My Sister’s Keeper(MSK)

The Lifespan Healthcare Resource LTD team is led by Dr. Ihedioha Emmanuel. He is a community health physician and epidemiologist with more than 14 years experience working and living with south eastern Nigeria communities. He has deep insight on how to work with Nigerian communities and is able to enlist the needed policy-maker and stakeholder support for program’s transition to scale. He holds an MD and MSPH degrees in Epidemiology and Biostatistics from the university of Portharcourt and the university of Nigeria respectively. He holds the CPH(Certified in Public Health) from the National board of public health examiners in the United States. Dr. Ihedioha is an alumni of McGill University's qualitative methods in global health and infectious diseases course and also an alumni of the risk analysis for public health program of Harvard University. He also has certificates in project management from the  University of California, Irvine.

Female genital mutilation(FGM) is an unheathy 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, MSK will cultivate the active participation of communities in determining the underlying root causes of FGM and empower them to end the practice. 

According to the WHO, 2.8 million 15 year-old girls in 6 African countries lose an approximate 130,000 years of life as a result of FGM procedures annually, thus the need for our program. MSK will lead to decreased incidence of perinatal mortality in children born to women with FGM which is as high as 55% in Nigeria(Odukogbe, 2017). MSK will also through psychological counselling and specialist hospital referral services address the mental health and obstetric challenges secondary to FGM faced by more than 200 million female victims worldwide.

FGM is a harmful practice on girls and women driven by tradition and social norms which causes irreparable sexual, reproductive and psychological harm. It is a gender based act of violence, an act of discrimination and a human rights violation (UN CRC Article 12). FGM leaves affected girls and women feeling scared, psychologically scarred and distressed (US Government fact sheet on FGM). FGM is a barrier to female civic participation and social inclusion and thus, leads to inequitable socio- economic growth and prosperity biased against women.

The WHO estimates that an alarming 200 million girls alive today have undergone female genital mutilation in the countries where the practice is concentrated. Furthermore, an estimated 3 million girls are at risk of undergoing female genital mutilation every year with majority cut before the age of 15years. Recently, growing migration has increased the number of girls and women living outside their country of origin who have undergone FGM or who may be at risk of being subjected to the practice. 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).

MSK is based on the ethnographic participatory action research model(e-PAR). MSK will firstly recruit and train local researchers from intervention communities. These researchers will collect and share information on community social structuring to help our understanding of community specific communicative ecologies and information flows. They will also do feasibility assessments on the potentials and barriers to using the communication technologies we will apply to achieve program objectives.

Based on the outputs from the work of the local researchers, health education, psychological counselling and specialist care referral services will be developed and targeted to specific segments of the community. MSK health education will be offered through training and workshops for community members and intermediaries on the dangers of female genital mutilation. It also involves the use of MSK outreaches through radio and television FGM themed programs and jingles co-designed with members of the community. MSK outreaches will also be through MSK themed pamphlets, fliers and posters handed out to community members. MSK also offers telephone based psychological counseling to victims of FGM to handle the attributable mental health complications. MSK referral services is also phone based. It will be offered to FGM victims with secondary gynaecogical and obstetrics complications. 

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

Using the e-PAR framework, MSK is actively interacting with community members  to understand these social norms drivers, then supports  and empowers  them to achieve the required behavioral change to stop FGM. 

Through sustained community engagement anchored on media, information and communication technology, we are addressing the root causes of FGM. We are promoting discussions between men, women and communities on the costs of these FGM perpetuating norms on the health, educational and economic achievement of women and its implication on the general community prosperity. MSK is also addressing the mental health and gynaecological challenges faced by FGM victims through the provision of toll-free mobile telephone based psychological counselling and specialist care hospital referral support.

Bearing in mind that FGM is driven by social norms and upheld by behavioural rules, MSK will elevate the understanding of community members to acknowledge  the mental, sexual and reproductive complications of the practice and how it impacts the socio-economic development of women. Through educational and participatory processes, MSK will improve knowledge, attitude, perception and beliefs of south eastern Nigerian communities to end female genital mutilation.

I am an epidemiologist and community health physician  with more than 10 years working with rural Nigerian communities. My work in these communities has given me an uncommon grasp of the realities of community life and broadened my knowledge on the social determinants of health.

It was while working on a project in southeastern Nigeria that I saw the widespread practice of female genital mutilation and how it was impacting women and girl child development. Being a physician, I witnessed firsthand women presenting with complaints attributable to female genital mutilation. I witnessed poor rural women presenting with infertility complaints, obstetric and gynaecological complications secondary to female genital mutilation.

Witnessing the suffering of these women and girls birthed my interest to contribute in solving this problem. To be able to contribute in solving this problem, I knew I needed training in qualitative research methods. I therefore obtained support and attended the McGill university’s training course on qualitative research methods. Lessons and connections I made during this training have been sustaining the MSK project with technical support as we continue working with communities to end FGM.

FGM results in serious health complications, including infections, chronic pain, infertility, dyspareunia, mental health complications and even death for women and girls. Rooted in gender inequality, FGM leads to girls dropping out of school and not achieving their academic potential, thus being hampered from contributing to the society. Globally, 200 million girls and women alive today have undergone FGM and if current rates persist, an estimated 68 million more will be under genital mutilation in the next ten years. This grim picture drives my passion to ensure the success of the MSK project.

Having worked and lived in FGM practising communities, I have seen firsthand women and girls suffer the emotional sufferings of being labelled infertile, ‘unclean’ and losing children during childbirth secondary to FGM complications. My sisters keeper project is thus my humble way of contributing my skill in public health and medicine towards helping communities uncover and address the harmful traditions and culture  perpetuating FGM. We will hopefully work with communities to end this unnecessary and harmful practice militating against the success of women and girls.

Lifespan Healthcare Resource LTD is a registered medical research organization headquartered in Nigeria. Our project team and members of research staff are all domiciled in Nigeria and are representative of the six geopolitical zones in Nigeria- we thus have the required human resources that understand the language and culture of Nigerian communities to increase the potential for sustainable program scale-up.

In 2018, we undertook the immunization schedule alert platform project which aims to increase the timely uptake of childhood vaccination in Nigerian communities especially in the rural areas. In 2019, we started the ‘My sisters keeper project’ to end Female Genital Mutilation in southeastern nigerian communities. Designing and implementing these projects have given our team an uncommon insight into the workings of rural Nigeria. Our work in improving immunization uptake has given us the experience on developing  effective ways to work with communities to counter the anti vaccination movement and promote childhood vaccine acceptance. Similarly, our ongoing MSK project centred on using participatory action research model to end FGM has empowered our team with skills to effectively work with communities on sensitive cultural issues. 

Lifespan Healthcare Resource has a standing policy of promoting our staff's continuing professional development and education.  In view of this, our team has undergone training on risk communication in public health, ethics in community participatory research, research methods in community based participatory action research. Our team leaders are also certified in project management.

In our ongoing program in South Eastern Nigeria to end Female Genital Mutilation, we have faced the challenge of changing long standing social norms. In some communities our anti FGM activities have been perceived as promoting  promiscuity and immorality due to the prevailing perception that FGM promotes female piety. This has led to program resistance with some communities not attending program activities as we envisaged, and some molesting program staff. Also, our highlighting the unsanitary methods used by traditional cutters in performing FGM has had the unintended consequence of its ‘medicalization' whereby health workers perform it. This challenge is rather difficult as health workers who are supposed to be our partners were sabotaging us. Further, our pointing out the criminal nature of the practice has led to secrecy in its performance. This has led to program resistance with villagers traveling to other communities to perform FGM secretely.

However, through ongoing Participatory Action Research processes, we are patiently working with communities to address these challenges. We remain committed to empowering communities to embark on a cost benefit analysis of practicing FGM and reflecting  on how it affects the general community prosperity through MSK health education, oureaches and campaigns. 

I am public health physician and epidemiologist who has dedicated his career to working in rural Nigerian communities. In 2016, worried by the unusual frequency of childhood vaccine preventable disease outbreaks in my community,  I set up a team to understand the causative variables. My team did a formative study in four communities and found that a major contributor to demand side gap in childhood vaccination was poor adherence to vaccine uptake schedules.

Informed by these findings, I led my team to develop the Immunization Schedule Alert Platform (ISAP). ISAP is an SMS text message application that provides caregivers with child vaccination time schedule before the scheduled vaccination day. It also provides caregivers information on the nearest vaccination center with vaccine availability. ISAP also incorporates the services of ‘Immunization god parents’ who also receive vaccination reminders to further re-inforce caregivers compliance to vaccination uptake.

In spite of challenges from anti vaccination sentiments and vaccine hesitancy occasioned by cultural barriers to child hood vaccinations, ISAP is presently working in 30 rural communities to promote vaccination uptake. Till date, our program has reached 30 communities in southeastern Nigeria and led to timely vaccination for an estimated 5000 children in rural communities.

None Applicable

MSK is based on the e-PAR framework and involves using media technology and Participatory action research in community health promotion(Sarah Flicker et al, 2008). We will work with communities to define underlying and structural causes of female genital mutilation, why it persists, assess their capacity to change, and empower them to end it. We will also provide toll free telephone based psychological lay counselling and specialist care referral for victims and persons at risk.

Current approaches consists of non-governmental bodies and various governments hoping to stop FGM by merely informing communities on the dangers of the practice and criminalization(Young et al 2015). These approaches have been ineffective as FGM persists. These approaches have failed because they were not designed with inputs from community members thus overlooking the underlying cultural drivers and root causes of FGM(Marge Berer, 2015).

We hypothesize that FGM is driven by community specific cultural and social norm drivers which prior programs have neglected.

MSK will actively work with communities to understand these social norm drivers, then empower them through knowledge gained from educational activities to achieve the behavioral change needed to end FGM. MSK also provides toll free telephone based psychological counselling services and hospital referrals for FGM victims and persons at risk.

In MSK’s approach, community members are the agents of change, they are the co-designers and co-implementers of the needed processes that the program enlists to end FGM. They understand the history and context of this practice like no other and when empowered are able to inform on these underlying root causes and drivers of FGM, thus uncovering programmatic approaches that have been previously overlooked.

Using this approach, MSK has in 12 months of operation in south eastern Nigeria, reached 6 communities and educated an estimated 1300 women, 1000 girls and 900 men. It has also led to an estimated 2000 girls not undergoing FGM in these communities during the same period. We have also counseled an estimated 2000 victims of FGM and referred 720 women with complications of FGM to tertiary hospitals. 

Other programs have used this approach successfully but not in Nigeria. The REPLACE project which is analogous to our model have been successful in tackling FGM among African migrant communities in the European Union(H, Barret. 2015). The TOSTAN project in senegal, Sierra Leone and the Gambia is also using this approach.

Our program is currently serving 6000 beneficiaries and 600 intermediaries. In the next one year, we will be serving an estimated 9000 beneficiaries and 900 intermediaries. In five years we will be serving an estimated 40000 beneficiaries and 4000 intermediaries.

Our pilot implementation is ongoing in 6 FGM practicing communities chosen from 4 south eastern Nigerian states of Ebonyi, Enugu and Imo and Abia states. Upon success and scale-up, we expect our program to reach an estimated 5 million Nigerian women. Using the (VAWS)violence against women and Girls: a compendium of monitoring and evaluation validated measure, we expect the following results:

a)12 months(10% positive change from baseline variables)

b) 5 years(50% positive change from baseline variables)

1.Proportion of women aged 15-19 who have undergone FGM.

2.Among cut women aged 15-19, proportion FGM performed by a health worker.

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

5.Proportion of women aged 15-49 diagnosed with infertility secondary to complications from FGM.

6.Proportion of women aged 15-49 seeking counselling secondary to FGM complications.

7.Proportion of women aged 15-49 seeking hospital referral secondary to FGM complications.

8.Proportion of women aged 15-49 with Vesico Vagino Fistulae secondary to FGM.

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

9.Proportion of births through cesarean section secondary to FGM/C complications.

10.Proportion of girls dropping out of school before senior secondary school examination secondary to FGM.

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

12.Proportion of Perinatal deaths secondary to FGM complications.

During the early parts of MSK intervention, indigenous community program leaders and positive deviants could be physically harmed or socially isolated from the community as they may be seen as conniving with strangers to desecrate traditional institutions.

Counselling and interviews with victims of female genital mutilation could be emotionally tasking  as victims relive their experience. Also, in patriarchal societies as most MSK intervention communities are, discussing issues of gender equality might be frowned upon leading to program resistance.

Our program involves empowering women, and thus involves power sharing with men who will not be keen on sharing power. This newly discovered sense of equality with men might lead to female beneficiaries starting quarrels with the men folk which may lead program resistance.

The ‘OSU’ caste system(traditional social exclusion) is still practiced in some of the FGM communities in south Eastern Nigeria, this might lead to program resistance as some participants might not readily accept attending meetings or being in the same group with the so-called socially excluded persons.

Our pilot program involves the generation of personal and sensitive data through interviews and focus group discussions and as such participants might feel unsafe to openly participate or be wary of being identified as sources of information to research assistants and counsellors.

Sourcing and recruitment of adequate numbers of psychological counsellors and gender specialists willing to work in rural communities might be a challenge as these professional designations are still new in our environment.

Program researchers will be trained on the rudiments of participatory action research and to abide by the highest ethical standards for research in communities. However, any perceived threat to life 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 counselors and interviewers. Trainings will emphasize the use of respectful dialogue when communicating about FGM.

Men are the custodian of tradition in our intervention communities, on these backdrop, women and girls will be educated on proper ways to garner male folk support and to eschew antagonism. However, women and girls facing physical threat or violence as a result of the program will be encouraged to seek help and protection from relevant government and community 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 of all classes.

We will ensure that all data from project is anonymized to protect the identity of informants. Interviews results will be coded and stored in formats that maintain data safety. Program research findings will also be reported back to intervention communities and stakeholders.

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

We are currently partnering with grand challenges Canada who are funding the pilot phase of our program and have graciously provided us with trainings on project finance and budgeting. They have also provided us with learning resources on how to incorporate gender equity in our projects.

We are also in partnership with TOSTAN who have done groundbreaking  work towards ending female genital mutilation in subsaharan Africa using the participatory action research model. They have been sharing insights with us on the success and challenges they have experienced working with communities in low resource settings. They are already providing us with online resource training  for staff capacity development. We are Presently working with them on sending our research team to learn their methodology on incorporating good citizenship and civic responsibility trainings in addressing  female genital mutilation.

We are also in partnership with the  First Lady flagship programs of four south eastern Nigerian state governments running MSK. They will be providing us with political legitimacy and encouraging communities to work with us to sustain the project.

We are also in partnership with the leadership of the village youth development organization in the 6 communities. They are intrinsic to the success of the program. These youth leaders constitute the majority of the positive deviants driving the success of the program by promoting community acceptance. The youth leaders also provides security for program staff and equipment.

MSK’s beneficiaries include women, girls and men in intervention communities. Age group subgroupings of these beneficiaries are 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, unique online campaigns, unique telephone campaign and toll free telephone counselling. These communication tools will serve to educate intervention community members, program intermediaries and the general public on the attributable complications  of FGM. These communication tools will also provide information on the availability of  the services which the  MSK program offers and how/where to access them.

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 will be sustained by cultivating ongoing stakeholder support. 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 addressing FGM. To garner this support, we will ensure our program’s alignment to rules and regulations of the relevant governmental bodies. 

Our organization have also ensured that the MSK program design and implementation is in alignment with Nigeria's strategic health development plan 2009-2015 and its health  promotion policy which stipulates community ownership and participation in health promotion. MSK’s sustainability policy framework therefore, entails developing strong cooperative relationships with  governmental, non- governmental stakeholders and local communities. We have also ensured a quarterly communication of program evaluation to stakeholders to keep them abreast of program’s progress and challenges.

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

Not Applicable.

We seek to raise through grant funding the sum of 300,000.00USD over the next 3 years starting from January 1st, 2021.                                         

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

Estimated budget is as follows:

Administrative Costs                                                                    $25,000.00 

Staff Remuneration                                                                      $35,000.00 

Subcontract(Gender Specialist)                                                     $15,000.00 

Subcontract(Psychological Counsellor)                                           $15,000.00 

Supplies                                                                                       $20,000.00 

Equipment                                                                                    $20,000.00

Transportation                                                                              $20,000.00

TOTAL.                                                                                       $150,000.00

The Elevate prize will offer us a veritable opportunity through the Elevate foundations network of partners to obtain technical expertise including online or in-person resources on the design and ethics of qualitative research. This will be relevant in tackling  barriers to program success  resulting from dearth of properly trained personnel. Benefitting from these trainings will help in building our capacity on evidence proven ways to work with communities and improve conflict resolution. 

The Elevate prize will also offer us the opportunity through the Elevate foundations network of partners help to obtain technical expertise on evidence proven ways for undertaking participatory action research in low resource settings. This partnership will again be useful in building capacity. Our work involves the generation of personal and sensitive data through interviews and focus group discussions and as such participants might be wary of being identified as sources of sensitive and facing repercussions. This partnership with the Elevate partners will therefore help us in building staff capacity for adequate data handling and dissemination.

The Elevate prize through its partnership 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 media content to effect behavioral change. This partnership will also help us in gaining knowledge on crowdsourcing platforms, software, support and administration. Our participating in BRL seminars will be an important opportunity to share and learn about study findings and best practices on behavioral change science.

We are in need of mentorship and coaching  which will provide us professional management and program research development services. We also need technical support especially regarding educational training and capacity building for research staff and program leaders. The connection with influencers, industry leaders, and experts which winning the Elevate prize will grant us will also be helpful in building sustainable support for the program transition to other communities in Nigeria and west Africa.

We are also in need of the tailored media exposure and the contingent platform which winning the Elevate prize will offer us in marketing our work and amplifying its impact by building recognition among local and neighbouring African communities. This will also increase the potential of our program to be sustained and transitioned to scale.

We will like to partner with WHO, UNICEF and UNFPA, these organizations have garnered years of experience working on FGM in Africa. These organizations have funded several research studies on FGM and have repositories of specific knowledge which will be valuable in our work. We will share our experience using the participatory action research model, and learn from the challenges they have faced using their current models. We are willing to receive training and technical resource materials from these organizations.

We will 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 in affected countries. Their work has helped in the development of our program’s Community Behavioral Change Framework. We will also  like to partner with TOSTAN, this organization has done FGM focused work in sub Saharan Africa and are in position to offer us guidance on how to improve our work with communities.

We also seek to partner with Action Research Network of the Americas(ARNA). ARNA will be helpful in our organization’s quest to promote action research that is conducted with a commitment to honesty, integrity, multivocality, engagement and sustainability. Partnership with ARNA will help our organization in developing effective models for knowledge production, knowledge dissemination and knowledge democracy for critical issues in our work against FGM. We have applied for membership of this organization and hopefully, will present our poster in the upcoming ARNA conference in 2021.