Multisectoral approach to address Female Genital Mutilation: a case study from Portugal

Issue

Female genital mutilation (FGM) comprises all procedures that injury female genital organs for non-medical reasons, with several health impacts. Due to global migration, FGM has been increasingly recognised as a healthcare issue in Europe, affecting nearly 1 million women. In Portugal it is estimated that 5483 migrant women have undergone FGM in the Lisbon region. Intervention is required to tackle this issue.

Description

Portugal launched the “Healthy Practices: End of FGM”, a multiagency project targeting Lisbon and Tagus Valley region. Project implementation started in Nov 2018 at 5 local public health units (PHU) and was scaled-up to 5 more in Feb 2020. Project comprises 3 main axes: 1) inclusion in public policy instruments; 2) professionals’ education and awareness; and 3) community intervention. We describe inclusion of FGM in public policy, professionals training and changes in FGM recording before and after intervention.

Results

Between 2018-2022, inclusion of FGM in municipalities’ migration policies doubled. Between 2019-2021, 110 training sessions (n = 1722 professionals) were promoted. During pandemic years, only 344 (2020) and 202 (2021) were trained. Raising awareness and empowerment to risk communities happened mainly through local/online open sessions, workshops, flyer distribution, video projections. These occurred in all 10 PHU, mostly through partnerships with Non-Governmental Organizations and municipalities. According to the Portuguese Health Records, until 2018 there were only 300 women registered with FGM. Between 2019-2021, 363 more were added.

Lessons

The multisectoral approach allowed PHU professionals to collaborate directly with external organizations from different society sectors. COVID-19 pandemic posed a challenge to implementation, especially in the community intervention axis. Notification numbers increased after interventions, though causality could not be established and impact evaluation is yet to be performed.

Key messages

• Multisectoral projects for FGM intervention have specific implementation challenges, including how to justify and evaluate them, that must be considered in each setting.

• Training health professionals might increase identification and notification of FGM, but the impact in preventing FGM in the Portuguese reality is still largely unknown.

Ending female genital mutilation – a city’s coordinated effort

Female genital mutilation (FGM) has short and long-term impacts on the health of girls/women. In Portugal, an estimated 5246 women were subjected to it, with 568 of them residing in the city of Amadora, in the metropolitan area of the capital Lisbon. As such, Amadora was considered a priority area for developing strategies to prevent female genital mutilation, under the coordination of the local public health unit.

Our aim was to capacitate professionals to recognise and act on risk/danger and on minimising potential health impacts of FGM on the local institutions these girls/women might come into contact with.

We created a task force that held meetings with different local actors: hospital, teams at the primary healthcare facility, city hall of Amadora, child protection services, a school, social inclusion projects, representatives of the justice system and a non-governmental organisation. We designed different scenarios for the different needs and entry points of these girls/women in the system and created appropriate procedures for all these actors. Within the primary healthcare facility, we created guidelines specifying criteria for referral to other specialties. This led to the development of a county protocol targeting FGM during the summer of 2019.

We trained 160 healthcare professionals. In addition, we created a booklet for schools and held sessions in school groups targeting teachers, psychologists and operational assistants with a focus on risk and danger indicators and on how to proceed. Overall, 360 school professionals received training. During these sessions, we also presented resources on how to integrate FGM in discussions with students regarding gender violence and human rights.

This intervention will be evaluated after one year (summer of 2020) through mixed-methods to understand the impact on the practice of the professionals in Amadora. We will conduct interviews and apply questionnaires to capture the implementation of this city-wide protocol.

Key messages

Given the complexity of FGM a wide societal and multidisciplinary approach should be used with a public health team coordinating the intervention. In Portugal there is a need for an organised and systematic response by professionals regarding FGM; our county-specific protocol aimed to create that response.

The Portuguese alcohol industry: friend or foe of public health authorities?

The influence of the alcohol industry is considered one of the most important obstacles to the implementation of policies that aim to tighten alcohol control. However, to our knowledge, our research is the first one to document the influence of the alcohol industry in the country, despite a 6.8% prevalence of alcohol use disorders and alcohol not featuring in the current National Health plan.

We performed a qualitative thematic analysis of information available on websites and social media pages of trade associations, charities funded by the alcohol industry, government, universities and media material. This analysis was based on the “Policy Dystopia” framework, dividing the strategies we found as either instrumental (action-based) and discursive (argument-based).

Overall, out of the 198 written records, 56% were instrumental and 44% discursive. The alcohol industry's representatives are part of the executive commission of the national task force responsible for consulting on policies regarding alcohol. We also found evidence of extensive community involvement through cooperation with security forces, among others. Also, after a discussion by the Portuguese Parliament of a possible increase in taxation of alcoholic beverages, a trade association delivered a study it had ordered from a consultancy company refuting any increase.

Trade associations also claimed stricter control measures were not necessary in southern European countries, such as Portugal, and they were only appropriate for countries with more harmful drinking patterns. When referring to health risks causes by alcohol consumption, the association with breast cancer was only found once with misleading language describing it as “chest cancer”.

This research has shown several tactics employed by the alcohol industry in Portugal and, as such, helped counteract some arguments used by the industry. This can enable the implementation of more effective control policies.

Key messages

Public health authorities should document the industry’s tactics in order to implement effective control policies regarding alcohol and other substances. There is a need for audits of health information made public by the alcohol industry.

Planned teenage pregnancy: a sociocultural health problem that lead to a local intervention

According to data from the National Statistics Institute (2018), Portugal was the country with the second highest birth rate in the European Union in mothers between 15 and 19 years old. This number of births may be influenced by ethnic-cultural issues, such as acceptance and encouragement of marriage and early motherhood, especially in some African ethnic-cultural groups. Our public health unit is located in Amadora, a suburban area of the Portuguese capital with a high percentage of migrants, a high rate of teenage pregnancies and economically deprived areas.

The aim of our research was to understand beliefs and values in both native and migrant girls regarding motherhood in order to better tailor interventions aiming to prevent teenage pregnancy.

We interviewed fifteen participants, seven migrants and eight natives, who were or had been teenage mothers. The participants were selected through non-probabilistic snowball sampling. Afterwards, we performed a qualitative content analysis.

Overall, we found no difference between the 2 groups of participants with most, 12, having wished for their pregnancies. The social and religious framing of fertility as a gift was often stated. The housing context was also mentioned given several participants lived in overcrowded houses with poor conditions and believed pregnancy could have provided a way out of their living situation. Low education and poor job prospects were also mentioned as pregnancy was framed as a “life project” in the absence of a career prospect.

We found evidence of a “social and cultural pregnancy” not related to certain migrant cultures but associated with a “neighbourhood” culture associated with economic deprivation. As such, we are now implementing a pilot study within the community, by creating regular group sessions to discuss the meaning and impact of motherhood to try to capacitate girls to find a different life project other than choosing pregnancy during teenage years.

Key messages

Teenage pregnancy can be planned who use it to try to find a life project, be accepted within their community and escape their daily conditions. Public health interventions aiming to prevent teenage pregnancies should acknowledge social and cultural factors that encourage these pregnancies.

A partnership between a local public health unit and schools to end female genital mutilation

Key messages

There is potential for a closer collaboration with schools to try to end female genital mutilation and to address other health topics. Local public health units should establish and mobilise local networks of institutions and community partners to tackle complex public health problems.