Models of Behaviour Change and Interventions to address FGM/C Theoretical models of behavioral change are needed to understand why and how interventions cause change (Askew, 2005; Gele et al., 2013). While awareness of FGM is growing, the issue of behavior change remains poorly understood (Hernlund & Shell-Duncan, 2007). “The decision about whether, when or how to perform FGM/C results in a constant process of negotiation about how to position oneself in the light of shifting social relationships, contexts and experiences.” (Hernlund & Shell-Duncan, 2007).
So what are the most important models of behaviour change?
Shell-Duncan et al (2011) discuss two approaches: rational choice and the social convention or social norms based approach. A rational choice approach weighs up the costs and benefits of behavioural options for independent actions - for example, community-based health education programmes focused on the delivery of information on the health risks associated with FGM/C. These programmes may raise awareness of FGM but they do not motivate large-scale abandonment of FGC (Shell-Duncan et al 2011). One of the limitations of the rational choice approach is the assumed link between intentions and behaviour. For example, someone may say they intend to have a reversal appointment but then they don’t turn up for their appointment. Thus intentions do not necessarily translate to a change in behaviour especially if there is a lack of trust and understanding.
According to social convention theory, the actions of individuals are interdependent in a competitive marriage market and where there is inequality in social and economic resources (Mackie, 1996)3. This model would predict that community-based programmes that seek to co-ordinate change within the community, such as that recently initiated by WHFS (2014), are likely to be successful.
Applying a social convention model to the practice of FGM/C, it is apparent that it improved the chances of marriage into higher social strata and it became exaggerated and diffused through lower stratas of society as parents attempted to get the best marriage prospects for their daughters. Hence FGM got ‘locked in place’ as a self-enforcing convention (Mackie, 1996). What is now needed is a convention shift or co-ordinated change whereby a critical mass abandon the practice and allow their children to marry women who have not been cut (Shell-Duncan et al 2011). The Tostan model4, which favours the community-centered approach in which community voice and diaglogue is key in anti-FGM decision making (see http://www.tostan.org/female-genital-cutting accessed 18-08-14), provides support for social convention theory. Public declarations supported by the majority of people in a community fit with the social norms literature since they signal the change of a norm among a critical mass, and not just individual attitudes (Mackie and Le Jeune, 2009). This also fits with the modified stages of change theory (see below), according to which people abandon the practice when they find a motivation to do so and have the ability to act upon their decision, i.e. when their social context supports, promotes or at least accepts abandonment. It is interesting to look at this approach in some detail to better understand both the theoretical underpinnings and impact.
The stages of change theory (Prosachka and DiClemente, 1983) was originally formulated to assess the behaviour of individuals as opposed to the behaviour of entire communities such as the practice of FGM/C. For this reason, Shell-Duncan modified the ‘stages of change’ theory to help fit it to the practice of FGM/C, in which the decision regarding the abandonment of the practice is not in the hands of any one individual, but rather with a group of decision makers. According to the modified stages of change theory, people abandon the practice when they obtain a motivation to end the practice and have the ability to act upon their decision, i.e. when the interconnected communities agree to stop FGM/C because of a realisation of its harmful effect. In some situations, people may abandon the practice even if they personally want it to continue, e.g. when other decision makers or social pressure force them to stop the practice. One example is when members of Community Management Committee (CMC)5members speak with friends and family and then travel to other communities to raise awareness about what they have learned. Hence people who received training in one village took it upon themselves to discuss abandoning FGM with people from other villages (Chege et al. 2001). Tostan is now active in six West African countries (http://www.tostan.org/tostan-model, accessed 6 June 2014). And so far, over 7,000 communities from Djibouti, Guinea, Guinea-Bissau, Mali, Mauritania, Senegal, Somalia, and The Gambia have declared their intention to abandon FGM. Interviews with people in programmes reached by Tostan – either directly or indirectly through word-of-mouth contact between villages – indicate that public declarations are often effective because people feel bound to honour them (Diop and Askew, 2009).
It is well established through previous research conducted with the Somali community in the USA that mobilisation of community social networks and trust-building through participation can inform the development of interventional programs to address FGM/C (Johnson, Ali and Shipp, 2011). Moreover, in order to foster a trusting relationship, those providing information need to have an accurate understanding of the cultural background surrounding the practice as well as a working knowledge of different practices (Braddy & Files, 2007). Sensitivity about culture and values and a non-judgemental approach are also critical and hence the importance of identifying community champions to challenge the cultural and language barriers and build trusting relationships. Once again, the research supports the practice of working with communities as they will be the advocates of change.
A social norms perspective
According to the Home Affairs Select Committee (2014-15) report : “ FGM is a deeply embedded social norm within practising communities - an improved understanding of social norms and communities is needed to break it down.”
In 2005, a UNICEF report called Changing a Harmful Social Convention: Female genital mutilation/cutting drew upon social psychological theory to explain the persistence of FGM/C. According to the social norms perspective, people’s behaviour and intention to change their behaviour are governed by the beliefs and practices of significant others (members of their community, for example). Thus beliefs or knowledge about various aspects of the practice – for example, that it causes harm, which is a correct belief or that it is mandated by religion, which is an incorrect belief (Gage and Van Rosen, 2006; Upvall et al. 2009), can influence behaviour. The recent WHFS (2014) report shows how beliefs relating to the role of religion in the practice of FGM/C can be changed. This gets at the heart of what a community-focused approach can achieve, both in terms of understanding the processes governing behaviour change and in motivating changes in practice. Thus a norm may be enforced through community pressures, and collective enforcement may be linked with honour and avoidance of shame. There may be social mechanisms in place both to encourage it (for example, meeting the family’s approval, increasing marriage prospects). The social norms perspective can enrich the understanding of FGM by offering an additional lens for analysing the mechanisms that regulate the practice. The social norm approach is also a central feature of an innovative programme developed by UNICEF with the European Union (2008-2012). The goal was to assess the extent to which, and under what circumstances the UNICEF programme has accelerated the abandonment of FGM/C over the last 5 years. The programme, which is currently under way in 15 African countries, is expected to embark on a second phase from 2014-2017. The preliminary data suggests the social norm perspective has been useful as reported in the preliminary report Joint Evaluation of the UNFPA-UNICEF Joint Programme on Female Genital Mutilation/Cutting: Accelerating Change (2012-2013). So far the programme has resulted in an increase in public commitment from community leaders toward FGM/C abandonment and a change in the public discourse surrounding FGM/C. However, changes at the regional level continue to be slow. Moreover, there is only limited data currently on the specific factors that influence whether and how specific combinations of strategies facilitate changes in behaviour. A systematic comparison of different strategies as well as their cost-effectiveness has yet to be undertaken (UNICEF, 2012).