1. The Navrongo FGC Trial: Impact and Lessons Learned Reshma Naik, MPH 4 th International Day of Zero Tolerance for Female Genital Cutting February 6, 2007

2. Navrongo Health Research Centre, Kassena-Nankana District

3. Context of the Trial More common in the north Rapid social change All three types practiced FGC outlawed in 1994

4. FGC Beliefs Engrained cultural practice Unique characteristics Extreme social pressure Clitoris child Burial as a man Restriction from participating in parents funeral rites

5. Navrongo FGC Trial Cell 1Cell 2 Cell 3Cell 4 Livelihood & Development Problem- focused: FGC Education Y N YN

6. FGC Education Activities Film shows and discussions Night Clinic School outreach Singing/drama competitions Public declarations

7. Livelihood & Development Activities Community change agents Literacy training Livelihood skills training Micro-lending

8. Methodology Longitudinal study design monitoring FGC incidence Yearly surveys of 8,473 adolescent girls aged 12-23 from 1999-2003 Cox Proportional Hazard model to control for time, age, education, marital status, and religion

9. What Worked? FGC Education 93% reduction in the hazard of FGC Combined Approach 94% reduction in the hazard of FGC

10. Interpreting the Results Common Factor Synergy Ongoing Social Change

11. Lessons Learned

12. Lesson learned: Mechanism of action is important Need to understand how and why it worked Need to distinguish intervention activities and separate geographic areas

13. Lesson learned: Must address the underlying cause May need to explicitly link interventions to the issue of promiscuity May be helpful to address FGC within a broader context of sexuality and reproductive health

14. Lesson Learned: Important to study social change Social change occurs naturally in some settings Studying change could inform future interventions Studying change could help isolate intervention effects

15. Lesson Learned: Need to reframe the dialogue Challenging to use a human rights approach in the community Discussion of health effects also challenging

16. Denial Phenomenon Denial influenced by a number of complex factors Social climate and acceptability Perceptions of the NHRC Peer and family member interactions Girls theories Interviewer characteristics and attitude Emotions

17. Social Climate Because she wants to be circumcised and FGC is no longer done and most of the girls too do not do it any longer she cannot tell you that she wants to be circumcised. - Adolescent Girl

18. Risk of Arrest Shes scared to say she is circumcised. She doesnt know if she says shes circumcised they will come and arrest her or do anything to her… – Adolescent Girl

19. Interview as a Test They want to know whether we listen to them or not. Or whether we listen to our parents advice and not them. - 16 year old student

20. Peer Interactions Our peers, when they ask you and you tell them you said you were circumcised then they tell you fool why did you say you were circumcised? If they ask you and you say you arent circumcised, who will open your vagina to know whether you are circumcised or not? -18 year old student

21. Emotions She is always angry and would be shouting that she didnt know. If she gets her clitoris she would like to stitch it back, but it has already happened. – Adolescent Girl

22. Lesson Learned: Social context can affect measurement Collection and interpretation of self-reported FGC data must consider the social context Need to consider alternate methods to validate data

23. In conclusion… Successful longitudinal trial in this setting though w/ limitations Unanswered questions remain Need to consider applicability to other settings Be aware of potential challenges for measurement and implementation

24. Thank You For Your Attention