The aim of this assignment is to critically evaluate a poster used to represent a public health issue (FGM). The chosen intervention and call to action will also be critically evaluated. This essay will discuss female genital mutilation (FGM) as a public health issue and the call to action; where affected women can access a free confidential service for specialist treatment; which is the chosen intervention.
Health care is a less important determinant of health than behaviour and the environment; however, paradoxically, spending on public health in most countries suggests the opposite. Although there is increasing evidence to support public health spending, certain barriers have been shown to affect this. Some barriers include; the idea that; health policy is driven by other factors other than evidence and the time frame needed by some public health interventions to be successful. (Brownson, Chriqui and Stamatakis, 2009)
Culture, tradition and beliefs all impact on the way individuals view their health. In other words, a practice deemed healthy in one culture may be deemed otherwise in another; thus making health promotion and public heath a complex and controversial phenomenon. (Obermeyer, 2005)
FGM AND WHY IT IS A PUBLIC HEALTH ISSUE.
FGM is explained as the excision of some or all parts of a woman’s external genitalia for reasons such as, culture and tradition. (WHO, 2014) The four main classifications of FGM are; type -1: involves the removal of part or all of the clitoris; type -2: this is when the clitoris, labia minora and or labia majora are removed; type -3: also known as infibulation, is when the vaginal opening is made smaller through the creation of a seal, type 4- refers to all other procedures performed on the external genitalia for reasons other than medical, some acts includes; piercing, pricking, etc. (WHO, 2016)
This practice occurs in 30 countries and is mostly common in Africa, and in some Asian and Middle Eastern countries. (Hoffmann, 2013) With a rise in migration from all parts of the world to Europe, FGM is no longer limited to Africa; there is evidence to suggest that FGM occurs in the UK and some families take their daughters during the summer to home countries to have this done. (Dustin 2010; Momoh, 2005) There are about 137000 women living with FGM in the UK although there is concern that this figure could be higher due to the lack of robust research into this issue. (McFarlane, Morrison and Dorkenoo, 2007)
There is increasing evidence to suggest the physical and mental harm FGM presents to women, it also increases the mortality and morbidity rates during childbirth. (Kaplan et al. 2013) Some of the physical effects include recurrent urinary tract infections, pelvic inflammatory disease which may lead to infertility, recurrent vaginal infections, and complications during childbirth. Some psychological effects include; post traumatic stress disorder, depression and low self worth. (Utz-Biling and Kentenich, 2009) There is a general consensus amongst health professionals that FGM impacts negatively on a woman’s physical and mental health, which also places added costs to the economy in treating its effects. (Lockhat, 2004; Ball, 2008) According to Dustin (2010), there is evidence to suggest that FGM is being practised in the UK, although there is little evidence on the actual scale of this due to its secretive and sensitive nature (Momoh, 2005). This makes it a public health issue as it affects the society in many ways. (Leye et al. 2006)
In order for health promotion to be an effective tool in maintaining and improving lives, it is important that professionals understand that cultural identity is an important aspect of one’s life and the depth and meaning to which certain practices like FGM have in certain societies. (Merry, 2009) A person’s individual interest and their cultural identity may sometimes clash, with cultural identity taking precedence over personal interest, for example, in some poorer societies where FGM is prevalent; a woman’s chances of getting married and her family gaining from her bride price, depends on whether she has been circumcised. (Phillips, 2010) This makes the women themselves have a different opinion of FGM, viewing it as an important rite of passage rather than a human right abuse/violation. (WHO, 2016; Althaus, 1997)
According to Daley (2004), women with FGM often feel shame, uncertainty, and worry; making them reluctant in accessing health services. Midwives usually act as a first point of contact for pregnant women living with FGM and therefore have the opportunity; to inform and educate women on services to maintain and/or improve their holistic using health promotion tools like posters, leaflets and other educational interventions. (Randolph and Viswanath, 2004) It is paramount that, care, be given in a sensitive and non-judgmental in order to ensure that women feel valued and not stigmatized and that midwives are well informed and have adequate knowledge on this issue. (Lockhat, 2004; Zenner et al. 2013)
CRITICAL ANALYSIS OF POSTERS AS A MEANS OF HEALTH EDUCATION
Each year, various mass media interventions are produced to drive behaviour change and improve health. The role of public health professionals include, steering unhealthy or risky health behaviour which may be deeply entrenched and introducing other habits which although healthier, may be difficult to adapt to. (Randolph and Viswanath, 2004)
Abroms and Maibach (2008) claim, public health has a long-standing history of employing the use of mass media communication aimed to effect both the population affected by a health issue and policy makers alike.
Posters have been documented as a cheap and simple means of knowledge transfer employed as a public health tool in health promotion; which may be graphical or theoretically based with the intent of educating the public. (Illic and Rowe, 2013)
Although there is very limited evidence on their effectiveness as compared to other forms of knowledge transfer in health, posters have been documented to be a successful tool or modality in health promotion; information displayed in posters, can increase awareness, and maybe alter attitudes and behaviour.
Despite being superficial, the success of a poster in enhancing knowledge depends on mostly the graphical design (imagery) as their intent is to give a visual presentation of an issue; ‘evidence suggests that the drawing point to a poster is mainly the graphics or imagery used. (Glasziou and Haynes, 2007; Berg, 2005)
Keely (2004) claim that layout, colour schemes, readability and the way in which key information is presented all affect the overall success of the poster.
On the other hand, a study conducted to evaluate the effectiveness of posters based on imagery and other posters theory driven, showed no difference in outcomes of knowledge transfer. (Rowe and Illic, 2013)
CRITIQUE OF POSTER
GOAL
The primary goal of this poster is to inform and create an awareness of specialist services; which are free at the point of access to women living with FGM. Pregnant women usually get specialist referrals and advice from midwives once they disclose FGM; however, other women or females do not usually have contact with maternity services may not have awareness of specialist services for reversals, counselling, etc.
AUDIENCE
The target audience of this poster is aimed at females with FGM. The title and presentation of the poster clearly demonstrates this; however, the writer is aware that the use of the word “cut” may be misinterpreted or could arouse feelings of anger and upset amongst women and men in the affected communities.
CONTEXT
This poster in real life; would be displayed in areas populated with ethnic minorities, in maternity departments, mosques, churches, supermarkets and other places of socialisation. This is aimed to capture an audience other than pregnant women who may not ordinarily be aware of such free and confidential services.
SUBJECT AND CONTENT
The content of the poster is relevant to its primary goal, although better visual representation of FGM through imagery that actually illustrate FGM may prevent misinterpretation of the poster; especially in women with limited English language. On the other hand, the use of such imagery could induce feelings of stigmatisation and prevent affected women from viewing the poster for the fear of being associated with a devalued group and in effect predispose them to discrimination and stigma. (Goffmann, 1990)
The poster (appendix 1), shows a picture of a young girl who appears to have just undergone FGM and is being comforted by some older women. This aspect of the poster aims to depict the physical pain and trauma as immediate effects experienced by women who have undergone FGM. According to Zenner et al. (2013), FGM can cause immense pain and even shock because of the lack of anaesthetic during the procedure; the female undergoing this procedure is often restrained during the process. This can cause both mental and physical trauma; as most women feel they were not given a choice to refuse this practice. (Hoffmann, 2013)
It can be assumed that the women surrounding the young girl in the poster, appear to be comforting her and reassuring her that it is a normal process as part of culture, tradition, religion, etc.; and that it is in her best interest in order to be socially accepted. FGM is known to have no medical benefits, however, the perpetuators often believe that it is in the best interest of the girl; as FGM is a rite of passage, which is necessary in ensuring the girls are “clean, pure, socially acceptable and marriageable”. (WHO, 2016)
The call to action of this poster is to inform women living with FGM, that there is free and confidential help and advice available to them, through self-referral.
The latter part of the poster shows an image of two women smiling; this is aimed to inform women with FGM that, there is “life after FGM”. According to (REF), FGM reversals can be performed; to improve a woman’s sexual experience, reduce pain during intercourse and to facilitate normal vaginal birth.
Other services offered through the self-referral clinic from the poster, include counselling; which may help women with FGM suffering from mental effects like, post traumatic stress disorder, loss of esteem/confidence, and feelings of anger. (Gordon, Comerasamy and Morris 2007)
Keely (2004) claim that layout, colour schemes, readability and the way in which key information is presented all affect the overall success of the poster.
The poster, (appendix 1) has a good display of graphics, and information displayed is readable, clear and concise, which are all factors necessary in making an effective poster. (Erren and Bourne, 2007)
A range of colour tones and imagery relevant to the issue of FGM was utilised in this poster; aimed to make it visually attractive and also increase interest. The most usual drawing point to a poster is the graphical content and imagery used; as posters seek to give a visual representation of an issue. (Glasziou and Haynes, 2007)
Posters are cost effective and a cheap means of health promotion; they may facilitate learning and drive behaviour change, patients/clients can read it at their own pace and seek further information and help at their convenience; however, it is felt that posters, do not consider alternative learning styles. (Keely, 2004) The poster contains some text and mostly imagery in its presentation, however, the writer is aware that although some people enhance their knowledge by reading, other individuals may not; thereby limiting the overall success of capturing a big audience. It is therefore vital that clear navigation planes are shown in posters to give a sequential logic. (Taggert and Aslanian, 2000)
Considering its passive nature, a poster may have limited success on its target population unless other learning styles like verbal and physical interaction are implemented, which may help establish rapport and trust between the professional and the client. (Butz, Kohr and Jones, 2004) The poster, in this circumstance is intended to serve as a basis for further interaction (physical and verbal) from professionals; once an affected woman accesses the service.
The wording of key information was kept simple, clear and concise; the font size is legible from at least a metre away; to prevent the audience from having to squint to read information. According to Keely (2004), the layout, legibility and colour schemes contribute to the success of a poster. A poster may have limited success if it is not readable or understandable. (Glasziou and Haynes, 2007). The writer is however, aware that, the intended audience of this poster, which are mostly immigrants, may not have English as their first language; therefore there is a possibility that people may not understand or misinterpret the information displayed on the poster. (Berg, 2005)
This barrier may be countered by the use of a graphical illustration of FGM in the poster; which may give people who have limited English to understand the purpose of the poster. The image in the poster depicts a female, who appears to be crying due to pain after FGM, covered in a blood soaked blanket and surrounded by older women). Most cultures employ the use of a few older women for this procedure; these women may help comfort the girl or even restrain her during the process. (Hoffman, 2013)
FGM according to Momoh (2005) has significant cultural meaning to those who practice it; therefore, this poster may bring feelings of stigmatisation and even resilience towards the services offered in the affected communities.
It is also possible, women with FGM, may not want to be seen viewing this poster; because doing this might inform others of their physical deformation caused by FGM (stigma of character traits) which may lead to discrimination towards them. (Goffmann, 1990)
Daley (2004) claim women with FGM feel stereotyped and devalued, there is also evidence to suggest prejudice towards FGM amongst health professionals; hence the reluctance of women in accessing health services. And as such, attending the clinic (call to action of the poster) may predispose them to discrimination (stigma of group identity) as explained in Goffmann’s theory of stigma. (Goffmann, 1990)
Clinics like the one proposed in the poster, as a call to action may be an effective way of reaching out to women with FGM, who may be underprivileged such as illegal immigrants, or people of poor socio economic status. (Gordon, Comerasamy and Morris, 2007)
A study conducted in a West London Clinic between 1994-2005 on Somalian women living with FGM, showed that clinics such as the one proposed in the poster, are not only effective and cost efficient but also encourage women with FGM attend with various health problems. (Gordon, Comerasamy and Morris, 2007) However, according to Lockhat (2004), women with FGM are reluctant in accessing these services because they feel health professionals are stereotypical, lack understanding and empathy for them; hence the need for training and cultural awareness of FGM across maternity units in order to improve practice and ultimately health outcomes of these women.
ROLE OF THE MIDWIFE
The midwife has a duty of care to provide sensitive, competent and appropriate to pregnant women affected by FGM. In spite of evidence suggesting poor care due to stereotype and lack of adequate training amongst professionals; it is necessary that all maternity units ensure that midwives have access to adequate training and are competent and capable of caring for these women (this includes correctly recognising FGM and management of the woman in labour. (Zenner et al. 2013) There should also be clear guidelines for referrals to specialist services. (Kaplan- Marcusan et al, 2009)
Conclusion
Posters can be a good means of knowledge transfer, whilst there is a wealth of literature on producing effective posters; there is a lack of evidence to evaluate their effectiveness on behaviour change.
Given the use of posters in public health for over two decades, it is disappointing that such an established practice in health is lacking evidence in its evaluation.
Research on comparative studies to assess the effectiveness of posters as a method of knowledge transfer is needed; so as to provide an evidence base for its use.