BACKGROUND

Kunnskapsesenteretsnye PPT-mal

Interventions to reduce the prevalence of female genital mutilation/cutting in African

countries

29.-31. May 2012

Rigmor C Berg, Ph.D., CHES

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

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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

April 22, 2023FGM/C prevalence among women aged 15-49Source: Female genital mutilation/cutting : a statistical exploration. New York, NY, UNICEF; 2005.

Somalia

April 22, 2023

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

April 22, 2023

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”

BACKGROUND – Our previous SRs re

FGM/C 3 systematic reviews

Reasons Consequences Effectiveness

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BACKGROUND – Our previous work re

FGM/C Reasons for and against FGM/C:

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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

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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

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OBJECTIVE

1. What is the effectiveness of interventions designed to reduce the prevalence of FGM/C compared to no or other active intervention?

2. 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?

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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

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METHODS

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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)

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RESULTS

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6,323 records identified through database searching

105 full texts assessed for eligibility

35 studies included-8 effectiveness studies (12 publications)-27 context studies (30 publications)

5,344 records excluded1 study not obtained in full text

63 full texts excluded:-7 effectiveness studies-56 context studies

472 records identified through other sources

5,450 records after duplicates removed

5,450 records screened

RESULTS - EFFECTIVENESS

8 studies Weak

methodological quality

Controlled before-and-after design

7 countries N=7,042

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Nigeria

Senegal

Mali EgyptEthiopi

a

Kenya

Burkina Faso

RESULTS

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1997 – 2004; duration 2 weeks – 18 months

Author Population Intervention Comparison Outcomes

Diop 1998 N=108. Mali. Health personnel Training, supervision No intervention Beliefs, attitudes, knowledge

Mounir 2003 N=682. Egypt. Female university students

Education No intervention Knowledge

Babalola 2006 N=957. Nigeria. Community members

Multimedia communication

No intervention Intentions, beliefs, attitudes, knowledge

Chege 2004a N=1,440. Somali refugees in Kenya Outreach, advocacy Education Intentions, beliefs, attitudes, knowledge

Chege 2004b N=819. Ethiopia. Community members

Outreach, advocacy No intervention Intentions, beliefs, attitudes, knowledge

Easton 2002 N=239. Mali. Community members Tostan educ. program No intervention Beliefs

Diop 2004 N=1,332. Senegal. Community members

Tostan educ. program No intervention Prevalence, intentions, attitudes, beliefs, knowledge

Ouoba 2004 N=1,465. Burkina Faso. Community members

Tostan educ. program No intervention Prevalence, behaviors, intentions, attitudes, beliefs, knowledge

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

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RESULTS - Pooled

Belief that FGM/C compromised the human rights of women

Prevalence of FGM/C among girls 0-10 years

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Study or Subgroup

Chege 2004aChege 2004b

Total (95% CI)

Total eventsHeterogeneity: Tau² = 0.55; Chi² = 57.60, df = 1 (P < 0.00001); I² = 98%Test for overall effect: Z = 0.50 (P = 0.62)

Events

223168

391

Total

720400

1120

Events

28876

364

Total

720400

1120

Weight

50.4%49.6%

100.0%

M-H, Random, 95% CI

0.77 [0.67, 0.89]2.21 [1.75, 2.79]

1.30 [0.46, 3.66]

Intervention Comparison Risk Ratio Risk RatioM-H, Random, 95% CI

0.01 0.1 1 10 100Favours intervention Favours comparison

Figure 3. Forest plot, belief that FGM/C compromise human rights of women

Study or Subgroup

Diop 2004Ouoba 2004

Total (95% CI)

Total eventsHeterogeneity: Tau² = 0.00; Chi² = 0.01, df = 1 (P = 0.93); I² = 0%Test for overall effect: Z = 2.84 (P = 0.004)

Events

14316

159

Total

358519

877

Events

1039

112

Total

199217

416

Weight

95.0%5.0%

100.0%

M-H, Random, 95% CI

0.77 [0.64, 0.93]0.74 [0.33, 1.66]

0.77 [0.64, 0.92]

Intervention Comparison Risk Ratio Risk RatioM-H, Random, 95% CI

0.1 0.2 0.5 1 2 5 10Favours intervention Favours comparison

RESULTS - Pooled

Knowledge of harmful consequences of FGM/C (women)

Knowledge of harmful consequences of FGM/C (men)

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Figure 3. Forest plot, belief that FGM/C compromise human rights of women

Study or Subgroup

Diop 2004Ouoba 2004

Total (95% CI)

Total eventsHeterogeneity: Tau² = 0.55; Chi² = 62.35, df = 1 (P < 0.00001); I² = 98%Test for overall effect: Z = 1.16 (P = 0.25)

Events

243497

740

Total

333578

911

Events

50166

216

Total

200228

428

Weight

49.4%50.6%

100.0%

M-H, Random, 95% CI

2.92 [2.28, 3.74]1.18 [1.08, 1.29]

1.85 [0.65, 5.22]

Intervention Comparison Risk Ratio Risk RatioM-H, Random, 95% CI

0.1 0.2 0.5 1 2 5 10Favours intervention Favours comparison

Study or Subgroup

Diop 2004Ouoba 2004

Total (95% CI)

Total eventsHeterogeneity: Tau² = 0.27; Chi² = 20.27, df = 1 (P < 0.00001); I² = 95%Test for overall effect: Z = 1.97 (P = 0.05)

Events

54394

448

Total

82448

530

Events

42137

179

Total

198229

427

Weight

48.1%51.9%

100.0%

M-H, Random, 95% CI

3.10 [2.28, 4.23]1.47 [1.31, 1.64]

2.11 [1.00, 4.42]

Intervention Comparison Risk Ratio Risk RatioM-H, Random, 95% CI

0.1 0.2 0.5 1 2 5 10Favours intervention Favours comparison

RESULTS – CONTEXT DATA

27 studies (1 qual)

Methodological quality= 9 high, 12 moderate, 6 low

N= 67 to 15,573 (median= 1,020)

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Nigeria

k=13

Senegal

k=1

Malik=1

Egypt k=9

Ethiopia

k=0

Kenya (Somali

s)k=1

Burkina Faso

k=2

Training of health personnel (Mali)

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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

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.

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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)

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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

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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%)

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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

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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

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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

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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

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ACKNOWLEDGEMENTS

Financial support: 3ie (International Initiative for Impact Evaluation)

Colleague: Eva Denison

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THANK YOU

Contact details:

Rigmor "Rimo" C Berg [email protected]

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