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