'Moving People up the Sympathy Spectrum': Building Hypotheses About How Abortion Values Clarification and Attitude...

Abortion stigma limits access to person-centred abortion care globally. Values clarification and attitude transformation (VCAT) is widely used to address abortion stigma and recommended by the World Health Organization to train abortion providers. Yet evidence is lacking about whether and how VCAT influences healthcare providers' behaviours. This study aims to generate hypotheses regarding (a) the specific behaviours that VCAT might influence and (b) the mechanisms of change.

This qualitative study generated hypotheses based on interviews with people who facilitated, designed and/or participated in VCAT globally. We recruited via email and by posting on online communities. Study design was informed by two behaviour change frameworks and engaged the concepts of stigma and person-centred care. We conducted semi-structured interviews online and analysed data thematically to develop hypotheses about VCAT's influence on behaviours.

The 17 interviewees (15 facilitators/curriculum designers, 2 VCAT participants) worked in five world regions. They described five categories of person-centred abortion care behaviours that VCAT can facilitate: increasing abortion-related communication with colleagues; reducing delays and obstruction of abortion care; enabling abortion seekers to access abortion care; expanding own abortion provision; and engaging in high-quality, non-judgemental abortion care. Interviewees described distinct forms of empathy through which VCAT influenced behaviour.

This study helps fill an evidence gap by offering hypotheses about how abortion VCAT can lead to behaviour change and which behaviours VCAT might influence in healthcare providers. We illustrate VCAT's ability to build empathy towards and destigmatise abortion across sociocultural contexts, forms of stigma, and legal frameworks - potentially motivating behaviour change along a spectrum from opposing to supporting abortion access. These hypotheses can be tested in future evaluations to assess whether VCAT contributes to change in a range of person-centred care behaviours. Our findings about VCAT's strengths and its potential gaps can inform future work to refine VCAT and develop complementary strategies to contribute to person-centred abortion care provision across contexts.

One of the co-investigators has lived experience implementing and designing values clarification trainings (the focus of this paper). Prior studies engaging people with lived experience of abortion care informed the design of this study. Patients, service users, care-givers, people with lived experience or members of the public were not involved in the conduct of study, analysis or interpretation of the data or in preparation of the manuscript.