Research Article: The Saleema initiative in Sudan to abandon female genital mutilation: Outcomes and dose response effects

Date Published: March 12, 2019

Publisher: Public Library of Science

Author(s): W. Douglas Evans, Cody Donahue, Jeremy Snider, Nafisa Bedri, Tibyaan A. Elhussein, Samira Ahmed Elamin, Kimmo Eriksson.


The overall goal of the Saleema Initiative in Sudan is to promote long-term abandonment of female genital mutilation and cutting (FGM) through a contribution to changing social norms, attitudes, and intentions related to the practice. The initiative aims to create positive cultural associations with a girl remaining uncut, a new social norm. Saleema hypothesizes that branding the alternative to FGM (abandonment) will promote social norms change. In 2014, the lead author designed a monitoring and evaluation framework for Saleema in partnership with UNICEF, the National Council for Child Welfare (NCCW), and local organizations.

The Saleema evaluation aimed to evaluate the effectiveness of the campaign in reducing pro-FGM social norms. A quasi-experimental design controlled for dosage of campaign messages delivered across the 18 states in Sudan to measure a dose-response effect. We operationalized social norms through a 4-item scale validated in previous research.

This paper reports on quantitative evaluation findings based on data gathered in from 2015–2017 and focuses on the dose-response relationship between Saleema exposure and changes in FGM social norms. We found that self-reported exposure was associated with reduced pro-FGM social norms (coeff. = -0.329, p < .001). Additionally, higher doses of Saleema, measured through an exogenous measure of campaign event exposure from an independent monitoring system was associated with reduced pro-FGM social norms (coeff. = -0.146, p < .001). Saleema was effective in reducing pro-FGM social norms. It is a promising strategy and findings contribute to the growing literature on social norms approaches to behavior change.

Partial Text

The World Health Organization (WHO) and other global health and development organizations, including the Department for International Development (DFID) and US Agency for International Development (USAID), note female genital mutilation and cutting (FGM/C, herein FGM) is a widespread and harmful practice [1]. There are 4 main types of FGM, ranging in severity from Type I to IV.2 FGM prevalence is highest in 27 countries in Africa and the Middle East [2–3]. In Sudan, FGM is highly prevalent among all age groups of girls and women, with an estimated national prevalence rate of 87% among women aged 15 to 49 years [4]. Recent data from the Multi-Cluster Indicators Survey (MICS) suggest there is a steady, though modest, decline in the rate of FGM among the younger age cohorts (age 25 and below) and 52% of women believe the practice should stop [4].

The total sample size at W3 was 3,824, at W2 it was 3,724, and at W1 it was 3,720, or 11,268 in total. The total sample was 55% female, mean age was 38.3 years, mean age among women at first cut (when applicable) was 6.7 years, and mean age at marriage (when applicable) was 20.2 years.

The Saleema outcome evaluation sheds light on the nature FGM in Sudan and provides evidence for the initiative’s effectiveness in changing social norms. Overall, findings suggest that social norms are changing in Sudan over time and during the Saleema implementation period. Dosage of Saleema has been effectively measured using both exogenous (independent) and endogenous (self-report) measures. Exposure to the initiative is associated with reduced pro-FGM social norms and other hypothesized outcomes. These findings both help to answer the initial questions that guided this research, and suggest the need for future programmatic initiatives and research on how to change FGM social norms and eliminate the practice.

There is evidence that higher levels of exposure to Saleema leads to reduced pro-FGM social norms. The campaign has been effective in affecting its primary outcome of interest, improved social norms, and represents a promising strategy for abandonment of FGM in Sudan. This study suggests future FGM elimination programs in other LMIC may also benefit from adopting a social norms approach based on branding for behavior change. This study contributes to the growing literature on social norms.