Living with FGM: Improving Knowledge and Skills of Health Care Providers in Iraqi Kurdistan

Background: Despite the high prevalence of female genital mutilation in many settings and the health consequences associated with it, many healthcare providers have limited knowledge of female genital mutilation and limited skills for preventing and managing related complications. With Knowledge of this Important matter aim of this study is to determine the effectiveness of TOT workshops on the knowledge and skills of social workers working with girls and women affected by FGM. Methods: To demonstrate the ndings, a quasi-experimental study was conducted with a pre and post-assessment. There were 44 participants who worked with FGM victims across Iraqi Kurdistan. Socio-demographic details of the participants who have collected knowledge on psychosexual and physical care, psychosexual skills, and referral programs were assessed using a continuum scale of 0 to 4. Descriptive and inferential statistics were carried out for the analysis. Results: The results showed that participants' knowledge and skills improved in relation to psychosexual and physical care for girls and women living with FGM and referral programs for them. The paired sample t-test carried showed a signicant increase in knowledge among participants in psychosexual and physical care for girls and women living with FGM (f=9.25, df=1, P=.001), Psychosexual skills (f=-8.20, df=1, P=.001), and FGM victims referral Programs (t=12.95, df=1, P=.001). Follow-up test also showed that these changes were constant from post-test to follow-up. Conclusions: Preparing the social workers on the integration of physical and psychosocial care for girls and women living with FGM in their existing activities would equip them in providing holistic care for them in addressing the emerging psychosexual problems.


Introduction
Female genital mutilation (FGM), also called female genital cutting, involves the partial or total removal of external female genitalia or another injury to the female genital organs for non-medical reasons [1].
FGM is usually performed with a blade or a shard of glass by an elderly person or a midwife with limited training and often in unsanitary conditions [2]. FGM is associated with various health consequences and even death. The practice can result in pain, bleeding, infection, and urinating problems as immediate health consequences. Chronic infections, cysts, chronic pain, birth complications, and sexual and emotional suffering are examples of long-term consequences of FGM [2][3][4].
FGM is a common practice in Iraqi Kurdistan, an independent region in northern Iraq that includes the three provinces of Erbil, Suleimaniya, and Duhok. In the early 2010s, the prevalence was found to be 40%, varying by geographic location and governorate from 4% in Dohuk to 58% in Erbil.
FGM/C provides no health bene ts and causes serious immediate and long-term physical, psychological and sexual harm, including chronic pain, recurrent urinary and vaginal infections, post-traumatic stress, and severe pain during sexual intercourse [10]. The immediate effects of FGM (signi cant pain and heavy bleeding) recur and are often exacerbated during and after childbirth, especially in women with type III FGM [10]. Girls and women who are living with FGM shared the di culties they had physically with childbirth, enjoying sexual relations, with menstruation, but also the many emotional di culties [11]. The negative effects of FGM also affect men, many complain of their wives being unable to enjoy sex and the strain this puts on a marriage [12].
The girls and women who live with FGM need care and protection, especially in a crisis-stricken country like Iraq, which is facing various problems where Where due to cultural and religious diversity social problems are high and varied in nature [13][14][15]. The girls and women who live with FGM have the right to live a life without pain and health, to live without stress, to enjoy sex, ensure physical, psychological, and sexual health will lead to care and protection. Mental health and sexual health are also two of the major aspects similar to physical care and protection. Therefore, the need to promote and practice knowledge and skill-based psychosexual care to girls and women who live with FGM is essential.
In the current study, an 18 days TOT workshop was conducted for the social workers working with FGM victims through the NGOs at Iraqi Kurdistan and reach out to social workers in these towns and villages to discuss and give them tools on how to live with the emotional and physical consequences of FGM.

Methodology
Hamraz counseling center associated with Wadi an association for crisis assistance and development co-operation working with FGM victims across Iraqi Kurdistan through sponsorship and education programs to train the social workers in physical and psychosexual care for FGM victims. The NGO is directly working with 300 villages and cities in Dohuk, Erbil and Solaimaniya through social workers mobile teams. The aim of the program is to incorporate care for FGM victims in their regular activities as well as in the villages and cities, thereby enhancing the psychosexual health of FGM victims through social workers.
The present research was a Quasi-experimental study with a pre-test/post-test control group design. The statistical population included all social workers who worked with violence victims in Iraqi Kurdistan, for the year 2021.

Population, Sample, and Sampling Procedure
The study sample was selected based on the random sampling method. Inclusion criteria were willingness to participate in the study and history of work with FGM victims as a social worker. Exclusion criteria were unwilling to participate in the study. According to the research methodology, the statistical sample consisted of 44 social workers, selected using the Morgan table by convenience sampling among eligible social workers who had willing to participate in the study. Then they were randomly assigned to the intervention and control groups (22 per group). The Ethical Review Board of the Regional Welfare Organization approved the research.

Living with FGM scale (LWFGM)
The tools used to collect data were LWFGM Continuum scale developed by the researcher was used to assess the knowledge level of the participants on care of girls and women living with female genital mutilation. The scale can be used by teachers, volunteers, social workers, health workers etc. 21 Items of this scale were designed on a 5-point Likert-type scale, from 0, indicating that the participant had lower level of Knowledge about the care of girls and women living with FGM, to 4, indicating that the participant had higher level of Knowledge about the care of girls and women living with FGM. The questionnaire requires participants to go through all the ten statements in each set (psychosexual and physical care, psychosexual skills and referral programs) given in it and mark their knowledge. Pilot implement of this scale reported Cronbach's alpha coe cients of .72, .77, and .70 for the subscales of Psychosexual and physical care, psychosexual skills, and referral Programs. They also found the test-retest reliability of .77, .89, and .85 for the subscales of Psychosexual and physical care, psychosexual skills, and referral Programs, respectively. Descriptive and inferential statistics were carried out for the analysis. To implement the six aforementioned programs, the selected participants were randomly assigned to the experimental and control groups, rst. The LWFGM scale was administered to both groups as a pretest. Next, the experimental group was given CBT during eight 120-min sessions (two sessions per month, for a total duration of 9 months). The control group, however, received no intervention. After eighteen sessions, the LWFGM scale was administered to both groups, as a post-test this time. Furthermore, the two groups received third administration of the test, as a follow-up measurement to examine the sustainability of changes in behaviors, 1 month later. The obtained data were then statistically analyzed using the SPSS.18 statistical software. It should be noted here that, in an attempt to adhere to ethical principles, the control group also received the treatment after the completion of this study. It is also noteworthy that the intervention program was run by the present researchers. Table 1 presents summaries of the training sessions. The results of the assessment on socio demographic variables and the knowledge gain the areas of psychosexual care, physical care and FGM victims and rehabilitation programs and student enrichment program was assessed. Results are given in Table-2. Out of 44 participants from Wadi (NGO), 44 participants who completed the pre and post assessment were included in analysis. All the participants were female and the mean age was 34.05. The average year of work experience with children was 8.55. Educational quali cation of the participants showed that majority were under graduate (54.5%) who had different background in social worker and psychology and 38.5% had Post graduate degree in social work (n = 18) whereas 9.09% had diploma degree (n = 2) Table-2.  MANCOVA results (Table 3) showed a signi cant difference in the posttest mean scores of the variables of knowledge and skills of psychosexual and physical care and referral programs between the two groups after removing the pretest effect (Wilks's lambda = 0.467; F = 6.48; p < .0001). As one can see from Table 3, the groups were different in level of knowledge and skills of psychosexual and physical care and referral programs. Therefore, based on the descriptive and inferential statistical results, care of girls and women living with FGM was effective in increasing the level of knowledge and skills of psychosexual and physical care and referral programs of social workers. In addition, follow-up measurement was performed and MANCOVA was run to investigate differences between the groups in levels of the relevant variables. To this end, prior to running MANCOVA, the Levine test was used to examine if the assumptions of homogeneity of variance were proved. The results were not statistically signi cant for any of the variables (Knowledge of psychosexual and physical care: F = 0.924, p > .05; Skills of psychosexual and physical care: F = 1.23, p > .05; Referral Program: F = 0.417, p > .05); therefore, MANCOVA could be run. In addition, to examine the homogeneity of covariance matrices, Box's M test was performed. The result was not statistically signi cant (M Box = 11.00, F = 1.56, p > .05).
Accordingly, the variance-covariance matrices of the dependent variables were equal in the two groups.
MANCOVA results (Table 4) showed a signi cant difference in the level of knowledge and skills of psychosexual and physical care and referral programs between the two groups after removing the pretest effect (Wilks's lambda = 0.489; F = 5.92; p < .0001). Table 4, on the results of follow-up measurement, shows that there have been signi cant differences between the groups in severity of knowledge and skills of psychosexual and physical care and referral programs after controlling for the effect of the pretest.

Discussion
The main objective of this study was to investigate the effect of care of girls and women living with FGM program on increasing the level of knowledge and skills of psychosexual and physical care and referral programs of social workers in Iraqi Kurdistan. The result revealed that the use of care of girls and women living with FGM program led to an increase the levels of knowledge and skills of psychosexual and physical care and referral program of the participants.
Training methodology included lectures, group discussion, activity, show videos, case analysis, etc. The methodology will be bene cial to retain participants' attention and break the monotony of sessions thereby capturing the attention of participants and ensuring their interest to gain knowledge through different activities and practice the same in their work.
The 18 days' workshop was divided into three parts, rst and second training focused on psychosexual and physical care for girls and women living with FGM. The topics covered were bio-psycho-sexual health, the impact of FGM on girls and women, techniques for physical and psychosexual care for girls and women, working with girls and women living with FGM using psychological services, and spectrum of psychosocial support. These sessions aimed to educate the participants on the curative aspects of psychosexual and physical care that will help to reduce the vulnerability of victims in different conditions.
The third and fourth training focused on the psychosexual skills education for girls and women living with FGM are essentials for the day and nightlife and individual psychosexual ability to adaptive and positive behavior (17)(18)(19). The core psychosexual skills education for girls and women living with FGM were addressed in the Third and fourth training (6 sessions) as its importance and signi cance in overall development of children is well explained by Cottingham et al (20) and the preventive intervention will further support girls and women to address the various FGM complications positively.
The FGM victim's referral program covered areas such as study-related referral problems, factors affecting referral, good refer, motivating victims to go near others, eliminating referral barriers, assertiveness, group study, the exam for a talk with other experts, were included in the fth and sixth training sessions (six sessions) aiming at the developing services and achievement in social workers work. The need for holistic care for girls and women living with FGM is well reported in various studies carried out in similar areas (21)(22)(23)(24).
The study revealed that enrich knowledge among social workers who would further train the community level workers and directly impart physical and psychosexual services for girls and women living with FGM and effective in reaching out to them in various accepts to improve the bio-psycho-sexual development and bringing in positive changes in personal, interpersonal, family, and community through the direct intervention by community-level social workers by similar studies (25)(26)(27)(28). Imparting knowledge to the grass-root social workers and reaching out to the unreached FGM population is the focus of the stop FGM project that will be achieved by training the social workers through this program.

Conclusion
The current study on the e cacy of training of trainers to impart knowledge for social workers working with girls and women living with FGM showed positive results in improving knowledge among the master trainers in major three areas of curative, preventive, and referral services in care for girls and women living with FGM. The knowledge and skills gained by the social workers from Wadi will be transferred to other community-level workers at the grass-root level with girls and women living with FGM. That will enable the services reaching to the unreached population thereby supporting FGM victims to ensure and enhance their health.