Variations in opinion between members of a community can be exploited to facilitate desirable changes in attitude, as exemplified by films that explore different beliefs about female genital cutting. See Letter p.506
Female genital cutting encompasses diverse practices, including removal of the clitoris itself. It is common in many parts of Africa and is performed on more than 2 million girls each year. On page 506, Vogt et al.1 report that a 90-minute film dramatizing conflicting opinions about female genital cutting (FGC) can reduce the appeal of the practice in Sudan, where the film was made.
FGC has attracted great interest in fields as diverse as public health, ethics, anthropology and development economics, as well as the social sciences more broadly, for two main reasons. First, FGC is often seen as a challenge to moral relativism — the claim that cultures have different, but equally worthy, moralities2,3. Second, it highlights the difficulty of changing deeply ingrained cultural practices, even when they seem manifestly unjust, dangerous or cruel4,5. But cultural norms are not adhered to uniformly. Local variations in attitudes and behaviour are common, so the seeds of change may already be present within cultures themselves (Fig. 1).
Researchers have exploited such variation between individuals by identifying clusters of like-minded people in social networks whose attitudes and behaviour could facilitate interventions ranging from polio vaccination6 to latrine adoption7. But some populations resist adopting new practices, especially when these practices are associated with colonialism. In these cases, local differences of opinion can be exploited to find exemplars of desirable behaviours. This has been done effectively with health-care providers in the United States — the quality of health-care provision can vary widely between neighbouring communities8, and superior providers have been presented as models of good practice for their peers9.
Vogt et al. addressed FGC using two field experiments that involved four differently edited versions of a high-quality film featuring Sudanese actors. The control version of the film lacked any special stimuli, containing only the main plot, which was not about cutting. By contrast, the treatment versions incorporated material that stressed differences of opinion about cutting among the characters. These differences stemmed from the point of view either of privately held values (whether FGC is healthy) or of marriageability (whether FGC enhances a girl's marriage prospects), or both.
In the authors' first experiment, a total of 189 people from 5 communities were randomly assigned to watch one of the four films. In a second experiment, 7,729 individuals from 122 communities were randomized in the same way. After the viewings, changes in attitudes were evaluated using an implicit association test designed to measure subconscious changes in attitudes. This computer-based procedure requires people to rapidly pair target concepts with an attribute. Faster pairings are interpreted as more strongly associated in the participant's mind than are slower pairings10.
The first experiment showed that, immediately after watching any of the three treatment films, viewers had the desired change in attitude: among the 189 people, attitudes towards uncut girls improved by approximately 55–64% of one standard deviation in the scores generated by the implicit association test. The second experiment showed that, one week after viewing the film, a treatment effect of about 10–11% of one standard deviation had occurred, but only in the group exposed to the film involving both types of treatment material (values and marriageability).
Unfortunately, both experiments measured attitudinal shifts at only one point in time after subjects had watched the film. We therefore do not know how stable the observed improvement was. It is possible that even a week later, for example, attitudes returned to baseline. This is a common concern in the evaluation of educational efforts, and it is usually dealt with by taking measurements at several time points after an intervention.
As Vogt et al. intimate, their results suggest that the improvements brought about by the single-treatment films disappeared within a week. Moreover, the data hint that the effect was fading even for the double-treatment film — possibly declining from around 50% to 10% of a standard deviation within a week. In addition, we do not know whether improved attitudes led to any change in behaviour, which could range from viewers discussing their beliefs with others to preventing their daughters from being cut. Closing this knowledge–behaviour gap is the holy grail of public-health interventions.
Judging by the evidence presented, a pessimist might conclude that a successful intervention must involve both types of treatment material in the film, but that even this might be effective only for a week. Moreover, the authors' analyses indicate that the individuals involved would ideally be those who are already less committed to genital cutting than are their peers.
Nevertheless, we can be sure that the film changed attitudes. And new tools to address the scourge of FGC are sorely needed. Perhaps highlighting variations in local opinion in more-sustained formats, such as long-running soap operas, might provide a means to deliver a message repeatedly, yielding longer-lasting change. Pairing film screenings with face-to-face interventions such as community meetings — or with UNICEF-supported FGC-free zones, in which entire villages agree to abandon the practice — might be even more effective. Communities often want to abandon FGC. This important work identifies an effective, indigenous tool to help them do so.Footnote 1
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Christakis, N. Female genital cutting under the spotlight. Nature 538, 465–466 (2016). https://doi.org/10.1038/nature19482