CONTENTS
HIGHLIGHTS
June, 1993 |
Mobilizing ProvidersTraining. Schools for health professionals have neglected STD training (73, 190, 227, 332). Medical schools, for example, may offer only classroom instruction on STDs and only in dermatology, preventive medicine, or urology courses (190, 243, 291, 332). Students receive little or no clinical training on STDs. Training has been neglected in part because the development of penicillin and other antibiotics has led doctors to think that STDs are easily treated (82, 178). There are exceptions in some schools. For example, medical schools in Chile and in some states of Brazil offer specialty training in STDs (332). In Zambia STD officers are physician's assistants who study clinical medical sciences for three years and then attend a 3-month STD course that covers epidemiology, diagnosis, management, counseling, and communication skills (133). Also, medical students in Zambia receive six weeks of STD training; clinical officers receive three weeks of training; and nurses receive two weeks (114). Special programs offer in-service STD training to refresh providers' knowledge and skills and to tell them of improvements in STD management. In-service training is especially effective when conducted at a center of excellence. There trainees see high-quality care and a variety of cases, while staff at the center can learn about services at primary care clinics. By building a personal relationship between primary care providers and center staff, such training strengthens lines of supervision and referral. In Harare, Zimbabwe, for example, staff of city-run primary health care clinics, usually nurses or midwives, attend 2- to 3-week STD courses at the clinic of the central STD referral center. In groups of 8 to 10, trainees learn to take a medical and sexual history, examine patients, use a microscope, diagnose STDs, follow standard flow charts, and prescribe drugs. After the course these providers are expected to be able to care for 95% of STD cases that they see and to refer the rest (162, 163). The Zimbabwe essential drugs program also provides in-service training. The program publishes an STD management manual to help providers dispense drugs appropriately. Of the 16 manuals produced by the program, the STD manual is one of the two most requested by providers (155, 156). In the first year of the Mozambique pilot project, in-service training helped to reduce referrals from primary care clinics to the central hospital clinic from 8% to less than 5% of patients. Also, the program improved providers' ability to diagnose and treat gonococcal urethritis: The proportion of referred patients who had gonococcal urethritis decreased from 42% to 23% (21). Supervision. With supervision, primary care providers can better apply their knowledge and skills, and morale rises. Supervision can come in the course of recordkeeping or in monitoring of referrals. In Zimbabwe, for example, the Ministry of Health collects monthly STD case reports from primary health clinics through the district and provincial health officers. If more than 5% of STD patients do not respond to the standard treatment and are referred to the district level, an STD expert visits the primary clinic to find out why (162). In some countries experts from the central referral clinic will not be able to supervise most primary health clinics. This task could then be carried out by clinical medical officers specially trained in STD management and stationed in district hospitals (148). Collaborating with private providers and traditional practitioners. Private providers treat many people with STDs (3, 142, 170). In parts of Latin America, for example, as many as 90% of people with STDs may go first to pharmacies or private doctors (250, 332). In Ethiopia rural drug vendors may treat seven times the number of STD cases that are treated at all public facilities combined (139). Only a few public STD programs work with private or traditional practitioners, however. In Kisumu, Kenya, for ex~ample, a program to prevent ophthalmia neonatorum worked with private practitioners, who are leaders of the medical community (148). In Zimbabwe all doctors are offered STD training in continuing education seminars. Also, private practitioners receive publications of the essential drug program, including the STD treatment guidelines. STD experts address the primary care physicians' association (162). Pharmacists in Cameroon, Ecuador, Mexico, Senegal, Tanzania, and other countries are studying STD management (6, 60, 225, 239, 265). In Tanzania training workshops have improved pharmacists' management of customers with STDs: Before the training none of 43 pharmacists said that they recommended drugs from the national STD treatment flow chart, but after the training more than half did (6). In Cameroon, in an innovative social marketing project, staff from about 200 pharmacies are being trained to sell an STD treatment package consisting of antibiotics, informational brochures, partner referral cards, and condoms (239, 240, 298). Working with pharmacists may be difficult, however. Programs that have trained pharmacy staff in family planning have found that the people who came to training sessions often were not the ones who usually waited on customers. Also, turnover of clerks may be frequent; thus staff may leave soon after being trained (159). Traditional practitioners—traditional birth attendants, traditional healers, injection doctors, and rural drug vendors—could play a role in STD management, depending on their roles in health care. The Zambian Ministry of Health has registered about half of the country's traditional healers. They attend workshops that include two hours of STD training, and they are encouraged to refer patients with STD symptoms to public clinics (114). In The Gambia traditional birth attendants carry tetracycline eye ointment to prevent ophthalmia neonatorum (100). Adding STD services to the work of traditional birth attendants may further burden them, however. Other health care programs—for example, family planning and maternal and child health programs—have also recruited traditional birth attendants in some countries. |