My Sister's Keeper(MSK)

Female genital mutilation(FGM) is an unhealthy traditional procedure on the female genitalia which causes irreparable sexual, reproductive and psychological harm (Odukogbe et al, 2017).

Using core ethnographic methods including participant observation and in-depth interviews, Our program My Sister’s Keeper(MSK) will cultivate active participation of communities in determining the underlying root causes of FGM, then empower them through media, information and communication technology(MICT) to end the practice. 

According to a WHO study, 2.8 million 15 year-old girls in 6 African countries will lose approximately 130,000 years of life as a result of FGM procedures annually, thus the need for our program. MSK will also decrease the incidence of perinatal mortality which is 55% higher in children born to women with FGM and through psychological counselling and hospital referrals improve the mental health and obstetric challenges faced by more than 200 million FGM victims worldwide(Odukogbe, 2017).

FGM is a harmful practice on girls and women which causes irreparable sexual, reproductive and psychological harm. It is an act of violence, extreme discrimination and fundamental human rights violation against women and girls(UN CRC Article 12).  This practice leaves victims feeling scared, psychologically scarred and distressed (travel.state.gov). FGM sustains deep rooted inequality between the sexes, constitutes a barrier to female civic participation and social inclusion and therefore, leads to inequitable socio- economic growth and prosperity.

The WHO estimates that an alarming 200 million girls alive today have undergone FGM, while an estimated 3 million girls are at risk annually. Unfortunately, the majority of these girls will be cut before the age of 15 years. Nigeria due to its population has the highest global FGM prevalence with an estimated 20 million women of reproductive age as victims (Epundu et al, 2018). 

A common factor influencing the continuation of FGM is the need for social acceptance and to avoid social stigmatization due to non conformity to social norms. In view of these, FGM carries a customary significance that can best be addressed by programmatic interventions fully involving members of communities that practice it (Coyne et al, 2017). 

Our intervention will be in South Eastern Nigerian communities practicing FGM. These are marginalized subsistence agrarian communities where women are traditionally excluded from economic and political participation. Program intervention will be focused on Adolescents aged 10-19 years, Adults aged 20-49 years and Adults aged 50+years. MSK will also directly benefit physicians, nurses, community health workers, patent medicine sellers, village heads, teachers and religious leaders in these communities who will act as program intermediaries.

We hypothesize that FGM is driven by community specific social norms. Using the e-PAR framework, MSK will actively interact with communities to understand these social norms, then support them through the use of MICT solutions to achieve behavioral change needed to stop FGM. 

Through sustained community participation and education anchored on MICT, MSK will address the implications of this practice. We will engender community driven cost benefit analysis of FGM to help communities appreciate how the practice affects the health, educational, economic and political achievement of women and its implication on shared community prosperity. Importantly, MSK also addresses the mental health, gynecological and obstetric challenges faced by FGM victims through the provision of psychological counselling and  hospital referral services.

MSK firstly recruits and trains local researchers(mostly drawn from intervention communities) who will be embedded in the intervention communities. These local researchers will collect and share information on community social structuring which will form the backbone in our understanding of community specific communicative ecologies and information flows. Consequently, their work will provide feasibility assessment on the potentials and barriers for success of the traditional and new media, information and communication technology (MICT) solutions we will apply towards achieving program objectives.

Based on the outputs from the communicative ecologies and information flow diagnosis, community preferred MICT solutions will be used to provide health education, psychological counselling and hospital referral services targeted to specific segments of the intervention community to achieve specific program objectives. While our primary objective is to reduce the incidence of FGM in south eastern Nigeria communities, secondary objectives includes using MICT solutions to change knowledge and perception of the sexual health, reproductive health, mental health and  human rights implications of FGM. In addition, MSK will support and take care of victims through provision of psychological counselling and hospital referral services. Our framework will also uncover community preferred MICT solutions which will be used in promoting discussions on sensitive topics like gender equality, girl child education and child marriage which usually co exists with FGM in intervention communities.

MSK’s MICT processes  includes:

•  Establishing  FGM information sharing networks among rural/urban women, men and youth. 

• Making use of uniquely themed billboards, pamphlets, newsletters and posters to share information on FGM.

• Making use of uniquely themed radio and television campaigns, jingles and mini dramas to promote behavioral change to end FGM.

• organizing  unique in-person outreach campaigns (i.e., people talking to individuals in the target community through information booths at local markets, local churches or mosques, door-to-door campaigns, etc.). This includes using town criers in sharing FGM information.

• Making use of unique online campaigns (including email campaigns or information on program website where people could learn the consequences of FGM.

• Making use of unique telephone and SMS campaigns to reach out to community members with FGM information. 

• Establishing toll free telephone counselling service whereby FGM victims could call in and receive psychological counselling. 

• Establishing toll free telephone service to provide hospital referral information to FGM victims. 

• Establishing toll free telephone services to avail persons at risk of forced FGM the opportunity to reach out to authorities.

Current approaches are top- down and consists of untargeted and unidirectional sensitization messages about the dangers of FGM carried out by Non Governmental Organizations (NGOs). It also includes criminal prosecution, prescribing of jail terms for offenders through laws and legislation by governments. Unlike these approaches, our solution is bottom up, democratic and participatory with communities acting as the agent of change to address FGM.

MSK integrates scientific, technological and social innovation. It is based on the e-PAR framework which involves melding media, information and communication technology(MICT) and Participatory action research (PAR) in community health promotion (Sarah Flicker et al, 2008). This innovative approach draws on the feminist framework which acknowledges that communities often already have local knowledge and understanding of the hidden social processes that drive practices like FGM, and therefore, are in a better position to proffer successful and sustainable solutions when fully involved in programs (Muntaner, 2013).

Through rapid, iterative rounds of research and synthesis, our approach is unique in using community preferred MICT solutions to empower communities to end the practice. MSK creates a new dimension of performance not only by incorporating inputs from community members, it integrates victim care and support through the provision of psychological counselling and hospital referral services which prior approaches overlooked. FGM victims because of their past experiences, will through participatory feedback anchored on MICT solutions stimulate and nurture deep representative discussions on the implications of this practice, and constitute first line positive deviants critical to achieving program objectives.

MSK will be offered through an integrated MICT platform that involves the following:

Native Gong-Ogene(African Town Criers): In the simplest form our MICT solutions involves the use of Town Criers. The town criers involved will use Gong, wood bloc or animal skin drums as attention direction device (ADD). These instruments will be beaten to attract attention before unique FGM focused information or education is shared to community members.

Radio and Tevision: Unique FGM focused radio and television jingles and call-in programs  from state owned radio stations will be used to reach out to targeted communities at strategic times of the day. Messages will be in Igbo, Pidgin English and English languages.

Internet: Dedicated web sites to share community specific information on FGM, individuals and community members could access this websites and get information on FGM and our program. These will importantly cater to the young and the  literate who want to get in depth information on our program.

Telephone: Toll free telephone lines will be used to provide psychological psychological counselling for victims. This will also provide hospital referral services to victims and serve as hotlines for would be victims who need help from government social services. 

SMS messaging: We will use bulk SMS messaging to convey anti FGM messages to telephone numbers of members of these communities. The format will be designed to effect behavioral change and will ideally be contained in a unit screen. These SMS messages will be receivable on all cell phone types.

Current approaches consists of NGOs and governments hoping to stop FGM by merely informing communities on the dangers of the practice and criminalizing it through laws. These have been resisted by communities and thus, ineffective as FGM persists (Marge Berer, 2015). In countries like Kenya, these have unfortunately driven the practice underground and even led to its ‘medicalization’, whereby healthcare providers conduct FGM (Parsitau, 2018). According to the WHO, current approaches failed because of inadequate participatory representation of community members in the design and implementation of programs. 

Research evidence shows that if communities participate in the design and implementation of interventions through democratic representation, the required program acceptance necessary for FGM abandonment will be garnered (WHO, 2018). Again formative study findings from our proposed intervention communities shows that communities are less resistant to interventions if they are encouraged to take ‘ownership’ by contributing actively in program design and implementation. The REPLACE and Tostan projects are examples of programs that have engaged democratic and participatory community representation in successfully addressing FGM among African migrant communities and sub-Saharan Africa respectively (H, Barret. 2015 and M. Jawo. 2019). 

We hypothesize that MSK will decrease the incidence of FGM and improve psychological health of FGM victims in south eastern Nigerian communities.

We therefore propose MSK, a program that empowers communities to become agents of change. Communities understand the history and context of FGM like no other and when empowered using MICT solutions will address the underlying root causes and drivers to ensure program success.

We are currently serving an estimated total number of 3000 beneficiaries,      subdivided into the following subgroups:

Adolescents(10-19 years)            1200

Adults(20-49 years)                     1300

Adults(50+ years)                          500

In one year, we will be serving an estimated total number of 5000 beneficiaries, subdivided into the following subgroups:                                                     

Adolescents(10-19 years)             2000

Adults(20-49 years)                      2200

Adults(50+ years)                           800

In five years, we will be serving an estimated total number of 9000 beneficiaries, subdivided into the following subgroups:                                                          

Adolescents(10-19 years)               3000

Adults(20-49 years)                        4500

Adults(50+ years)                           1500

Our pilot implementation will be in FGM practicing communities chosen from 4 south eastern Nigerian states of Ebonyi, Enugu and Imo and Abia states with an estimated total population of 20 million. Upon successful pilot and scale -up we expect our program to improve the lives of an estimated 40 million Nigerian women. Using the violence against women and girls (VAWS): a compendium of monitoring and evaluation validated measure, proof of concept will be shown by:

1. 10% positive change from baseline variables, 1 year post program inception.

2. 50% positive change from baseline variables, 5 years post program inception. 

Baseline variables include:

1. Proportion of women aged 0-19 who have not undergone FGM.

2. Proportion of mothers aged 15-49 who have at least one daughter with FGM.

3. Proportion of women who do not intend to have any of their daughters undergo FGM

4. Proportion of women aged 15-49 using MSK’s counselling services.

5. Proportion of women aged 15-49 using MSK’s hospital referral services.

6. Proportion of Perinatal deaths secondary to FGM complications.

7. Proportion of births needing resuscitation secondary to complications from FGM.

8. Proportion of women with obstetric complications secondary to FGM.

9.Change in knowledge and perception of the reproductive health complications of FGM.

10.Change in knowledge and perception of the Sexual health complications of FGM.

11.Change in knowledge and perception of the human rights implication of FGM.

12.Change in Knowledge and perception and of the mental health complications of FGM.

During the early period of MSK intervention, locally sourced community program leaders and positive deviants could be physically harmed or socially isolated in the community as they may be seen as conniving with outsiders to desecrate traditional institutions.

Counselling and interviews with victims of FGM could be an emotionally tasking procedure as victims relive their experience. Again, in a patriarchal society as our intervention communities are, discussing sensitive issues like gender equality, child marriage might be frowned upon with researchers seen as overturning revered traditional institutions.

Our program involves empowering women, and thus involves encouraging power sharing. This newly found awareness and sense of equality might lead to some female beneficiaries instigating rebellion with their husbands which may lead to domestic violence and intimate partner violence. 

The ‘OSU’ caste system(traditional social exclusion) is still practiced in some of the FGM communities in south Eastern Nigeria and this may lead to program resistance as some beneficiaries may not readily accept attending meetings or being in the same MICT social media group with traditionally social excluded persons.

Our pilot program involves the generation of sensitive personal and community data through interviews and focus group discussions and as such beneficiaries might be wary of being identified as the source of information to research assistants and counsellors.

Sourcing and recruitment of adequate numbers of well trained psychological counsellors and gender specialists may be a challenge as this professional designation is still new in our environment.

Program researchers will be adequately trained on the rudiments of e PAR and to abide by the highest ethical standards for research in communities. However, any perceived threat will be reported to authorities and police protection sought if need be.

To address the issue of emotional distress due to interviews or during counselling, we will ensure adequate training for researchers. Researchers will be trained on appropriate use of respectful dialogue to achieve program objectives.

Men are the custodian of cultures and traditions in our intervention communities, on these backdrop, female beneficiaries will be educated on proper ways to garner male folk support and to eschew antagonism and rancour. However, female beneficiaries facing physical threat or violence as a result of MSK will be encouraged to seek help from relevant authorities.

Possible program resistance due to the 'Osu' caste system will be addressed by organizing separate programs in the few communities that have FGM coexisting with traditional social exclusion. This will encourage openness in communication and improve participation.

We will ensure that all personal data from MSK is anonymized to protect the identity of key informants and beneficiaries. Interview results will be coded and stored in formats that maintain data safety. Anonymized Program research findings will be reported back to intervention communities, stakeholders and published in research journals.

In case of shortage of required number of psychological counsellors and gender specialists, we have devised plans to recruit and train community health workers living and working in intervention communities.

Not Applicable.

Our program involves the following number of people:

Number of new full-time Staff (i.e. work 30+ hrs/week)- 35 persons

Number of new part-time Staff(i.e work <30+hrs/week)- 26 persons

Number of subcontractors(Gender Specialists)-4 persons

Number of subcontractors(Psychological counsellors)-8 persons

Our team is comprised of well trained members who will see to a robust and ethical study design and implementation of the program.We all are alumni of McGill university's qualitative methods in global health and infectious diseases course 2018. Our team lead is a public health physician and epidemiologist with more than 13 years working experience in south eastern Nigeria. We thus have an uncommon local insight on how to work with these communities and also enlist much needed policy-maker support for scale up.

Dr. Ihedioha Emmanuel Chukwunwike is a community health physician and Epidemiologist who is presently working in Ebonyi state, which has the highest prevalence of FGM in Nigeria. He is engaged in public health innovations for disease control, is a CEO of a company, an alumnus of the Harvard University’s risk analysis program and has Health Management and Health Economics certificates from The World Bank.

Deborah Gatenby is a gender activist and the CEO of Hope Place recovery program in Canada, she holds a Masters in Public Health degree and is an alumnus of the Harvard University’s Risk Analysis and Emerging Women Executives in Healthcare programs. 

Leyla Camarilo is an experienced geneticist with a working history in government administration. She is skilled in research, strategic planning and project management. She is an alumnus of the Harvard risk analysis program and holds Diplomas in Epidemiology and Health Systems Management.

Ijeoma Ukachukwu is a registered nurse practitioner working in south eastern Nigeria. She also  holds a Master’s in Public Health degree.

We are currently partnering with Grand Challenges Canada who will be funding the first 12 months pilot phase of our program and also providing the opportunity for technical assistance in terms of project output monitoring.

We are in partnership with TOSTAN, an organization who have done groundbreaking work towards FGM in sub-Saharan Africa through the participatory action model  involving communities. They will be sharing insights with us on the successes and pitfalls they have experienced working with communities. They are already providing us with online resource training for human resource development. We also hope to be part of the December 2019 training organized by Tostan in Senegal.

We are also in partnership with flagship programs of the first ladies of the 4 state governments that our program will be focused on. They will provide us with political legitimacy and encourage communities to work with us. This partnership is critical for program sustainability.

We are also in partnership with the leadership of the village youth development organization in the intervention communities. They are intrinsic to the success of the program. These youth leaders constitute an important segment of firstline positive deviants who will drive the acceptance and logistics of the program.

MSK’s beneficiaries include women, girls and men in intervention communities. Age group subgroupings of these beneficiaries include Adolescents (10 - 19 years), Adults (20 - 49 years) and Adults (50+ years).

MSK will provide health education and psychological counselling through unique radio/television campaigns, unique printed information materials campaign (information pamphlets, posters, etc,  unique in-person outreach campaign (i.e., people talking to individuals in the target community (e.g. information booths or door-to-door campaigns), unique online campaigns (including email campaigns or information on a website that people are directed to), unique telephone campaign and toll free telephone counselling.

Program Impact Measures include number of Individuals (women/girls and men/boys) who will report a change in knowledge Sexual Reproductive Health and Rights(SRHR) due to MSK, number of women/girls who report feeling more comfortable speaking about FGM and SRHR topics with other individuals in the community and number of women and men who do not intend to have any of their uncut daughters undergo FGM. Others include number of women and men who intend to teach their children about FGM topics covered in MSK, number of women/girls using MSK counselling services to improve resilience and number of women/girls using MSK services to seek hospital referrals. 

Key Resources include research assistants, gender specialists, psychological counsellors and media/information/communication technology resources.

Partners and Key stakeholders include GCC Canada, Federal Ministry of Women Affairs of Nigeria, First lady FGM flagship projects in the intervention states and intervention communities in southeastern Nigeria.

Our program is primarily sustained by cultivating ongoing stakeholder support towards achieving our primary objective which is ending FGM in Nigeria. In February 2016, the current first lady of Nigeria launched a national campaign to end FGM, this was followed by the launching of the family support and succor initiative to end FGM by the current first lady of Ebonyi State. Through the above policy initiatives, federal and state governments of Nigeria have pledged support and showed willingness to offer technical assistance and political legitimacy to programs like ours that are working to address FGM. To garner this support, we will ensure our program’s alignment to rules and regulations of the relevant governmental bodies. 

Importantly, we have ensured that our program is in alignment with Nigeria's strategic health development plan 2009-2015 and Health promotion policy which stipulates the importance of community ownership and participation in health promotion. MSK’s sustainability policy framework therefore, entails developing strong cooperative relationships with local and extended communities through prompt and consistent demonstration to stakeholders that identified objectives are being met.

MSK will also be sustained through grants from sexual reproductive health and rights research focused funding organizations. We have also cultivated community and governmental ‘MSK champions’ and volunteers. These are community members, local movie actors and government officials with the passion to keep the program running. We  also have in place mechanisms to enlist the partnership and support of UNICEF Nigeria and TOSTAN who have demonstrated willingness to offer technical assistance to program like ours.

Solve MIT will provide our organization the opportunity to obtain technical expertise assistance and mentorship from MIT’s School of Humanities, Arts and Social Sciences, particularly in the design and ethics of qualitative research. This will be relevant in tackling one of our project barriers which is dearth of properly trained personnel. Affiliation with the school will be helpful in the production and designing of training resources for our staff.

Solve MIT will help us in gaining collaboration with MIT’s department of urban and regional planning who have experience of actual cases where PAR have been used to deepen civic engagement, improve community practice, inform policy, mobilize community assets, and generate shared prosperity. They will be helpful for our deeper understanding of the theory and practice of PAR. They will help us to access individuals and organizations involved in PAR collaborations and offer technical expertise and mentorship in the design and implementation of e PAR research. We will specifically seek mentorship from Lawrence Susskind and Dayna Cunningham who are involved with PAR at MIT.

Solve MIT will help us in gaining access and collaboration with MIT’s Behavioral Research Lab(BRL). We will be particularly interested in modalities for developing effective and evidence proven MICT content to effect behavioral change. This partnership will also be helpful in gaining access to information on crowdsourcing platforms, panel vendors, software, support and administration. Attending BRL seminars will be an important opportunity to share and learn about study findings and best practices on behavioral change science.

Not Applicable.

We will like to partner with WHO, UNICEF and UNFPA , these are UN organizations who have garnered years of experience working on FGM in Africa. These organizations have carried out several research studies on FGM and therefore, have repositories of specific knowledge which will be valuable in our work. We will be interested in sharing our experience using the ethnographic participatory action research model and learn about  the challenges they have faced using their current models. We are willing to receive technical assistance in terms of training and supply of resource materials from these organizations if available. 

We will particularly seek to partner with the REPLACE project of the Centre for Communities and Social Justice at Coventry University UK. The REPLACE project has done a formidable work in addressing FGM among African migrant communities in the European Union. Their work has also being insightful in the development of the Community Behavioral Change Framework which we will be using in intervention communities.

We also seek to partner with Action Research Network of the Americas(ARNA). ARNA will be helpful towards our organization’s quest to promote action research that is conducted with a commitment to honesty, integrity, multivocality, engagement and achievement within sustainable democratic societies. Attending ARNA conferences will be valuable to our organization with regard to knowledge production, knowledge dissemination and knowledge democracy for critical issues like FGM. We have applied for membership of this organization and hopefully will present our poster in the upcoming ARNA conference in 2020.

Not Applicable.

The GM prize will fund:

1) 4 workshops for staff for12 months. 2)Administrative Costs for 6 months.3)Staff Remuneration for 4 months. 3) Subcontracting 2 gender specialist for 12months. 4)Subcontracting 2 Psychological Counsellors for 12months. 5)Supplies for 6months. 6) Staff transportation for staff for 6months.

Estimated budget is as follows:

Administrative Costs                                                $10,000.00 

Staff Training                                                          $10,000.00 

Staff Remuneration                                                 $10,000.00 

Subcontract(Gender Specialist)                                 $5,000.00 

Subcontract(Psychological Counsellor)                       $5,000.00 

Supplies                                                                    $5,000.00 

Transportation                                                          $5,000.00 

The prize winning from the Vodafone Innovation for women prize will be used to fund: 

Administering an estimated 20,000 SMS messages over a period of one year to community members.

Administering of an estimated 4 uniquely themed Radio Jingles and uniquely themed dramas lasting 2 minutes and 20 minutes respectively  over a period of  52 weeks.

Securing of an estimated 5000 hours of telephone time to be used for Psychological counselling for victims and hospital referrals for victims.

Creation and maintenance of a web site where community members and other individual could seek information on project objectives, know more about our work in Nigeria and learn about our model.

Provision of project supplies. 

Not Applicable.

Not Applicable.

The Morgridge Family Foundation Community-Driven Innovation Prize will be used in:

Publishing of research findings in two high impact Journals.

Staff Remuneration-This will be direct remuneration(wages) due to researchers for a period of 4 months.

Supplies- Direct costs for project supplies for a period of 6months.

Transportation- Direct costs for project transportation for staff and principal investigator for a period of 6 months.

The table below documents estimated direct project expenses that will be met by winning the Morgridge Family Foundation Community-Driven Innovation Prize.

Publishing                                                    3,000.00 USD

Supplies                                                       2,000.00 USD

Staff Remuneration                                     10,000.00 USD

Transportation                                              5,000.00 USD

Subcontracting(Psychological Counsellor)      5,000.00  USD

Not Applicable.