Ethical Considerations

IntHEC project was approved by the Liverpool School of Tropical Medicine Ethics Committee and by the Ministry of Health and Social Welfare through the Medical Research Coordination Committee. This study was included therefore under IntHEC project’s LSTM REC approval no. 09.75 and MRCC approval no. NIMR/HQ/R.8a/Vol.IX/1012. After the approval by the ministry, senior staff of IntHEC project met with regional and district authorities (in both Mwanza and Iringa) to request for assent to conduct the study in their region. Two months before the actual field work the officers in charge of health facilities were informed at a central meeting of the mystery client study, but the details of the dates and names of the specific health facilities were not provided to reduce potential bias from the Hawthorne effect (a phenomenon which refers to participants adapting their normal behaviour for reasons of social desirability). During the meeting with in-charges, IntHEC researchers orally presented information about the study, its objectives and procedures. Following clear understanding of the nature of the study, in-charges signed written consent forms stating their willingness for their respective facilities to participate in the research. This process was witnessed by respective District Medical Officers who attended the meetings. Thereafter, in-charges were requested to inform all health workers in their respective facilities about the study. No direct consent was obtained from the health workers as it was not possible to ascertain which health workers would attend young people during their visits to the facilities. However in-charges were asked to communicate with the research team if any of the health workers did not wish to participate and we did not receive any communication from in-charges on this matter. Confidentiality and anonymity of health workers were guaranteed by using codes in identifying health facilities during fieldwork and report writing.

Young people who eventually became our MCs provided written consent as follows: they were recruited in the capacity of research assistants and were provided with a copy of the study protocol that included an ethics statement, and signed a formal contract that included informed consent. On this basis, they received a standard field allowance for their training and during fieldwork. Parents were also informed of the terms and conditions that applied to their children’s participation in the study and were given an opportunity to ask questions about the study. Parents did not provide formal consent as the young people involved were all 18 years and above and able to provide their own consent. Although young people did not require parental consent, for cultural reasons we felt it was important to make parents aware of the study and the potential adverse outcomes to participation in case the MC identities were discovered; an event for which in this setting, the parents may be held accountable. For further protection, and once the field work started, MCs carried a signed letter of authorisation from their respective Regional Medical Officers in the event of their discovery by health workers.

Inadequate or hostile reception

MCs reported a lack of clear signage or instructions in the majority of facilities visited (particularly dispensaries). In many cases, clients had to ask other patients where to access the services they required. One MC reported waiting three hours before being told on entry into the consultation room that she was in the wrong place. Youth specific waiting areas or signposting were entirely absent.

Health workers were often unavailable or facilities closed because of staff absences. Health workers often lacked motivation and professional demeanour. One nurse was found sleeping in the office and frequent lack of uniforms made other staff difficult for MCs to identify. Furthermore, receptionists were sometimes rude to young people:

“… Where were you when I was calling your name? […] Didn’t you hear your name? I was calling Lucia Marko, eeeh? [pseudonym registered by the MC], but you kept quiet, what does your behaviour mean? You make people sick and tired, are you the one who pays their salary? […]”

(Health worker, rural-intervention ward, Mwanza)

Health worker attitudes to adolescent use of SRH services

In a number of cases across both regions, health workers displayed negative and paternalistic attitudes towards adolescent use of SRH services, including expressing the view that family planning should be reserved for adults, particularly married couples. This may have arisen from a common view that family planning services are largely meant for child spacing.

“…When I started to explain my need of FP methods s/he asked me twice, Family planning? So, are you married?

(Mystery Client, urban-intervention ward, Mwanza)

Knowledge and attitudes towards condom use among health workers were very variable. Whereas a number of health workers had positive attitudes to condom use, several expressed misgivings or openly discouraged young people from using them. For example:

“…It is okay you can use condoms, but condoms do not protect someone from getting HIV infections because condom has got tiny invisible holes. Don’t say I have used condom, I will not get HIV, what we advise is that, it protects in a very small percentage, it protects pregnancy, sexual transmitted infections, but it doesn’t protect HIV […]”

(Health worker, rural-control ward, Iringa)

Conversely, health workers also spoke out against this kind of attitude:

“…Those are lies, people speak lies, had it been true, the government would have noted it because all the items imported are approved before being supplied, they don’t supply without approving them, people fight against AIDS […]”

(Health worker, special risk-control ward, Iringa

In addition there were unfortunately several examples of unprofessional behaviour by health workers. One laughed at a young person when he admitted to a lack of knowledge about condoms, and MCs at times complained of hostile and judgmental health workers who made them uncomfortable. MCs also expressed discomfort at being asked questions about themselves and their complaints in the presence of strangers in waiting rooms or open offices.

Even when attitudes to youth access were positive, health workers sometimes demonstrated discriminatory gender stereotypes:

“....as for a woman, you shouldn’t have multiple partners. As for men, it’s not easy to abstain, for example; he can’t stay in Dar without having another partner… “

(Health worker, rural-intervention ward, Iringa)

“If you let her use pills she will be engaging with sexual affairs with other guys. For someone who is not your wife do not take pills as she will use them and sleep with other people [men]. The time she sleeps with other people, you will not realize. There are STIs and HIV, do not use that one [Pills]!! Now, in protecting yourself [form STIs], just take condoms, understand […]?”

(Health worker, special risk-control ward, Iringa)

Lack of privacy and confidentiality

In a significant proportion of cases (19 out of 48), mystery clients complained of inadequate infrastructure, or efforts made, to protect their privacy. In some health facilities, consultation room windows were reported to be open and facing the waiting rooms. In addition, MCs were attended to while other patients were in the room. There were a number of examples of this lack of privacy, partly due to the infrastructural challenges and partly due to health worker breaches of confidentiality. The following mini-scenarios illustrate some of the key issues encountered by young people:

1. Two clients regardless of their different age and or gender attended concurrently by two health workers in the same room;
2. Consultation with adolescent clients took place in a corridors or waiting lounge in presence of other people;
3. Adult clients were sometimes allowed to enter the consultation rooms before the health providers had finished with the preceded patient;
4. In two health facilities, service providers invited their colleagues to enter the consultation room to listen the conversation between the provider and the clients and/or staff members entered the consultation room without notice;
5. In another health facility service providers were heard discussing about the health complains of their previous clients, immediately after their clients had left the room.

In most cases and particularly at dispensary level, consultation rooms were located close to waiting rooms. Moreover the windows and/or doors of these facilities were kept open and therefore, where two MC clients were sent to one facility (to perform different scenarios), the succeeding mystery client could easily hear the conversation between her/his colleague and the service provider. The following quote is illustrative of the combined challenges of the physical constraints to privacy, exacerbated by the service provider decisions that further reduced privacy and how this impacted on MCs sense of the confidentiality of their consultations:

“…That room [consultation room] lacked privacy. Because on the chairs, when I got in, other women came, about four of them, they were standing at the door waiting to see the same doctor, and then another doctor came and got in to that room, I think two doctors use to stay in that same room while attending clients…”

(Mystery Client, special risk-control ward, Mwanza)

Logistical challenges

Several facilities, especially the dispensaries had no STI treatment services. Furthermore, where STI treatment was available, young people were usually charged for their use. In Tanzania, although services for STIs are supposed to be given for free (under the community health insurance scheme) there are often minimal charges that people have to pay when they visit facilities. Thus, young people ended up having to pay fees for services that should have been free, for example for a registration card or a consultation fee. In addition, due to drug stock-outs, patients are often advised to purchase medicines for drug shops to treat STIs, mostly antibiotics in capsule form which in Kiswahili are nicknamed rangi mbili (meaning two-coloured medicine).

Lack of an appropriate working schedule in provision of family planning services was also an important barrier toward access of services to adolescents. Although government facilities are required to operate from 7:30 am to 3:30pm, Monday to Friday, facilities often closed early. Additionally, in most health facilities visited, family planning was only available in the morning, making access for those attending schools particularly difficult.

Good practice

Across Mwanza and Iringa regions, we found that that the strongest themes emerging from the data illustrated the challenges explored above. However in a smaller number of cases, across both regions the study also revealed some very good practices including support for condom use, sympathy at expressed symptoms of STI and encouragement to bring other young people to the service, as in the following examples:

“… We are always singing [insisting] that you use condoms to protect yourself. Now everyone should do it [use condoms]. This is because you cannot test someone by merely looking at him, she might be looking smart but only to find that she is already infected [with HIV], guys use condoms, stop being careless, how long is it since you had sex with her…”

(Health worker, rural-control ward, Mwanza)

“Would you please bring many others who are in need of advice so that they get counselling services hence protect themselves from STIs, HIV/AIDS as well as early and unplanned pregnancies […]”

(Health worker, rural-intervention ward, Mwanza)

Finally, while we did not undertake a rigorous evaluation of the MC experiences of carrying out the research we asked them to reflect on the research process and explored whether they would be willing to participate in future studies. Our young, trained mystery clients reflected positively on their experiences of being involved in the study and expressed willingness and enthusiasm for getting involved in future research.

Methodological constraints and considerations

An important limitation of our work is that for cultural reasons the MCs could not ask the health workers their names as this would have been unusual in the local setting and would have raised suspicion as to their identity and would have jeopardised the research. We were therefore unable to assess the proportion of health workers involved in this study who had actually received youth friendly services training.

The tone and language used in an interaction between health worker and client is critical to the quality of the interaction. This is particularly so in the case of adolescents. Yet capturing this is extremely difficult. Our ability to review verbatim transcripts of both the consultations and the MCs’ immediate reactions improved the rigour and depth of our evaluation. The size of the study and inclusion of a range of communities further improves the credibility of the findings.

The ethical challenges of MCs adopting different persona to approach health workers, were largely addressed by the briefing of staff well in advance of the study. For their part, the MCs were exposed to negative attitudes which could have led to anxieties at the time, however it was clear from debriefs that their thorough training coupled with the research team’s support of MCs during fieldwork allowed young people to appropriately deal with their experiences. In fact, they expressed considerable satisfaction in relation to their role in the study. This supports findings from other studies that ‘mystery client’ or ‘simulated patient’ methods offer feasible and acceptable opportunities to explore health worker-client interactions in this context [10, 13].

Finally it is important to note that whilst we have disseminated the findings of this study at national conferences attended by policy makers and programs officers from the regions and Ministry of Health and Social welfare, the names of the participating facilities and their respective staff were strictly anonymized. Shortly before carrying out a follow-up MC study (in early 2014) we gave very preliminary feedback to the District Medical Officers, but we also strictly anonymised the names of the facilities and health workers who participated in the baseline (MC) study to ensure that the DMOs could not identify the individuals or facilities, to avoid any repercussions for them. The dissemination to the health workers from the intervention and control arms is scheduled to take place once the analysis of the final MC study is completed (the IntHEC study ended at the end of October 2014 and the final stage of data analysis and write-up is on-going). We will continue to anonymize the names health workers who participated in the study and will not link facilities to any specific finding at future dissemination events.