BACKGROUND
description
Transcript of 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
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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
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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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