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Table 3 Characteristics of included studies and type of intervention, associated strategies and findings

From: Preventing female genital mutilation in high income countries: a systematic review of the evidence

Reference/ context

Aim

Methodology / Sample

Prevention activities examined

Findings: intervention outcomes

Primary prevention

 Johansen et al., 2018. [33]

Australia, Austria, Belgium, Finland, France, Germany, Greece, Ireland, Italy, Netherlands, Norway, Portugal, Saudi Arabia, Slovakia, Spain, Sweden, Switzerland, UK, USA

To examine Countries national policies on FGM and health sector involvement in the management of FGM

Mixed methods: desktop review, survey with 21 respondents in 19 countries

•Training of health care professionals (HCP), involving HCP in the preventive work

•Legal regulations on HCP duties to avert and report as well as to perform FGM

•Availability of healthcare services (de-infibulation, clitoral reconstruction, sexual and psychological counselling

•4 of the 19 countries (France, Ireland, the Netherlands and Norway) had policies on FGM that were implemented, funded, coordinated and with systems of monitoring and evaluation in place; •15 countries had national policy on FGM, (exception Austria, Greece);

• 12 countries had assigned coordination bodies (exception Australia, Austria, Greece, Sweden, and USA); 13 have partially or fully implemented the plans (exception: Austria, Greece, Spain, Sweden,); HCPs are legally prohibited from performing FGM on minors in •Psychological and sexual counselling were available predominantly in 13 countries

 Leye & Deblonde, 2004 [38], Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxemburg, Portugal, Spain, Sweden, Netherlands, UK

To examine FGM legislation specifically: Criminal laws, Child/Minor Protection laws, Specific FGM legislation, General Criminal Law, Professional secrecy law.

Mixed methods: -content analysis of legal documents, semi-structured interview with key informants in 5-member states (Belgium, France, Spain, Sweden, UK) (number of participants in each country not stated)

• Legal provisions pertaining to FGM

• 5 countries have child protection guidelines or protocols that guide those who are confronted with a girl at risk of FGM, except in Belgium

• Cases are reported, and investigations have been initiated, although the number of cases brought to criminal court is limited (in France and Spain)

• Issues in relation to type IV and piercing and cosmetic surgery where the latter has not been taken into consideration by legislators hence ambiguity.

• Lack of knowledge of the law among health professionals, authorities and police.

• Attitudes of these people may obstruct implementation i.e. fear of being labelled as racist

• Workshops for professionals raised awareness of FGM

 Leye & Alexia, 2009 [44], Belgium, France, Spain, Sweden, United Kingdom

To examine the implementation of criminal and child protection laws on FGM in 5 EU member states and associated activities

Mixed methods: content analysis of documents, survey questionnaire with key informants, in-depth interviews with participants from 5 countries, (number not stated).

• FGM related laws

• Awareness raising and education to improve knowledge and compliance with the law including capacity building workshops for professionals from various sectors (targeted training and information campaigns about FGM issues, legislation, child protection procedures)

• Legislation alone is not enough (Barriers - Case identification and Collection of sufficient evidence to mount a prosecution)

• No evidence was found to state that specific criminal law provisions are necessary to guarantee the punishment of FGM, or that they are more successful in their implementation than general criminal law provisions.

• Only France and Italy have had prosecutions

 Mohamed, Schickler et al., 2014 [40], UK

To report on participatory workshops on FGM to increase knowledge and awareness of FGM

Qualitative. 36 grandmothers, 52 young mothers; 38 men were interviewed using a structured questionnaire

• 5 local women trained as community champions to conduct 10 participatory workshops on FGM

• The champions held one-to-one sessions with women, home visits were also made to speak with families about FGM

• Visits were made to mosques to educate men and to schools

• At the end of the workshops 25% of participants stated that FGM was required by religion compared with 40% before the workshops began.

• At the end of the workshops 79% of participants agreed that FGM should be stopped compared with 62% at the start.

• Stories of women informed the development of materials and scenarios for discussion

• Principles developed for action

 Scott & Jerse, 2011 [41], New South Wales, Australia

To evaluate the state wide FGM multidisciplinary model of service delivery.

Mixed methods: document, consultations with 72 stakeholder informants and on-line survey of 63 respondents.

• Continuing professional development for health and other professionals;

• Education and community development with affected communities involving community workers;

• Resource and information development and dissemination

• Advocacy to prevention FGM including media campaigns on ethnic radio run over 8 weeks

• Collaborative work with NSW Police Child Protection Unit

• Build strong links with the community

• increased awareness, knowledge and empowerment of affected community members and increased understanding in a diversity of professional health and other community service providers.

 Simret, 2014 [42], Winnipeg, Canada

To evaluate a community-based education program, 10 weeks of educational, health and sociocultural support sessions on FGM

Qualitative: focus groups, questionnaires and observations with 187 immigrants and refugee participants in 3 African national communities; 24 service providers & other professionals. Examination of staff logs, and documentation review.

• Manual of materials designed for services to use with migrant and refugee women

•Networking with key community organisations

• Workshops for health and social service professionals on cultural competence

• Increased knowledge of mainly “high” to “very high” of women on FGM issues; 88% “strongly agreed” that workshops were suited to their needs; healthcare professionals showed increase in knowledge; most “strongly agreed” that content & process of training were appropriate

• Having community co-facilitators helps ease the communications and acceptability of the intervention

Secondary prevention

 NHS 2016 [41], Clinical commissioning groups (CCGs) in the London Region, UK

To conduct a performance assessment of all CCG’s safeguarding governance, arrangements and processes.

A formal assurance review was carried out quarterly in line with the published framework and technical guidance. Eleven audits, the Safeguarding Adults Board Self-Assessment Audit, Safeguarding Workforce Gap analysis and baseline review, serious untoward incidents and section 2 audits and the safeguarding adults review and SCR (Single Central Record) tracker for adults and children

• Clear policy for adult and children safeguarding that includes FGM

• Service engagement around FGM

• 37% of CCGs were judged as needing to make improvements to put in place clear children and adult policies that make sufficient references to prevent FGM

• Most CCG’s were assessed as outstanding were engaging with FGM policy, 21% (n = 7) were given this score.

Multi-prevention

 Brown & Hemmings, 2013 [35], England & Wales, UK Liverpool, Leicester, Cardiff, Middlesbrough, Manchester, Birmingham, Bristol, Bolton, & 6 projects in London

To evaluate community based preventive work to safeguard children from FGM

Qualitative: 15 stakeholder interviews, interviews with community members using PEER ethnographic evaluation, rapid policy mapping and review of self-reported M&E

Primary

• Community engagement and awareness raising incorporating FGM messages in wider sexual health messages, provision of safe spaces for discussion on FGM, using community champions, and use of drama and visual arts.

Secondary

• Mainstreaming FGM under violence against women and girls /safeguarding strategies involving multiple agencies, clinical & community champions and community awareness raising

• Indication of change in community views. •Community engagement improved rejection of FGM and has built networks of groups working together

• Younger women have been empowered to speak out and make decisions

• Some religious leaders have dismissed the perceived religious basis for certain forms of FGM

Secondary

•Mainstreaming: resources are committed To FGM, sustainability of efforts is high

 Brown & Porter, 2016 [34], England and Wales UK

To evaluate the support provided to community-based organisations to carry out FGM prevention work

Qualitative: PEER interviews with 51 participants

Primary

• Community education to promote a rights-based approach to tackling FGM

• Awareness raising of FGM amongst affected communities, policy-makers, statutory agencies, and the public

• Networking of groups and policy-makers to contribute to wider campaign to end FGM

• Building skills and capacity of affected communities

Secondary

• Safeguarding practices e.g. child protection, legal action

•Developing materials- culturally appropriate means of talking about FGM as a part of child protection

• Promoting access to services for girls and women at risk through strengthening links between groups and statutory agencies

• Groups where there was a visible shift towards speaking out against FGM included parents, grandparents and young women who either had undergone or were at risk of FGM.

• Respondents felt that changes in attitudes, awareness, levels of information and opposition were closely linked to the work of the national-level anti-FGM campaign and in particular the community-level work of the ten projects

• Discussions about FGM in many areas, which many reported has changed the status of FGM, with it no longer being viewed as a ‘taboo’ subject.

• Law was seen as a powerful and effective part of ending FGM

 EIGE, 2013, All EU countries and Croatia [36]

Analysis of FGM policy and legal frameworks of FGM in EU-27 countries and Croatia and to understand past and present good practices in relation to prevention, protection, prosecution, provision of services and partnerships.

Qualitative: desk review of laws. In depth interviews with at least 6 people in 9 countries and five in-depth interviews at European /international level.

Primary

• FGM related law

• Awareness raising activities to improve knowledge and compliance with the law including awareness raising aimed at the general public

•Development of training material

Secondary

•Training professionals on child protection

• Currently, there are nine EU Member States which have specific criminal law provisions on FGM.

• No EU Member State has a specific provision on international protection and FGM in its national legislation.

• Sweden, the Netherlands and Italy have prioritised funding for prevention activities, but the majority of Member States have not.

Prevention activities lack baseline data and are poorly evaluated

Secondary

• Training on child protection in relation to FGM appears random and does not seem to be conducted on a continuous, structured and nationwide basis.

• In many Member States, health professionals cannot break their code of silence when the crime of FGM has already been performed, because FGM is not generally considered as a type of repetitive, recurrent child abuse

 McCracken, Fitzsimons et al., 2017 [39]

3 local authority areas within London, UK

To evaluate a pilot FGM early intervention model involving clinics at local hospital midwifery services.

Qualitative: In-depth one-to-one semi-structured interviews with 24 professionals & 6 women & 1 FGD with 6 women. Structured observation of 5 stakeholder and community events.

Primary

• Community advocates raise awareness at local events and identify women’s needs

• Support & information provided to men; local and religious leaders

• Engagement with students at schools

• Local media used to raise awareness

Secondary

• Training and development of assessment tools and protocols for health and education professionals and social workers for safeguarding and referral.

• Community advocates accompany women to the clinic

Tertiary

• Education provided to women with FGM by midwives, social workers and therapists at clinics

• At least 235 women with FGM were seen in clinics in London; study showed clinics offered referral pathways & education; services, confirmed physical & mental health problems in women with FGM

• Holistic service was reportedly provided: mental health services; advice on effective safeguarding approaches; support to access wider services and benefits; links to community-based classes and activities; emotional and practical support.

• Health and social care professionals, therapists and community advocates reported strong working relationships and effective service protocols.