Developing a community action plan to enhance male involvement in FGM abandonment in Kenya: A qualitative and co-design approach

Study settings and participants

Study participants were recruited from two counties (Meru and Kajiado) in Kenya with variable FGM prevalence, 31 % and 78% respectively³². Meru county is located in the Eastern part of the country. The Meru people (Ameru) comprise different sub-groups and speak a variety of dialects of the Kimeru language. Kajiado county is in the southern part of the country and inhabited predominantly by the Maasai, a pastoralist community with a unique and distinct culture. Maa is the language spoken among the Maasai, although there are a variety of dialects of this language³³ The two counties were purposefully selected to ensure that the CAP was adaptable to diverse contexts.

The first author (PM) is from one of the communities where the research was conducted and has a good familiarity with the language, customs, and traditions. In collaboration with local communities and organisations, she has conducted extensive research in the region. These aspects were key to informing the selection of individuals with a broad range of attitudes and abilities. Potential participants were approached by members of the advisory team set up at the start of the project. The advisory team was comprised of representatives from local NGOs, local leaders and community health volunteers (CHVs). Members of the advisory team approached potential participants and explained the purpose of the study and what involvement entailed. To help incorporate a wide range of perspectives, purposive sampling was used to sample potential participants to achieve the maximum variation in terms of gender, age, social-economic status, and occupation. Study participants included men and women (18 years or older) living within the two counties.

We conducted three co-design workshops with a total of 26 participants (13 men and 13 women). One workshop in Meru (mixed gender; n=8) and two workshops in Kajiado (separate genders; n=18 (9 participants in each workshop)). Participants were community members, local leaders (for example assistant chiefs) religious leaders (pastors), anti-FGM advocates, CHVs, young males and females, schoolteachers, and NGO representatives. It was important to elicit the views of these groups of people, particularly local leaders (chiefs, and assistant chiefs), in terms of male involvement in FGM abandonment given their influential role among community members. The workshops were conducted in February 2022 and were facilitated by PM with the help of a research assistant. Each lasted about 2 hours including breaks and participants were offered food and refreshments. The workshops were conducted either at a conference room or a community centre. Participants were reimbursed for their travel expenses.

Ethics

This study received ethical approval from University College Dublin, Ireland- Human, Research Ethics Committee (LS-21-38-Mwendwa; Date of approval September 30 2021), Kenya Methodist University, Scientific and Ethical Review Committee (SERC) (KeMu/SERC/MUST/13/2021/RNW; Date of approval August 13, 2021) and the National Commission for Science Technology and Innovations (NACOSTI/P/21/9102; Date of approval March 2 2021). Prior to the study participants provided informed written or verbal consent. Verbal consent was taken for participants who could not read or write.

Data collection

This study was part of a larger project that explored the readiness to change among men and women to inform the co- design of targeted anti-FGM interventions in Kenya. The larger study involved two phases. Phase 1 entailed focus groups (FGs) that explored male involvement in FGM abandonment and potential effective strategies to enhance male involvement¹¹. Phase 2 (the current study) entailed two steps (i) assessing men’s readiness to engage in FGM abandonment as well as communities’ readiness to involve men and (ii) developing a CAP for male engagement in FGM using co-design workshops.

Step 1: Assessing men’s readiness to engage in FGM abandonment and community readiness to end FGM through the involvement of men.

In step 1 we assessed the FG data collected in Phase 1 based on six dimensions of change in the REPLACE Community Readiness to End FGM Assessment Model^27,34. We tailored our dimensions to community readiness to involve men in FGM abandonment (extended data Table 1) as follows: A) men’s knowledge concerning FGM, B) men’s knowledge of efforts to end FGM in the community, C) community belief systems and attitudes towards male involvement in FGM abandonment D) community efforts to end FGM through the involvement of men, E) “community leaders’ and influential peoples’ attitudes to ending FGM and F) community resources available to support efforts to end FGM”^34(p4). Consistent with REPLACE, we used independent scorers (who were members of the advisory team established at the start of the larger project) to score the transcripts and calculate the stage of readiness of the communities to involve men in FGM abandonment in each of the two counties. The scoring and rating of the focus group transcripts followed Barret and Alhassan guide³⁴.

Step 2: Developing a Community Action Plan for Male Involvement in FGM Abandonment

We developed an approach (see extended data Table 2) informed by the literature on participatory design³⁵ to structure the workshops and help stimulate discussions that would inform the co-design of the CAP. The co-design process entailed plenary sessions as well as small group discussions which were audio-recorded. The workshop began with introductions and with the facilitator reiterating the purpose of the workshops. This was followed by a presentation by the facilitator of FG findings (from phase 1) in terms of community readiness to end FGM through the involvement of men and suggested strategies to enhance male involvement in the study areas.

Patient and Public Involvement

To inform the development of the CAP, we first engaged participants in identifying and prioritising strategies or approaches they considered potentially effective, sustainable and locally suited to male involvement in FGM abandonment. Participants were divided into smaller groups and asked to identify and rank their top three strategies. Each group noted their prioritised strategies on sticky notes and these were displayed on a flipchart. This was followed by a presentation of the prioritised strategies by each group explaining the rationale for their prioritisation, any disagreements and how/if consensus was reached.

Second, the facilitator restated what each group had chosen as their priority strategies. This was followed by a critical discussion of the strategies, highlighting both the strengths and weaknesses of each. To inform this latter step, the facilitator asked participants follow up questions, for example ‘has this strategy been used before in this community?’ ‘what has worked before?’ ‘what have been the set-backs with this strategy?’

The third step was to agree on the content, format and process of the CAP. Participants suggested activities and resources needed, the objectives to be met, and how, where and when the CAP would be implemented. Given the cultural issues surrounding the involvement of men in FGM, the facilitator engaged participants to explore who the key messenger(s) would be in each context. Participants then articulated what they thought success would look like, anticipated challenges and how they would deal with the difficulties. Finally, the facilitator summarized the draft CAP with participants and highlighted the steps and their commitment to the plan. These facilitated discussions and deliberations culminated into an agreement among participants on the priority strategy(ies) that would inform the CAP for male involvement in FGM abandonment. The draft CAP was discussed with the local advisory team and with the research team at the lead author’s institution who provided comments and suggestions for refinement. We held three follow-up workshops with participants from the previous workshops to validate the draft CAP and gave participants an opportunity to provide feedback on the draft. Suggested changes were incorporated into the final CAP Extended data Tables 3& 4.

Analysis

The assessment focused on the six dimensions outlined in extended data Table 1. Each dimension comprised nine statements relating to the stages of readiness to change and assigned the scores of 1 to 9. The dimensions were scored and equated to one of the nine stages of readiness to change for each county. Once scoring was completed, discrepancies with the scores were discussed and resolved, and agreed scores were used to determine each county’s level of readiness based on the nine stages. Co-design workshop data were transcribed verbatim, translated, and analysed thematically. Thematic analysis is a method used to identify, analyse, and report patterns within data³⁶. The method proposes a six-step process which we adapted in the analysis. PM took the lead with the analysis, and the advisory team and the co-authors provided further input and suggestions with the refinement of the themes.

Assessment of community readiness to end FGM through the involvement of men

Extended data figures 1–6 indicate the scores assigned by independent scorers, how they were combined to produce the final scores for both counties as well as the suggested approaches to male engagement in FGM abandonment. In Figure 1, the stages of both counties’ readiness to end FGM through the involvement of men are shown.

Figure 1. Community Readiness to Involve Men in the Abandonment of FGM Assessment (Meru and Kajiado County).

Figure 1 shows that the two counties were clearly at different stages of readiness to involve men in FGM abandonment, although there was overlap within the stages. The scores put Meru county at stages 2,3 and 4 of readiness, suggesting that men in this county are aware of the importance of involvement but lack the support and avenues to get involved. The scores also suggested that community members recognise the need to engage men to end FGM. Still, no efforts have been made to include them due to cultural beliefs which preclude male involvement in FGM. Kajiado county was placed at stages 1 and 2 suggesting that men lack the understanding about the need to be involved in FGM abandonment and like Meru county, cultural beliefs precluded male involvement. The assessment of community readiness was critical to help inform the co-design of the CAP.

Prioritisation exercise

This exercise involved working in small groups to prioritise potentially effective strategies for male involvement in FGM abandonment. Results from the community readiness assessment informed the format of the workshops in each county. In addition, they helped tailor the co-design workshop discussions in line with community readiness for male engagement in FGM. As a result, Meru county participants were organised in 3 groups (mixed gender), while in Kajiado there were a total of 8 small groups (female workshop n=4; male workshops n=4). Findings from phase 1 on potentially effective male engagement strategies were used for this exercise as follows.

The top priorities varied amongst the groups and the two counties (Table 2). The top three strategies listed as most likely to have the greatest impact on male engagement on FGM were: (i) educational seminars delivered through the church, NGOs, and credible educators (ii) male champions/male peer mentors to engage and educate men (iii) collaboration between spouses and closer relationships between fathers and daughters.

(i) Educational seminars delivered through the church, NGOs, and credible educators

This strategy was prioritised by 6 of the 11 workshop groups and was the second priority for the rest of the groups. Workshop participants noted the importance of educating men about FGM. It was argued that in most cases men lack the knowledge and that most have no interest in finding out more about FGM due to social and cultural norms and a strong belief that FGM is predominantly a woman’s issue. Participants stressed that to get men interested in fighting FGM, it was important to sensitise them about what exactly FGM entails and educate them about associated health consequences so that they can decide whether it is a good practice or not.

The church, NGOs and local social groups were suggested as best suited and potentially effective in delivering these educational programmes. This was based on their previous work on FGM with communities. There was a particular emphasis among participants from Kajiado county that the church can be a good avenue to educate men. The shifting attitudes and social norms as it relates to FGM in these communities was largely attributed to the role of the church by several participants. For example one participant related how education from the church had influenced her performance of FGM.

Other participants believed that because the community, especially men, tend to listen more to leaders in the church, this strategy would potentially be more effective to reach men and educate them.

However, some participants noted that because not all men attend church, this strategy could exclude those that need the education the most.

NGOs were considered another avenue that can be used to educate men as they have been used in the past to engage women and girls in anti-FGM initiatives. It was believed that NGOs were well-placed to deliver programmes to men.

While the role of NGOs was recognised, some participants noted that in the past NGOs have focused solely on women and girls and have never involved men in sensitisation programmes. Others noted that few NGOs were addressing this issue in their community, suggesting that this strategy may not be the most effective.

Social groups that include influential people and leaders were also deemed important in educating men about this issue. Some participants cited the Njuri Ncheke, a council of elders who play a mediating and unifying role among communities in Meru county. The council has previously been involved in the promotion of gender equity and equality in the county (https://meru.go.ke/697/njuri-ncheke-joins-move-promote-governor-kiraitus-social-development-agenda)

ii) Male champions/male peer mentors to engage and educate men

This strategy was prioritised by 4 of the 11 workshop groups (3 male and 1 female group) and was the second priority for two groups. As a first step participants suggested that men should form (self-help) groups like the ones commonly associated with women. These groups, it was argued would be a way to get men to meet regularly and eventually broach the topic of FGM and the importance of engaging. Men champions/ ambassadors could spearhead the formation of such groups which should be formed according to age groups.

It was suggested that male champions/ambassadors could work closely with the local authorities (the chief, sub-chief, or Nyumba kumi representatives) to convene a meeting with men to discuss the issue. (Nyumba kumi (Swahili for ten households) is a community policing initiative)

Workshop participants reiterated the value of men only groups as an educational avenue; these groups present an opportunity to have men-to-men talks where men themselves debate this issue.

iii) Family-oriented approaches

The lack of male involvement in FGM abandonment was attributed to culture but equally to a lack of male involvement with the family. Participants stated that in the Meru tradition, for example, there is usually no close relationship or communication between a daughter and her father. Therefore, collaboration between spouses and the need for fathers to develop a close relationship with their daughters was deemed essential to enhance fathers’ involvement in family matters, including discussions about FGM.

Participants argued that collaboration would foster an enabling environment for spouses and children to discuss issues freely. This would make it possible for family members to be open with each other. It was argued that if a father was close to his daughter(s), he was likely to be privy to plans to have his daughter circumcised.

A critical discussion of the prioritised strategies and consensus building

The next step of the workshop was to critically discuss the prioritised strategies and agree on which one(s) was/were likely to be most effective for each community. The following questions guided the discussion;

There was consensus in Meru county that CHVs are well suited to offer educational seminars to men during community dialogue days. A community dialogue is “a mutual continuous exchange of views, ideas and opinions about an issue or a concern.”^37(p55). For this strategy to succeed, participants agreed that the following actions and resources need to be in place. CHVs would need to be trained on this issue of FGM and male involvement through the Ministry of Health. The meetings need to be supported by local authorities and CHVs would work with the local authorities to gain this support. Participants talked of the importance of choosing a suitable venue with some suggesting the church, but others noted that this would discourage those who do not belong to the church from attending. It was agreed that a neutral venue, such as a school playground might be more suitable. The weekends were considered the best time to hold such a meeting. Chairs, tents and refreshments for attendees would be needed as would remuneration for organisers and CHVs to cater for transportation and phone credit. Participants noted the need for CHVs to have a form of identification, such as a badge or T-shirts so that the community could identify them easily in relation to their work on FGM and male involvement. Trainers and facilitators are also needed to train CHVs. Modules for these trainers would be needed as well as venue for training them.

The greatest challenge to implementing this strategy was thought to be funding. Others noted that there was likely to be a lack of engagement or attendance due to cultural issues or simply a lack of interest in the topic. The need to use complementary strategies to reach men was highlighted. Participants argued that as CHVs conduct regular door-to-door home visits and are involved in health promotion programmes or clinics which men attend, they could use such opportunities to talk to men about this issue and encourage their involvement in community dialogues. Additionally, the importance of organising these dialogues according to age-groups was noted.

Table 3 provides a summary of the prioritised strategies, rationale, potential challenges and agreed strategies for Meru county.

If the community dialogues were successful, participants anticipated the following outcomes; the dialogues are likely to lead to a greater collaboration between a man and his wife; and if the man finds the dialogues beneficial, he might have a discussion with his wife and if they have daughters they may decide not to subject them to FGM. These dialogues were believed to be likely to create a closer relationship between the father and his daughter. If the man and his wife are in agreement, the wife might tell the daughters about what they have agreed with the husband. This close relationship might help the daughter to get closer with her father and she would likely tell him of any plans to have her circumcised. It was also argued that men and men leaders who attend these dialogues may decide to seek support from the government to organise more dialogues to educate more men about this issue. Once the government is on board, it can advertise future dialogues through the radio or via text messages, as almost everyone has access to a cellular phone. Once the information is out in the media, most men will get the message and this will create more awareness. Extended data Table 3 provides the detailed CAP for Meru county.

Participants from Kajiado county agreed that a community baraza (plural mabaraza) (community assembly) would potentially be the best way to reach men and get them involved in FGM abandonment efforts. A baraza is a large group gathering in which community issues are deliberated and resolved³⁸. They discussed how mabaraza have worked before and how this strategy might be implemented in practice. It was noted that while mabaraza are not frequent, in the past they have succeeded in the area of development for example when communities needed to construct a dam or a road. In that case the entire community came together and spoke in one voice and the leaders or government departments would take community needs and suggestions into consideration. It was suggested that Nyumba Kumi representatives, who are responsible for 10 households and engage regularly with families could be trained to pass on the information at a community baraza.

Some participants opined that for such meetings to be effective and to ensure that men engaged, it might be necessary to identify male and female champions in the community and provide them with training about FGM and the importance of engaging men. These champions can then pass on the information they have learned during the baraza, and this way all community members will feel represented.

For these mabaraza to succeed, participants agreed that the following would need to be in place. The local government and agencies (chiefs, assistant chiefs, Nyumba Kumi, health departments, social services) would need to be collaborating to help support the initiative and mobilise the community. Such meetings should be scheduled during school holidays to make it easier to attract an audience. Similar to Meru county, the importance of carefully selecting a venue was noted: and while the church premises as a possible avenue was suggested, participants noted the importance of avoiding venues that would potentially alienate some community members. The best days to hold such a meeting were deemed to be the weekends from 11am. To help facilitate the organization of this meeting influential people, such as the chief and church leaders would be needed to publicise the meeting. Speakers (men and women champions) would need to be trained on FGM and male involvement. Male participants suggested that ex-circumcisers could be invited to address the meetings and videos which show how FGM is performed and how it affects girls can be shown at the baraza. The event would need to be funded to cater for food/refreshments, remuneration for presenters, hiring of tents, chairs, video equipment and public address equipment. Participants suggested that the media houses should be invited to cover such an event.

Quite similar to participants in Meru county, funding was identified as a potential challenge to the success of such an event. Timing of the meetings was also noted as likely to impact attendance, while others felt that people, in particular men might not take this meeting seriously as they could regard it as “just another talk for women.” (Kajiado participant) Others highlighted the importance of clear communication with local leaders about the issue in order to gain support to convene the meetings.

Table 4 provides a summary of the prioritised strategies, rationale, potential challenges and agreed strategies for Kajiado county.

If the mabaraza are successful, participants anticipated the following outcomes; men in the community would get the message about the dangers of FGM and the benefits of not performing it and, potentially this message would spread to other men in the community. As one participant put it;

Some argued that eventually, cases of FGM will decline although they did not anticipate that the practice would end dramatically following these community engagements. These mabaraza would equip men with knowledge about FGM (because in this community it is mostly women with knowledge about FGM) and this may result in a closer collaboration within the family unit. Extended data Table 4 provides the detailed CAP for Kajiado county.