Introduction to Abortion Values Clarification and Attitude ...

1. Introduction to Abortion Values Clarification and Attitude Transformation

3. What is values clarification (VC)? Both a theory and an intervention; People discovering their values through a process of honest self-examination and open-minded search for life�s truths (Maslow, 1959; Rogers, 1961); �VC is the process of examining one�s basic values and reasoning for the purpose of understanding oneself, to discover what is important and meaningful� (Rokeach, 1973; Steele, 1979). �Valuing occurs when the head and heart � unite in the direction of action� (Dewey, 1939). Values clarification (VC), inspired by the field of humanistic psychology, is both a theory and an intervention. The theory was inspired by thinkers such as Abraham Maslow (1959) and Carl Rogers (1961), who believed that people are responsible for discovering their values through the process of honest, open-minded self-examination and search for life�s truths. Values are closely related to and affected by our beliefs, ideals and knowledge, and they affect our attitudes and behaviors. Values serve as our internal roadmap; they play a key and enduring role in the decisions we make, what we spend our time and energy on and how we act. According to Milton Rokeach (1973), VC is the process of examining one�s basic values and moral reasoning. Steele added that VC is done to understand oneself, to discover what is important and meaningful (Steele, 1979). John Dewey eloquently stated that �valuing occurs when the head and heart � unite in the direction of action� (Dewey, 1939).Values clarification (VC), inspired by the field of humanistic psychology, is both a theory and an intervention. The theory was inspired by thinkers such as Abraham Maslow (1959) and Carl Rogers (1961), who believed that people are responsible for discovering their values through the process of honest, open-minded self-examination and search for life�s truths. Values are closely related to and affected by our beliefs, ideals and knowledge, and they affect our attitudes and behaviors. Values serve as our internal roadmap; they play a key and enduring role in the decisions we make, what we spend our time and energy on and how we act. According to Milton Rokeach (1973), VC is the process of examining one�s basic values and moral reasoning. Steele added that VC is done to understand oneself, to discover what is important and meaningful (Steele, 1979). John Dewey eloquently stated that �valuing occurs when the head and heart � unite in the direction of action� (Dewey, 1939).

4. VC process Choosing a value freely, from alternatives, with understanding of positive and negative consequences of that choice; Prizing that chosen value, as it is associated with some level of satisfaction, affirmation and confidence; Acting repeatedly upon that freely chosen, affirmed value, which leads to positive outcomes. (Raths et al., 1966) Raths, Harmin and Simon (1966), considered the pioneers of VC, advanced the notion that values clarification involves a trilogy of processes: choosing a value freely, from alternatives, with an understanding of both positive and negative consequences of that choice; prizing that chosen value, as it is associated with some level of satisfaction, affirmation and confidence; and acting repeatedly upon that freely chosen, affirmed value, which leads to positive outcomes. As an intervention, values clarification was originally developed in the context of education (moral education in schools), but has since been widely adapted to such diverse topics as: career counseling and decisionmaking, weight loss, hormone replacement therapy and sexual and reproductive health.Raths, Harmin and Simon (1966), considered the pioneers of VC, advanced the notion that values clarification involves a trilogy of processes: choosing a value freely, from alternatives, with an understanding of both positive and negative consequences of that choice; prizing that chosen value, as it is associated with some level of satisfaction, affirmation and confidence; and acting repeatedly upon that freely chosen, affirmed value, which leads to positive outcomes. As an intervention, values clarification was originally developed in the context of education (moral education in schools), but has since been widely adapted to such diverse topics as: career counseling and decisionmaking, weight loss, hormone replacement therapy and sexual and reproductive health.

5. Choosing A value must be chosen freely, from alternatives, with an understanding of both positive and negative consequences of that choice. A value must be chosen freely, from alternatives, with an understanding of both positive and negative consequences of that choice. Some questions that an individual might consider when choosing a value include: What are the alternatives? What made you decide on this particular choice? What will the results of this choice be? What assumptions are you making? How did you arrive at this choice? Did anyone suggest this to you, or did you make this choice on your own? Were you pressured or coerced into this choice? Noncoercive, free, reasoned choice is emphasized in this stage of VC. A value must be chosen freely, from alternatives, with an understanding of both positive and negative consequences of that choice. Some questions that an individual might consider when choosing a value include: What are the alternatives? What made you decide on this particular choice? What will the results of this choice be? What assumptions are you making? How did you arrive at this choice? Did anyone suggest this to you, or did you make this choice on your own? Were you pressured or coerced into this choice? Noncoercive, free, reasoned choice is emphasized in this stage of VC.

6. Choosing Some questions to consider: What are the alternatives? What made you decide on this particular choice? What will the results of this choice be? What assumptions are you making? How did you arrive at this choice? Did anyone suggest this to you, or did you make this choice on your own? Were you pressured or coerced into this choice?

7. Prizing A chosen value must be associated with some level of satisfaction and affirmation, as well as confidence in the value. A chosen value must be associated with some level of satisfaction and affirmation, as well as confidence in the value. Some questions to consider: How do you feel about your choice? Is this something that is really important to you? How satisfied are you with this decision? Would you be prepared to stand up and announce your choice in public? Are you willing to put it in writing? A chosen value must be associated with some level of satisfaction and affirmation, as well as confidence in the value. Some questions to consider: How do you feel about your choice? Is this something that is really important to you? How satisfied are you with this decision? Would you be prepared to stand up and announce your choice in public? Are you willing to put it in writing?

8. Prizing Some questions to consider: How do you feel about your choice? Is this something that is really important to you? How satisfied are you with this decision? Would you be prepared to stand up and announce your choice in public? Are you willing to put it in writing?

9. Acting A freely chosen, affirmed value must translate into action. Ideally, the action will lead to some kind of positive outcome and be done repeatedly. A freely chosen, affirmed value must translate into action. Ideally, the action will lead to some kind of positive outcome and be done repeatedly. Some questions that an individual might consider when acting on a value include: What are the first steps you will take, or have taken, to make this choice a reality? Have you made definite plans to act on this value? Is your decision definite or tentative? Have you acted on your value and will you act on it regularly? Have you been consistent in your actions? A freely chosen, affirmed value must translate into action. Ideally, the action will lead to some kind of positive outcome and be done repeatedly. Some questions that an individual might consider when acting on a value include: What are the first steps you will take, or have taken, to make this choice a reality? Have you made definite plans to act on this value? Is your decision definite or tentative? Have you acted on your value and will you act on it regularly? Have you been consistent in your actions?

10. Acting Some questions to consider: What are the first steps you will take, or have taken, to make this choice a reality? Have you made definite plans to act on this value? Is your decision definite or tentative? Have you acted on your value and will you act on it regularly? Have you been consistent in your actions?

11. VC to resolve values conflicts Values conflict is two or more opposing value positions within an issue. Values conflicts range from highly conflicted to resolved. A person who is confused or unclear about her values will tend to act in immature, overly conforming or dissenting ways. The clarified person will exhibit characteristics of Maslow�s �self-actualized person,� acting in a calmly confident and purposeful way (Kinnier, 1995). Value conflict is an idea that was developed by Richard Kinnier that suggests people can have values that are opposing in a given context. For example, with respect to access to abortion services, if I value freedom of choice and the sanctity of life, there exists a potential values conflict that I need to resolve in order to affirm my beliefs about the right to choose abortion and how abortion protects the sanctity of life (if we focus on the pregnant woman�s life). While the literature does not suggest any definitive end point for what determines whether a value is clear or unclear, respected theorists in this field agree that a person who is confused or unclear about her values will tend to act in immature, overly conforming or dissenting ways, whereas a person with a clear set of values will tend to act in calmly confident and purposeful ways. Value conflict is an idea that was developed by Richard Kinnier that suggests people can have values that are opposing in a given context. For example, with respect to access to abortion services, if I value freedom of choice and the sanctity of life, there exists a potential values conflict that I need to resolve in order to affirm my beliefs about the right to choose abortion and how abortion protects the sanctity of life (if we focus on the pregnant woman�s life). While the literature does not suggest any definitive end point for what determines whether a value is clear or unclear, respected theorists in this field agree that a person who is confused or unclear about her values will tend to act in immature, overly conforming or dissenting ways, whereas a person with a clear set of values will tend to act in calmly confident and purposeful ways.

12. Abortion VCAT interventions Honest, open-minded and critical reflection and evaluation of new or reframed abortion information and situations; Content is accessible, setting specific and personally relevant; Challenge deeply-held assumptions and myths about abortion and related issues; Discover values and potentially transform attitudes; Express intentions to convey attitudes and act in a manner consistent with affirmed values. VCAT is VC plus advocacy. (Turner et al., 2008) As defined by Ipas (Turner et al., 2008), an abortion values clarification and attitude transformation (VCAT) intervention is a process conducted in a safe environment in which individuals take responsibility to engage in honest, open-minded and critical reflection and evaluation of new or reframed abortion information and situations. The content is designed to be accessible, setting specific and personally relevant. Abortion VCAT activities are designed to help participants challenge their deeply-held assumptions and myths about abortion and related issues; discover their values and potentially transform their attitudes on abortion; and express their intentions to convey attitudes and act in a manner consistent with their affirmed values. Unlike simple values clarification, which does not posit any universal set of preferred values, abortion VCAT was designed to move participants along a progressive continuum of support for abortion and related sexual and reproductive health care and rights: from obstruction to tolerance to acceptance to support, and then ultimately to advocacy for and/or provision of woman-centered, comprehensive abortion services to the full extent of the law. Depending on who the participants are, this could include enacting favorable abortion policies, providing abortion services, advocating for women�s right and access to abortion, referring women to safe services, seeking abortion services when needed and supporting women who have had abortions and providers who perform them. At the very least, we hope participants in the end can agree to abstain from blocking favorable policies and impeding women�s access to safe services. As defined by Ipas (Turner et al., 2008), an abortion values clarification and attitude transformation (VCAT) intervention is a process conducted in a safe environment in which individuals take responsibility to engage in honest, open-minded and critical reflection and evaluation of new or reframed abortion information and situations. The content is designed to be accessible, setting specific and personally relevant. Abortion VCAT activities are designed to help participants challenge their deeply-held assumptions and myths about abortion and related issues; discover their values and potentially transform their attitudes on abortion; and express their intentions to convey attitudes and act in a manner consistent with their affirmed values. Unlike simple values clarification, which does not posit any universal set of preferred values, abortion VCAT was designed to move participants along a progressive continuum of support for abortion and related sexual and reproductive health care and rights: from obstruction to tolerance to acceptance to support, and then ultimately to advocacy for and/or provision of woman-centered, comprehensive abortion services to the full extent of the law. Depending on who the participants are, this could include enacting favorable abortion policies, providing abortion services, advocating for women�s right and access to abortion, referring women to safe services, seeking abortion services when needed and supporting women who have had abortions and providers who perform them. At the very least, we hope participants in the end can agree to abstain from blocking favorable policies and impeding women�s access to safe services.

13. Values Clarification for Abortion Attitude Transformation Theoretical Framework The Values Clarification for Abortion Attitude Transformation theoretical framework is a conceptualization of the process of abortion VCAT that includes the critical elements of the VC process values theory � the process of choosing, prizing and acting that we discussed earlier (Rokeach, 1973; 1979), and the Theory of Planned Behavior (Ajzen, 1985; 1988; 1991). It informed the development and organization of the toolkit and can serve as a visual aid when explaining the abortion VCAT process and as a reference when designing abortion VCAT interventions to help ensure objectives are met. � The theoretical framework and process take place within existing cultural and social structures and ideologies. Cultural and societal norms are extremely influential in shaping people�s attitudes and values. Also, this framework places the process of values clarification within a larger context of attitude transformation, behavioral intention and, ultimately, behavior or performance � unlike traditional VC, in which the end is clarified values, whatever those may happen to be. As previously discussed, this framework and toolkit are designed to advance a pro-abortion rights agenda � to move participants along a progressive continuum of support for abortion and reproductive rights: from obstruction to tolerance to acceptance to support, and ultimately to advocacy for and/or provision of woman-centered, comprehensive abortion care to the full extent of the law. Starting at the left of the model: We start with the motivation to change � people must be open to changing their attitudes, values and behaviors or we cannot expect VCAT to have any impact. In order to effectively engage in the abortion values clarification process one must: gain new knowledge, deepen understanding of existing or new knowledge, experience empathy for people affected by or who provide abortion, acknowledge current values on abortion, examine alternative values, recognize barriers to change and remain open to change. Ipas modified the three main stages of values clarification to making an informed value choice, affirming that choice, and acting on the chosen value, which reflects the process and cognitions an individual would go through when thoughtfully choosing among competing alternatives and deciding on a particular course of action. Although it has not yet been empirically tested, we hypothesize that attitude transformation is a logical outcome of values clarification. After undergoing the VCAT process, participants� attitudes would be expected to be consistent with their affirmed values. In the formative work that led to the acceptance of TPB, empirical research consistently demonstrated that TPB constructs � beliefs, attitudes and norms � are consistently associated with behavioral intention, which in turn predicts behavior or performance. Empirical studies demonstrate that performance of a behavior can best be predicted by an individual�s intention to perform that behavior (behavioral intention), which is directly influenced by personal attitude toward that behavior, as well as two other factors that are not directly addressed here (Ajzen, 1985; 1988). These constructs of personal attitude and behavioral intention have been successful in predicting health workers� behaviors in several studies (Millstein, 1996; Armitage et al., 2004). The Values Clarification for Abortion Attitude Transformation theoretical framework is a conceptualization of the process of abortion VCAT that includes the critical elements of the VC process values theory � the process of choosing, prizing and acting that we discussed earlier (Rokeach, 1973; 1979), and the Theory of Planned Behavior (Ajzen, 1985; 1988; 1991). It informed the development and organization of the toolkit and can serve as a visual aid when explaining the abortion VCAT process and as a reference when designing abortion VCAT interventions to help ensure objectives are met. � The theoretical framework and process take place within existing cultural and social structures and ideologies. Cultural and societal norms are extremely influential in shaping people�s attitudes and values. Also, this framework places the process of values clarification within a larger context of attitude transformation, behavioral intention and, ultimately, behavior or performance � unlike traditional VC, in which the end is clarified values, whatever those may happen to be. As previously discussed, this framework and toolkit are designed to advance a pro-abortion rights agenda � to move participants along a progressive continuum of support for abortion and reproductive rights: from obstruction to tolerance to acceptance to support, and ultimately to advocacy for and/or provision of woman-centered, comprehensive abortion care to the full extent of the law. Starting at the left of the model: We start with the motivation to change � people must be open to changing their attitudes, values and behaviors or we cannot expect VCAT to have any impact. In order to effectively engage in the abortion values clarification process one must: gain new knowledge, deepen understanding of existing or new knowledge, experience empathy for people affected by or who provide abortion, acknowledge current values on abortion, examine alternative values, recognize barriers to change and remain open to change. Ipas modified the three main stages of values clarification to making an informed value choice, affirming that choice, and acting on the chosen value, which reflects the process and cognitions an individual would go through when thoughtfully choosing among competing alternatives and deciding on a particular course of action. Although it has not yet been empirically tested, we hypothesize that attitude transformation is a logical outcome of values clarification. After undergoing the VCAT process, participants� attitudes would be expected to be consistent with their affirmed values. In the formative work that led to the acceptance of TPB, empirical research consistently demonstrated that TPB constructs � beliefs, attitudes and norms � are consistently associated with behavioral intention, which in turn predicts behavior or performance. Empirical studies demonstrate that performance of a behavior can best be predicted by an individual�s intention to perform that behavior (behavioral intention), which is directly influenced by personal attitude toward that behavior, as well as two other factors that are not directly addressed here (Ajzen, 1985; 1988). These constructs of personal attitude and behavioral intention have been successful in predicting health workers� behaviors in several studies (Millstein, 1996; Armitage et al., 2004).

14. VCAT teaching methods Large- and small-group discussion Individual and group work Hypothetical and real dilemmas and case studies Rank ordering and forced choices Empathy-evoking experiences Active listening techniques Expressive activities, such as songs, skits, and artwork Games Simulations such as role plays and visualizations Journaling and interviewing Self-analysis These are many of the types of teaching methods used for VCAT interventions. They are basically methods that are consistent with adult learning principles. Most of these teaching methods are employed in the various activities in Ipas�s Abortion attitude transformation: A values clarification toolkit for global audiences. These are many of the types of teaching methods used for VCAT interventions. They are basically methods that are consistent with adult learning principles. Most of these teaching methods are employed in the various activities in Ipas�s Abortion attitude transformation: A values clarification toolkit for global audiences.

15. The role of the VCAT facilitator Does not attempt to influence the selection of values; Respects that the values clarification process is internal and relative; Does not posit any universal set of appropriate values; Assists the individual to develop his or her internal processes; Allows the person, rather than external factors, to be the prime determinants of their behavior; Respects that the individual should be free to change the environment to meet his or her needs. A vital component to the success of a VCAT activity or workshop is a facilitator who does not attempt to influence the selection of values. Values clarification assumes that the valuing process is internal and relative, and it does not posit any universal set of appropriate values. However, it is clear that this toolkit is designed to advance a progressive agenda in support of comprehensive, woman-centered abortion care and reproductive rights. This apparent contradiction can be balanced skillfully by a trained facilitator who can advance this agenda and the overall goals of attitude and behavior change, while also respecting that values clarification is an individual process that requires freedom of choice. Behaviors should be the result of free, autonomous choice, based on personal analysis of a given issue or situation. The VCAT facilitator should assist the individual to develop his or her internal processes, thereby allowing them, rather than external factors, to be the prime determinants of their behavior. A vital component to the success of a VCAT activity or workshop is a facilitator who does not attempt to influence the selection of values. Values clarification assumes that the valuing process is internal and relative, and it does not posit any universal set of appropriate values. However, it is clear that this toolkit is designed to advance a progressive agenda in support of comprehensive, woman-centered abortion care and reproductive rights. This apparent contradiction can be balanced skillfully by a trained facilitator who can advance this agenda and the overall goals of attitude and behavior change, while also respecting that values clarification is an individual process that requires freedom of choice. Behaviors should be the result of free, autonomous choice, based on personal analysis of a given issue or situation. The VCAT facilitator should assist the individual to develop his or her internal processes, thereby allowing them, rather than external factors, to be the prime determinants of their behavior.

16. Abortion VCAT intervention: Goal For individuals to learn, question, affirm and support their positions with respect to the need for and provision of abortion and related care, such that awareness of and access to comprehensive, woman-centered, high-quality abortion care is increased. For individuals to learn, question, affirm and support their positions with respect to the need for and provision of abortion and related care, such that awareness of and access to comprehensive, woman-centered, high-quality abortion care is increased. For individuals to learn, question, affirm and support their positions with respect to the need for and provision of abortion and related care, such that awareness of and access to comprehensive, woman-centered, high-quality abortion care is increased.

17. Abortion VCAT intervention: Objectives By the end of an abortion values clarification and attitude transformation workshop, participants will be able to: Distinguish between assumptions, myths and realities about unwanted pregnancy and abortion and the women and families who experience them; Explain correct information about abortion and the circumstances surrounding it; Demonstrate empathy toward the women, families and health-care workers who experience abortion; There are eight main objectives of an Abortion VCAT workshop. By the end of an abortion values clarification and attitude transformation workshop, participants will be able to: Distinguish between assumptions, myths and realities about unwanted pregnancy and abortion and the women and families who experience them; Explain correct information about abortion and the circumstances surrounding it; Demonstrate empathy toward the women, families and health-care workers who experience abortion; There are eight main objectives of an Abortion VCAT workshop. By the end of an abortion values clarification and attitude transformation workshop, participants will be able to: Distinguish between assumptions, myths and realities about unwanted pregnancy and abortion and the women and families who experience them; Explain correct information about abortion and the circumstances surrounding it; Demonstrate empathy toward the women, families and health-care workers who experience abortion;

18. Abortion VCAT intervention: Objectives Identify the values that inform their current beliefs and attitudes about abortion; Describe alternative values and their consequences Choose and affirm values that inform their attitudes and beliefs towards abortion services and the women who seek them; State their abortion-related behavioral intentions that are consistent with their affirmed values; Demonstrate a separation of their personal beliefs from their professional roles and responsibilities in the provision of abortion services (for service providers). There are eight main objectives of an Abortion VCAT workshop, continued: Identify the values that inform their current beliefs and attitudes about abortion; Describe alternative values and their consequences; Choose and affirm values that inform their attitudes and beliefs towards abortion services and the women who seek them; State their abortion-related behavioral intentions that are consistent with their affirmed values; Demonstrate a separation of their personal beliefs from their professional roles and responsibilities in the provision of abortion services (for service providers). There are eight main objectives of an Abortion VCAT workshop, continued: Identify the values that inform their current beliefs and attitudes about abortion; Describe alternative values and their consequences; Choose and affirm values that inform their attitudes and beliefs towards abortion services and the women who seek them; State their abortion-related behavioral intentions that are consistent with their affirmed values; Demonstrate a separation of their personal beliefs from their professional roles and responsibilities in the provision of abortion services (for service providers).

19. VCAT toolkit contents Introduction to VCAT Abortion VCAT theoretical framework 14 VCAT activities with instructions and materials Trainers� workshop sessions Tips for effective VCAT facilitation Sample workshop agendas Sample evaluation tools Certificates of completion Literature review Additional VCAT resources Ipas�s Abortion attitude transformation: A values clarification toolkit for global audiences contains the following: Presentation and background paper on VCAT theory and interventions Abortion VCAT theoretical framework 14 VCAT activities with instructions and materials Trainers� workshop sessions to improve VCAT facilitation skills Tips for effective VCAT facilitation Sample workshop agendas Sample evaluation tools Certificates of completion Literature review Additional VCAT resources Ipas�s Abortion attitude transformation: A values clarification toolkit for global audiences contains the following: Presentation and background paper on VCAT theory and interventions Abortion VCAT theoretical framework 14 VCAT activities with instructions and materials Trainers� workshop sessions to improve VCAT facilitation skills Tips for effective VCAT facilitation Sample workshop agendas Sample evaluation tools Certificates of completion Literature review Additional VCAT resources

20. Evaluation of VCAT More empirical research is needed; VC principles used to affect and measure cognitive and behavioral changes (Karel et al., 2004; Schwartz et al., 1988; Mosconi et al., 2003); Improvements in attitudes toward women who have abortions (Marais, 1996); VC participants� behavioral changes six-months post workshop (Mitchell et al., 2005); VC participants� increased compassion for abortion clients and providers (Mitchell et al., 2005). Although more empirical research is needed to evaluate the effectiveness of abortion-related VCAT interventions and measure their impact over time, there is evidence to support the use of values clarification as a general strategy to improve attitudes and behaviors for a variety of social issues and audiences. A number of social and behavioral interventions have used principles of VC to affect and successfully measure cognitive and/or behavior change on varied topics including advance care planning (Karel et al., 2004), weight loss (Schwartz et al., 1988) and student self esteem (Mosconi et al., 2003). Successful results have been reported from abortion values clarification workshop evaluations. Preliminary results from an abortion values clarification workshop evaluation in South Africa found that 57 percent of participants felt that their attitudes towards women who obtain an abortion had changed as a result of the workshop, and 69 percent of participants felt that the workshop clarified their values to the point where they felt that they would deal with patients �quite a bit� or �a lot� better than they would have before the VC workshop (Marais, 1996). In another evaluation of the impact of abortion VC workshops on stakeholders� knowledge, attitudes and behaviors in South Africa, 70 percent reported behavioral changes six-months post workshop, and 93 percent reported increased compassion for women who seek, and providers who render, termination of pregnancy services (Mitchell et al., 2005). Further evaluations concluded that as a tool of social change, values clarification workshops are intensive enough to produce measurable results, yet sufficiently flexible to be adapted to different audiences and settings (Mitchell et al., 2005). .Although more empirical research is needed to evaluate the effectiveness of abortion-related VCAT interventions and measure their impact over time, there is evidence to support the use of values clarification as a general strategy to improve attitudes and behaviors for a variety of social issues and audiences. A number of social and behavioral interventions have used principles of VC to affect and successfully measure cognitive and/or behavior change on varied topics including advance care planning (Karel et al., 2004), weight loss (Schwartz et al., 1988) and student self esteem (Mosconi et al., 2003). Successful results have been reported from abortion values clarification workshop evaluations. Preliminary results from an abortion values clarification workshop evaluation in South Africa found that 57 percent of participants felt that their attitudes towards women who obtain an abortion had changed as a result of the workshop, and 69 percent of participants felt that the workshop clarified their values to the point where they felt that they would deal with patients �quite a bit� or �a lot� better than they would have before the VC workshop (Marais, 1996). In another evaluation of the impact of abortion VC workshops on stakeholders� knowledge, attitudes and behaviors in South Africa, 70 percent reported behavioral changes six-months post workshop, and 93 percent reported increased compassion for women who seek, and providers who render, termination of pregnancy services (Mitchell et al., 2005). Further evaluations concluded that as a tool of social change, values clarification workshops are intensive enough to produce measurable results, yet sufficiently flexible to be adapted to different audiences and settings (Mitchell et al., 2005). .

21. Attitudinal changes using VCAT toolkitResults from four workshops: Ghana (2), Ethiopia and Kenya (12 countries represented) in 2006-2007 Ipas combined matched pre- and post-survey results across four VCAT workshops held with participants in Ghana (2 workshops), Ethiopia and a regional workshop in Kenya with clinician trainers from 12 African countries. VCAT appeared to improve personal comfort, attitudes and beliefs about abortion at a statistically significant level. For example, noted improvements with working to increase access to comprehensive family-planning services and comprehensive abortion care; respectfully explaining values that conflict with their own; feeling empathy for women receiving abortion care; believing all women should have access to safe abortion and second-trimester abortion care.� There were improvements, but not statistically significant differences, in the remaining attitudinal items (not shown here but available from Ipas upon request). Less impact was observed among dimensions that measure interaction with others (family, colleagues).�It may be that more community-wide or policy-level work needs to be done to create a more enabling environment that would facilitate people�s willingness to engage others on the topic.� Also not shown here are behavioral intentions, which were high to begin with and remained high after VCAT, with over 90 percent of respondents indicating an intention to participate in the following activities within the next six months: learn more about the need for safe, comprehensive abortion care; learn more about women�s experiences with abortion; raise awareness about the need for safe, comprehensive abortion care; advocate to make safe, comprehensive abortion care available; and learn how to provide, assist with or refer women to safe abortion procedures. 100 percent of respondents intended to participate in at least one of the five activities.�Because these were mostly health-care provider workshops on abortion care, this suggests that participant selection was appropriate and that we might have expanded their thinking about different behaviors to engage in. Ipas combined matched pre- and post-survey results across four VCAT workshops held with participants in Ghana (2 workshops), Ethiopia and a regional workshop in Kenya with clinician trainers from 12 African countries. VCAT appeared to improve personal comfort, attitudes and beliefs about abortion at a statistically significant level. For example, noted improvements with working to increase access to comprehensive family-planning services and comprehensive abortion care; respectfully explaining values that conflict with their own; feeling empathy for women receiving abortion care; believing all women should have access to safe abortion and second-trimester abortion care.� There were improvements, but not statistically significant differences, in the remaining attitudinal items (not shown here but available from Ipas upon request). Less impact was observed among dimensions that measure interaction with others (family, colleagues).�It may be that more community-wide or policy-level work needs to be done to create a more enabling environment that would facilitate people�s willingness to engage others on the topic.� Also not shown here are behavioral intentions, which were high to begin with and remained high after VCAT, with over 90 percent of respondents indicating an intention to participate in the following activities within the next six months: learn more about the need for safe, comprehensive abortion care; learn more about women�s experiences with abortion; raise awareness about the need for safe, comprehensive abortion care; advocate to make safe, comprehensive abortion care available; and learn how to provide, assist with or refer women to safe abortion procedures. 100 percent of respondents intended to participate in at least one of the five activities.�Because these were mostly health-care provider workshops on abortion care, this suggests that participant selection was appropriate and that we might have expanded their thinking about different behaviors to engage in.

22. Post-workshop survey comments �The workshop has really changed my values.� �I have learned not to be judgmental.� �Practical tools that could be applied to other areas, too.� �A very timely program to equip a group of people that will educate others on the importance of unsafe abortion.� �Using experiences of colleagues encouraged me to be bold about issues on abortion.�

23. Programmatic uses for abortion VCAT Secure key stakeholders� buy in of abortion program; Preparation for developing abortion clinical standards and guidelines that allow broad access; Screening, selection and preparation of clinicians and health workers for abortion training and service provision (first and/or second trimester); Preparation for abortion advocacy training; Community stakeholders� buy in to create enabling environment for women�s use of abortion services; Many others. Programmatic uses for abortion VCAT (with country examples of where Ipas has used VCAT for this purpose � this is not an exhaustive list): Secure key stakeholders� buy in of abortion program and services (Ethiopia, Ghana, Nepal, South Africa); Preparation for developing abortion clinical standards and guidelines with broad access (Ghana); Screening, selection and preparation of clinicians and health workers for abortion training and service provision (Brazil, Ghana, Nepal, U.S.); Screening, selection and preparation of second-trimester abortion service providers (Nepal, South Africa, Vietnam); Preparation for abortion advocacy training (Ghana, Mozambique, Senegal, prerequisite for Ipas Providers as Abortion Advocates training); Community stakeholders� buy in to create enabling environment for women�s to access safe services as early as possible in their pregnancy (South Africa); Many others. Programmatic uses for abortion VCAT (with country examples of where Ipas has used VCAT for this purpose � this is not an exhaustive list): Secure key stakeholders� buy in of abortion program and services (Ethiopia, Ghana, Nepal, South Africa); Preparation for developing abortion clinical standards and guidelines with broad access (Ghana); Screening, selection and preparation of clinicians and health workers for abortion training and service provision (Brazil, Ghana, Nepal, U.S.); Screening, selection and preparation of second-trimester abortion service providers (Nepal, South Africa, Vietnam); Preparation for abortion advocacy training (Ghana, Mozambique, Senegal, prerequisite for Ipas Providers as Abortion Advocates training); Community stakeholders� buy in to create enabling environment for women�s to access safe services as early as possible in their pregnancy (South Africa); Many others.

24. Acknowledgments Toolkit development and data analysis: Katherine Turner, Kimberly Chapman Page, Ellen Mitchell, Kathryn Andersen Clark, Alyson Hyman, Monica Yungeberg, Kym Register, Debbie Billings, Traci Baird, Joan Healy, Erika Steibelt, Luz McNaughton, Maria de Bruyn, Cynthia Greenlee-Donnell, Marty Jarrell and Elizabeth Randall-David Ipas offices and intervention partners in Africa Alliance countries, Brazil, Ethiopia, Ghana, Nepal and South Africa International reviewers: Leila Adesse, Traci Baird, Kapila Bharucha, Daniela Draghici, Beatriz Galli, Jessica Meyer, Monica Oguttu, Lynne Randall and Karen Trueman

25. References Ajzen, I. 1985. From intentions to actions: A theory of planned behavior. In Kuhl, J. , and J. Beckman eds., Action-control: From cognition to behavior. Heidelberg, Springer. Ajzen, I. 1988. Attitudes, personality, and behavior. Chicago, Dorsey Press. Ajzen, I. 1991. The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50:179-211. Dewey, J. 1939. Theory of valuation. Chicago, University of Chicago Press. Karel, M., J. Powell, and M. Cantor. 2004. Using a values discussion guide to facilitate communication in advance care planning. Patient Education and Counseling, 55:22-31. Kinnier, R.T. 1995. A reconceptualization of values clarification: Values conflict resolution. Journal of Counseling & Development, 74:18-24. Marais, T. 1996. Abortion values clarification training manual. Melrose, South Africa, Planned Parenthood Association of South Africa. Mosconi, J., and J. Emmett. 2003. Effects of a values clarification curriculum on high school students' definitions of success. ASCA, 7(2), 68-78. Maslow, A.H. 1959. New knowledge in human values. New York, Harper & Brothers.

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27. Questions and discussion Solicit questions and facilitate discussion.Solicit questions and facilitate discussion.