BACKGROUND

1. Interventions to reduce the prevalence of female genital mutilation/cutting in African countries29.-31. May 2012Rigmor C Berg, Ph.D., CHES

2. BACKGROUND • Female genital mutilation / cutting (FGM/C): ”the partial or total removal of the female external genitalia or other injury to the female genital organs for cultural or other non-therapeutic reasons”(WHO, 1997) • 4 classifications / types: (WHO, 2008) • Clitoridectomy • Excision • Infibulations • Other

3. BACKGROUND - Prevalence • About 100 – 130 million worldwide • About 3 million at risk every year • Primarily in 28 countries in Africa • Some countries in the Middle East and Asia • Immigrant communities in Western countries

4. Somalia FGM/C prevalence among women aged 15-49 Source: Female genital mutilation/cutting : a statistical exploration. New York, NY, UNICEF; 2005.

5. BACKGROUND - Concerns • Violates a series of well established human rights principles, norms and standards, e.g.: • Universal Declaration of Human Rights, 1948 • International Covenant on Civil and Political Rights, 1966 • Convention on the Elimination of all Forms of Discrimination against Women, 1979 • Convention on the Rights of the Child, 1989 • No known health benefits

6. BACKGROUND - Concerns • Almost all cut girls/women experience health problems: • pain, chronic infections, difficulty in passing urine and faeces; obstetrical complications (WHO 2000, 2006, 2008) • systematic review on physical health complications following FGM/C underway at NOKC • Little or no change in prevalence over last decades • Usually carried out on girls under the age of 15  trend towards lowering of age • Usually performed by traditional practitioners trend towards “medicalization”

7. BACKGROUND – Our previous SRs re FGM/C • 3 systematic reviews Reasons Consequences Effectiveness

8. BACKGROUND – Our previous work re FGM/C • Reasons for and against FGM/C:

9. BACKGROUND – Our previous work re FGM/C • Consequences • Psychological: • may be more likely to experience psychological disturbances (have a psychiatric diagnosis, suffer from anxiety, somatisation, phobia, and low self-esteem) • Sexual: • more likely to experience pain during intercourse • more likely not to experience sexual desire • lower sexual satisfaction

10. BACKGROUND – Our previous work re FGM/C • Effectiveness of interventions • Included 6 studies of low methodological quality • Uncertainties regarding relevance of the interventions (e.g. regarding objectives, intervention targets, activities); reasons for limited effectiveness

11. OBJECTIVE • What is the effectiveness of interventions designed to reduce the prevalence of FGM/C compared to no or other active intervention? • How do factors related to the continuance and discontinuance of FGM/C help explain the effectiveness of interventions designed to reduce the prevalence of FGM/C?

12. METHODS • Systematic review (transparent, reproducible) • Search: 13 e-databases, organizations’ websites, reference lists, experts • Independent and paired screening, appraisal of methodological quality, data extraction • Data analysis

13. Research Questions: 1. What is the effectivenessofinterventionsdesigned to reduce the prevalenceof FGM/C compared to no or other activeinterventions? 2. How do factorsrelated to the continuance and dicontinuanceof FGM/C helpexplainthyeeffectivenessof interventionsdesigned to reduce the prevanelceof FGM/C? Literaturesearch: One comprehensivesearch for empirical studies thataddress the topicof FGM/C METHODS Screening 2: Sorting ofpublicationsaboutfactorsrelated to the continuance and discontinuanceof FGM/C. Applicationofinclusioncriteria Screening 1: Sorting ofpublicationsabout the effectivenessofintervention programs to reduce the prevalenceof FGM/C. Applicationofinclusioncriteria. Synthesis 1: Effectiveness studies -Qualityassessment -Description, in text and tables, of the programs -Extractionofeffectestimates Synthesis 5: Realist synthesisapproach Synthesisofresults from synthesis 1 (the effectivenessofinterventins) and synthesis 4 (factorsrelated to the continuance and discontinuanceof FGM/C) Synthesis 2: Quantitative studies -Qualityassessment -Extractionofquant. data -Synthesisofquant. data Synthesis 4: Quant-QualIntegrative Quantitative and qualitative data synthesisoffactorsrelated to the continuance and discontinuanceof FGM/C) Synthesis 3: Qualitative studies -Qualityassessment -Extractionofqual. data -Synthesisofqual. data

14. METHODS – Realist synthesis • Realist synthesis attempts to explain how outcomes (efficacy) of an intervention varies depending on the particular configuration of its constituent mechanisms and contexts • The approach is hypothesis generating, the result of which leads to tentative recommendations meant to influence the design of new programs • “interventions offer resources which trigger choice mechanisms (M) which are taken up selectively according to the characteristics and circumstances of subjects (C), resulting in a varied pattern of impact (O)” (Pawson, 2006 p25) • Mechanisms are the engine behind behaviour (what is on offer in the program that may persuade participants to change) • Context is important because the action of mechanisms to some extent depends on the realities of the context in which they are used (Pawson, 2006; Pawson et al., 2005)

15. Identification 6,323 records identified through database searching 472 records identified through other sources Screening 5,450 records after duplicates removed 5,450 records screened 5,344records excluded 1 study not obtained in full text Eligibility 105 full texts assessed for eligibility 63 full texts excluded: -7 effectiveness studies -56 context studies Included • 35 studies included • 8 effectiveness studies (12 publications) • 27 context studies (30 publications) RESULTS

16. RESULTS - EFFECTIVENESS Mali Egypt Ethiopia • 8 studies • Weak methodological quality • Controlled before-and-after design • 7 countries • N=7,042 Senegal Kenya Nigeria Burkina Faso

17. RESULTS • 1997 – 2004; duration 2 weeks – 18 months

18. RESULTS – Study level • 49 study level outcomes • 19 of 49 (39%) of outcomes for which there was baseline similarity showed significant differences between the groups • Most of these (74%) were for the secondary outcomes attitudes/beliefs and knowledge regarding FGM/C in the community-based interventions

19. RESULTS - Pooled Figure 3. Forest plot, belief that FGM/C compromise human rights of women • Belief that FGM/C compromised the human rights of women • Prevalence of FGM/C among girls 0-10 years

20. RESULTS - Pooled Figure 3. Forest plot, belief that FGM/C compromise human rights of women • Knowledge of harmful consequences of FGM/C (women) • Knowledge of harmful consequences of FGM/C (men)

21. RESULTS – CONTEXT DATA Mali k=1 Egypt k=9 Ethiopia k=0 • 27 studies (1 qual) • Methodological quality= 9 high, 12 moderate, 6 low • N= 67 to 15,573 (median= 1,020) Senegal k=1 Kenya (Somalis) k=1 Nigeria k=13 Burkina Faso k=2

22. Training of health personnel (Mali) • Pro: custom (61%), good tradition (28%), religious necessity (13%) • Con: medical complications (45%), bad tradition (30%), prevents sexual satisfaction (13%), painful experience (13%) • Improvements not triggered by the intervention • Not clear extent to which contextual factors embedded in program • Intervention seems to be fitting response: • Program embedded in local public health services • Aimed at improving health providers’ involvement with FGM/C • Medical complications the most frequently voiced reason for opposing the practice among Malians thinking FGM/C should be stopped

23. Education of female students (Egypt) • Pro: custom (45%), sexual morals (30%), reduce sexual desires/preserve virginity (16%) • Con: complications (22%), sexual problems (16%), no benefit or value (14%) • Increase in knowledge of dangers of FGM/C • Not clear extent to which contextual factors embedded in the curriculum • Benefits of placing FGM/C in a reproductive health context • Egypt DHS data showed few women recognized the potential adverse physical consequences of the practice for women.

24. Communication program (Nigeria) • Pro: custom (61%), reduce/control female sexual desire (37%), religion (19%) • Con: medical complications (38%), bad tradition (49%), unnecessesary (19%) • Some positive effects • Not clear extent to which identified cultural factors were embedded in the communication intervention • Sound fit between the program theory of change and program components • With convention theory as a driver of change, dosage of program messages important (advantage of exposure to a combination of activities and mass media)

25. Outreach and advocacy (Kenya & Ethiopia) • 97% of Somalis in favour of FGM/C: custom license for marriage (84%), religious obligation (70%), protection of virginity (27%) • Pre intervention research, embedded in program • In Kenya, change in comparison group • In Ethiopia, some positive effects in intervention group • Embedded in existing reproductive health projects • Critical factors: • religious leaders • program exposure

26. Tostan educ. prog. (Mali, Senegal, Burkina Faso) • Mali: • Pro: custom (61%), good tradition (28%), religious necessity (13%) • Con: medical complications (45%), bad tradition (30%), prevents sexual satisfaction (13%), painful experience (13%) • Senegal: • Pro: respect tradition (94%), obey religious demand (39%), guarantee women’s cleanliness (52%), initiate girls (53%), for women to get married (22%), men prefer cut women (21%) • Burkina Faso: • Pro: custom (77%), hygiene (15%), avoid immoral behaviour/preserve virginity (15%)Con: medical complications (59%), prohibited by law (35%)

27. Tostan educ. prog. (Mali, Senegal, Burkina Faso) • Unclear whether pre-implementation research • Issue of FGM/C integrated within a larger project curriculum • Mali: Marginal effects • Senegal: Several positive effects • Burkina Faso: Several positive effects • Role of religion addressed? Religious leaders’ engagement and commitment sought? • Major implementation problems

28. SUMMARY • Some positive developments as a result of interventions, but: • low quality of the body of evidence affects the interpretation of results and draws the validity of the findings into doubt • none of the studies randomised, most contained prognostically dissimilar intervention and comparison groups, contamination of the intervention seems to have occurred in four sites

29. SUMMARY • Extent to which can conclude regarding how factors related to the continuance and discontinuance of FGM/C help explain the effectiveness of interventions is limited, because: • difficult judging match between the interventions’ content components and factors related to FGM/C’s continuation, because effectiveness reports lacked descriptions on intervention content • studies did not explicitly report on the relevant effective components of the mechanisms that were assumed to bring about FGM/C related behavior change

30. SUMMARY • All programs based on a theory that provision of information improves cognitions about FGM/C • All measured change in knowledge or beliefs related to FGM/C; positive results from six programs • Success contingent upon contextual factors: • Integrating the issue of FGM/C in a larger set of community-relevant issues facilitated acceptance • Alliance with religious leaders • Process factors: • Participants not aware of or signed up to take account of the research dimension of the study; information was not recalled/retained • Role conflict or uncertainties for staff • Insufficient measures in place to reduce confounding • Adverse prevailing program and evaluation climate

31. ACKNOWLEDGEMENTS • Financial support: 3ie (International Initiative for Impact Evaluation) • Colleague: Eva Denison

32. THANK YOU Contact details: Rigmor "Rimo" C Berg rib@nokc.no