Recommendation 2: In addition to training, health workers should have access to capacity-building resources including information, education and communication (IEC) materials and job aids, e.g. clinical guides, handbooks, algorithms, flow charts, anatomical models and other digital/print resources explaining the types of FGM, the associated complications and their management.

 

Strength of recommendation: Strong (very-low-certainty evidence)

A key element of multisectoral efforts to promote FGM prevention is the creation and enforcement of national laws and policies to protect women and girls from all forms of violence, including FGM, by any person – including health workers. This is a vital component of FGM prevention as it helps to ensure adherence to human rights principles and establishes mechanisms of accountability for violating them. In addition to laws and policies, there is a need for professional codes of conduct that discourage health workers from performing FGM (i.e. medicalization of FGM), and also penalties for violating these codes of conduct.

- Summary of the evidence- 

 The evidence review for this recommendation considered any interventions aimed at improving health workers’ access to capacity-building resources (or a combination of resources) and encouraging their direct application at the point of care. These capacity-building resources include, but are not limited to, information, education and communication (IEC) materials and job aids, such as clinical guides, handbooks, algorithms, flow charts, anatomic models and other digital/print resources explaining the types of FGM, the associated complications and their management – in all relevant languages to ensure accessibility. The review identified two studies: one non-randomized controlled study conducted in Mali with 108 participants (intervention arm n = 59, control arm n = 49) (44) and a multicentre CRT conducted in Guinea, Kenya and Somalia in 180 ANC clinics (intervention arm n = 115 health workers, control arm n = 117 health workers). For both studies, the certainty of evidence was very low on all assessed outcomes. The CRT assessed the effect of a two-level intervention package. All sites received IEC materials, including WHO’s 2018 clinical handbook on the care of girls and women living with FGM, accompanying job aids, WHO’s 2016 guidelines, anti-FGM posters and national ministry of health directives against FGM and FGM medicalization (Level 1 package). The health workers in the intervention arm also participated in a training session on person-centred communication (PCC) for FGM prevention, and received related job aids to guide a structured implementation of PCC (Level 2 package). Findings from this CRT showed that after three months, health workers who had received the intervention had improved knowledge of any type of FGM; improved ability to identify FGM-related health complications; improved willingness to lead anti-FGM efforts in their community; and they indicated reduced support for FGM, its medicalization and reinfibulation. Additionally, health workers who had received the intervention: (i) were more likely to report being confident in their knowledge to provide FGM prevention and care services compared with those in the control arm; (ii) had improved communication skills; and (iii) had applied the PCC approach in their interactions with clients, including asking their clients if they had undergone FGM, asking about their clients’ personal beliefs regarding FGM, and discussing with their clients why and how FGM could and should be prevented. While the impact of the job aids and other IEC materials independent of the training intervention could not be isolated since both the control and intervention sites had received them, a sub-analysis indicated that exposure to IEC materials may have had a positive effect. The study in Mali (44) found that providing access to capacity-building resources appeared to improve health workers’ knowledge of at least three immediate complications of FGM from 40% to 86%, and knowledge of subsequent complications from 49% to 72%. To a lesser extent, respondents from the control sites also registered improvement in their knowledge of FGM complications, with 61% aware of short- or long-term consequences at baseline rising to 73% at follow-up. There was also a reduction in the proportion of participants who thought that FGM guaranteed virginity until marriage, from 14% to 9%, and the proportion of participants who felt that women and girls who did not undergo FGM had “loose morals”, from 39% to 26%. The study also reported that among the health workers who had received training on IEC materials, more than half were willing to address FGM-related issues, compared with a third of those who had not received training. 

- Rationale -

 Acknowledging the limited evidence presented but noting the clear benefits of providing capacity-building resources to health workers based on the knowledge and experiences of the GDG members as well as indirect evidence from established training programmes from other health conditions, the GDG concluded that the benefits outweighed any potential harms, and made a strong recommendation that, in addition to training, health workers should be provided with capacity-building resources, including job aids, IEC materials, clinical support resources, and other digital/print resources explaining the types of FGM, the associated  complications and their management, to support their work. The GDG noted that the lack of studies to illustrate the effect of capacity-building materials on FGM-specific outcomes could be related to the long-standing acceptance of these materials by the health sector as part of capacity-building initiatives even though they may have not been independently studied. The GDG also suggested that IEC materials and job aids may complement and enhance the effect of other capacity-building interventions, although it is difficult to disentangle their independent effects. 

- Implementation remarks -

The GDG noted the possibility of significant variability depending on context and whether or not the IEC materials and job aids are provided as part of a comprehensive capacity-building package for health workers. However, indirect evidence from research on other topics involving the use of IEC materials suggests that health workers do prefer and appreciate IEC materials and job aids to support their work. The GDG also noted that while distribution of IEC materials and job aids might be expensive in the short term, the ultimate benefit in terms of supporting the prevention of FGM and management of complications makes this intervention cost-effective in the long run. The GDG noted that, paradoxically, depending on context (e.g. FGM prevalence, status of laws and policies on FGM, such as reporting mandates for health workers), access to IEC materials and job aids could potentially increase FGM-related stigma. As such, health workers should be adequately trained while being given access to these resources to mitigate this potential unintended effect. A systematic review of qualitative evidence on programme managers’ perceptions of health system interventions found that managers supported innovative approaches to training, awareness raising and partnerships, as a means of enhancing the uptake of anti-FGM messages among medical students. A SCORAtalk (like a TED Talk), was perceived to improve the spread and uptake of anti-FGM messages by medical students when delivered in a context of partnership among medical students and professional health groups, which facilitated the implementation of this innovative approach. Furthermore, the review found that health workers’ knowledge of FGM and their capacity for managing FGM was suboptimal. This finding is based on three studies conducted in three African countries – Guinea, Kenya and Sudan. In the Sudan study, a government official felt that health workers lacked knowledge about FGM; the lack of adequate training was also perceived to affect the selfefficacy of health workers. In Guinea, poor FGM-related knowledge and capacity among health workers were perceived to be due to the absence of a training curriculum that included the topic of FGM, while in Kenya, the authors concluded that the diagnosis, prevention, care services, and documentation of FGM and related complications were suboptimal, even in settings of high FGM prevalence. In this regard, the GDG noted that innovative approaches to training and capacity-building may need to be deployed to increase health workers’ knowledge on FGM. GDG members also noted that professional health associations could 

facilitate awareness raising and training on FGM, including by having FGM training modules in the training curricula for health workers. 

- Research gaps -

 Little evidence exists on the role of IEC materials and job aids in building and sustaining the capacity of health workers on provision of FGM-related care. There is also a lack of evidence on the impact of IEC materials and job aids on client/patient satisfaction or on improving client/patient outcomes in the short or long term.

- Summary of the evidence -

A review was conducted to explore the impact of laws and policies relating to mandatory reporting of FGM, criminalization of the practice, and support to women and girls who have undergone FGM on health workers’ knowledge, attitudes and skills, and their confidence in providing respectful FGM-related prevention and care services within clinical settings and communities (research question 3, see Annex 4).7 No studies meeting the inclusion criteria were found. The GDG noted the methodological challenges in attributing FGM-related outcomes to laws and policies. The GDG decided to issue this best practice statement, given the obligations of States to adhere to international human rights legal standards and to encourage key actors, including in the health sector, to take actions that promote the rights of women and girls. International human rights treaties require States Parties to respect, protect and fulfil the enjoyment of individual rights in their jurisdictions. States Parties to these treaties have an obligation to perform due diligence by taking all necessary steps to enable every person to enjoy their rights.

Laws and policies are tools for health governance that provide transparency about government commitments to a certain issue, outline a course of action and detail the responsibilities in terms of implementation, as well as provide progress measures. Based on learnings from developing and implementing laws and policies for other health topics (such as gender-based violence, safe abortion care, and HIV), rights-based laws, policies and regulations have the potential to strengthen health systems, to improve the availability, accessibility, acceptability and quality of care, and to improve health outcomes. In addition, laws and policies are considered to play a foundational role in FGM-abandonment efforts – providing the legal grounding and impetus for country-level stakeholders to advocate for and implement actions to bring about FGM abandonment. Finally, laws and policies are crucial for monitoring progress in terms of human rights, and they are important reference points for those seeking accountability for human rights violations.

The Global strategy to stop health-care providers from performing female genital mutilation elaborates why legal and policy frameworks in support of women’s and girls’ human rights are important components in the prevention of FGM. The Global strategy explains why the practice of FGM should give rise to legal and professional sanctions, such as criminal penalties for health workers who perform FGM and withdrawal of their licences. The Global strategy also highlights the need for health workers to be adequately sensitized and trained on the content of the relevant laws and policies, in order to be able to adhere to them and to accurately inform their clients and patients about their rights so as to empower them to access available legal-support resources. Wherever possible, health workers should assist women and girls who have undergone FGM and who are seeking legal support by providing evidence to back up their legal claims when requested. A recent review conducted to synthesize and assess the quality and strength of existing evidence on interventions designed to prevent or respond to FGM noted that while legislative interventions alone may not be effective in changing attitudes towards FGM or its prevalence, in settings where community members are already questioning or abandoning the practice and are seeking social acceptance, these interventions could accelerate change, especially if accompanied by political will, the existence of locally appropriate enforcement mechanisms, sensitization activities and sufficient resources for implementation.

- Rationale -

GDG members noted that it is difficult to disaggregate the effects of laws and policies supporting the prevention of FGM from other interventions targeting health workers (66, 67). This also applies to mandatory reporting laws under which a health worker has a duty to report if they believe that a girl might be at risk of FGM. Additionally, the GDG noted that the effects of the laws or policies would depend on the type of law being proposed, stating that laws on mandatory reporting, laws criminalizing the practice and laws that promote access to FGM prevention and care services would each have different effects. It was also noted that the illegality of FGM might affect women’s and girls’ health-seeking behaviour and the ability  of health workers to engage with them around the topic of FGM. It was agreed that sensitizing health workers to laws and policies against FGM remains an important element of health worker capacity-building. 

- Implementation remarks -

The GDG noted that the effect of FGM-related laws and policies also needs to be contextualized and that in some settings, legislation enacted without consideration of local contexts may be counterproductive and even harmful for the intended beneficiaries, leading to changes in the practice rather than elimination. GDG members also noted that while most laws and policies in countries with low FGM prevalence, including those with diaspora populations from countries where FGM is prevalent, outlaw all forms of FGM, attention mainly focuses on Type III FGM, which could potentially lead to racial or ethnic profiling and increase the vulnerability of migrant women and girls from countries where Type III FGM is commonly practised. Finally, the GDG noted that there was a lack of clarity on the criminality of less severe forms of FGM, e.g. Type IV.

- Research gaps -

Although evidence on the impact of different laws and policies on the elimination of FGM is lacking, and it is difficult to measure their impact, still laws and policies are needed to protect women and girls from FGM conducted by any person, including health workers, and to ensure compliance with international human rights standards. Qualitative research and programmatic evaluations seeking to understand the impact of various laws and policies on the elimination of FGM are recommended to fill important research gaps in this area. The GDG considered indirect evidence from a study conducted in Kenya, which suggested that health workers’ obligation to report appeared to negatively affect their clients’ health-seeking behaviour (69), but more evidence is needed to confirm this finding and its implications for service provision.

- Summary of the evidence -

Similar to the search for evidence on the effects of laws and policies, in the same systematic review no studies were identified to provide evidence on whether or not the implementation of professional codes of conduct for health workers reduces the medicalization of FGM or improves the quality of care provided to clients and patients.

- Rationale -

 The Global strategy to stop health-care providers from performing female genital mutilation calls on professional organizations “to adopt and disseminate clear standards condemning the practice of any type of FGM and issue firm guidelines for their members not to perform FGM, and not to accept or support its practice. This should be backed up by the application of strict sanctions against practitioners who violate those standards and guidelines” (34). These actions can be implemented in different ways in different settings but will align with the ethical principles to which health workers are subject. 

- Implementation remarks -

GDG members noted that if professional associations had mechanisms for enforcing their professional codes of conduct this would help to ensure that health workers honour the principles of medical ethics. The GDG noted that while laws and policies can frame the scope of programmatic work that influences the prevention of FGM and FGM medicalization, they can be leveraged to enforce professional codes of conduct among health workers with a view to preventing the medicalization of FGM. It is therefore necessary to ensure that health workers comply with such professional codes as part of human rights and ethical principles. This, however, needs to be context-specific and the types of enforcement mechanisms (e.g. penalties, loss of licence, fines) should be adapted to different settings.

-  Research gaps -

Although evidence on the impact of professional codes of conduct on preventing health workers from performing FGM is lacking, and it is difficult to measure the impact of specific codes of conduct, still accountability measures are needed to ensure compliance with international human rights standards. Programmatic evaluations to understand the impact of various professional codes of conduct on the elimination of FGM are recommended to fill research gaps in this area.