The Applicability of Behaviour Change in Intervention Programmes Targeted at Ending Female Genital Mutilation in the EU: Integrating Social Cognitive and Community Level Approaches
With increased migration, female genital mutilation (FGM) also referred to as female circumcision or female genital cutting is no longer restricted to Africa, the Middle East, and Asia. The European Parliament estimates that up to half a million women living in the EU have been subjected to FGM, with a further 180,000 at risk. Aware of the limited success of campaigns addressing FGM, the World Health Organization recommended a behavioural change approach be implemented in order to end FGM. To date, however, little progress has been made in adopting a behaviour change approach in strategies aimed at ending FGM. Based on research undertaken as part of the EU’s Daphne III programme, which researched FGM intervention programmes linked to African communities in the EU (REPLACE), this paper argues that behaviour change has not been implemented due to a lack of understanding relating to the application of the two broad categories of behaviour change approach: individualistic decision-theoretic and community-change game-theoretic approaches, and how they may be integrated to aid our understanding and the development of future intervention strategies. We therefore discuss how these can be integrated and implemented using community-based participatory action research methods with affected communities. 1. Introduction Female genital mutilation (FGM), sometimes called female circumcision or female genital cutting, is a deep rooted traditional practice that adversely affects the health and well-being of millions of girls and women. It is estimated that 100–140 million females worldwide have been subjected to FGM and that 3 million are at risk each year [1]. The practice is common in 28 countries in Africa as well as parts of the Middle East and Asia [1, 2]. However, with increasing international migration, the practice of FGM is no longer restricted to the traditional practising countries. In 2010, the European Parliament estimated that up to half a million women living in Europe had been subjected to FGM, with a further 180,000 at risk [3, 4]. According to the UNCHR, nearly 20,000 women from FGM practising countries applied for asylum to the EU in 2011 with an estimated 8,809 female applicants aged 14–64 likely to be affected by FGM [5]. In addition to those coming to the EU who have already been subjected to FGM, there is anecdotal evidence supported by criminal prosecutions, particularly in France and Sweden, that suggests that FGM is conducted in the EU [6–9]. This has led to the implementation of FGM elimination campaigns in the EU. There are a growing number
References
[1]
Female Genital Mutilation/Cutting: Data and Trends: Update 2010, Population Reference Bureau, Washington, DC, USA, 2010.
[2]
Female Genital Mutilation in the European Union and Croatia, European Institute for Gender Equality, Vilnius, Lithuania, 2013.
[3]
Ending Female Ganital Mutilation: A Strategy for the European Union Institutions, EndFGM, Brussels, Belgium, 2010.
[4]
European Parliament, Combating Female Genital Mutilation in the EU: European Parliament Resolution of 24 March 2009 on Combating Female Genital Mutilation in the EU (2008/2071(INI)), European Parliament, Brussels, Belgium, 2009.
[5]
United Nations Commissioner for Refugees (UNHCR), Too Much Pain: Female Genital Mutilation and Asylum in the European Union. A Statistical Overview, UNHCR Bureau for Europe, Geneva, Switzerland, 2013.
[6]
J. Hemmings, TackingFGM Special Initiative PEER Research Full Report, Esmee Fairbairn Foundation, London, UK, 2011.
[7]
E. Leye, Female genital mutilation: a study of health services and legislation in some countries of the European Union [Ph.D. thesis], Faculty of Arts and Philosophy, Ghent University, Ghent, Belgium, 2008.
[8]
J. F. Nijboer, N. M. D. van der Aa, and T. M. D. Buruma, Criminal Investigations and Prosecution of Female Genital Mutilation: The French Practice: Crime, Law Enforcement and Safety, Ministry of Justice, Netherlands, 2010.
[9]
K. Norman, J. Hemmings, E. Hussein, and N. Otoo-Oyortey, Experiences, Perceptions and Beliefs of Women Affected by Female Genital Mutilation in London: Results from a PEER Study, Options Consultancy Services and FORWARD, London, UK, 2009.
[10]
World Health Organization, A Systematic Review of the Health Complications of FGM, Department of Women's Health, Family and Community Health, Geneva, Switzerland, 2000.
[11]
World Health Organization, “Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries,” The Lancet, vol. 367, no. 9525, pp. 1835–1841, 2006.
[12]
UNFPA, A Holistic Approach to the Abandonment of FGM/Cutting, UNFPA, New York, NY, USA, 2007.
[13]
Female Genital Mutilation. Fact Sheet N°241, World Health Organization, Geneva, Switzerland, 2012.
[14]
S. Lloyd-Roberts, “Female genital mutilation rife in Egypt despite ban,” BBC Newsnight, London, UK, 2012, http://news.bbc.co.uk/1/hi/programmes/newsnight/9696353.stm.
[15]
B. Shell-Duncan, K. Wander, Y. Hernlund, and A. Moreau, “Dynamics of change in the practice of female genital cutting in Senegambia: testing predictions of social convention theory,” Social Science and Medicine, vol. 73, no. 8, pp. 1275–1283, 2011.
[16]
World Health Organization, Female Genital Mutilation Programmes to Date: What Works and What Doesn't. A Review, Department of Women's Health, Geneva, Switzerland, 1999.
[17]
Frontiers in Reproductive Health and Population Council, “Abandonment of female genital cutting,” Report of a Consultative Meeting on Methodological Issues for FGC Research, Frontiers in Reproductive Health Population Council, Washington, DC, USA, 2002.
[18]
H. Barrett, K. Brown, D. Beecham, N. Otoo-Oyortey, Z. Naleie, and West Midlands European Centre, REPLACE Pilot Toolkit for Replacing Approaches to Ending FGM in the EU: Implementing Behaviour Change with Practising Communities, Coventry University, Coventry, UK, 2011.
[19]
G. Mackie and J. Le Jeune, Social Dynamics of Abandonment of Harmful Practices: A New Look at the Theory, UNICEF Innocenti Research Centre, Florence, Italy, 2009.
[20]
R. E. Johansen, “Experiencing sex in exile: can genitals change their gender? on conceptions and experiences related to female genital cutting (FGC) among Somalis in Norway,” in Transcultural Bodies: Female Genital Cutting in Global Context, Y. Hernlund and B. Shell-Duncan, Eds., pp. 248–277, Rutgers, London, UK, 2007.
[21]
A. Talle, “The making of female fertility: anthropological perspectives on a bodily issue,” Acta Obstetricia et Gynecologica Scandinavica, vol. 73, no. 4, pp. 280–283, 1994.
[22]
Y. Hernlund and B. Shell-Duncan, “Transcultural positions: negotiating rights and culture,” in Transcultrual Bodies: Female Genital Cutting in Global Context, Y. Hernlund and B. Shell-Duncan, Eds., pp. 1–43, Rutgers University Press, London, UK, 2007.
[23]
M. Foucault, The History of Sexuality, Penguin, London, UK, 1981.
[24]
C. M. Obermeyer, “The consequences of female circumcision for health and sexuality: an update on the evidence,” Culture, Health and Sexuality, vol. 7, no. 5, pp. 443–461, 2005.
[25]
E. Vloeberghs, J. Knipscheer, A. van der Croak, Z. Naleie, and M. van den Muijsenbergh, Valied Pain, Pharos, Amsterdam, The Netherlands, 2010.
[26]
F. Ahmadu, ““Ain't I a woman too?” Challenging myths of sexual dysfunction in circumcised women,” in Transcultural Bodies: Female Genital Cutting in Global Context, Y. Hernlund and B. Shell-Duncan, Eds., pp. 278–310, Rutgers University Press, London, UK, 2007.
[27]
J. Boddy, “Gender crusades: the famle circumcision controversy in cultural persepctive,” in Transcultural Bodies: Female Genital Cutting in Global Context, Y. Hernlund and B. Shell-Duncan, Eds., pp. 46–66, Rutgers University Press, London, UK, 2007.
[28]
M. Dustin, “Female genital mutilation/cutting in the UK: challenging the inconsistencies,” European Journal of Women's Studies, vol. 17, no. 1, pp. 7–23, 2010.
[29]
S. Harris-Short, “International human rights law: imperialist, inept and ineffective? Cultural relativism and the UN Convention on the rights of the child,” Human Rights Quarterly, vol. 25, no. 1, pp. 130–181, 2003.
[30]
B. Parekh, Rethinking Multiculturalism: Cultural Diversity and Political Theory, Palgrave Macmillan, Basingstoke, UK, 2006.
[31]
J. Lennahan, Do We Know Consent When We See It? Female Genital Mutilation and the Dilemmas of Consent, Western Political Science Association, Portland, Ore, USA, 2004.
[32]
D. L. DeLaet, “Framing male circumcision as a human rights issue? Contributions to the debate over the universality of human rights,” Journal of Human Rights, vol. 8, no. 4, pp. 405–426, 2009.
[33]
S. Johnsdotter and B. Essén, “Genitals and ethnicity: the politics of genital modifications,” Reproductive Health Matters, vol. 18, no. 35, pp. 29–37, 2010.
[34]
M. Dustin and A. Phillips, “Whose agenda is it? Abuses of women and abuses of 'culture' in Britain,” Ethnicities, vol. 8, no. 3, pp. 405–424, 2008.
[35]
Committee on Women's Rights and Gender Equality, On Priorities and Outline of a New EU Policy Framework to Fight Violence against Women (2010/2209(INI)), European Parliament, Brussels, Belgium, 2010.
[36]
E. Leye, S. Bauwens, and O. Bjakander, Behaviour Change towards Female Genital Mutilation: Lessons Learned from Africa and Europe, International Centre for Reproductive Health, Ghent, Belgium, 2005.
[37]
A. Phillips, Gender and Culture, Polity Press, Cambridge, UK, 2010.
[38]
A. Palfreyman, E. Brown, and S. Nam, Understanding Female Genital Mutilation in Birmingham: Findings from a PEER Study, Options UK and Birmingham and Solihull Women's Aid, London, UK, 2011.
[39]
B. Shell-Duncan, Y. Hernlund, K. Wander, and A. Moreau, Contingency and Change in the Practice of Female Genital Cutting: Dynamics of Decision Making in Senegambia, University of Washington, Seattle, Wash, USA, 2010.
[40]
E. H. Boyle, Female Genital Cutting: Cultural Conflict in the Global Community, John Hopkins University Press, Baltimore, Maryland, 2002.
[41]
H. Lockhat, Female Genital Mutilation: Treating the Tears, Middlesex University Press, Middlesex, UK, 2004.
[42]
E. Leye, “Exchanging experiences and information at community level,” Workshop Report, International Centre for Reproductive Health, Ghent, Belgium, 2000, European network for the prevention of female genital mutilation in Europe.
[43]
A. Talle, Female Circumcision: Attitudes and Practice among Somali Women in Norway, The Directorate of Health, Oslo, Norway, 2008.
[44]
E. Johansen, “An update on WHO's work on female genital mutilation (FGM),” Progress Report, WHO, Geneva, Switzerland, 2011.
[45]
R. Berg, E. Dension, and A. Fretheim, Psychological, Social and Sexual Consequences of Female Genital Mutilation/Cutting (FGM/C): A systematic Review of QuantitAtive Studies, Norwegian Knowledge Centre for the Health Services, Oslo, Norway, 2010.
[46]
R. Berg, E. Dension, and A. Fretheim, Factors Promoting and Hindering the Practice of Female Genital Mutilation/Cutting (FGM/C), Norwegian Knowledge Centre for the Health Services, Oslo, Norway, 2010.
[47]
E. Denison, R. Berg, S. Lewin, and A. Fretheim, Effectiveness of Interventions Designed to Reduce the Prevalence of Female Genital Mutilation/Cutting, Norwegian Knowledge Centre for the Health Services, Oslo, Norway, 2009.
[48]
I. Ajzen, “The theory of planned behavior,” Organizational Behavior and Human Decision Processes, vol. 50, no. 2, pp. 179–211, 1991.
[49]
J. O. Prochaska and C. C. DiClemente, “Stages and processes of self-change of smoking: toward an integrative model of change,” Journal of Consulting and Clinical Psychology, vol. 51, no. 3, pp. 390–395, 1983.
[50]
A. Obiora, “A refuge from tradition and the refuge of tradition,” in Transcultural Bodies: Female Genital Cutting in a Global Context, Y. Hernlund and B. Shell-Duncan, Eds., pp. 67–90, Rutgers University Press, London, UK, 2007.
[51]
E. M. Rogers, Diffusion of Innovations, Collier Macmillan, London, UK, 1983.
[52]
B. Oldenburg and K. Glanz, “Diffusion of innovations,” in Health Behavior and Health Education: Theory, Research and Practice, K. Glanz, B. K. Rimer, and K. Viswanath, Eds., pp. 313–334, John Wiley and Son, London, UK, 2008.
[53]
L. K. Bartholomew, G. S. Parcel, G. Kok, N. H. Gottlieb, and M. E. Fernandez, Planning Health Promotion Programs: An Intervention Mapping Approach, Jossey-Bass, San Francisco, Calif, USA, 3rd edition, 2011.
[54]
B. Wejnert, “Integrating models of diffusion of innovations: a conceptual framework,” Annual Review of Sociology, vol. 28, pp. 297–326, 2002.
[55]
R. W. Edwards, P. Jumper-Thurman, B. A. Plested, E. R. Oetting, and L. Swanson, “Community readiness: research to practice,” Journal of Community Psychology, vol. 28, no. 3, pp. 291–307, 2000.
[56]
N. Diop and I. Askew, “Strategies for encouraging the abandonment of female genital cutting: experiences from Senegal, Burkina Faso, and Mali,” in Female Circumcision: Multicultural Perspectives, R. M. Abusharaf, Ed., pp. 125–141, University of Pennsylvania Press, Philadelphia, Pa, USA, 2006.
[57]
M. Conner and P. Norman, Predicting Health Behaviour, Open University Press, Maidenhead, UK, 2005.
[58]
S. Michie, M. M. van Stralen, and R. West, “The behaviour change wheel: a new method for characterising and designign behaviour change interventions,” Implementation Science, vol. 6, article 42, 2011.
[59]
C. Abraham and S. Michie, “A taxonomy of behavior change techniques used in interventions,” Health Psychology, vol. 27, no. 3, pp. 379–387, 2008.
[60]
K. Glanz, “Perspectives on group, organization, and commuity interventions,” in Health Behavior and Health Education: Theory, Research, and Practice, K. Glanz, B. K. Rimer, and F. M. Lewis, Eds., pp. 389–403, Jossey-Bass Press, San Francisco, Calif, USA, 2002.
