Towards quality improvement: Training and supportive supervision in STI control programme, Himachal Pradesh.

Sir,

Historical and observational evidence suggests that successful control of sexually transmitted infections (STIs) have led to decline in HIV/AIDS, while countries with poor STI control programmes have been most vulnerable to HIV epidemic.[1] STI control efforts have usually been outlined in relation to HIV programme priorities ever since the emergence of HIV in the 1980s.[2] National AIDS Control Organisation (NACO) under the Ministry of Health and Family Welfare, Government of India has developed “Operational Guidelines for Strengthening STI/RTI services” restructuring the STI control programme with a robust training support system.[3] Supportive supervision provides a comprehensive service delivery frame work in which periodic support and supervision are given to the STI/RTI provider. Supportive supervision has shown a three- to sevenfold improvement in STI interventions with sex workers, men having sex with men/transgender, and injecting drug users.[4]

The aim of the study was to assess the impact of supportive supervision and training on the STI/RTI clinic service delivery. Sixteen NACO supported STI/RTI clinics remodelled as Suraksha clinics have been setup in Himachal Pradesh (HP). The supervisory visits were carried out individually or by a joint supervisory team once every quarter to each Suraksha clinic. The supervisory team comprised of nationally trained State STI/RTI faculty members from the Departments of Microbiology, Community Medicine, Obstetrics and Gynecology, and Dermatovenereology along with the HP State AIDS Control program manager. The performance of Suraksha clinics was evaluated according to the monitoring tool provided by NACO.[3] The supervisory check list has 10 major service quality monitoring indicators with 25 questions, and 7 quality indicators. The service quality monitoring indicators include (a) observational parameters: signage, clinic space, privacy, and infection control measures; (b) physical verification parameters: equipments, consumables, drugs, and documentation. Quality indicator data was generated from the prescription audit of the patient wise cards. These cards are filled by the STI/RTI service providers for each new STI/RTI episode and provide information regarding patient history, examination, diagnosis, treatment, drugs given and other services offered. On site supervision provided an opportunity to address performance issues with a quick feedback to the state headquarters. As reported by others, this helped ensure quality services, recording and reporting.[4] There was two- to threefold improvement in four areas of performance; coverage, quality of clinic services, skill development of counsellors, and data collection. During the year 2009–2010, 23,317 patients were counselled as compared to 12,110 clients in the year 2008–2009 indicating a twofold increase in the level of utilization of counselling services in the second year. On the basis of the syndromic diagnosis, 12,469 patients were provided with prepackaged drug kits and treated. Partner notification was undertaken in 6042 index clients, and their 5891 partners (97.5%) were subsequently managed. Condoms were provided to 1,16,966 clients as against 20,118 in 2008–2009. Thirteen day intensive induction training was conducted for the STI counsellors as designed by NACO.The training proved to be very effective. The average training scores are depicted in Table 1. The difference of mean pre- and post-test scores were found to be statistically significant, P value = 0.01656 (<0.05). There was remarkable improvement in their knowledge as was evident from the significant difference between the pre-test and post-test scores ranging from 25.5 to 30.5 with an average gain index of 19.6. In the induction training session, the change in the attitude was from 0 to 0.8 based on the pre- and post-test scores. Attitudinal change was also noted by role plays. Intensive training was much appreciated by the STI counsellors, similar to the views expressed by ICTC counsellors.[5]

Table 1

Average scores of induction training of STI/RTI counsellors

Supportive supervision is an excellent process-oriented, continuous, interactive methodology. It has an effective role in providing administrative and educative support but to sustain and have a long-term impact, it is essential to work closely with the supervisory STI team to develop a definite strategy. Besides, repeated refresher training is essential for upgradation of knowledge and skill development.