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Objectives This study describes a female genital cutting (FGC) elimination communication programme in Enugu State and assesses its impact in changing relevant knowledge, attitudes and behavioural intentions.
Methods The FGC programme combined a community mobilization component with targeted advocacy and mass media activities. Data for assessing the impact of the programme derived from baseline and follow-up surveys in three intervention local government areas (LGA) in Enugu State and three comparison LGAs in Ebonyi State. An ideation model of behaviour change guided the analyses of the impact of the programme on personal advocacy for FGC, perceived self-efficacy to refuse pressure to perform FGC, perceived social support for FGC discontinuation, perceived benefits of FGC, perceived health complications of FGC and intention not to perform FGC on daughters. The analytical methods include comparing change in pertinent outcome variables from baseline to follow-up in the two study states and using logistic regression on follow-up data for the intervention state to assess the link between programme exposure and the relevant outcome indicators.
Results The data show that while the pertinent ideational factors and the intention not to perform FGC either worsened or remained stagnant in Ebonyi State, they improved significantly in Enugu State. The logistic regression results show that programme exposure is associated with the expected improvements in all the pertinent indicators.
Conclusion The multimedia communication programme has been effective in changing FGC-related attitudes and promoting the intention not to perform FGC.
Objectifs Cet article décrit le programme de communication sur l’élimination de l'excision dans l’état d'Enugu et évalue son impact sur la modification des croyances, des attitudes et des comportements.
Méthodes Le programme contre l'excision combinait une mobilization communautaire avec des recommandations ciblées et des actions de masses médiatiques. Les données pour évaluer l'impact du programme provenaient d’études de suivi de trois zones locales gouvernementales (ZLG) d'interventions dans l’état d'Enugu et trois ZLG comparatives dans l’état d'Ebonyi. Un modèle d'idéation du changement comportemental était utilisé pour l'analyse d'impact du programme sur la perception personnelle de l'excision, sur la perception personnelle à refuser la pression pour réaliser l'excision, sur la perception du support social pour l'abolition de l'excision, sur la perception des bénéfices de l'excision, sur la perception des complications sur la santé de l'excision et sur l'intention de ne pas pratiquer l'excision sur les filles. Les méthodes d'analyse incluent la comparaison des changements de certains critères de jugement pertinents entre le début et la fin du suivi du programme dans les deux états impliqués dans l’étude. Une régression logistique a été réalisée sur les données de suivi dans l’état d'Enugu où l'intervention avait lieu pour étudier le lien entre l'exposition au programme et des critères de jugement pertinents.
Résultats Les données montrent que tandis que les facteurs d'idéation et l'intention de ne pas exécuter l'excision ont empiré ou sont demeurés stables dans l’état d'Ebonyi, ils se sont améliorés de manière significative dans l’état d'Enugu. Les résultats de la régression logistique montrent que l'exposition au programme est associée aux améliorations prévues de tous les indicateurs choisis.
Conclusions Le programme de communication multi media a été efficace dans le changement d'attitude envers l'excision et pour la promotion de ne pas pratiquer l'excision.
Mots clefs Excision , Nigeria , communication , cycle d'action communautaire , Idéation
Objetivos Este trabajo describe un programa de comunicación destinado a eliminar la mutilación genital femenina (MGF) en el estado de Enugu, y evaluar su impacto en la modificación de relevantes conocimientos, actitudes e intenciones de comportamiento.
Métodos El programa MGF combinó un componente de movilización comunitaria con acciones de defensas dirigida a sectores específicos, y actividades en medios de comunicación. La información para evaluar el impacto del programa fue obtenida a través de entrevistas de inicio y posterior seguimiento en tres áreas con intervención del gobierno local (LGA) en el estado de Enugu, y tres LGAs de comparación en el estado de Ebonyi. Una concepción de modelo de cambio de comportamiento guió el análisis del impacto del programa de defensa contra la MGF, la percepción de la auto eficacia para negarse a realizar la MGF, la percepción de apoyo social a descontinuar realizando la MGF, beneficios percibidos de la MGF, complicaciones de salud percibidas de la MGF, e intención de no realizar la MGF en las hijas. Los métodos analíticos incluyen comparar cambios en las variables pertinentes de los resultados desde el inicio al seguimiento en los dos estados estudiados, y la utilización de regresión logística en el seguimiento de la información en el estado intervenido para establecer el enlace entre la exposición del programa y los relevantes indicadores de los resultados.
Resultados La información muestra que a pesar de que los pertinentes factores conceptuales y la intención de no llevar adelante la MGF en el estado de Ebonyi empeoraron o permaneció estancado, sin embargo mejoró significativamente en el estado de Enugu. Los resultados de la regresión logística muestran que la promoción del programa está asociada a las mejoras esperadas en todos los indicadores pertinentes.
Conclusión El programa de comunicación multimedia ha sido efectivo para modificar las actitudes relacionadas con la MGF y en promover la intención de no llevar a cabo la mutilación genital femenina.
Palabras clave Mutilación Genital Femenina , Nigeria , comunicación , ciclo de acción comunitaria , creación de conceptos
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Over the last couple of decades, female genital cutting (FGC), also known as female circumcision or female genital mutilation, has attracted considerable attention from policy advocates and researchers across the globe. In recent years, there has been some controversy surrounding its prevalence and the justification for increased advocacy efforts to eliminate the practice (Obermeyer 1999, 2003; Mackie 2003). Nonetheless, FGC is a potentially harmful practice associated with both short-term and longer-term complications (Jones et al. 1999; Larsen & Yan 2000; El-Defrawi et al. 2001; Larsen & Okonofua 2002; Okonofua et al. 2002). While quantifying the prevalence and severity of the health consequences of FGC at the community level has proved to be a challenge, there is overwhelming consensus that FGC in any form is an unnecessary procedure that has no clear benefit (Obermeyer 2002; Yoder et al. 2004; Behrendt & Moritz 2005).
Although there is evidence of its decline, FGC is still widely practiced among many ethnic groups in Nigeria (Snow et al. 2002). A 1999 survey put the prevalence at 59% in Enugu State and 76% in Ebonyi State [Research and Marketing Services (RMS) 1999]. In these states, the most common forms of FGC are type I (removal of the prepuce, with or without removal of all or part of the clitoris) and type II (removal of the clitoris with partial or total excision of the labia minora), with both forms carried out during infancy or adolescence (RMS 1999).
While there have been considerable efforts to stop FGC in Enugu State in the past, support for the practice persists in many parts of the state. The factors underpinning the practice in the state are cultural and support the convention hypothesis (Schelling 1960; Lewis 1969; Mackie 2003). For example, in the areas where the practice persists, women who have not undergone the procedure are generally believed to be unmarriageable, unclean and potentially promiscuous (Health Communication Partnership 2005). In contrast, the cutting of the clitoris is believed to reduce the ‘natural tendency for promiscuity in women’. It is also widely believed that an ‘uncircumcised’ woman puts the lives of her male children at risk. The belief in this regard is that if the head of the male child touches the clitoris of the mother during childbirth, the child will die. As parents do not wish to jeopardize the health of their future grandsons or risk that their daughters will remain unmarried or be labelled promiscuous, the practice persists in these areas, even among individual parents who no longer believe in its benefits. Indeed, the convention theory predicts that practices informed by convention will either persist indefinitely or stop abruptly when a significant number of people in the affected communities simultaneously decide to discontinue the practice (Schelling 1960; Mackie 1996, 2000). A strong support for this prediction is found in the ending of foot-binding in China in the 20th century. After persisting for more than a thousand years, the practice ended within a generation in response to pressures from an internal Chinese and missionary-inspired antibinding movement. The efforts of the antibinding reformers quickly resulted in entire villages and communities abandoning the practice (Levy 1992; Mackie 1996).
Against this background, the Health Communication Partnership, in collaboration with the National Association of Women Journalists (NAWOJ) and Women Action Research Organization (WARO), designed a multitiered and multimedia programme called Ndukaku (Igbo word for ‘health is better than wealth’), with funding from the United States Agency for International Development (USAID). The programme focused on three local government areas (LGAs) in Enugu State (Uzo-Uwani, Isi-Uzo and Enugu South) and aimed to contribute to the elimination of FGC in the project communities by challenging individuals and communities to examine their beliefs and values around FGC and encouraging action towards the elimination of the practice. Specifically, the programme was designed to raise awareness of the possible negative effects of FGC, increase community dialogue about the practice, address the cultural and socio-economic props that reinforce the practice, and mobilize community members to abandon the practice and advocate in favour of its elimination among their peers. This study describes the programme and provides evidence of its impact using population-based data.
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To achieve the project goal, Ndukaku used a non-confrontational, multichannel approach which combined community capacity strengthening and mobilization with targeted advocacy and mass media interventions. The community component involved a community-driven process known as the Community Action Cycle (CAC). CAC was developed by Save the Children and draws on theories of social systems approach to individual and social change. The method consists of six phases: (i) prepare to mobilize; (ii) organize the community for action; (iii) explore the health issue and set priorities (with the community); (iv) plan together; (v) act together; and (vi) evaluate together (Howard-Grabman & Snetro 2003; Tsuyuki 2005).
The project was implemented at three administrative levels: hamlet, LGA and state. WARO led the CAC component at the hamlet level, assisting community core groups to examine their knowledge, attitudes and practices surrounding women's reproductive health and then providing the groups with guidance and support as they developed action plans to improve women's health situation. A key WARO input was the facilitation of community meetings where FGC and other maternal health issues were discussed and analysed. WARO also trained the core community groups and supported them in developing action plans for the elimination of FGC in their communities, provided support to the groups to facilitate advocacy meetings with traditional leaders and ruling councils and larger community meetings to discuss the social and health complications of FGC. There were an estimated 50 000 adults in the three communities, all of whom were eligible for participation in the community activities.
LGA-level activities included visits to traditional leaders, religious leaders, local government officials, school authorities and women groups, and FGC discussions at the annual tribal ‘Home and Abroad’ meetings and during LGA town forums. ‘Home and Abroad’ is a cultural event that takes place every August and provides opportunities for Igbo women residing within and outside their community of origin to come together and contribute to community development. State-level activities were designed and implemented by NAWOJ and involved the use of mass media to stimulate and publicize dialogue around FGC. NAWOJ supported regular newspaper columns, radio call-in shows and public forums on FGC. One of the key roles of the non-governmental organization was publicizing the dialogue and actions taking place in the hamlets and LGA forums.
Data analysed in this paper were derived from two sources: a baseline survey conducted in July/August 2003 and a follow-up survey implemented in September 2004. Both surveys were based on an intervention–comparison group design and took place in Enugu (intervention) and Ebonyi (comparison) States. The surveys were cross-sectional but with comparable samples. Three intervention LGAs in Enugu State and three comparative LGAs in Ebonyi State were selected to participate in the surveys. In each LGA, one community consisting of two or more enumeration areas (EAs) was selected and all the households in each EA were listed. One hundred households were then randomly selected from each LGA and surveyed. Each of the selected households was visited and all eligible men and women (aged between 18 and 59 years) were listed and targeted for interview using a structured questionnaire.
The questionnaire included pre-tested questions about socio-demographic characteristics, media habits, FGC-related attitudes, personal experience with FGC, FGC intentions and exposure to FGC information. The response rate was around 90% for both surveys. The sample included 957 respondents (426 men and 531 women) at baseline and 971 respondents (386 men and 585 women) at follow-up.
The survey followed standard ethical guidelines. The Institutional Review Board at Johns Hopkins University approved the study. Verbal consent was obtained from respondents prior to interview. Respondents’ confidentiality was protected by face-to-face private interviews with no third party, appropriate training for interviewers, adequate field supervision, limited access to completed questionnaires and exclusion of individual identifiers in the electronic dataset. Moreover, a local Internal Review Board reviewed and approved the study prior to commencement of data collection.
The outcome variables that are examined in this paper include four psychosocial variables (the belief that there are benefits to FGC, personal approval of FGC, perceived self-efficacy to resist pressure to practice FGC and perceived community support for discontinuation of FGC) and reported intention not to perform FGC on daughters. The analyses were performed using STATA (version 8.2).
We determined the impact of the programme by comparing the change from baseline to follow-up in pertinent outcome variables in Enugu and Ebonyi States. In addition, using the follow-up data, we examine the impact of programme exposure on the key outcome variables using logistic regression.
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Table 1 summarizes the key socio-demographic characteristics of the respondents. The samples included more women than men, and the respondents from both states are predominantly economically active and lowly educated. In both study states, the baseline and follow-up respondents are basically comparable along most of the key socio-demographic variables. There are, however, a few exceptions: religiosity and distribution by sex in Enugu and religiosity, FGC status and radio-listening habits in Ebonyi. In addition, both the baseline and the follow-up surveys reveal significant differences between Enugu and Ebonyi State in selected variables. For example, the baseline data show that there are significant differences between the two states in respect of sex composition, educational characteristics, employment status and children-ever-born. Similarly, the follow-up data reveal significant differences in sex composition, employment status and children-ever-born.
Table 1. Selected indicators of socio-demographic characteristics by state of residence and by survey, Enugu and Ebonyi, 2003, 2004
|Per cent male*†||40.9‡||35.5||48.2||43.5|
|Mean age in years||33.1||34.6||34.3||34.7|
|Per cent with secondary education or more*||39.2||38.3||28.7||34.0|
|Mean number of children ever born*†||3.1||3.5||4.7||4.3|
|Per cent protestant†||58.9||59.0||56.6||51.2|
|Regularly radio-listening habit*||80.8||83.9||71.4‡||83.0|
|Per cent very religious†¶||62.8‡||56.4||46.9‡||54.5|
|Number of respondents||484||454||473||517|
The follow-up data indicate that more women in Ebonyi (76.9%) than in Enugu (67.0%) had personally experienced FGC. There are considerable variations by LGA. For example, in Enugu, FGC prevalence varied between 29.4% in one LGA and 83.0% in another. In Ebonyi, the variations by LGA ranged between 73.3% and 83.3%.
We measured programme exposure through recall of messages provided on any of the programme materials or during any of the programme-related community events. More than three-fifths (63.4%) of the respondents in Enugu State were exposed to at least one programme material or participated in at least one programme activity. The major source of exposure to the programme is the radio. Nonetheless, many (26.2%) respondents participated in community events through which they learnt about FGC. Overall, slightly more men (67.1%) than women (61.4%) were exposed to at least one component of the programme.
Impact on ideational factors
Table 2 presents the levels of selected psychosocial indicators at baseline and follow-up in Enugu and Ebonyi States. In general, the variables changed in the expected direction in Enugu State while they either remained stagnant or became worse in Ebonyi. For example, in Enugu State there has been a significant decline in the belief that there are benefits to FGC among men and women whereas the prevalence of the belief remains practically at the same level in Ebonyi State. The result is such that this belief is more common in Ebonyi than in Enugu State at follow-up whereas the reverse was the case at baseline. A similar pattern of change is observed in connection with personal approval of FGC. This indicator declined by 10% among Enugu men and 15% among their female counterparts. In contrast, the indicator has not changed conspicuously in Ebonyi. The data further show that there has been a significant increase in the perceived self-efficacy to refuse pressure to perform FGC among men and women in Enugu State whereas there has been no significant change in Ebonyi. Finally, while perceived social support for FGC discontinuation has become more widespread in Enugu since the baseline, it has become less common in Ebonyi, particularly among women.
Table 2. Level (per cent reporting) of selected indicators by state and by survey, Enugu and Ebonyi, 2003, 2004
|Baseline (n = 162)||Follow-up (n = 161)||Baseline (n = 225)||Follow-up (n = 217)|
| Believed that there are benefits to FGC||46.9||24.2****||42.3||34.7*|
| Personally approved of FGC||32.7||22.5**||30.3||29.7|
| Perceived self-efficacy to resist pressure from spouse to perform FGC on daughters||71.8||88.0***||50.9||40.4|
| Believed that most men and women in the community favour discontinuation of FGC||24.2||35.4**||25.4||19.5|
| Encouraged someone not to perform FGC on daughters||11.8||14.3||9.7||12.0|
| Reported intention not to perform FGC on daughter||53.4||72.7****||63.9||66.3|
| ||Baseline (n = 252)||Follow-up (n = 293)||Baseline (n = 239)||Follow-up (n = 292)|
| Believed that there are benefits to FGC||42.1||24.6****||33.9||28.4|
| Personally approved of FGC||36.9||21.5****||29.4||27.1|
| Perceived self-efficacy to resist pressure from spouse to perform FGC on daughters||57.2||72.4***||39.9||42.4|
| Believed that most men and women in the community favour discontinuation of FGC||35.7||49.1****||20.8||13.7**|
| Encouraged someone not to perform FGC on daughters||16.3||23.9**||10.6||9.2|
| Reported intention not to perform FGC on daughter||58.7||76.3****||64.2||66.9|
To assess the impact of the programme on ideational factors, we estimated a series of four logistic regression models, each of which related programme exposure to personal approval of FGC, perceived self-efficacy to resist pro-FGC pressure from spouse, perceived social support for FGC discontinuation and personal advocacy for FGC abandonment. Each of the four models controlled for gender, education, LGA of residence, religiosity, religion (Catholic vs. non-Catholic), employment status, radio-listening habits and television-viewing habits. Due to the relatively small sample size, we did not estimate separate models for men and women. The results, presented on Table 3, show that programme exposure is associated with a graduated impact on the ideational factors. Specifically, programme exposure is associated with increased perceived self-efficacy to resist pro-FGC pressure, increased perceived social support for FGC discontinuation, increased personal advocacy in favour of FGC abandonment and decreased personal approval for FGC. For all the ideational factors, exposure to the programme through a combination of mass media and community events presents a marked advantage over exposure through either mass media alone or community events alone.
Table 3. Results (odds ratio) of logistic regression† of the effects of programme exposure on selected ideational variables, Enugu, 2004
|Ideational variable||Odds ratio|
|No exposure||Mass media or community alone||Mass media and community|| n|
|Personally approved of FGC||1.00||0.42 (0.23–0.76)**||0.17 (0.07–0.39)**||454|
|Perceived self-efficacy to resist pressure from spouse to perform FGC on daughters||1.00||6.28 (3.45–11.43)**||8.30 (3.65–18.88)**||454|
|Believed that most men and women in the community favour discontinuation of FGC||1.00||3.16 (1.83–5.46)**||6.32 (3.26–12.26)**||454|
|Encouraged someone not to perform FGC on daughters||1.00||3.21 (1.48–6.96)*||11.00 (4.88–24.73)**||454|
Impact on female genital cutting intention
At baseline, 64.1% in Ebonyi and 56.6% in Enugu reported the intention not to perform FGC on their daughters who were yet to undergo the procedure. The follow-up data indicate clear improvements in this indicator in Enugu but not in Ebonyi (Table 2). In Enugu State, the increase in the intention not to perform FGC on daughters between baseline and follow-up is significant for both men and women. The follow-up data also show that the intention not to perform FGC is now more widespread in Enugu than in Ebonyi.
In addition, the follow-up data show for both men and women that exposure to the programme at any level is associated with higher level of intention not to perform FGC (Figure 1). The data further indicate that, for women, intention not to perform FGC increases by level of programme exposure.
We estimated a set of logistic regression models to determine the predictors of the intention not to perform FGC and highlight the role of the programme exposure. Three models were estimated: Model A includes only socio-demographic and contextual explanatory variables; Model B includes programme exposure in addition to the socio-demographic and contextual variables; Model C includes ideational factors in addition to the explanatory variables in Model B. Several versions of each model were estimated and the best-fitting was retained. Only those variables that, at the bivariate level, were significantly related to intention were included in the estimated models. The results are presented in Table 4.
Table 4. Results (odds ratio) of various models estimating the socio-demographic, ideational and communication predictors of the intention not to perform female genital cutting (FGC) on daughters, Enugu, 2004
|Variables||Model A†||Model B‡||Model C§|
| None (RC)||1.00||1.00|| 1.00|
| Primary||0.72 (0.38–1.36)||0.64 (0.32–1.28)|| 0.38* (0.13–1.12)|
| Post-primary||1.04 (0.49–2.17)||0.80 (0.35–1.81)|| 0.37 (0.11–1.31)|
| Uzo-Uwani (RC)||1.00||1.00|| 1.00|
| Isi-Uzo||2.38 (1.31–4.31)***||1.34 (0.70–2.58)|| 0.60 (0.23–1.54)|
| Enugu South||0.45 (0.26–0.77)***||0.19 (0.10–0.36)****|| 0.26 (0.09–0.70)***|
|Listened to the radio regularly||2.72 (1.49–4.94)****||1.40 (0.71–2.73)|| 1.98 (0.73–5.36)|
|Attended religious services at least twice a week||0.59 (0.37–0.94)**||0.57 (0.34–0.94)**|| 0.45 (0.22–0.93)**|
|Children-ever-born||1.22 (1.11–1.34)****||1.17 (1.06–1.30)***|| 1.32 (1.13–1.55)****|
| Not exposed (RC)|| ||1.00|| 1.00|
| Mass media alone/community events alone|| ||5.91 (3.22–10.85)****|| 3.16 (1.29–7.73)**|
| Mass media and community events|| ||12.04 (4.96–29.20)****|| 4.50 (1.32–15.30)**|
|Perceived that most community members favour discontinuation of FGC||–||–|| 3.86 (1.50–9.91)***|
|Personally approved of FGC||–||–|| 0.06 (0.02–0.16)****|
|Perceived that spouse approved of FGC||–||–|| 0.41 (0.13–1.27)|
|Perceived that FGC could cause problems for the girl/woman||–||–|| 3.30 (1.26–8.63)**|
|Perceived self-efficacy to resist pro-FGC pressure from spouse||–||–|| 7.50 (3.35–16.82)****|
|Pseudo-R2 (%)||12.9||22.8|| 57.0|
|Per cent correctly predicted||75.8||76.5|| 90.7|
|Likelihood ratio test: χ2/P||–||52.46/0.001||181.41/0.001|
|Number of observations||442||442||442|
In Model A, the most significant socio-demographic predictors of the intention not to perform FGC on daughters are radio-listening habits, LGA of residence, children-ever-born and religiosity. It is interesting to note that extremely religious people are less likely to be willing to abandon FGC while having a large number of children is associated with increased intention not to practice FGC. Introducing programme exposure in Model B significantly increased the predictive power of the model and revealed a strong dose–response relationship between programme exposure and the intention not to perform FGC. The results of this model also show that, with the exception of radio-listening habits, the socio-demographic variables that were significant in Model A maintained their significance.
When the ideational factors were introduced (Model C), the predictive power of the model increased dramatically. The results of the likelihood ratio test indicate that the ideational factors are jointly strongly significant in predicting the intention not to perform FGC. The data show that perceived self-efficacy to resist pro-FGC pressure from spouse, perceived social support for FGC discontinuation, and the perception that FGC could cause problems for the girl or woman significantly increase the odds of reporting the intention not to perform FGC. In contrast, personal approval of FGC reduces the odds of intending not to engage in the practice.
It is interesting to note that in the presence of ideational predictors, programme exposure continued to be associated with a significant dose–response effect on the intention not to perform FGC. Exposure to the programme through both the mass media and community events increased the odds of not intending to perform FGC more than fivefold while exposure through either source increased the odds more than threefold. With the ideational factors in the estimated model, the effects of programme exposure were less significant than without (Model B).