Our project describes attempts of using the CoP concept to improve understanding and application of the AHR model for improving access to CAC in a context where abortion is legally restricted. Fostering different opportunities and levels of participation, and emphasis/focus on values are critical for the CoP. In our findings, Capability related to physical and psychological abilities that enabled participation in the CoP activities, Opportunity related to the external factors that enhanced participation in CoP activities, while Motivation related to CoP rmembers’ interpretation of the events, experiences and activities and how these influenced their beliefs, intentions and participation in the CoP.

Our findings present a case study on initiation and operation of a CoP among health workers, with related challenges in both conceptualization and implementation. Designing a CoP to achieve both aliveness and effectiveness is challenging as involves creating structures, systems, and roles for different members, being flexible and tolerant to values of other members, ensuring the knowledge shared is applicable to the members working environment and maintaining direction, character, vibrancy and energy. Being members of a CoP did not indicate having similar views and values in relation to far health workers were ready to implement comprehensive abortion care. While all were knowledgeable about comprehensive abortion care and could identify some aspect of care they could routinely provide along the abortion trajectory (from primary prevention to tertiary complication of abortion complications), few were willing to provide safe abortion using manual vacuum aspiration. The choice of how much they could offer depended on their value clarification. Many were able to align their personal and professional values via VCAT, and thus were able to provide care to the extent of their clarified values, and always provided harm reduction counseling to clients. Therefore, using the AHR model as the bedrock of the CoP strategy-due to its inclusiveness—could be particularly appropriate at bringing together health workers with different views and values onto the same platform.

All CoPs, whether planned or spontaneous, need coordination. Our CoP had a “coordinator” who organized the zoom seminars and mentors stimulated interaction within the WhatsApp group. While it was envisaged that midwives would initiate the discussions, they often did not initially, and even when prompted, few of the midwives participated in the discussions. The six mentors also actively stimulated lively discussions, focused on application of knowledge. Besides, mentors spontaneously took on leadership roles, actively participating in the discussions and debates, and suggesting varied topics which emphasized the application of knowledge and the values/attitudes that promote access to care. Even then, even with prompting by the mentors, participants would initially engage in shallow or narrow discussion of particular issues in relation to how they affected access to abortion care and related SRH policies. However, over subsequent weeks, the discussions deepened, the debates became more engaging, the number of participants increased, and there quite some regular participants (of the trained health workers) who participated on the WhatsApp forum, call centre or in the bimonthly zoom continuous professional development (CPD) seminars. Considering that procuring abortion is judged negatively both morally and socially and that abortion on request is legally prohibited, there was limited sharing of experiences on provision of safe abortion at the beginning. Thus there was limited sharing and open discussions. This situation changed over the subsequent weeks, when the members knew more about each other, had built trust and were able to share freely. Thus, promoting trust, a sense of belonging and a supportive environment were key to successful establishment of the CoP.

The presence of facilitators/mentors (who were part of the initial trainer team) promoted sustainability of the CoP, since a facilitator plays a crucial role in addressing the challenges of establishing and nurturing a CoP [33, 34]. Facilitation can be defined as “making things easier by using a range of skills and methods to bring the best out in people as they work to achieve results in interactive events” [36, 37]. The facilitator role entails several behaviors, including directing, guiding, leading, counselling and giving feedback [38]. Prompting midwives to lead sessions and identify which topics to discuss was one way of promoting participation and leadership. In virtual environments, leadership ensures CoP members look to a facilitator to exercise leadership to a greater extent than in other kinds of virtual entities because COPs typically do not have an assigned leader. Good design requires an insider’s perspective of what the CoP is about. Facilitators are instrumental in helping a group capitalize on the technology’s potential to achieve meaningful interaction and learning.

Our study shows individual, interpersonal and organizational factors that influence success of a CoP. Individual-level factors such as previous experience, skills or social capital of an individual member, empowerment, motivation or confidence building are critical. Potential organizational mechanisms include nurturing trust between members and improving their level of communication and collaboration [37, 38]. System mechanisms include appreciation by the health supervisors, openness for (policy) changes and willingness to invest in time and resources for member participation [12,13,14]. The identified contextual factors include potential factors which can lead to influences at individual, interpersonal or organizational level. These include improved opportunities for knowledge acquisition or learning (individual outcomes), improved practice, sharing or implementation of new ideas (interpersonal and organizational outcomes), or quality improvements and policy changes (system outcomes) [12].

To promote success, the objectives and expectations of the CoP should be explicit to all those involved. The assumptions and expectations must be clarified to members, particularly the purpose of repeating some of the topics in the discussions, especially the need for moving progressively from theoretical to applied knowledge. The theory of change needs to be clear to all members to a CoP. To achieve CoP objectives, a more explicit ‘theory of change’, including how to monitor and evaluate effectiveness needs to be explicit. For our CoP, the assumption was that an initial competence-based training emphasizing knowledge, attitudes, skills and decision-making in using the AHR model, followed by both on-job mentorship and virtual mentorship (to reinforce sharing of knowledge and skills), regular communication and connection (to ensure sharing of experiences, challenges and concerns), as well as ongoing updates on clinical management, would foster a sense of community support and belonging, which would facilitate both rapid adoption of the AHR model and deeper learning through sharing, social learning and collaborative learning. Monitoring the CoP is key to assess whether activities are in line with a wider process of mobilization of resources for the achievement of explicit healthcare goals, as well as influencing health policy among stakeholders (such as clinicians, managers and analysts) [26]. As shown by our findings, the CoP strength lies in its promotion of an environment that is conducive to learning through knowledge sharing/exchange, by fostering social relationships and recognizing the importance of knowledge sharing through emphasis on interactions in a climate of mutual trust [2, 39, 40]. Our CoP was designed to strengthen adoption and implementation of the 2022 WHO guidelines on abortion care. Monitoring should entail decisions, plans, and actions undertaken to achieve specific healthcare goals and strategies to enhance exchange and co-production of knowledge [22, 38]. Thus, monitoring ensure that membership in the CoP enhanced both ability and willingness to initiate and use the AHR model, while addressing foreseen and emergent barriers to implementation.

Regarding opportunity, exposing trainees to new knowledge in a mode different from that in which it has traditionally been done (such as seminars and conferences) provided immense opportunity for learning and improvement in practice. While there is still clearly value in these forms of teaching and learning, the top/down approach, with internal or external ‘experts’ presenting to a relatively passive and unengaged audience has limitations in ensuring that either adequate knowledge is acquired or the acquired competences are implemented routinely during performance of the trainees. The respondents of the CoP found it easier to share, discuss and apply the knowledge shared from the different sessions. The sharing of views, values and experiences made it easier to reflective on personal and professional values and reduce value conflicts. Discussions also made it easier to grasp how new knowledge could be applied as well as how challenges encountered could be overcome, especially in relation to applying knowledge about the WHO 2022 abortion care guidelines, protocols for medical abortion and guidelines for instrument handling. Often, trainees and service providers identify growing dissatisfaction with this sort of professional development, conceived of as something that one ‘does’, or that is ‘provided’, or is ‘done to’ trainees [41]. However, some midwives often wanted topics such as obstetric complications included in the discussion, yet his was not part of the original plan. This is often a challenge [33]. Securing trust of shared information was also challenging. Lowering barriers among members to become involved in knowledge sharing activities was a challenge [33]. Besides, sustaining members’ active participation, since participation is central to the evolution of the community and to the creation of relationships that help develop the sense of trust, mutual sharing and collaboration [34,35,36].

Healthcare providers are often isolated in their practice and individualism, rather than collaboration, is the norm. AOGU envisaged creation and supporting a CoP for SRH, specifically ending morbidity and mortality from abortion complications. CoPs, on their own or as part of larger interventions, may improve healthcare performance, and it was assumed that an opportunity to have for a for sharing updates, experiences, challenges and opportunities. A CoP represents a potentially valuable tool for creating, disseminating or sharing both tacit and explicit knowledge and implementation practices. The CoP may also be effective in creating links among the different ‘knowledge holders’ contributing to health practice or policy. From the midwife interactions, there were several benefits of creating CoP. They had potential to solve emerging problems especially stigma of abortion elf-care. The CoP enabled providers to explore ideas and act as sounding boards to each other. CoPs may create tools, standards, algorithms or job-aids. They also develop personal relationships and established ways of interacting, as well as a common sense of identity. The mentorship in the CoP promoted professional communication and understanding among and across different disciplines, cultures, perspectives, experience, languages. It encouraged technical exchange and professional development, providing benefits to both individuals and health facilities. For individuals, CoP participation increased access to technical resources, provide opportunities to contribute to discussions, and fostered a sense of membership and raised personal professional visibility. For organisations, the CoP allowed an effective way to raise awareness of SRH activities and services, and identified collaborators. CoPs were found to be less expensive, more interactive and more inclusive than physical conferences.

Though institutions are not set up for trainers to engage in “continuous and sustained learning”, the role of leadership in the CoP is critical in providing a regular, localised and supportive environment for engendering this sort of change in professional development cannot be ignored, and needs to be nurtured, embraced, supported and reinforced as the best way of ensuring that learning and training achieve the objective of improved provider performance [36, 37]. The CoP addresses the disparity between theory and practice and promotes sustainable service delivery suitable for different practical settings and contexts [5, 38]. Having an effective facilitator is key [10, 38,39,40,41, 43,44,45]. A facilitator leads a group towards achieving its objectives through designing and offering effective and efficient process structures, whether this takes place during a focused 2-h workshop or a multi-month period. Facilitators always provided a summary of learning points and take-home messages related to knowledge application. Most of the participants appreciated the idea of a CoP.

Lave and Wenger [39] emphasized that learning did not occur best from transmission of facts in the master/apprentice relationship, but rather, when facilitated within a community of apprentices and more experienced workers working together, interacting, sharing experiences and addressing concerns that arise through practice. Indeed, while CoPs were previously conceptualized as capable of emerging spontaneously in organizations, leadership and stewardship play a critical role in nurturing these communities [40] to ensure actualization of the three dimensions that define a CoP: joint enterprise (what it is about); mutual engagement (the interactions that lead to shared identity and meaning); a shared repertoire (of resources such as techniques, tools, experiences or process and practice) [41,42,43,44,45]. That COPs may bring different types of knowledge holders onto the same platform is very relevant because decisions on policies and their implementation are not only based on technical issues, but also on political and cultural as well as interactions between institutional actors and contextual factors [27, 43, 44]. In our context, these factors are exemplified by the role of personal and professional value conflicts which need to be addressed in implementation of the harm reduction model.

The concept of CoP as ‘groups of people who share a concern, a set of problems, or a passion about a topic and who deepen their knowledge and expertise in this area by interacting on an ongoing basis’ was coined by Wenger et al. [14] to describe a tool through which how novices (mentees) may learn from experts (mentors)within the contexts of workplaces. The CoP presents an innovative tool, where “…new ideas are developed and implemented by people who engage in relationships with others and make adjustments needed to achieve desired outcomes within an institutional and organizational context” [45]. Thus, learning in a CoP results from a social process consisting of knowing, acting, and structuring [44,45,46]. Nurturing trust, privacy and confidentiality while encouraging participation, communication and interaction is key for success in virtual communities of practice [33].

The primary benefits of a CoP is the individual practitioner largely by increasing their job efficacy through mutual leaning, social learning and collaborative learning [18]. This is manifest as people sharing knowledge through mutually guiding each other through their understandings of the same problems in their area of shared interest [18]. The learning value of a CoP stems from the groups collective intention and commitment to advance learning within the domain [47,48,49,50]. Over time, the shared history of learning also becomes a resource among the participants in the form of a shared repertoire of cases, techniques, tools, stories, concepts, and perspectives [39].

The study highlights technology, incentives, facilitation, leadership as key factors for success and sustainability of the CoP, thus ably presents the COP as a group of people who share a concern or a problem and who come together to connect, collaborate, cooperate, interact, learn and create a sense of identity, and in the process, build and share knowledge and solve problems. While the COM-B model elucidates on these factors ad their roles as barriers or facilitators of a CoP in the domains of capability, opportunity and organization, it may not delineate the organizational landscape or the deeper contextual factors in which the CoP is embedded, yet these may influence performance of the CoP, especially regarding effectiveness of the CoP. In outlining mainly the positive outcomes of the CoP, the model and the qualitative study design may not fully explain the potential challenges confronting CoPs, yet it may be such challenges that are crucial for performance and sustainability of the CoP. Outcomes are affected by context on different levels (individual, interpersonal or organizational), some of which are potentially modifiable by facilitators or members (such as structure, ways of interacting, nature of facilitation, shared resources or time) [47,48,49]. Since CoP structures allow members to draw on experience, reflect on action, and make adjustments after feedback on action [18, 49, 50], CoPs have the potential to drive systems change. In this way, CoPs can interrogate basic assumptions that underlie current policies, practices, and programs with the aim of system improvements [49, 50]. In our context, the CoP was able to adopt both the AHR and VCAT for improving access to abortion care.