MCH Student:

Audrey Hanson

Date of Defense:

October 5, 2018

Abstract:

Introduction

Female Genital Cutting (FGC) or Female Genital Mutilation (FGM) is a procedure that involves injury to or removal of the external female genitalia. It is a worldwide issue that has currently affected over 200 million girls and women (1). FGC is considered a public health issue because it impacts the physical, emotional, mental, and social health of those who are exposed to the practice. Numerous studies have found evidence supporting the negative short- and long-term consequences associated with being cut (2). The consequences can range from severe bleeding or infection to a higher likelihood of complications during childbirth (1). The reasons for practicing FGC differ by community or culture. According to the World Health Organization (WHO), one of the main reasons the practice continues is adherence to social norms (1,2). Religion is another commonly cited reason for practicing FGC; however, most scholars agree that no religious texts explicitly require the practice (2). In the United States, FGC is illegal on a federal level (2). Even so, the most recent U.S. estimates suggest that over 500,000 girls and women have experienced, or are at risk of, FGC (3). State-specific prevalence rates are unknown, yet, given the U.S. estimate, FGC prevention efforts are on the rise. In Minnesota, organizations are working towards community-centered prevention projects and a bill was recently proposed by the House of Representatives that would enact harsher punitive measures against parents that support the practice (4).

Experience

As the Impacted Communities Committee Intern for the Minnesota Female Genital Cutting Prevention and Outreach Project, the activities that I conducted during this field experience contributed to the information gathering phase of the greater work plan. My learning objectives for this field experience included:

• Exploring and applying methods of working effectively with communities or special populations within the community, e.g., immigrant populations associated with the FGC Working Group;
• Completing a quasi-needs assessment to inform the goals and strategies of the FGC Working Group;
• Examining and utilizing communication skills important for facilitating collaboration between state government and community members

The primary activities that were conducted during this field experience were:

• Literature Review: A systematic review was conducted on successful community-based interventions aiming to prevent or otherwise address female genital cutting. Research was compiled into an annotated bibliography organized by geographic location of the intervention. Findings and common themes were presented at subsequent meetings.
• Review of Evaluations and Documentation: If available online, published evaluations of interventions were reviewed and cataloged for future reference. Additionally, organizations were contacted to supply documentation or evaluation reports.
• Informal Focus Groups Protocol: Questions for informal focus groups were developed and presented to Impacted Communities Committee for review and approval. Tracking system was created to document conversations and identify any gaps in communities reached. Protocol was created and presented to the committee to assist with data reporting.

Organization

The Minnesota Female Genital Cutting Prevention and Outreach Project is a collaboration between the Minnesota Department of Health (MDH) and the International Institute of Minnesota (IIMN). The Minnesota Department of Human Services provided funding to MDH’s Refugee and International Health Program and IIMN to create and lead the working group for this project. The working group meets bi-monthly and is made up of four committees: Impacted Communities Engagement and Education, Legal and Law Enforcement, Healthcare, and Other Professionals/Broader Community Engagement and Education. The primary aim of the working group and project is to bring together a diverse group of stakeholders to identify strategies, coordinate efforts, and make recommendations to prevent FGC in Minnesota (5).

Lessons Learned

This field experience contained many valuable learning experiences. First, was the opportunity to observe the role of the state health department as a leader of the FGC project. There was a need for balance between leading meetings, while also allowing community members to take ownership of their efforts and develop their own recommendations. Next, was the ability to observe and participate in the many partnerships across community organizations. Besides the meetings with the working group and the committees, this project also coordinated a grant program for community-based organizations to develop and implement their own programs to address FGC in Minnesota (5). Finally, although challenging, the need for continued adaptability and expectation management when working with a community-based initiative was a critical learning opportunity. For example, although the original work plan had outlined when the informal focus groups would take place, barriers of low-attendance and committee member capacity hindered the timeline for data collection. As a solution, a simple protocol was developed, and specific questions were prioritized with input from the committee. This will, ideally, assist community members in conducting the informal focus groups.

Recommendations

Beyond the simple recommendations of continued documentation and transparency with community members about the work of the project, the following two recommendations may assist with similar future projects:

• Utilizing a Peer Ethnographic Evaluation and Research (PEER) Interview approach for the informal focus groups. Training committee members how to be PEER interviewers may allow for skill-building opportunities, which may incentivize more members to participate. Additionally, given the sensitivity of the topic, PEER interview training may equip committee members with conversational techniques that ease dialogue and make them feel more comfortable talking about FGC in their communities (6,7).
• A process evaluation should be conducted throughout this project. An evaluation could assess participant satisfaction with the progress of the working group. It could also provide transparency to the public about the activities of the project and working group (8). Beyond attendance logs and documentation notes, surveys could be administered at working group and committee meetings and interviews could be conducted with committee leads (9).

Conclusion

This field experience provided immense learning opportunities related to community engagement strategies and components of a needs assessment. While addressing the sensitive topic of FGC with community members in Minnesota, the importance of relationship-building was apparent. Overall, this experience was very rewarding and will help inform my future public health evaluation work with diverse community groups.

References

1. Female genital mutilation [Internet]. World Health Organization. [cited 2018 Sep 9]. Available from: http://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation
2. Female genital cutting [Internet]. womenshealth.gov. 2017 [cited 2018 Sep 9]. Available from: https://www.womenshealth.gov/a-z-topics/female-genital-cutting
3. Goldberg H, Stupp P, Okoroh E, Besera G, Goodman D, Danel I. Female Genital Mutilation/Cutting in the United States: Updated Estimates of Women and Girls at Risk, 2012. Public Health Rep. 2016 Mar;131(2):340–7.
4. Minnesota bill against female genital mutilation raises opposition [Internet]. Star Tribune. [cited 2018 Sep 9]. Available from: http://www.startribune.com/minnesota-bill-against-female-mutilation-raises-opposition/423070383/
5. Minnesota Female Genital Cutting Prevention and Outreach Project – Minnesota Dept. of Health [Internet]. [cited 2018 Sep 10]. Available from: http://www.health.state.mn.us/divs/idepc/refugee/fgc/index.html
6. PEER [Internet]. [cited 2018 Sep 11]. Available from: https://options.co.uk/peer
7. Elmusharaf K, Byrne E, Manandhar M, Hemmings J, O’Donovan D. Participatory Ethnographic Evaluation and Research: Reflections on the Research Approach Used to Understand the Complexity of Maternal Health Issues in South Sudan. Qual Health Res. 2017 Jul;27(9):1345–58.
8. Kelly T. Five Simple Rules for Evaluating Complex Community Initiatives. 2010;22(1):5.
9. Butterfoss FD. Process Evaluation for Community Participation. Annu Rev Public Health. 2006;27(1):323–40.