1 / 32

BACKGROUND

Interventions to reduce the prevalence of female genital mutilation/cutting in African countries 29.-31. May 2012 Rigmor C Berg, Ph.D., CHES. BACKGROUND.

yelena
Download Presentation

BACKGROUND

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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

More Related