Recommendation 3: Women and girls living with or at risk of any type of FGM, as well as men and boys from communities that perform FGM, should be provided with educational interventions such as group health education (in health facilities and/or outreach settings, including in humanitarian settings and among refugees), one-on-one FGM education, informationsharing or FGM-prevention counselling.

 

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

Individual and group health education or counselling sessions at health facilities and community-based education and awareness-raising activities targeting women and girls living with or at risk of FGM and men and boys in affected communities are aimed at increasing knowledge about FGM, promoting relevant human rights, and changing attitudes, as precursors to FGM abandonment. These interventions can be stand-alone or integrated into other education and information-sharing efforts.

- Summary of the evidence -

Quantitative and mixed-methods evidence reviews were conducted to inform this recommendation. The quantitative review considered interventions seeking to improve the knowledge, attitudes and health-seeking behaviour of women and girls living with or at risk of any type of FGM. The interventions included group education (in health facilities and/or outreach settings) as well as one-on-one education, information-sharing or counselling. Four studies conducted among women and girls living with or at risk of FGM were identified from the evidence search, including one retrospective cohort study in Switzerland and three preversus post-intervention assessments in Ethiopia and Kenya, Senegal and Sudan. No randomized controlled trials (RCTs) were identified. Regardless of study type and setting, the certainty of the evidence was very low for all assessed outcomes in all four studies. The study conducted by Mahgoub et al. in Sudan among 154 school girls showed an increase in the proportion of female students with improved knowledge of FGM types; improved knowledge that FGM could result in psychological problems, infertility and sexual problems; improved awareness that FGM was a violation of human rights; greater interest in joining activities aimed at discontinuing the practice; greater support for legislation against FGM; greater support for FGM abandonment; and greater likelihood of objecting if someone in their family wanted to arrange for a girl to undergo FGM. The study from Switzerland by Abdulcadir et al. explored the effect of a health education intervention among immigrant women with FGM who requested postpartum reinfibulation. The study found that none of the eight women with Type III FGM who had requested reinfibulation wished to undergo reinfibulation after they had undergone deinfibulation during childbirth; however, the certainty of the evidence was very low. The evidence reviews for this recommendation also considered interventions seeking to improve the knowledge, attitudes and health-seeking behaviour of men and boys from the same communities. The interventions included community-based group education as well as one-on-one information sharing or counselling. No study was identified that explored the effects of the interventions on reducing requests for FGM medicalization, reducing support for reinfibulation of women and girls with Type III FGM who are deinfibulated and/or reducing FGM-related stigma, discrimination and disrespectful care. Overall, community-based education in addition to information-sharing efforts appeared to lead to an improvement in knowledge about FGM and its complications among both men and women, achieving a change in participants’ attitudes (i.e. reduced support for FGM), and stronger commitment to not perform FGM in communities where FGM is practised. The study included in the review which was conducted in Senegal, by Diop & Askew, involved women and men from 20 villages in the intervention group and 20 villages in the control group, respectively, and used pre- and post-intervention assessment. The aim of the study was to evaluate the effect of a community education programme – compared with no intervention – on community members’ willingness to abandon FGM in rural areas of southern Senegal. The authors reported that a higher proportion of the participants in the community education arm of the study had improved knowledge about FGM and its complications than did those in the “no intervention” arm. The evidence also showed that group education may lead to a greater change in attitude, i.e. more of a reduction in participants’ support for FGM, FGM medicalization and reinfibulation (very-low-certainty evidence). Participants who received the community education intervention also showed more commitment to stop performing FGM than those who did not receive the intervention. The study in Ethiopia and Kenya was conducted by Chege et al. and also used pre- and postintervention assessment. In Ethiopia (n = 819 men and women), the researchers assessed the effectiveness of behaviour change communication (BCC) and advocacy activities by religious and other key leaders in the intervention site while no intervention was implemented in the control sites. In Kenya (n = 1440 men and women), the effectiveness of advocacy was assessed by comparing BCC strategies alone for one group versus the combination of BCC and advocacy activities for the other group. The authors reported greater improvement in knowledge about FGM and its complications in the group receiving community-based group education plus advocacy than in the “no intervention” group in Ethiopia. Group education plus advocacy may be better than “no intervention” in achieving a change in attitudes about FGM, FGM medicalization and reinfibulation (i.e. support was reduced among intervention participants). Findings at the Kenya sites did not indicate greater impact in the group with BCC plus advocacy activities compared with the BCC-only group in terms of intentions to cut their daughters and reductions in support for FGM, but both groups demonstrated higher knowledge scores post-intervention as compared with baseline. Very-low-certainty evidence suggests that exposure to group education plus advocacy resulted in greater commitment not to perform FGM. A mixed-methods evidence review identified qualitative studies conducted in refugee and humanitarian settings addressing the acceptability, appropriateness, feasibility and sustainability of different educational interventions relating to FGM. One study, by Mitike & Deressa, found that educational interventions calling for an end to FGM/explaining the risks of FGM were perceived as acceptable by refugees living in a refugee camp in Ethiopia, and a study by McNeely & Christie-de-Jong found this was also the case among those who were now settled in the USA. The findings of another study conducted by Turkmani et al. among settled refugees and migrants in Australia suggested that male-inclusion interventions could foster further engagement of men who may not have been previously involved in FGM-related educational initiatives. A systematic review on the effectiveness of health education interventions by Waigwa et al. reported that several factors were associated with facilitating or hindering the effectiveness of health education interventions. These include sociodemographic factors; traditions and beliefs; and factors associated with the strategy, structure and delivery of the intervention. In particular, younger participants were more likely to be school educated, which potentially increased their chances of engaging with FGM-abandonment efforts. The ethnicity of those delivering the interventions also affected the impact of the intervention and participants’ acceptance of the FGM-related health education programmes (77). Additional indirect evidence from an impact evaluation of a programme implemented in Belgium focused on women and men from the diaspora and their health-care providers. The study demonstrated a snowball effect: not only did the direct recipients benefit from the programme, they also sensitized family and friends who were still living in their country of origin on the importance of ending FGM.

- Rationale -

The GDG noted that education, counselling or information-sharing for women and girls living with or at risk of any type of FGM is more beneficial than harmful, regardless of the setting. Based on the GDG members’ diverse professional experiences, workshops for women and girls living with FGM were deemed to have helped in sensitizing communities to the idea of FGM abandonment. GDG members felt that women and girls have a right to be offered information-sharing and health promotion about FGM and female anatomy, and they also noted that women and girls value these education/sensitization sessions and that the content should be evidence-based to reduce the risk of unintended harm. A recent evidence review found that community-based education can be useful for imparting information about the negative health consequences of FGM, and that this triggers discussions among members of practising communities about the need for action to eliminate the practice (78). Similarly, the GDG agreed that the benefits of training, education, counselling or informationsharing for men and boys from FGM-practising communities outweigh the harms, regardless of the setting, although there was a lack of evidence on the effects of these interventions on male engagement in FGM-abandonment efforts. Current literature on addressing harmful cultural practices points to the value of a gender-transformative approach targeting men and boys to address gender inequality and restrictive gender norms (79). Based on GDG members’ experiences, workshops with men and boys in affected communities can help sensitize and raise awareness about FGM being a harmful practice and a violation of women’s and girls’ rights. The GDG noted that in many countries male members of the community play a significant role in driving the practice of FGM, such that engaging them is critical to abandonment efforts. The GDG acknowledged the limitations in the evidence but issued a recommendation based on the available direct evidence as well as the indirect evidence and their professional experience.

- Implementation remarks -

With regard to resource considerations, the GDG noted that interventions seeking to improve the knowledge, attitudes and health-seeking behaviour of women and girls living with or at risk of undergoing FGM, as well as men and boys from practising communities, might be cost-intensive in the short term, but that the potential benefits in terms of preventing FGM may make them cost-effective in the long term. More data are needed, however, to determine the effectiveness of these interventions. A study on the economic burden of FGM by Tordrup et al., which was the basis for the WHO FGM Cost Calculator (80), provides quantitative evidence on the importance of investing in FGM prevention, with potentially significant savings to national health systems. The cost-effectiveness of prevention interventions would depend on content, modality and context, with great variation expected depending on how and where the intervention is delivered, i.e. whether it is community-based or health-facility based; whether it is delivered one-on-one or in group sessions; whether the setting has a low or high level of income or resources. The GDG also considered evidence from related studies that did not fit the criteria for the types of interventions to be included in the review on this topic, but which shed light on other types of community-based interventions. The evaluation of the Saleema Initiative in Sudan, for example, aimed to determine the effectiveness of a community campaign, which included engagement of local opinion leaders, public pledges to end FGM, and dissemination of branded items to indicate opposition to FGM, all aimed at addressing social norms related to FGM. Findings from the evaluation suggest that community dialogues that address social norms may be a promising strategy in FGM abandonment efforts, although the interventions were outside the scope of these reviews, which relates to educational interventions. The GDG agreed that implementation of interventions targeting men and boys should include standardized content that is contextualized to the specific setting, and should be implemented in a cost-effective manner. Care should be taken to avoid stigma and discrimination, especially if targeting specific communities that might already face marginalization. The findings from a mixed-methods synthesis of evidence from humanitarian settings indicate that the personal and interpersonal characteristics of the individual participants may influence the sustainability of educational interventions on FGM. The qualitative study on refugees and migrants in Australia showed that the family–community unit, including local and religious leaders, plays an important role in shifting intergenerational attitudes and practices (76). The systematic review by Waigwa et al. (2018) emphasized the importance of involving affected communities – including religious and traditional leaders and other stakeholders – in the development, implementation and monitoring of programmes to ensure adequate support for and promotion of relevant interventions (77). Community members can be involved in disseminating information to relatives and friends, thereby promoting public awareness on FGM abandonment.

- Research gaps -

Since the included studies measured short-term changes following exposure to communitybased educational interventions and no studies assessed long-term impact, additional research is needed to assess how to maintain and reinforce the positive effects of such educational interventions. While the available evidence (direct or indirect) shows promising effects of community education interventions among men and boys, the effects need to be explored within multi-component intervention packages in a range of settings and when brought to scale. While it is critical to contextualize interventions for specific settings to ensure their relevance, effectiveness, acceptability and feasibility, it can be difficult to determine which components are most impactful in different settings and to attribute change to a specific component. Similarly, there is a need to build the capacity of community-based programme implementers so that the interventions are appropriately rooted in context and theory, and to allow for effective evaluation of the intervention’s impact and adequately document what works and what doesn’t for FGM prevention. Finally, while the costs of treating health complications have been measured and cost-saving estimates have been produced, little research has assessed the costs or cost-effectiveness of implementing these interventions at scale. It is also not known which factors could improve cost-effectiveness across a range of settings and contexts.