Zambia Post-Intervention Mystery Client Form
Information to be completed in the office from sampling list:
Mystery Client ID (circle one): 1 | 2 | 3 | 4
Mystery Client Sex (circle one): Male | Female
Pharmacy name: ___________________________________
Pharmacy code: __ __ __
Was this pharmacy part of the OR study intervention? (circle one) Yes |
No
Information below is part of a TRAINED SIMULATED CLIENT FOLLOW-UP FORM: COMPLETE after
interaction (CONFIDENTIAL: DATA USED FOR RESEARCH PURPOSES ONLY)
Mystery client should say she/his girlfriend is 7 weeks pregnant and has had a positive pregnancy
test.
Section 1. General information about the pharmacy and pharmacy worker
Age of pharmacist
101
102
Sex of pharmacist
What was the position of the pharmacist?
103
104
How many other customers were in the shop
when you started the interview?
1
2
3
4
1
2
Less than 20
20 to 30
31 to 40
41 or older
Male
Female
1
2
3
4
Pharmacist
Pharmacy attendant
Couldn’t tell
Other (specify): _____________________
________________ Customers
Section 2. Did the pharmacist offer anything to help you?
201
Did the pharmacist recommend any medication
to complete the abortion?
IF NO, why not?
(Circle all that apply)
202
0 No
1 Yes  Go to question 203
1 Said role was not to provide medical
advice
2 Did not sell drugs to bring down a period
3 Did not know of any drugs to bring down a
period
4 Was too busy and sent me away
5 Told I needed a prescription and sent me
away
6 Referred me to a health facility
7 Referred me to another pharmacy
8 Referred me to a traditional healer
9 Referred me to a private doctor/midwife
10 Told me he/she is opposed to abortion
and asked me to leave
11 Told me to come back later to get help
12 Told to go somewhere else
13 Other (specify) __________________
__________________________________
14 Other (specify) __________________
__________________________________
Any additional relevant information about what they told you to do?
203
How did the pharmacist react when you asked
for something to ukuponya ifumo/kuchotsa
mimba?
204
(Circle the best answer)
Did the pharmacist seem afraid?
205
206
207
208
209
Did the pharmacist tell you that abortion is
illegal?
Did the pharmacist tell you that abortion is
illegal if you do not have a prescription?
Did the pharmacist suggest you/your girlfriend
use contraception/family planning?
Did the pharmacist offer to sell you/your
girlfriend contraception/family planning?
1 Was interested in helping
2 Completely refused any information
3 Refused but gave some
information/answered some questions
4 Acted indifferent or unconcerned
5 Other (specify) ____________________
___________________________________
0
1
2
0
1
0
1
0
1
0
1
No
Yes
Could not tell/unsure
No
Yes
No
Yes
No
Yes
No
Yes
If the pharmacist did not offer any information or sale of any medication, STOP
HERE.
If the pharmacist offered you any medication or advice, PLEASE FILL IN REMAINING
FORM.
Section 3. If the pharmacist offered you any medication or advice
What type of medication did the pharmacist
suggest?
(Circle all that apply)
301
302
303
304
305
306
307
Were you asked for a prescription?
0 No  Go to question 304
1 Yes
If you were asked for a prescription, when you
tried to persuade them did they agree to sell
the medication to you?
0 No
1 Yes
Did pharmacist offer to sell you Medabon?
0
1
0
1
0
1
Did pharmacist offer to sell you Zizhu Chinese
pills?
Did pharmacist offer to sell you Cytotec or
misoprostol?
If the pharmacist offered you one of the
medications listed above, what was the
number of pills suggested?
What was the number of days the pharmacist
suggested for taking the pills?
308
How did the pharmacist tell you to take the
pills?
309
310
311
312
1 Cytotec/Misoprostol
2 Medabon
3 Zizhu Chinese pills
4 Emergency
contraception/Postinor/morning after pill/72
hour pill
5 Oral contraceptives
6 Other (specify):
___________________________________
Did the pharmacist ask you when you/your
girlfriend last had your/her menstrual period?
Did the pharmacist use a gestational wheel to
determine your/your girlfriend’s eligibility for
the medication?
Did the pharmacist tell you that you/your
girlfriend should have been pregnant no longer
than 9-10 weeks?
No
Yes
No
Yes
No
Yes
________________ pills
1 Take all at once
2 Take over 2 days
3 Take over 3 days
4 Take every day as needed
5 Other (specify):
__________________________________
6 The pharmacist did not say how many
days to take the pills
1 Under the tongue
2 In the vagina
3 In the cheek
4 Swallow orally
5 Other (specify):
__________________________________
6 The pharmacist did not say how to take
the pills
0 No
1 Yes
0 No
1 Yes
0 No
1 Yes
Did the pharmacist tell you any of the following
information about the medication?
(Circle all that apply)
313
Did the pharmacist tell you that…
314
(Circle all that apply)
Did the pharmacist tell you that you/your
girlfriend may have…
315
316
317
(Circle all that apply)
Did the pharmacist tell you/your girlfriend to
seek help as soon as you/she start(s) bleeding?
Did the pharmacist tell you/your girlfriend that
bleeding is normal and only to seek help if
you/your girlfriend have/has a complication?
Did the pharmacist tell you to seek help if
you/your girlfriend have/has…
318
319
(Circle all that apply)
Would you describe your interaction with the
pharmacist as hostile or unfriendly?
1 When to use it
2 How to use it
3 Side effects of it
4 Effectiveness of it
5 When to seek help
6 When not to use the drug
7 When you know it worked
8 Other (specify):
___________________________________
_____________________________________
1 You/your girlfriend will bleed for a few
days then it will stop
2 You/your girlfriend will have cramping for
a few days then it will stop
1 Nausea/vomiting
2 Diarrhea
3 Fever/chills
4 Headache
5 Other (specify):
____________________________________
_____________________________________
0 No
1 Yes
0 No
1 Yes
1 Heavy bleeding
2 Severe pain
3 Bleeding lasting more than 2 weeks
4 Pain lasting more than 2 weeks
5 High fever
6 Other (Specify):
____________________________________
_____________________________________
0 No
1 Yes