The provision of emergency contraceptives in private sector pharmacies in urban Kenya: Experiences of mystery clients

This paper presents the results of an assessment of the provision of emergency contraceptives (EC) in private pharmacies in Nairobi, Kenya. Trained female mystery clients (MCs) made a total of 103 visits to 20 randomly selected pharmacies and presented accounts of their experiences. The results show that: 1) some providers insist on doctors’ prescriptions before they can dispense EC; 2) there are variations among providers on the recommended dosage and possible side-effects of EC pills; 3) MCs presenting as inexperienced clients were significantly more likely to be given additional information on EC than the experienced ones; 4) there was no significant difference in the provision of additional reproductive health (RH) information/services by the scenario presented. This suggests the need for: 1) provider training and/or updates on EC to enhance their capacity to offer additional RH information/services; 2) sensitizing EC clients on the importance of obtaining additional RH information/services from providers.


Introduction
Over the past decade, emergency contraceptives (EC) have become increasingly available across Africa (Schiappacasse and Diaz, 2006). 2  Although more government clinics than ever before are providing EC, in many countries private sector pharmacies remain the main channel through which clients obtain EC pills (Programme for Appropriate Technology in Health (PATH), 2004;Blanchard et al., 2005; United Kingdom Office of National Statistics, 2005;Moreau et al., 2006;Schiappacasse and Diaz, 2006).This is mainly because of the conveniences such outlets offer, namely, affordability, quick service delivery, and confidentiality.Owing to client preference, private pharmacies can play an important role in providing EC and possibly other reproductive health (RH) information and services to clients (Wells et al., 1998;PATH, 2004).To begin with, the need for EC because of regular unprotected sex or method failure suggests the need for a new or more reliable method of family planning (FP).Moreover, clients who seek EC may also have exposed themselves to the risk of sexually transmitted infections (STIs), including HIV/AIDS in high prevalence settings, and are therefore candidates for voluntary counselling and testing (VCT) services.Thus, a client's decision to use EC can be seen as marking the beginning of a new set of RH needs.
It is, however, not clear whether private sector pharmacy providers have the capacity to offer the additional information and services to EC clients.First, from a public health perspective, private pharmacies lack the incentives to take up important steps in providing services to EC clients such as counselling or referrals for on-going contraception and STIs/HIV prevention, a concept referred to as bridging.This could be attributed to two factors, namely, the nature of training for pharmacists (which may not include the provision of public health information and services) and the fact that interactions with clients at pharmacies are mostly with frontline staff some of whom lack formal training in health service provision (PATH, 2004).Second, private pharmacy providers are often faced with the challenge of balancing operations as a business establishment and performing the role of health service providers (Skibiak et al., 2001;PATH, 2004).
Given these limitations and the fact that private sector pharmacies are the preferred sources of EC pills (Morgan, 2007;Keesbury et al., 2008), effectively enhancing the capacity of the providers to offer additional RH services to EC clients remains a challenge.One strategy which has been found to be effective is the provision of on-the-job training (PATH, 2004).Nonetheless, this strategy can, in the long-term, be unsustainable because of high rates of staff turnover and cost.In 2008, Population Council tested the feasibility of using a strategy that involved regular visits and updates to the providers at the facilities as a way of enhancing their capacity to offer counselling and referral for regular FP and other RH services to EC users.The study was conducted in Nairobi, Kenya, and involved the provision of information, education and communication (IEC) materials as well as regular updates on EC use and provision, including the need to 'bridge' users to regular FP and other STI/HIV services.This paper presents the results of the baseline assessment of the provision of EC in the private sector pharmacies as experienced by mystery clients.

Baseline study design
The first criterion for selecting the pharmacies to include in the study was that they already had contact with the Population Services International (PSI) social marketing programs.This meant that they were stocking and selling EC.PSI provided a list of the busiest pharmacies in Nairobi that were staffed by a pharmacologist, a pharmacist, or a pharmacy assistant.From a total of 98 pharmacies that satisfied this criterion, 20 were randomly selected for inclusion in the study.Time and financial constraints played a role in the decision to base the study on the 20 pharmacies.Twelve female research assistants were then recruited and trained to act as mystery clients (MCs) in need of EC pills.These were single women aged between 19 and 32 years, in line with findings from previous studies which show that the main users of EC fall within this age group (Shawe et al., 2001;Olszewski et al., 2007).
The MCs were trained to present the providers with two scenarios which were developed with the help of a group of pharmacists from some of the outlets that were not selected for inclusion in the study.The first scenario was that of an inexperienced EC client who had had unprotected sex one or two days prior to the visit date, and was not sure if there was a method that she could use to avoid getting pregnant.
The second scenario was that of an experienced client who knew the product she wanted and went to the pharmacy to ask for it.The visits to pharmacies were arranged such that each pharmacy could only be visited by at most two different MCs each day to avoid saturating the pharmacies with visits.The MCs played alternating roles such that if the first visitor to a pharmacy in a particular day was an inexperienced client, the next would play the role of an experienced one.Nonetheless, the proportion of visits when the MCs presented as inexperienced EC users was more than when they presented as experienced users by the ratio of three to one (Table 1) because: 1) each day all MCs started by presenting as inexperienced clients; and 2) not all pharmacies were visited six times (the maximum number of visits to a pharmacy).
The MCs observed the provider's ability to respond to the need for EC as an FP method as well as to special needs within the broader RH context, including counselling and referral for regular FP and STI/HIV services.To reduce recall bias, the MCs were debriefed immediately following their pharmacy visits.They responded to a short questionnaire on whether: 1) there were any IEC materials on EC at the pharmacy, 2) they were provided with EC pills and any information on the method, and 3) the provider talked to them about other FP methods as well as STIs and HIV.In addition to the questionnaire, the MCs provided qualitative accounts of their experiences at each pharmacy, first by narrating their experiences verbatim, then by recording the narratives in notebooks provided for the purpose.This paper presents findings from both the quantitative data and the qualitative accounts.

Mystery client method and ethical issues
The mystery client method entails using trained people to visit program facilities in the assumed role of real clients, and then report on their experience by completing a survey or through an interview (Boyce and Neal, 2006).The use of MCs helps to avoid bias in the service delivery process that can result from directly observing service transactions.In the case of EC provision, direct observation is likely to lead to even more serious bias as clients usually prefer fast and confidential delivery of service.Moreover, since MCs are used to assess and improve the quality of services, they serve the interests of clients, providers and programs by highlighting ways in which service provision could be enhanced (Boyce and Neal, 2006).However, the method has its disadvantages.For instance, service providers may consider it deceitful if they find out that they are not dealing with real clients.The MCs face potential physical or psychological harm when their real intentions are discovered, or when they are provided with services they do not need (Huntington and Schuler, 1993;Boyce and Neal, 2006).
To minimize the possibility of providers discovering the real intentions of the MCs, two-thirds of the training was devoted to role plays to ensure that the MCs were comfortable with their roles.They were also made to understand that under no circumstances were they to act in a manner that would raise suspicion on the part of the providers that they were not genuine clients.Further-more, the MC visits were scheduled such that no client visited a pharmacy more than once.With respect to the potential risk of MCs being offered services they did not need, it was emphasized during training that they were not required to undergo any type of medical exam or procedure during their visits.The project also provided the MCs with money for purchasing EC from the pharmacies in the event that they were offered the pills.The purchased pills were then surrendered to the project during debriefing.
The project further obtained written consent to participate in the study from the selected pharmacies.The process involved explaining the study and its purpose, letting the pharmacists know that their facilities would be visited by MCs, explaining the potential risks and benefits of participating in the study, as well as emphasizing that participation was voluntary and that a facility could withdraw from the study any time.The providers were, however, not informed about the identities of the MCs or the exact dates when they would visit.Written consent was also obtained from the MCs on the first day of training after they were provided with the relevant information about the assignment, including the risks and benefits involved.Ethical clearance for the study was obtained from the Ethics Review Committee of the Kenya Medical Research Institute (KEMRI).

Results
The MCs made a total of 103 visits to the selected pharmacies over three days of baseline assessment of EC provision (Table 1).Only one pharmacy was visited twice because, though the http://aps.journals.ac.za management had expressed willingness to allow the pharmacy to be included in the study, written consent was obtained on the second day of the assessment.The MCs presented the scenario of inexperienced clients in nearly threequarters of the visits, and were attended to by female service providers in more than half of the visits.Whereas the MCs were offered additional information on EC in more than half of the visits, they received additional information and/or services on other FP services and HIV/AIDS/STIs in less than a quarter of the visits (Table 2).This is also reflected in the proportion of pharmacies that offered these additional services: 60% offered additional information on EC to clients in one-half or more of the visits while only 15% offered additional information and/or services on other FP methods and HIV/AIDS/STIs for a similar proportion of client visits (Figure 1).
Additional information on EC given to clients mostly entailed how (dosage) and when (time frame) to use the method, with side-effects and efficacy ranking third and fourth respectively (Table 2).However, qualitative accounts indicate that the content of the additional EC information varied from provider to provider: She told me to take the two tablets at once and the other one within the first 72 hours.She told me that some people substitute EC for FP but that will affect them later in life.Then I inquired what these effects are and she said that it causes some hormonal imbalance and can result in irregular periods and a time will come when they will not work in the body of the user.In addition, whereas some providers recommended taking one tablet twelve hours apart, others recommended a shorter time between doses while others told the clients to take the two tablets at once.Furthermore, most providers who mentioned side-effects identified nausea and vomiting as the most common ones with some mentioning hormonal imbalance, ectopic pregnancy, infertility, body resistance, and irregular monthly periods as other side-effects.In some instances, the pro- The likelihood of clients being offered additional information on EC was significantly higher when they presented as inexperienced rather than as experienced users of EC (Table 2).However, there was no significant difference in the proportion of MC visits when the providers talked about other FP methods or HIV/AIDS/STIs by the scenario presented.Providers who talked about other FP methods mostly recommended a regular method while those who talked about HIV/AIDS/STIs more often recommended condoms or referred the clients to a health centre.

Discussion and implications
One of the key experiences of mystery clients in the study is the insistence by some pharmacists on doctors' prescriptions before they could dispense EC.This is in contrast to the 2005 Ministry of Health (MOH)/Department of Reproductive Health (DRH) guidelines for family planning service provision in Kenya.With respect to EC, the guidelines stipulate that the pills can be provided by all trained service providers, and in any facility with a qualified provider (MOH/DRH, 2005).The requirement for a prescription from a doctor has both time and financial implications for potential EC users, especially those who need it because they engaged in consensual unprotected sex.The time required to secure a doctor's appointment and for consultation beats the logic of EC being used for emergency cases while the doctor's consultation fee adds additional cost to the user.This could have a double-sided effect on EC use: on the one hand, doctors might be in a better position to provide adequate information to potential clients than pharmacists; on the other hand, it could limit access by those who genuinely need the method but are unable to raise the doctor's fees.
The second important experience of MCs is the variation among providers on how and when to use EC pills.Most providers were aware of the 72-hour window of opportunity during which EC pills can help prevent unwanted pregnancy after unprotected sex.However, recent guidelines indicate that EC pills can be effective for up to 120 hours (International Consortium for Emergency Contraception (ICEC), 2004;MOH/DRH, 2005).This discrepancy http://aps.journals.ac.za

Table 1 :
Percent distribution of mystey client visits to pharmacies by various background characteristics http://aps.journals.ac.za

Table 2 :
Percent distribution of mystery client visits by the type of reproductive health information/ services offered and by the scenario presented