Enmity then empathy: How militarisation facilitated collaborative but exclusive exchange in Sierra Leone's Ebola response.

In the autumn of 2014, with the 2013-16 West Africa Ebola epidemic spiralling out of control, the United Kingdom announced a bespoke military mission to support-and in some ways lead-numerous Ebola response functions in Sierra Leone. This study examines the nature and effect of the civil-military relationships that subsequently developed between civilian and military Ebola response workers (ERWs). In total, 110 interviews were conducted with key involved actors, and the findings were analysed by drawing on the neo-Durkheimian theory of organisations. This paper finds that stereotypical opposition between humanitarian and military actors helps to explain how and why there was initial cooperative and collaborative challenges. However, all actors were found to have similar hierarchical structures and operations, which explains how and why they were later able to cooperate and collaborate effectively. It also explains how and why civilian ERWs might have served to exclude and further marginalise some local actors.

Nutrient profiles of commercially produced complementary foods available in Cambodia, Indonesia and the Philippines.

OBJECTIVE: To assess the nutritional suitability of commercially produced complementary foods (CPCF) marketed in three South-East Asian contexts. DESIGN: Based on label information declared on the products, nutrient composition and content of CPCF were assessed against the WHO Europe nutrient profile model (NPM). The proportion of CPCF that would require a 'high sugar' warning was also determined. SETTING: Khsach Kandal district, Cambodia; Bandung City, Indonesia; and National Capital Region, Philippines. PARTICIPANTS: CPCF products purchased in Cambodia (n 68) and Philippines (n 211) in 2020, and Indonesia (n 211) in 2017. RESULTS: Only 4·4 % of products in Cambodia, 10·0 % of products in Indonesia and 37·0 % of products in the Philippines fully complied with relevant WHO Europe NPM nutrient composition requirements. Sixteen per cent of CPCF in Cambodia, 27·0 % in Indonesia and 58·8 % in the Philippines contained total sugar content levels that would require a 'high sugar' warning. CONCLUSIONS: Most of the analysed CPCF were not nutritionally suitable to be promoted for older infants and young children based on their nutrient profiles, with many containing high levels of sugar and sodium. Therefore, it is crucial to introduce new policies, regulations and standards to limit the promotion of inappropriate CPCF in the South-East Asia region.

Improving health system readiness to address violence against women and girls: a conceptual framework.

BACKGROUND: There is an increasing focus on readiness of health systems to respond to survivors of violence against women (VAW), a global human rights violation damaging women's health. Health system readiness focuses on how prepared healthcare systems and institutions, including providers and potential users, are to adopt changes brought about by the integration of VAW care into services. In VAW research, such assessment is often limited to individual provider readiness or facility-level factors that need to be strengthened, with less attention to health system dimensions. The paper presents a framework for health system readiness assessment to improve quality of care for intimate partner violence (IPV), which was tested in Brazil and Palestinian territories (oPT). METHODS: Data synthesis of primary data from 43 qualitative interviews with healthcare providers and health managers in Brazil and oPT to explore readiness in health systems. RESULTS: The application of the framework showed that it had significant added value in capturing system capabilities - beyond the availability of material and technical capacity - to encompass stakeholder values, confidence, motivation and connection with clients and communities. Our analysis highlighted two missing elements within the initial framework: client and community engagement and gender equality issues. Subsequently, the framework was finalised and organised around three levels of analysis: macro, meso and micro. The micro level highlighted the need to also consider how the system can sustainably involve and interact with clients (women) and communities to ensure and promote readiness for integrating (and participating in) change. Addressing cultural and gender norms around IPV and enhancing support and commitment from health managers was also shown to be necessary for a health system environment that enables the integration of IPV care. CONCLUSION: The proposed framework helps identify a) system capabilities and pre-conditions for system readiness; b) system changes required for delivering quality care for IPV; and c) connections between and across system levels and capabilities.

Integrated delivery of family planning and childhood immunisation services: a mixed methods assessment of service responsiveness.

BACKGROUND: Postpartum women represent a considerable share of the global unmet need for modern contraceptives. Evidence suggests that the integration of family planning (FP) with childhood immunisation services could help reduce this unmet need by providing repeat opportunities for timely contact with FP services. However, little is known about the clients' experiences of FP services that are integrated with childhood immunisations, despite being crucial to contraceptive uptake and repeat service utilisation. METHODS: The responsiveness of FP services that were integrated with childhood immunisations in Malawi was assessed using cross-sectional convergent mixed methods. Exit interviews with clients (n=146) and audits (n=15) were conducted in routine outreach clinics. Responsiveness scores across eight domains were determined according to the proportion of clients who rated each domain positively. Text summary analyses of qualitative data from cognitive interviewing probes were also conducted to explain responsiveness scores. Additionally, Spearman rank correlation and Pearson's chi-squared test were used to identify correlations between domain ratings and to examine associations between domain ratings and client, service and clinic characteristics. RESULTS: Responsiveness scores varied across domains: dignity (97.9%); service continuity (90.9%); communication (88.7%); ease of access (77.2%); counselling (66.4%); confidentiality (62.0%); environment (53.9%) and choice of provider (28.4%). Despite some low performing domains, 98.6% of clients said they would recommend the clinic to a friend or family member interested in FP. The choice of provider, communication, confidentiality and counselling ratings were positively associated with clients' exclusive use of one clinic for FP services. Also, the organisation of services in the clinics and the providers' individual behaviours were found to be critical to service responsiveness. CONCLUSIONS: This study establishes that in routine outreach clinics, FP services can be responsive when integrated with childhood immunisations, particularly in terms of the dignity and service continuity afforded to clients, though less so in terms of the choice of provider, environment, and confidentiality experienced. Additionally, it demonstrates the value of combining cognitive interviewing techniques with Likert questions to assess service responsiveness.

Globalisation and transitions in abortion care in Ghana.

BACKGROUND: Access to safe abortion is a globally contested policy and social justice issue - contested because of its religious and moral dimensions regarding the right to life and personhood of a foetus vs. the rights of women to make decisions about their own bodies. Many nations have agreed to address the health consequences of unsafe abortion, though stopped short of committing to providing comprehensive services. Ghana has a relatively liberal abortion law dating from 1985 and has ratified most international agreements on provision of care. Policy implementation has been very slow, but modest efforts are now being made to reduce maternal mortality caused by unsafe abortions. Understanding whether globalisation has played a role in this transition to practice is important to institutionalise the transition in Ghana and to learn lessons for other countries seeking to implement policies, but analysis is lacking. METHODS: Drawing on 58 in-depth key informant interviews and policy document analysis we describe the development of de jure law and policies on comprehensive abortion care in Ghana, de facto interpretation and implementation of those policies, and assess what role globalization played in the transition in abortion care in Ghana. RESULTS: We found that an accumulation of global influences has converged to start a transition in the culture of abortion care and service provision in Ghana, from a restrictive interpretation of the law to facilitating more widespread access to legal, safe abortion services through development of policies and guidelines and a slow change in attitudes and practices of health providers. These global influences can be categorised as: a global governance architecture of reproductive rights-obligations which creates pressure on signatory governments to act; and global communication of ideas and mobility of health providers (particularly through cross-cultural training opportunities and interaction with international NGOs) which facilitate global cultural interaction on the benefits of safe abortion services for reducing consequences of unsafe abortions. CONCLUSION: Globalisation of information, debate and training experience as well as of international rights frameworks can together create a powerful force for good to protect women and their children from the needless pain and death resulting from unsafe abortions.

Factors shaping political priorities for violence against women-mitigation policies in Sri Lanka.

BACKGROUND: Although violence against women (VAW) is a global public health issue, its importance as a health issue is often unrecognized in legal and health policy documents. This paper uses Sri Lanka as a case study to explore the factors influencing the national policy response to VAW, particularly by the health sector. METHODS: A document based health policy analysis was conducted to examine current policy responses to VAW in Sri Lanka using the Shiffman and Smith (2007) policy analysis framework. RESULTS: The findings suggest that the networks and influences of various actors in Sri Lanka, and their ideas used to frame the issue of VAW, have been particularly important in shaping the nature of the policy response to date. The Ministry of Women and Child Affairs led the national response on VAW, but suffered from limited financial and political support. Results also suggest that there was low engagement by the health sector in the initial policy response to VAW in Sri Lanka, which focused primarily on criminal legislation, following global influences. Furthermore, a lack of empirical data on VAW has impeded its promotion as a health policy issue, despite financial support from international organisations enabling an initial health systems response by the Ministry of Health. Until a legal framework was established (2005), the political context provided limited opportunities for VAW to also be construed as a health issue. It was only then that the Ministry of Health got legitimacy to institutionalise VAW services. CONCLUSION: Nearly a decade later, a change in government has led to a new national plan on VAW, giving a clear role to the health sector in the fight against VAW. High-level political will, criminalisation of violence, coalesced women's groups advocating for legislative change, prevalence data, and financial support from influential institutions are all critical elements helping frame violence as a national public health issue.

Barriers and Facilitators to Integrating Health Service Responses to Intimate Partner Violence in Low- and Middle-Income Countries: A Comparative Health Systems and Service Analysis.

This systematic review synthesizes 11 studies of health-sector responses to intimate partner violence (IPV) in low- and middle-income countries. The services that were most comprehensive and integrated in their responsiveness to IPV were primarily in primary health and antenatal care settings. Findings suggest that the following facilitators are important: availability of clear guidelines, policies, or protocols; management support; intersectoral coordination with clear, accessible on-site and off-site referral options; adequate and trained staff with accepting and empathetic attitudes toward survivors of IPV; initial and ongoing training for health workers; and a supportive and supervised environment in which to enact new IPV protocols. A key characteristic of the most integrated responses was the connection or "linkages" between different individual factors. Irrespective of their service entry point, what emerged as crucial was a connected systems-level response, with all elements implemented in a coordinated manner.

The Current Status of Research on the Integration of Sexual and Reproductive Health and HIV Services.

Integration of services for sexual and reproductive health (SRH) and HIV has been widely promoted globally in the belief that both clients and health providers benefit through improvements in quality, efficient use of resources, and lower costs, helping to maximize limited health resources and provide comprehensive client-centered care. This article builds on the growing body of research on integrated sexual SRH and HIV services. It brings together critical reviews on issues within the wider SRH and rights agenda and synthesizes recent research on integrated services, drawing on the Integra Initiative and other major research. Unintended pregnancy and HIV are intrinsically interrelated SRH issues, however broadening the constellation of services, scaling up, and mainstreaming integration continue to be challenging. Overcoming stigma, reducing gender-based violence, and meeting key populations' SRH needs are critical. Health systems research using SRH as the entry point for integrated services and interaction with communities and clients is needed to realize universal health coverage.

Impact of Integrated Services on HIV Testing: A Nonrandomized Trial among Kenyan Family Planning Clients.

The impact of integrated reproductive health and HIV services on HIV testing and counseling (HTC) uptake was assessed among 882 Kenyan family planning clients using a nonrandomized cohort design within six intervention and six "comparison" facilities. The effect of integration on HTC goals (two tests over two years) was assessed using conditional logistic regression to test four "integration" exposures: a training and reorganization intervention; receipt of reproductive health and HIV services at recruitment; a functional measure of facility integration at recruitment; and a woman's cumulative exposure to functionally integrated care across different facilities over time. While recent receipt of HTC increased rapidly at intervention facilities, achievement of HTC goals was higher at comparison facilities. Only high cumulative exposure to integrated care over two years had a significant effect on HTC goals after adjustment (aOR 2.94, 95%CI 1.73-4.98), and programs should therefore make efforts to roll out integrated services to ensure repeated contact over time.

Fertility intentions and contraceptive practices among clinic-users living with HIV in Kenya: a mixed methods study.

BACKGROUND: Preventing unwanted pregnancies in Women Living with HIV (WLHIV) is a recognised HIV-prevention strategy. This study explores the fertility intentions and contraceptive practices of WLHIV using services in Kenya. METHODS: Two hundred forty women self-identifying as WLHIV who attended reproductive health services in Kenya were interviewed with a structured questionnaire in 2011; 48 were also interviewed in-depth. STATA SE/13.1, Nvivo 8 and thematic analysis were used. RESULTS: Seventy one percent participants did not want another child; this was associated with having at least two living children and being the bread-winner. FP use was high (92%) but so were unintended pregnancies (40%) while living with HIV. 56 women reported becoming pregnant "while using FP": all were using condoms or short-term methods. Only 16% participants used effective long-acting reversible contraceptives or permanent methods (LARC-PM). Being older than 25 years and separated, widowed or divorced were significant predictors of long-term method use. Qualitative data revealed strong motivation among WLHIV to plan or prevent pregnancies to avoid negative health consequences. Few participants received good information about contraceptive choices. CONCLUSIONS: WLHIV need better access to FP advice and a wider range of contraceptives including LARC to enable informed choices that will protect their fertility intentions, ensure planned pregnancies and promote safe child-bearing. TRIAL REGISTRATION: Integra is a non-randomised pre-post intervention trial registered with Current Controlled Trials ID: NCT01694862 .

Public accountability needs to be enforced -a case study of the governance arrangements and accountability practices in a rural health district in Ghana.

BACKGROUND: Improving public accountability is currently high on the global agenda. At the same time, the organisation of health services in low- and middle-income countries is taking place in fragmented institutional landscapes. State and non-state actors are involved in increasingly complex governance arrangements. This often leads to coordination problems, confusion of roles and responsibilities and possibly accountability gaps. This study aimed at assessing the governance arrangements and the accountability practices of key health actors at the level of a Ghanaian health district with the aim to understand how far public accountability is achieved. METHODS: We adopted the case study design as it allows for in-depth analysis of the governance arrangements and accountability relations between actors, their formal policies and actual accountability practices towards the public and towards stakeholders. Data were collected at a rural health district using in-depth interviews, observation and document review. In the analysis, we used a four-step sequence: identification of the key actors and their relationships, description of the multi-level governance arrangements, identification of the actual accountability relations and practices between all actors and finally appraisal of the public accountability practices, which we define as those practices that ensure direct accountability towards the public. RESULTS: In this rural health district with few (international) non-governmental organisations and private sector providers, accountability linkages towards management and partners in health programmes were found to be strong. Direct accountability towards the public, however, was woefully underdeveloped. This study shows that in settings where there is a small number of actors involved in organising health care, and where the state actors are underfunded, the intense interaction can lead to a web of relations that favours collaboration between partners in health service delivery, but fails public accountability. CONCLUSIONS: It is clear that new formal channels need to be created by all actors involved in health service delivery to address the demand of the public for accountability. If the public does not find an adequate response to its genuine concerns, distrust between communities and service users on one hand, and providers, international non-governmental organisations and District Health Management Teams on the other is likely to increase to the detriment of all parties' interests.

Stigmatized by association: challenges for abortion service providers in Ghana.

BACKGROUND: Unsafe abortion is an issue of public health concern and contributes significantly to maternal morbidity and mortality globally. Abortion evokes religious, moral, ethical, socio-cultural and medical concerns which mean it is highly stigmatized and this poses a threat to both providers and researchers. This study sought to explore challenges to providing safe abortion services from the perspective of health providers in Ghana. METHODS: A descriptive qualitative study using in-depth interviews was conducted. The study was conducted in three (3) hospitals and five (5) health centres in the capital city in Ghana. Participants (n = 36) consisted of obstetrician/gynaecologists, nurse-midwives and pharmacists. RESULTS: Stigma affects provision of safe-abortion services in Ghana in a number of ways. The ambiguities in Ghanaian abortion law and lack of overt institutional support for practitioners increased reluctance to openly provide for fear of stigmatisation and legal threat. Negative provider attitudes that stigmatised women seeking abortion care were frequently driven by socio-cultural and religious norms that highly stigmatise abortion practice. Exposure to higher levels of education, including training overseas, seemed to result in more positive, less stigmatising views towards the need for safe abortion services. Nevertheless, physicians open to practicing abortion were still very concerned about stigma by association. CONCLUSIONS: Stigma constitutes an overarching impediment for abortion service provision. It affects health providers providing such services and even researchers who study the subject. Exposure to wider debate and education seem to influence attitudes and values clarification training may prove useful. Proper dissemination of existing guidelines and overt institutional support for provision of safe services also needs to be rolled out.

Reliance on condoms for contraceptive protection among HIV care and treatment clients: a mixed methods study on contraceptive choice and motivation within a generalised epidemic.

OBJECTIVES: To (i) describe the contraceptive practices of HIV care and treatment (HCTx) clients in Manzini, Swaziland, including their unmet needs for family planning (FP), and compare these with population-level estimates; and (ii) qualitatively explore the causal factors influencing contraceptive choice and use. METHODS: Mixed quantitative and qualitative methods were used. A cross-sectional survey conducted among HCTx clients (N=611) investigated FP and condom use patterns. Using descriptive statistics, findings were compared with population-level estimates derived from Swaziland Demographic and Health Survey data, weighted for clustering. In-depth interviews were conducted with HCTx providers (n=16) and clients (n=22) and analysed thematically. RESULTS: 64% of HCTx clients reported current contraceptive use; most relied on condoms alone, few practiced dual method use. Rates of condom use for FP among female HCTx clients (77%, 95% CI 71% to 82%) were higher than population-level estimates in the study region (50% HIV-positive, 95% CI 43% to 57%; 37% HIV-negative, 95% CI 31% to 43%); rates of unmet FP needs were similar when condom use consistency was accounted for (32% HCTx, 95% CI 26% to 37%; vs 35% HIV-positive, 95% CI 28% to 43%; 29% HIV-negative, 95% CI 24% to 35%). Qualitative analysis identified motivational factors influencing FP choice: fears of reinfection; a programmatic focus on condoms for people living with HIV; changing sexual behaviours before and after antiretroviral therapy (ART) initiation; failure to disclose to partners; and contraceptive side effect fears. CONCLUSIONS: Fears of reinfection prevailed over consideration of pregnancy risk. Given current evidence on reinfection, HCTx services must move beyond a narrow focus on condom promotion, particularly for those in seroconcordant relationships, and consider diverse strategies to meet reproductive needs.

Factors affecting adherence to short-course ARV prophylaxis for preventing mother-to-child transmission of HIV in sub-Saharan Africa: a review and lessons for future elimination.

Despite the biomedical potential to eliminate vertical HIV transmission, drug adherence to short regimens is often sub-optimal. To inform future programmes, we reviewed evidence on the factors influencing maternal and infant drug adherence to preventing MTCT drug regimens at delivery in sub-Saharan Africa. A literature review yielding 14 studies on adherence to drug regimes among HIV-positive pregnant women and mothers in sub-Saharan Africa was conducted. Rates of maternal adherence to preventive drug regimens at time of delivery varied widely across sites between 35 and 93.5%. Factors most commonly associated with low adherence to antiretroviral therapy (ARV) prophylaxis for preventing MTCT at the health system level include giving birth at home, quality and timing of HIV testing and counselling, and late distribution of nevirapine (NVP). Socio-demographic and demand-side factors include fear of stigma, lack of male involvement, fear of partner's reaction to disclosure, few antenatal (ANC) visits, young age and lack of education. With the implementation of the newly published WHO guidelines recommending triple-drug ARV regimen during pregnancy and breastfeeding for all women with HIV, it is important that women are able to adhere to recommended drug regimens. Service improvements should include clear and timely communication with women about the benefits of combined regimens and greater emphasis on patient confidentiality. Efforts must be made to help women overcome barriers that reduce adherence, such as financial logistical challenges, social stigma and women's fear of violence.

Experiences of stigma among women living with HIV attending sexual and reproductive health services in Kenya: a qualitative study.

BACKGROUND: Researchers have widely documented the pervasiveness of HIV stigma and discrimination, and its impact on people living with HIV. Only a few studies, however, have analysed the perceptions of women living with HIV accessing sexual and reproductive health (SRH) services. This study explores the experiences of stigma of HIV-positive clients attending family planning and post-natal services and implications for service use and antiretroviral therapy (ART) adherence. Our aim was to gain a better understanding of the impact of various dimensions of stigma on service use and ART adherence among HIV clients in order to inform the response of integrated SRH services. METHODS: In-depth interviews were conducted with 48 women living with HIV attending SRH services in two districts in Kenya. Data were coded using Nvivo 8 and analysed using a thematic analysis approach. RESULTS: Findings show that many women living with HIV report high levels of anticipated stigma, resulting in a desire to hide their status from family and friends for fear of being discriminated against. Many women feared desertion following disclosure of their positive status to partners. Consequently some women preferred to hide their status and adhere to HIV treatment in secret. However, the majority of study participants attending postnatal care (PNC) services also revealed that anticipated stigma does not adversely affect their HIV drug uptake and ART adherence, as their drive to live outweighs their fear of stigma. Our findings also seem to suggest a preference for specialist HIV services by some family planning (FP) clients because of better confidentiality and reduced opportunities for unwanted disclosure that could lead to stigma. CONCLUSIONS: The findings highlight that anticipated stigma leading to low disclosure is widespread and sometimes reinforced by health providers' actions and facility layout (contributing to enacted stigma). However, the motivation to stay healthy and look after the children appears in many cases to override fears of stigma related to ART adherence in our client-based sample.

A story of (in)coherence: climate adaptation for health in South African policies.

Climate adaptation strengthens and builds the resilience of health systems to future climate-related shocks. Adaptation strategies and policies are necessary tools for governments to address the long-term impacts of climate change and enable the health system to respond to current impacts such as extreme weather events. Since 2011 South Africa has national climate change policies and adaptation strategies, yet there is uncertainty about: how these policies and plans are executed; the extent to which health policies include adaptation; and the extent of policy coherence across sectors and governance levels. A policy document analysis was conducted to examine how South African climate change, development and health policy documents reflect the health adaptation response across national and Western Cape levels and to assess the extent of coherence across key health and environment sector policy documents, including elements to respond to health-related climate risks, that can support implementation. Our findings show that overall there is incoherence in South African climate adaptation within health policy documents. Although health adaptation measures are somewhat coherent in national level policies, there is limited coherence within Western Cape provincial level documents and limited discussion on climate adaptation, especially for health. Policies reflect formal decisions and should guide decision-makers and resourcing, and sectoral policies should move beyond mere acknowledgement of adaptation responses to a tailored plan of actions that are institutionalized and location and sector specific. Activities beyond documents also impact the coherence and implementation of climate adaptation for health in South Africa. Clear climate risk-specific documents for the health sector would provide a stronger plan to support the implementation of health adaptation and contribute to building health system's resilience.

Did aid to the Ebola crisis divert aid for reproductive, maternal, and newborn health? An analysis of donor-reported data in Sierra Leone.

BACKGROUND: Infectious disease outbreaks like Ebola and Covid-19 are increasing in frequency. They may harm reproductive, maternal and newborn health (RMNH) directly and indirectly. Sierra Leone experienced a sharp deterioration of RMNH during the 2014-16 Ebola epidemic. One possible explanation is that donor funding may have been diverted away from RMNH to the Ebola response. METHODS: We analysed donor-reported data from the Organisation for Economic Cooperation and Development (OECD)'s Creditor Reported System (CRS) data for Sierra Leone before, during and after the 2014-16 Ebola epidemic to understand whether aid flows for Ebola displaced aid for RMNH. We estimated aid for Ebola using key term searches and manual review of CRS records. We estimated aid for RMNH by applying the Muskoka-2 algorithm to the CRS and analysing CRS purpose codes. RESULTS: We find substantial increases in aid to Sierra Leone (from $484 million in 2013 to $1 billion at the height of the epidemic in 2015), most of which was earmarked for the Ebola response. Overall, Ebola aid was additional to RMNH funding. RMNH aid was sustained during the epidemic (at $42 m per year) and peaked immediately after (at $77 m in 2016). There is some evidence of a small displacement of RMNH aid from the UK during the period when its Ebola funding increased. CONCLUSIONS: Modest changes to RMNH donor aid patterns are insufficient to explain the severe decline in RMNH indicators recorded during the outbreak. Our findings therefore suggest the need for substantial increases in routine aid to ensure that basic RMNH services and infrastructure are strong before an epidemic occurs, as well as increased aid for RMNH during epidemics like Ebola and Covid-19, if reproductive, maternal and newborn healthcare is to be maintained at pre-epidemic levels.

Shaping legal abortion provision in Ghana: using policy theory to understand provider-related obstacles to policy implementation.

BACKGROUND: Unsafe abortion is a major public health problem in Ghana; despite its liberal abortion law, access to safe, legal abortion in public health facilities is limited. Theory is often neglected as a tool for providing evidence to inform better practice; in this study we investigated the reasons for poor implementation of the policy in Ghana using Lipsky's theory of street-level bureaucracy to better understand how providers shape and implement policy and how provider-level barriers might be overcome. METHODS: In-depth interviews were conducted with 43 health professionals of different levels (managers, obstetricians, midwives) at three hospitals in Accra, as well as staff from smaller and private sector facilities. Relevant policy and related documents were also analysed. RESULTS: Findings confirm that health providers' views shape provision of safe-abortion services. Most prominently, providers experience conflicts between their religious and moral beliefs about the sanctity of (foetal) life and their duty to provide safe-abortion care. Obstetricians were more exposed to international debates, treaties, and safe-abortion practices and had better awareness of national research on the public health implications of unsafe abortions; these factors tempered their religious views. Midwives were more driven by fundamental religious values condemning abortion as sinful. In addition to personal views and dilemmas, 'social pressures' (perceived views of others concerning abortion) and the actions of facility managers affected providers' decision to (openly) provide abortion services. In order to achieve a workable balance between these pressures and duties, providers use their 'discretion' in deciding if and when to provide abortion services, and develop 'coping mechanisms' which impede implementation of abortion policy. CONCLUSIONS: The application of theory confirmed its utility in a lower-middle income setting and expanded its scope by showing that provider values and attitudes (not just resource constraints) modify providers' implementation of policy; moreover their power of modification is constrained by organisational hierarchies and mid-level managers. We also revealed differing responses of 'front line workers' regarding the pressures they face; whilst midwives are seen globally as providers of safe-abortion services, in Ghana the midwife cadre displays more negative attitudes towards them than doctors. These findings allow the identification of recommendations for evidence-based practice.

When can research from one setting be useful in another? Understanding perceptions of the applicability and transferability of research.

Determining whether research findings from one setting are relevant to another is complex and poorly understood. This study aimed to explore the factors affecting whether research from other settings was perceived to be of potential use to those working in or researching maternal health in Ghana. Semi-structured interviews were conducted with 69 purposively sampled government decision-makers, researchers and other stakeholders working in maternal health in Ghana in 2008-09. The most influential factors affecting perceptions of applicability/transferability were the study's congruence with interviewees' previous experiences and beliefs. Interventions' adaptability was also considered crucial (and more important than remaining faithful to the original intervention). However, it was frequently considered a distinct stage in the research use process rather than a consideration of applicability/transferability. More attention was paid to the implementability of the intervention in the new setting, than to whether it would be as effective there. Interpretations of intervention descriptions and evaluation findings varied between interviewees, even when the same information was presented. This study is one of the first to explore perceptions of applicability/transferability of public health research among researchers and potential research users in a low-income setting. The findings suggest that existing frameworks of applicability/transferability do not reflect the factors considered to be most important in Ghana.