Wrong Perceptions Towards Health Consequences of Female Genital Mutilation and Associated Factors Among Women in Adama District, Oromia, Ethiopia

Background: Wrong perceptions towards health consequences of female genital mutilation among women can contribute to the continuation of this harmful practice. So this study was aimed at determining the prevalence of wrong perception towards health consequences of female genital mutilation and associated factors among women at Adama District. Objectives: to determine the prevalence of wrong perceptions towards health consequences of female genital mutilation and associated factors among women in Adama District from October 15 to 20, 2019. Method: Community based cross sectional study design and strati�ed sampling techniques were used. Semi structured interviewer administered questionnaire translated to Amharic and Afan Oromo was used. A pretest of 10% was done on women at non-selected kebeles. Data were planned to be collected from a sample of 554 women by 4 female health extension workers. Its completeness was checked daily by supervisor and principal investigator. Data entered to Epi info version 7 were exported to SPSS version 20 for cleaning, recoding and analysis. Descriptive statistics and binary logistic regression was employed with 95% CI and p-value <0.25. Multi co-linearity was checked with variance in�ation factor >10 and multivariable logistic regression was used to determine the association between wrong perception towards health consequences of female genital mutilation among women and associated factors with 95% CI, p-value <0.05. Result: the response rate, median age and inter

So, this study was aimed at determining the magnitude of wrong perception towards health problems of female genital mutilation and associated factors among women which can help in designing intervention programs so that girls and women shall be free from this gender based violence.
Community based survey was conducted among > 15 years old women living in Adama district, Oromia region, Ethiopia from October 15 to 20, 2019.Their perception (feeling, understanding/awareness, cognition) towards health consequences or problems of female genital mutilation was determined based on 10 questions with short term and long term health consequences.Out of 507 respondents, 158 women had wrong perception towards health consequences of female genital mutilation.
Residence, no mass media exposure, no maternal care and age at circumcision were the factors associated with women's wrong perception towards health consequences of female genital mutilation.
In conclusion: nearly one in three women had wrong perceptions towards health problems of female genital mutilation which can contribute to the continuation of this practice in their community.Thus, if similar researches shall be conducted, girls and women will bene t from the interventions done based on the ndings.

Background
Female genital mutilation/cutting refers to all procedures involving the removal of part or total female external genitalia & injuries to female external genitalia for non-medical reasons (1).World Health Organization (WHO) classi ed female genital mutilations/ cutting (FGM/C) in to four types: Type I is named as Sunna and Clitoridectomy.Type II (excision), Type III (in bulations) and Type IV is unclassi ed FGM (2).
Any type of FGM is internationally recognized as violence against human rights of girls & women which violets the right to physical integrity, right to life, the right to freedom from torture or cruel act & right to health (1,3).
Globally, more than 125 million girls & women alive today have undergone FGM in 29 countries of Africa, Yemen, Asia & Middle East where the practice is concentrated (1).Globally, more than 70 million girls under 15 years have been cut or are at risk of FGM.More than 35 million girls under 15 years are living in Egypt, Ethiopia, Indonesia & Nigeria.Among these 3.6 million girls are at risk of FGM every year (3).
Ethiopia was classi ed among moderately high prevalence countries with FGM of 74% (3).According to EDHS 2016 the national prevalence of FGM among girls & women aged 15-49 years is 65.2% and in Oromia region it is 76.5% (4,5).The prevalence of FGM in under 15 years girls in Ethiopia was 16% (4,6) whereas study done in Habobo Guduru shows that 48% of girls under 15 years have been cut (7).
Although reasons for FGM vary from country to country, from culture to culture & from ethnic to ethnic, the commonest are girls should respect, obey cultural and social norms related to sexual control, womanhood and maturity, to controls girl's hyper sexuality, promiscuity, preserves virginity, avoids dis gurement and unhygienic environment of female genitalia (1,3,(8)(9)(10)(11).In Afar & Somali, it is believed that in bulations protects rape (12).Eradication of FGM had pertinent relation to SDGs 1&2( no poverty and zero hunger), goal 3(good health and wellbeing), goal 4(quality education), goal 5(gender equality), goal 8( economic growth) etc. (12,13).Perception is the process by which a person interprets and organizes sensation (see, touch, feel) to produce a meaningful experience of the world.Perception is de ned as the way youthink about something, the way you notice things with your sense organs, the ability to understand or notice things quickly.It is also de ned in philosophy, psychology and cognitive science as the process of getting awareness or understanding of sensory information.Perception is subjective interpretation and is one among components of attitude where attitude has components like perception/thoughts, feelings or belief/ and behavior/practice/ (14,15).
Perceiving the severity of health consequences of FGM affects health behavior practice.Individuals who well perceived the severity of FGM might have no likely hood of involving in the practice of FGM.In other word, wrong perception of respondents towards health consequences of FGM couldn't bring attitudinal changes which in turn makes elimination of the practice of FGM di cult (12,13).
The health extension package launched since 2003 was one of the strategy to address harmful traditional practices like FGM etc. through health education and promotion employing more than 42,000 female health extension workers (17).Ethiopia launched strategic action plan to improve awareness or perception towards the harms of FGM on economy and health of girls and women.Among activities done, awareness raising and social mobilization to bring attitudinal changes through community conversation, empowerment of girls and women through training, skill building, sharing information, religious based interventions, 'iddir', folksong social media to increase girls' & women's perception of health problems of FGM (18,19).
But, lacking coordination among institutional structures, non-uniformity of awareness creation activities in entire country, nancial or resource constraint, unsustainable intervention activities, absence or low legal support, deep rooted cultural and religious beliefs that promote FGM in many parts of the country, low level of awareness at grass root level and rural areas are the challenges to eliminate harmful traditional practices like FGM (19).
Female genital mutilation has a direct harmful effect on reproductive health of women that is an irreversible damage to female external genitalia that has immediate & long term complications (20).
Hemorrhagic and neurogenic shocks, severe pain, urine retention, infection (HIV/AIDS infection and tetanus) are some of the immediate complications.Damage to adjacent organs, pain during sex, failure of the wound to heal, formation of abscess, dermoid cyst, kelloid scar, narrowing of the opening of vagina so that di culty in passing head of the new born, excessive bleeding during delivery, risk of caesarian section, episiotomy, and death(estimated 100, 000 teenagers death per year during child birth due to complications related from FGM etc. are the long term complications (2,3,21).Degree of severity of complication depends on the type of FGM performed, cleanliness of instrument used and skill of the person who performed the procedure.Type I & II having less severe, but type III (in bulations) results in more severe complications (3).
A study conducted in Nigeria shows that 26.3% of women didn't perceive FGM has gynecological problems (22).Other study conducted in Nigeria also shows that 47.2% 36.8%,31.1% and 36.8% of women didn't perceive FGM can result in dyspareunia, excessive bleeding during procedure, infection and incontinence respectively (23).
Studies conducted in West Shewa and Bale Zone of Ethiopia reveal that 11.6%, 63% of women didn't perceive FGM has health consequences respectively (24)(25)(26).Study conducted in West Shewa shows that 40.5% of women didn't perceive the immediate complications of FGM and study at Kersa, West Hararge shows 68.8% of women didn't perceive any health complications of FGM (24,26).These studies show large number of women had low perception towards health consequences of FGM.
Wrong perception towards health consequences of FGM is believed to result in attitude towards continuation of FGM which makes eliminating or ending FGM programs di cult.Studies show women's perception towards complications of FGM was low in Ethiopia (19,24) and as far as the knowledge of the investigator, there is no or scarce study done on similar topic.Thus this study was aimed to determine the prevalence of wrong perceptions towards health consequences of FGM and associated factors among women in Adama District.

Study Area and Period
Adama district is one of the district /woreda/ among East Shewa Zone which is located around Adama City 100 Km South West from Addis Ababa in Oromia regional sate.According to the Adama district /Woreda/ Health O ce, the district has 9 health centers and 35 health posts to serve 37 rural kebeles / the lowest administrative structure/ & 5 sub urban kebeles with an estimated population of 200,563.Among these, the total number of women 15 years and above is 44, 385 with 41,784 households.The study was conducted from October 15 to 20, 2019.
Study Design: community based cross sectional study design was used.
Source population: all women of reproductive ageand above (≥ 15 years) who live in Adama district.
Study Population: all women of reproductive age and above (≥ 15 years) who lived in study area & who wereselected during data collection.
Inclusion Criteria: all volunteer women of reproductive age and above (≥ 15 years) who lived in the area for more than 6 months.
Exclusion Criteria: critically ill respondents were excluded.

Sample Size Determination
Single population proportion formula was used to calculate the sample size of 358 women.
Thus, using design effect of 1.45 (519 respondents) and adding 10% non-response rate (35 respondents), the nal sample size (n) was 554 women.

Sampling Procedure
Strati ed sampling technique was used to homogenize kebeles of Adama district in to urban and rural.
Due to feasibility problem, 4 rural kebeles having 3,492 households and 2 sub urban kebeles with 2,927 households were selected with lottery method.Then, households from those 6 selected kebeles were selected randomly.Two hundred fty three (253) and three hundred one (301) respondents were randomly selected from selected urban and rural kebeles respectively which resulted in a total of 554 respondents.Finally, only a woman (≥ 15 years) from selected households was interviewed.Where more than one woman encountered in a household, one respondent was selected by lottery method.The next house hold was selected where there was illegible woman in the household.Dependent Variable: wrong perceptions towards health consequences of FGM.Adama District: Adama district is one among woredas in East Shewa Zone which is different from Adama town.
Wrong perception: is an individual's unperceived or not aware of or unrecognized health consequences of FGM through senses or cognition.It was aggregated from 10 Likert item questions containing immediate and long term consequences of FGM that were given scale of 1-5 where 1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree and 5 = strongly disagree were used to measure perceptions(36-38).And wrong perception was the study participants score below median score for it is categorical variable.Data collection tool: A pre-tested, semi structured interviewer administered socio demographic and10 Likert scale items questionnaire adapted from different literatures (3,4,9,22) was prepared in English.
Data collection procedure: Questionnaire prepared in English was translated to Amharic and Afan Oromo language by university lecturers to collect primary data from respondents at selected households.Four female health extension workers and a BSc nurse who speak Amharic and Afan Oromo were used as data collectors and supervisor respectively.The data were collected during market free days at rural house hold and weekend at urban house hold to get respondents at home.

Data quality control
To ensure the quality of the data, training of the data collectors and their supervisor was under taken for half day by the principal investigator on the objectives, relevance of the study, way of interview, con dentiality of information and informed consent.Pretest was done on 10% of sample size of similar population at non selected kebele to check the errors and take correction before the actual data collection.Completeness of questionnaires was checked daily by supervisor and principal investigator.

Data processing and analysis
After the data collection was completed; the data were checked visually for completeness and entered in to EPI Info version 7 and exported to SPSS version 20 for cleaning, recoding and analysis.Summary statistics like median and inter quartile range were done.
Wrong perception towards health consequences of FGM was measured by 5 point Likert Scale(36-38) and constructed by aggregate summationof scores from 10 Likert item question responses.Based on different literatures, respondent's responses were collapsed in to two to make outcome variable dichotomous (wrong or Right perception)in order to employ logistic regression analysis (37,38).Then, individual responses were summed and those who had scored abovemedian score were classi ed as having right perception, but those who scored below median score classi ed as having wrong perceptions.
Binary logistic regression was employed with 95% CL and p-value < 0.25 to determine the relationship between dependent and independent variables.Multi co-linearity among factors was checked with VIF > 10.Then, multivariable logistic regression was employed to determine factors associated with wrong perceptions towards health consequences of FGM with 95% CL, p-value < 0.05.Goodness of t test was checked using Hosmer-Lemishow with p-value > 0.05.

Ethical clearance
Ethical clearance was obtained from Adama Hospital Medical College Ethical Review Board, OHB, Adama District health o ce and leaders of selected kebeles.Then, after explaining the objective of the study, oral consent was obtained from the respondents for interview.

Socio demographic characteristics of Respondents
In this study, 554 women were included, but 507 women responded to our interview making the response rate of 91.52%.The median age of the respondents was 30 years.Then, Q1 and Q3 were 24 and 42 making IQR of 18 years old respectively.Most of the respondents 364(71.8%)and 371(73.2%)were married and born in rural areas respectively.Fifty percent of women live in rural area.Most of respondents 219(43.20%)were in elementary education, 299(59%) were house mothers, 317(62.53%)were Oromo in ethnicity and 301(59.4%)were Orthodox in religion (see Table 1

Bivariate analysis
Extreme responses (strongly agree, agree and neutral were collapsed to agreement whereas strongly disagree and disagree were collapsed to make disagreement) to dichotomize responses for bivariate analysis.Those who scored above median (≥ 25) were coded (0) as having right perception and those who scored below median (< 25) were coded (1) as having wrong perception.
Binary logistic regression was employed with 95% CI, p-value < 0.25, multi-collinearity was checked with variance in ation factor (VIF > 10) and nally Logistic Regression was employed with 95% CI, p-value < 0.05 to assess factors associated with wrong perceptions towards health consequences of FGM among women.

Factors associated with wrong perceptions towards health consequences of FGM
Rural residence, having no mass media exposure like TV/Radio, not having maternal care service (ANC/PNC) and age at circumcision ≥ 11 years were variables that had statistically signi cant association with wrong perception towards health consequences of FGM in Multivariable Logistic regression analysis.
Women from rural areas had 76% more odds of having wrong perceptions towards health consequences of FGM compared to women residing in urban (AOR = 1.78, 95% CI: (1.03, 3.01).
Respondents who had no maternal care service (ANC/PNC) had 2.61 times higher odds of having wrong perceptions towards health consequences of FGM compared to those who had maternal care service during last pregnancy or child birth (AOR = 2.61, 95% CI: (1.45, 4.69).
Those respondents who had no mass media exposure (TV/Radio) had 2.79 times higher odds of having wrong perception towards health consequences of FGM compared to women who had mass media at home (AOR = 2.79, 95% CI: 1.23, 6.32).
Finally, respondents who had been circumcised at age ≥ 11 years had 61% lesser odds of having wrong perception towards health consequences of FGM compared to those who had been circumcised at age less than or equal to 5 years (AOR = 0.39, 95% CI: 0.19, 0.80).(See Table 4 below)

Discussions
This study showed that about 31% (95% CI: 27, 35.5) of women had wrong perceptions towards health consequences of FGM which was higher than 26.3% of study conducted in Nigeria (22).Similarly, the nding of this study was higher compared to 10.6% of study conducted in West Shewa(26), lower compared to 63% of study conducted at Bale Zone (25) and 68.8% of West Hararge.
These differences could be due to differences in age at circumcision, mass media exposure and difference in study population which resulted in differences in wrong perception.Girls and women who had been circumcised at earlier age may not recall immediate consequences and circumcised women who experienced health problems during delivery might not also relate the problem with FGM which resulted in differences ofwrong perceptions towards health consequences of FGM (39).
In this study, respondents who had no mass mediaexposure to TV/Radio had 2.79 times higher odds of havingwrong perceptions towards health consequences of FGM compared to those who had mass media at home.This is because having mass media exposure can help in increasing awareness orunderstanding of health consequences of FGM which could help to bring healthy behavior in the community.
In this study, women from rural had 76%more odds of having wrong perceptions towards health consequences of FGM to those living in urban areas.Women living in urban also have more access to information about health consequences of FGM than those women living in rural area.Women residing in denser urban area have more relation with different women having better educational status and different experiences through neighborhood, work place and social interaction.Thus, woman's perception towards health consequences of FGM can be affected by other women's perception towards health consequences of FGM.This could be the reason for rural women to havewrong perceptions towards health consequences of FGM.
In this study educational status of respondents didn't associate with wrong perception towards health consequences of FGM.But as educational level of respondent increases, through educational discussions with teachers and peers about FGM, the perception towards health consequences of FGM increases (29).
This study revealed that women had no maternal care services during their last pregnancy or child birth had 2.61 times higher odds of having wrong perception towards health consequences of FGM compared to those who had maternal care services.It is believed that women who have maternal care service can have a chance to get some health educations and have a chance to see posters related to harms or consequences of FGM which can improve their perception towards health consequences of FGM.
In this study, respondents who underwent mutilation at age of ≥ 11 years had 61% lesserodds of having wrong perceptions towards health consequences of FGM compared to those who underwent circumcision at under 5 years of age.Respondents who underwent mutilation at early childhood can have wrong perception towards health consequences of FGM due to immature mental status compared to older age.Consequences due to FGM during early age can be undermined or unrecalled.To the contrary, those who underwent FGM at older age can have better perception towards health consequences of FGM.
Because of the absence of similar qualitative and quantitative literatures, the results of this study were not compared or discussed further.Thus, qualitative and quantitative studies were recommended.
Strength of the study: The title of this study was new and employed strati cation sampling method to increase representativeness from urban and rural areas.It also used primary data which helps to make generalization and can help in intervention programs.

Limitation of
Since cross sectional study design was used, there could be interviewer information bias, social desirability bias and couldn't detect cause and effect temporal relationship.

Conclusions
Nearly one third of respondents had wrong perceptions towards health consequences of FGM in the study area.Rural residence, having no maternal care service, having no mass mediaexposure and being circumcisedat age ≥ 11 yearswere factors that had statistically signi cant association withwrong perception towards health consequences of FGM in multivariable logistic regression analysis.

RECOMMENDATIONS
Based on the result of this study, the following recommendation was forwarded: To PHCU: Health centers and health posts in the study area shall increase maternal health care services like ANC, PNC and institutional delivery.Health education about FGM and its health consequences shall be given to women in the study area to decrease women's wrong perception towards health consequences of FGM.
To Adama District Health O ce: Shallprovide campaigns, health education at schools, and awareness creation to women during meeting days etc. in collaboration with NGOs in the area to decrease women's wrong perception towards health consequences of FGM.
To regional health Bureau: Oromia region health bureau shall design behavior change intervention programs through health education in health extension program and provide training to women to improvewrongperceptions of women towards health consequences of FGM.
To NGOs: NGOs shall also set programs like awareness creation campaigns and distribute health education lea ets prepared in local languagesto address wrong perceptions towards health consequences of FGM.
To Researchers: I recommend qualitative and quantitative studies on similar topic.
Independent Variables:Socio demographic factors: age, educational status, residence, birth place, marital status, occupation, religion, ethnicity Gynecologic and Obstetric factors: parity, maternal care service (ANC & PNC), status of circumcision, type of FGM performed, place of delivery and age at circumcision Behavioral factors: exposure to mass media (TV/Radio) Health Consequences of FGM:Short and long term consequences of FGM Operational De nition Female Genital Mutilation: In this study, if the participant admits or gives verbal autopsy of only part of esh cut as type I, part of esh cut & removed classi ed as excision & if sewn or closed as in bulations to avoid di culty of identifying the type of mutilation(35).

Table 1
85%) had given the last birth at health institution.Four hundred fty one (89%) of respondents claimcurrently there was no practice of FGM in their community.Prevalence of FGM was 399(78.7%)andmost of the respondents 170(42.6%)didn'tknowtheirageatcircumcision.Nearly 93% was type II FGM with 88% of FGM performed by female traditional circumcisers (See Table2below).Out of 507 women, 158(31.2%)hadwrongperceptions towards health consequences of FGM.Among 507 respondents, 190(37.48%)disagreedthatFGM can result in urine retention after the procedure.One hundred seventy ve (34.52%) respondents disagreed FGM can be a cause for HIV/bacterial infection and 178(35.11%)of the respondents disagreed on the wound healing problem of FGM.There was disagreement of severe bleeding during the procedure of FGM among 172(33.92%) of women.Fifty percent of the respondents disagreed on FGM as a risk for prolonged labor.Similarly, 254(50.1%) of women disagreed that FGM can result in severe bleeding during delivery.About 74% of women disagreed that FGM can cause urine incontinence, 218(43%) of women disagreed FGM can lead to sexual dissatisfaction, 191(37.67%) of women disagreed that FGM can cause sexual pain and 176(34.72%) of respondents disagreed on FGM can be a risk for neonatal and maternal death.(SeeTable3below).

Table 3
Perceptions towards health consequences of FGM among respondents in Adama District, Oromia, NB: FGM-Female Genital Mutilation, HIV-Human Immune De ciency Virus

Table 4
Factors associated with wrong perceptions towards health consequences of FGM among women of reproductive age and above, Adama District, Oromia, October, 2019