district Meet with pharmacist District manager As soon as possible Next month
Drugs not ordered in time Ensure sufficient stocks are Sister in charge Monthly Monthly
ordered on time
Wrong drug treatments Lack of motivation/support Increased frequency of Supervisor Starting this month - ongoing After six months
support visits
monthly
Information not cascaded Better resources and support Trainer and supervisor Starting this month On monthly support visits
by staff trained to other staff for those who cascade
? Under or misdiagnosis Speculum examinations not In service training and District trainer and supervisor Next district in service 3 months after in service
of STI syndromes (total done support meeting training
number of STI clients and
PID rate)
Incomplete histories taken In service training and Monthly supervisory support
from FP and ANC clients support visits
Stock out of condoms Under ordering at clinic level Increase order by 25% Sister in charge Next month Monthly
Delay in receiving RPR Clinic overlooked in Meet with transport District manager As soon as possible - within Subsequent district meeting
results transport route to collect manager next 10 days
specimens
Remember, an action plan is only
as good as its implementation