Facility and Provider Characteristics
Equal proportions of providers were female and male and 40% were under the age of 30 years of age (table 2). Most providers were married (75%) and Protestant Christian (71%). Over half (64%) were nurses and 27% were community health providers known as Health Surveillance Assistants (HSAs), who also can provide services in facilities. Mangochi district had the greatest number of facilities, and the greatest number of providers (23%) (table 2). Generally, there is one hospital per district and the remaining are clinics or dispensaries (data on facility type not collected).
Findings by domain
Refusal of care
We considered two reasons for refusal of care: the facility was closed on reported days of operations or the facility mandated HIV testing and counseling (HTC) and/or tetanus toxoid vaccination (TTV) to receive family planning services. Almost 12 percent of the simulated clients did not receive their preferred method because of refusal of HTC (7%), refusal of TTV (2%), refusal of both HTC and TTV (1%) or facility closure (2%) (data not shown).
“Provider told me to go for HTC before I can access services. Provider said it is compulsory for me to do the test. If I refused then they will not assist me. So I told the provider that I was not ready for the test hence I’m going home. Provider told me to go only come again when I’m ready for the test. So I exited that facility without any method.”
– Adolescent SC
We found facilities conducted counseling with individual clients or multiple clients at the same time (group counseling). Regardless of whether they had individual or group counseling, in 59% of the visits there was no visual or auditory privacy (table 3). Over half of the counseling sessions (54%) were held as a group. Out of the individual consultations (n=90), 76% had both visual and auditory privacy.
“The family planning room had no visual privacy and we were more than 6 women in room to get family planning methods at once.” – Adolescent SC
Poor client-centered care
The SCs were not asked their preference for family planning method in 57% of the visits (table 3). In 5% of the visits, the SCs documented that they felt the provider was advocating for a specific method. In over half the visits (56%), the provider did not mention any additional methods besides hormonal pills, which was the SC’s stated preferred method (table 3).
“We were not asked our preferred method but they assumed that we all came for injectable. I had to tell the provider that I wanted pills.” – Adolescent SC
We did not collect information on counseling inaccuracies, however in the field notes the SC recorded two events where they were counseled with inaccurate information on injectables and implants.
“One of the HSA who was providing the contraceptive injectable told me that I am too young to access methods. Methods will destroy my bones.”
- Adolescent SC
“During group counselling the provider (HSA) warned us ‘don’t get tempted to use some of these satanic family planning methods like the implant. Whites are clever they always want to try out things on us blacks and Asians. Some of these are not good. They will just drain your blood’.”
- Adult SC
In 28% of the visits, SCs reported they were not greeted respectfully and in 20% of the visits, the SCs reported that the provider either interrupted them while they were speaking or interrupted the consultation to conduct unrelated business (table 3). For example, during a visit one adolescent SC reported the nurse was using Whatsapp on their phone throughout the visit.
In 18% of the visits the SC reported humiliating treatment (table 3). In 6% of the visits the provider or staff person yelled at the client. Some providers (5% overall) raised their voice or yelled at the SCs after they declined to consent to HTC and/or TTV.
“[Provider] stationed at the Health Centre forced me to go for an HIV test, I refused. She raised her voice at me for refusing to get tested. – Adult SC
The adolescent SCs reported humiliating treatment related to their (simulated) age and marital status in 5% of the visits.
“[Provider] counseled me to abstain not trusting my boyfriend in order to finish school properly. I was given pills and condoms for backup if my boyfriend insists to have sex before 7 days and the provider said that am young and should not be thinking of relationships.” – Adolescent SC
In one case out of the 222 consultations, the SC documented verbal sexual harassment by a family planning provider in the field notes. Using our framework, we defined this one documented instance as “Non-dignified care”. However, all the adolescent SCs reported to their team supervisors or the field coordinator being asked for their phone numbers by health providers seeking further relationship at one or more of the study facilities, although they did not document this in the field notes.[c]
“One of the health surveillance assistant who was also assisting [family planning] clients was proposing me for a relationship. [He was saying…] ‘Give me your number. Let us meet somewhere away from the facility for where we can discuss. Where do you live? Please, be serious. I am serious. You can flash me on this number’” – Adolescent SC
The median waiting times for the SCs was one hour, ranging from immediately being seen to waiting four hours. Nearly a third of the SCs reported waiting longer than one hour for services (29%) (table 3). None of the SCs documented being asked for additional payments but in the field notes they recorded two events that may be related to additional payments.
“The provider told us in a group that everyone should be menstruating of which he was to check to confirm, if [not menstruating] everyone should undergo for a pregnancy test, which was worth K1,000 [Malawi Kwacha or approximately 1.50 US dollars] to receive a service. This was for those who wanted to start using family planning (first time).” – Adult SC
“I was not prescribed pills though but was rather given condoms because the provider said the only pills available at the hospital were being sold at MK300 [Malawi Kwacha or approximately 0.50 US dollars] per strip because they belonged to [NGO].” – Adult SC
In 95% of the consultations, at least one of the pre-defined disrespectful care actions described above occurred (table 3).
Differences by case scenario and district
The adult SC who wanted to switch methods received poorer counseling quality compared to the adolescent SC, who was simulating a first-time user. The providers mentioned fewer methods beyond hormonal pills for the adult (31%, CI: 23 – 40%) compared to the adolescent SC (58%, CI: 48 – 67%). Also, adult SCs were asked their method preference less (32%, CI: 24 – 41%) compared to the adolescents (55%, CI: 46 – 64%). There were no other differences in proportions of adult and adolescent SCs reporting care refusal, long wait times, non-private consultations, or providers advocating for a specific method or exhibiting poor listening/attention. Despite some of the adolescent SCs experiencing humiliating treatment related to their simulated age (table 3), they experienced the same level of humiliation as the adult SCs (Adult SCs: 18%, CI: 12 – 26% versus Adolescent SCs: 17%, CI: 11 – 25%).
The SCs reported refusal of care in three of the six districts. In one of the districts (in the high outcome district group), 58% of SCs were refused service, predominantly because the facilities mandated HTC, in two other districts (one in the high- and one in the low-outcome district group) <15% of SC visits were refused care, and in three districts none of the SCs were refused care. In the other districts, the SCs noted several instances where the provider encouraged HTC and/or TTV but the SCs were able to decline those services and still receive family planning care (14% of the visits). We found a few statistically significant differences by district, but no clear pattern between high and low outcome district groups (data not shown).
There was no statistically significant difference in the respectful care indicators reported by the SCs during the first half time-period of data collection compared to the second half (data not shown).
[c] Personal communication, Patrick Msukwa, 19th December 2019