A ‘Mystery Client’ Evaluation of Adolescent Sexual and Reproductive Health services in Health Facilities from Two Regions in Tanzania

Abstract

Unwelcoming behaviours and judgemental attitudes have long been recognised as a barrier to young people’s access to reproductive health services. Over the last decade youth friendly reproductive health services have been promoted and implemented world-wide. However, long term evidence of the impact of these programmes is lacking. We report the results of a large mystery client evaluation of adolescent sexual and reproductive health services in Tanzania, a country that has had a long established youth friendly policy. Forty-eight visits made to thirty-three health facilities were conducted by twelve young people (six in each region) trained to perform three different scripted scenarios (i.e., condom request, information on sexually transmitted infections and family planning). The study revealed barriers in relation to poor signage and reception for services. In addition health workers demonstrated paternalistic attitudes as well as lack of knowledge about adolescent sexual and reproductive health services. In some cases, health workers discouraged young people from using services such as condoms and family planning methods. Lack of confidentiality and privacy were also noted to be common challenges for the young people involved. Intervention strategies that focus on changing health workers’ mind-set in relation to adolescent sexual and reproductive health are crucial for ensuring quality provision of sexual and reproductive health services to young people. The study identified the importance of reception or signs at the health units, as this can facilitate young people’s efforts in seeking sexual and reproductive health services. Likewise, improvement of health workers knowledge of existing policy and practice on sexual and reproductive health services and youth friendly services is much needed.

A systematic review of the use of adolescent mystery clients in assessing the adolescent friendliness of health services in high, middle, and low-income countries

“…Six of the evaluations/studies aimed to assess the youth friendliness of the services and providers in their study [16,26,29,35,40,44]. Nine evaluations/studies also examined the effects of the implementation of training for service providers or youth friendliness programmes [16–18,25,28,34,42,44,45].…”

“…The most common reason for the use of MCs was to assess/observe the interaction between service providers and patients, with particular interest in the friendliness of services, from the perspective of adolescents [16,30,35,39,40]. Another reason was to reduce or eliminate bias [13,17,18,21–25,29,33,36]. By using trained MCs, the researchers and evaluators intended to avoid observation bias or bias from the Hawthorne effect, whereby the observer could observe the subjects without their knowledge of the observation to influence their behaviour.…”

“…In these cases, MCs were asked to assess ease of access to health facilities, the environment of health facilities, staff and health provider behaviour, and service provision or specific aspects of care, such as quality of advice received [7,17,18,31,38,44]. Twenty-one of the reviewed evaluations/studies provided their MCs with specific scenarios, with either a script or a specific question or concern to ask during the medical visit [17,19,21–25,27,29,32–35]. Two of the reviewed evaluations/studies provided MCs with scripted scenarios, but failed to include information on what the scenarios or roles entailed [16,26,36].…”

“…Five evaluations/studies did not specify sex of the MCs in the description of the methods [28,31,38,40,43]. Eleven of the 30 evaluations/studies reviewed did not specify the ages of the MCs recruited for the study [17,19,20,30,32,33,35,38,40,41,43], while the rest recruited individuals who were 25 years old and under [16,18,21–29,31,34,36,37,39,44,45]. …”

“…Adolescent MC roles in the reviewed evaluations/studies included: (I) young females seeking pregnancy prevention or contraception/emergency contraception services [13,15–18,21–26,29,30,32,34], (II) females seeking counselling on premarital sex [29,35], (III) males seeking condoms [27,29,32,36,37,44], (IV) males and females seeking information or treatment for STIs [29,35,39], (V) or HIV testing and information [20,37,42], (VI) females requesting information about menstrual and associated problems [30], and (VII) seeking counselling for unwanted pregnancy or abortion [33,35]. …”