Table 2 Overview of factors that influenced HSAs’ roles in the provision of contraceptive services

General awareness and access of contraceptive services

Community members were generally aware of possible advantages of modern contraceptives, and where to access them.

This enabled HSAs’ roles in the provision of contraceptive services, as people had basic knowledge about these services and some would actively approach HSAs.

Cultural and gender norms

Cultural norms around the importance of having many children resulted in a low perceived need for contraceptives, especially among men.

This hindered HSAs’ roles in the provision of contraceptive services, as HSAs seemed not to involve men in awareness raising activities.

Gender norms around the importance of attractiveness of women, especially in a culture where polygamy is there, resulted in some women perceiving a need for contraceptives.

The exact influence on HSAs’ roles in the provision of contraceptive services is unclear, however women’s perceived need for contraceptives fitted with the women-centred focus of HSAs’ contraceptive service provision.

Gender norms around women’s responsibility to childcare and contraception led them to often secretly decide on contraceptive use.

This did not enable or hinder HSAs’ roles in the provision of contraceptive services. HSAs did not encounter a lot of direct problems while secretly providing services.

Misconceptions

Misconceptions about contraceptives negatively influenced the perceived need for and decision-making on contraceptive use.

This hindered HSAs’ roles in the provision of contraceptive services, as HSAs seemed not able to address these misconceptions.

Religion

A few religions did not officially support contraceptive use, but seemed to silently tolerate it.

This did not directly hinder HSAs’ roles in the provision of contraceptive services, but HSAs got limited support of some religious leaders during awareness raising.

Perceived quality of HSA-provided care

The majority of the study participants perceived the quality of care provided by HSAs as good.

This enabled HSAs’ roles in the provision of contraceptive services, as they were approached and supported by community members.

HSAs’ knowledge and role perception

HSAs were well aware of their roles in the provision of contraceptive services, the importance of these roles and their position regarding other health workers.

This enabled HSAs’ roles in the provision of contraceptive services, as they transferred their knowledge to community members and knew when to refer if needed.

HSAs’ norms and values on contraception

For the majority of the HSAs, their own norms and values on contraception were in line with their expected roles.

This enabled HSAs’ roles in the provision of contraceptive services.

HSAs’ characteristics

Age, sex and origin of HSAs did not significantly influence their relationships with community members.

This did not enable or hinder HSAs’ roles in the provision of contraceptive services. However, older HSAs might be less able to serve youth.

Community members preferred HSAs residing in their area.

This hindered HSAs’ roles in the provision of contraceptive services, because it was impossible for them to reside in all their catchment areas as they had large areas to cover.

Policies and related resources

Inadequate policy dissemination and resources led to challenges in policy implementation.

This generally hindered HSAs’ roles in the provision of contraceptive services.

NGOs had a large role in (facilitation of) the provision of contraceptive services.

This enabled HSAs’ roles in the provision of contraceptives services, through provision of training and supplies, however, it hindered their roles because of challenges regarding coordination and perceived inequity of support between areas.

HSAs’ training

HSAs’ training in the provision of contraceptive services was dependent on partners and therefore, only half of them were trained.

While this enabled trained HSAs in providing contraceptive services, the differences between trained and untrained HSAs led to confusion or mistrust in the community, which hindered HSAs’ roles in the provision of contraceptive services.

HSAs’ supervision and monitoring

There was a disconnect between the environmental health and nursing department with regard to supervision of HSAs.

This hindered HSAs’ roles in the provision of contraceptive services, as their direct supervisors, AEHOs, felt disconnected to the family planning programme and thus provided limited supervision.

Supervision was more administrative than supportive in nature.

This hindered HSAs’ roles in the provision of contraceptive services, as feedback did not focus on quality of care and client satisfaction.

Contraceptive supply

There was erratic supply of contraceptives at health centre and community level.

This hindered HSAs’ roles in the provision of contraceptive services, partly because of dissatisfied clients.

HSAs’ working relationships with others

HSAs had generally good working relationships with health professionals.

This enabled HSAs’ roles in the provision of contraceptives services, partly through effective referral.

Community groups and traditional/ religious leaders sometimes assisted HSAs by provision of platforms for awareness raising.

This enabled HSAs’ roles in the provision of contraceptives services, however, a more active role of traditional leaders would further enable HSAs’ work.

Other resources

Stationary supply was constrained, and transport remained a challenge for HSAs, although they were provided with pushbikes.

This hindered HSAs’ roles in the provision of contraceptive services, specifically in relation to quality of care and provision of services in hard-to-reach areas.