Enhancing Culturally-Informed Health Care Services for Women Affected by Female Genital Cutting in Arizona

Prevalence of Female Genital Cutting (FGC) in Arizona is uncertain; no available state or national surveys with either prevalence or risk estimates exist, necessitating estimates indirectly derived. Acknowledging a diversity of African-born communities where FGC is prevalent within Arizona, for this proposal our team chose to focus specifically on the Somali and Somali Bantu communities in Phoenix and Tucson for three reasons: 1) size of the community and FGC-related health care concerns, 2) Type III FGC (most severe form) is most common among Somali women, and 3) a long-standing record of robust community partnerships that exist among our partnering agencies and the Somali community. This Project Community will establish comprehensive strategies to ensure diverse input from partners in developing collaborative operating principles. The community partners will be: 1) involved in the planning and design of the project; 2) given the responsibility to identify Community Mobilizers; and, 3) evaluate and align the educational content of outreach materials to match cultural standards.

RWHC Clinical Care, Prior Research, and History of CBPR Engagement/Partnership RWHC: Since 2008, RWHC at Maricopa Integrated Health System (MIHS) has addressed disparities in knowledge and expertise in care of women with FGC, establishing a patient-centered medical home for refugee women. The first of its kind in Arizona, it is nationally recognized as a best practice model for refugee women's health care, addressing reproductive health disparities among newly-resettled refugee women. The multilingual, bicultural staff, refugee women who serve as Cultural Health Navigators (CHNs), facilitate an integrated team approach to comprehensive health care delivery and health care system navigation. RWHC has robust partnerships with local communities affected by FGC, engaging in Community-Based Participatory Research (CBPR) to enhance community collaboration in culturally relevant intervention/program design. Despite these efforts, there remains a critical need for increased provider cultural competency in caring for FGC-affected populations and in de-monopolizing care so that providers become skilled in caring for FGC-affected women.

Prior Research: Training among Healthcare Providers: In 2014, RWHC surveyed 508 US healthcare providers to assess awareness of FGC, prior training exposure, and current approaches to care for women affected by FGC. Results showed widespread knowledge gaps among providers, with 81% expressing a desire for further education/training on FGC. Results also showed that exposure to FGC training and direct clinical care encounters with FGC-affected populations predicted increased competency in the care of these women.

Prior Research: Gaps between Providers and Somali Women: Our team conducted a mixed-methods study in Maricopa County, Arizona (July 2011-May 2012) exploring knowledge, perceptions and experiences in the context of FGC among Somali women (n=73) and obstetrics/gynecology healthcare providers (n=74). Findings suggested a substantial lack of agreement between Somali women and health care providers on prenatal care, labor, and delivery in the context of FGC. Although providers often failed to recognize FGC-related health concerns and management around childbirth and agreed they lacked formal training on FGC- related care, they linked all types of FGC to adverse birth outcomes. Stigmatization, alienation, distrust, lack of cultural knowledge and clinical skills, and fear of surgical interventions led Somali women to delay prenatal care and arrangements for labor and delivery while they categorically rejected the imposed construct of "FGC-victimization." History of Community Engagement/Partnership: An established infrastructure of community partnership, engagement, and shared community leadership exists through the Refugee Women's Health Community Advisory Coalition (RWHCAC). The RWHCAC is an interdisciplinary team of more than 60 stakeholders from various community organizations representing local ethnic organizations, refugee resettlement and volunteer agencies, mental health and social services agencies, and academic partners. Through RWHCAC, we have partnered with the Somali community on numerous collaborative initiatives to build community capacity on Somali reproductive health issues of importance Goal and Anticipated Outcome To address health disparities for Somali women, the goal of this initiative will be to elucidate gaps in care and enhance the provision of FGC-related health care and social services for women in Arizona who have experienced FGC. Outcome 1: Identify specific FGC-related health care needs and available health and social services for FGC-affected women in Arizona. Outcome 2: Identify gaps, barriers, and/or assets in FGC-related health care and social services for women in Arizona. The Somali community has expressed their desire for greater engagement of all community stakeholders in providing community-wide education enhancing community awareness on available health services/resources, interpreting FGC-related legislation, and educating health care providers. Outcome 3: Create and implement FGC education efforts to improve culturally competent care in healthcare and social service settings for FGC-affected women. Outcome 4: Implement comprehensive community outreach and education about FGC- related health issues, prevention, and services available.

Year 1 Strategy: Outcomes 1 and 2 will be addressed by identifying specific FGC-related health care needs and available health and social services for FGC-affected women including an identification of the gaps, barriers, and/or assets in FGC-related care. Instrument: The CNHA will assess baseline and interval changes in: knowledge, attitudes, and behavioriii on FGC-health related issues, as well as gaps, barriers and/or assets in the receipt of health services (see Work Plan Appendix). This same survey will re-administered in-person or via telephone by Community Mobilizers in Year 3 to assess changes in knowledge, attitudes and behavior.