Enabling and hindering factors of health surveillance assistants’ roles in the provision of contraceptive services in Mangochi, Malawi

BACKGROUND: Contraceptive services are essential for promoting people’s health, and economic and social well-being. Despite increased contraceptive use over the past decades, unmet need is still high in Malawi. As a result of task shifting, health surveillance assistants (HSAs), Malawi’s paid community health worker cadre, provide an expanded range of contraceptive services, aimed at increasing access at community level. We conducted a qualitative study to explore enabling and hindering factors of HSAs’ roles in the provision of modern contraceptive services in Mangochi district, Malawi. METHODS: The study involved HSAs and their supervisors, a variety of community members, health workers and policy makers using 34 interviews and 12 focus group discussions. Data were recorded, transcribed, translated, coded and thematically analysed according to a framework that included community-, HSA- and health system-related factors. RESULTS: HSAs were found to be trusted providers of contraceptive services. At community level, gender norms, decision-making and beliefs about contraceptives were intertwined. They resulted in women using contraceptive services, including those offered by HSAs, in secret. There were misconceptions about contraceptives among both men and women, which were insufficiently addressed by HSAs. Residence and age of HSAs influenced their role in the provision of contraceptive services to (young) community members, whereas sex was not regarded as an enabling or hindering factor. While most community members reported to be satisfied with the quality of HSAs’ services, quality was compromised by a lack of contraceptive supplies and other resources, and limited supportive supervision and training. CONCLUSIONS: HSAs in Mangochi are important contraceptive service providers. Their ability to ensure male involvement, increase access to services for youth and address misconceptions about contraceptives needs improvement. This requires a thorough understanding of socio-cultural norms and improved behavioural change communication competencies, which need to be incorporated in future training under Malawi’s Community Health Strategy.