Forsker på risiko for og utbredelse av kjønnslemlestelse i Norge
Målet er bedre helsehjelp og forebyggende tiltak.
Navn: Mai Mahgoub Ziyada
Alder: 46 år
Arbeidssted: Nasjonalt kunnskapssenter om vold og traumatisk stress (NKVTS)
– Using a refined methodology, this research project aims to provide updated knowledge about the prevalence and risk of FGM/C (female genital mutilation or cutting red.anm.) in Norway.
Why is this important?
– FGM/C causes physical, psychological, and sexual health problems. Therefore, many girls and women who have been subjected to FGM/C need healthcare and those who have not yet been subjected need protection from FGM/C and its associated health problems.
– In order for the services to cater to the potential healthcare needs among the exposed, we need knowledge of the number of those affected, their age, country of origin, type of FGM/C, and thus type of needed healthcare. Similarly, preventive services need to know the number of those at risk, which factors prevent or promote the risk of FGM/C, and which municipalities to prioritize.
– Currently available estimates are based on data from 2013. Moreover, the methodology for the previous estimates has some limitations that this research project aims to address and subsequently provide policy- and decision-makers with recent and reliable estimations of the prevalence and risk of FGM/C in Norway. The research project will also strive to improve the extrapolation models for the prevalence and risk estimation of FGM/C in countries of migration.
Female genital mutilation or cutting (FGM/C)
Female genital mutilation or cutting (FGM/C) is defined by the World Health Organization (WHO) as «all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons».
What do you want to find out?
– We are organizing the research project in two work packages (WP). The first WP aims to identify factors influencing attitudes and behaviors towards FGM/C in Norway and estimate the effect size of migration and acculturation and preventive and protective measures (MAPPM) on attitudes and behaviors towards FGM/C among different affected migrant groups.
– The second WP, on the other hand, aims to estimate the number of girls and women subjected to FGM/C and the number of girls at risk in Norway.
How will the project be carried out? Do you have a schedule?
- The Delphi method is a process mostly used in research and economics, that aims to collect opinions on a particular research question or specific topic, to gain consensus.
- The opinions are collected from a group of experts that are not physically assembled, normally through questionnaires.
– In the first WP, we combine a literature study with an expanded use of Delphi, and limit our target group to the six largest affected population groups (Somalis, Sudanese, Eritreans, Ethiopians, Gambians, and Kurds). In a previous study, these six groups constituted over 90 percent of all girls and women subjected to FGM/C in Norway. We will recruit people with experience from and/or knowledge of FGM/C among the target group to participate in four Delphi panels (Somalis and Sudanese, Eritreans and Ethiopians, Gambians, and Kurds). The experts will include researchers, service providers (e.g., child protection services), and those involved in FGM/C preventive works, including immigrant organizations. We will prioritize people with a background from the relevant FGM/C practicing countries while selecting the experts.
– The Delphi method is based on group consensus among experts accomplished through several rounds of structured communication. Using ranking-type Delphi, we will first conduct a literature review to identify factors that influence attitudes and behaviors related to FGM/C in Norway and other countries of migration. These factors will then be discussed and adjusted in a reference group with user representatives.
– Thereafter, the Delphi process will be conducted in three phases combining qualitative and quantitative data. In the first phase, we will send a questionnaire with a list of identified factors via email, asking all experts to use their expertise to add to the list and explain the newly added factors. Returned questionnaires will be processed, duplicates will be deleted, and a new questionnaire with all identified factors will be developed and sent back to the experts for validation. In the second phase, we will send the new validated questionnaire to the experts on each panel and ask them to narrow down the list and justify their decisions. Subsequently, we will include factors retained by more than 50 percent of experts at each panel in a questionnaire with four different lists.
– In the third phase, we will ask the experts at each panel to use their expertise to score the effect size of each factor on their list with a total score of 10. We will also ask the experts to justify their scores. We will then analyze the data and provide the experts with an anonymized overview of both their own and other panel participants’ weighting and justification and the opportunity to adjust their scores. This process will be repeated until consensus is reached within each panel, assessed by statistical analysis (Kendall’s W coefficient of concordance). Finally, we will calculate the MAPPM impact factor separately for each panel by summing up the scores (0-10) given to all factors related to MAPPM in each of the four lists.
– In the second WP, we will first estimate the number of girls and women in Norway subjected to FGM/C pre-migration by extrapolating prevalence data on FGM/C from countries of origin to our reference population and adjusting for age, education, and regional differences. We will then present this estimation stratified by types of FGM/C and the municipality of current residence. For this step, we will use data from SSB on our reference population divided by age upon arrival in Norway, place of birth, municipality of current residence, and education level upon arrival in Norway. From the latest DHS and MICS reports from the 31 FGM/C practicing countries, we will use prevalence data on FGM/C divided by region, age, levels of education, and types of FGM/C.
– Next, we will estimate the number of first-generation girls subjected to FGM/C post-migration, the number of second-generation girls subjected to FGM/C, and the number of first- and second-generation girls at risk of FGM/C. We will extrapolate prevalence data on FGM/C from countries of origin to our reference population and adjust for age, length of stay in Norway, and regional differences. In addition, to adjust for changes in attitudes and behaviors towards FGM/C among the reference population in countries of migration, we will use the MAPPM impact-factor values that we calculated in the first package for Somali, Sudanese, Ethiopian, Eritrean, Gambian, and Kurds. We will assign a value of “1” to the impact factor for the rest of the groups. After that, we will present the estimation of FGM/C prevalence post-migration and among second-generation girls stratified by types of FGM/C and the municipality of current residence.
– Similarly, we will present risk estimation stratified by the municipality of the current residence. We will use SSB data on first-generation resident girls divided by birthplace, age upon arrival in Norway, current age, and residence municipality. We will also use SSB data on second-generation resident girls divided by the mother’s birthplace and length of stay in Norway, current age, and residence municipality. DHS and MICS data will consist of the prevalence of FGM/C divided by region, age, and types of FGM/C.
Who has initiated the project, and who is involved?
– Ziyada (postdoc and project leader) and Johansen (supervisor) took the initiative. Representatives of all project end-users (Norwegian policy- and decision-makers, national and international researchers, service providers, NGOs, and girls and women from FGM/C-affected communities) participate in a reference group and provide input and advice during the planning, implementation, and dissemination of the research project.
- Professor assistant Els Leye, University of Ghent. Leye is an esteemed FGM/C researcher who has a central role in adapting the extrapolation models in the EU. She was the principal investigator of the first study for the EIGE on FGM/C in the EU and the lead of an EU-funded project that aimed to enhance FGM/C prevalence estimations in the EU. In addition, she was a member of the expert group for the Dutch prevalence study of 2019 and published many papers on the subject.
- Dr. Abdi Gele, the Norwegian Institute of public health (FHI). Gele is an esteemed senior researcher who had previously received funding from DAM (through NKS) for his FGM/C-related research. In his Ph.D. project, Gele compared attitudes toward FGM/C between Somali immigrants in Oslo, Norway, and their corresponding group in Hargeisa and Galka’ayo Somalia.
- Marit Severinsen, NKS. Severinsen is a midwife, senior advisor of integration and diversity, and the national project leader of the multicultural doula «Flerkulturell doula». She has extensive experience and knowledge of sexual and reproductive health issues, including issues particularly relevant to immigrant communities.
- Janne Waagbø, the Norwegian Directorate for Children, Youth, and Family Affairs (Bufdir). Waagbø is the coordinator of the national competence team against forced marriage, female genital mutilation, and negative social control.
- Gro Saltnes Lopez, senior advisor, the Norwegian directorate of health (Hdir) (a tentative representative of Hdir in the project’s reference group)
- Wolela Haile, general manager of THI, and Leoul Mekonen, leader of RKF: Haile and Mekonen, first-generation immigrants from FGM/C practicing countries, have a deep cultural understanding of the problem. They have also conducted numerous projects on FGM/C prevention among various immigrant groups in Norway and attained essential insights relevant to our research project.
Stiftelsen Dam makes demands for user participation. How is that taken care of in this project?
– The end users of this research project include Norwegian policy- and decision-makers, national and international researchers, service providers, NGOs, and girls and women from FGM/C-affected communities. Representatives of these end-users form our reference group and will provide input and advice during the planning, implementation (first- and second- WP), and dissemination of the study.
– They will first offer feedback and advice concerning the identification and selection of participants for the four expert panels in the first WP and then help to recruit selected participants. They will also provide input and advice on which variables to order from SSB for the second WP, quality-assure the analysis plan, and help disseminate the findings.
– National and international researchers will also help disseminate the findings through scientific articles and oral presentations. The results will also be published via NKVTS’ and NKS’ digital platforms, including social media. NKS will use findings in their current and future projects targeting immigrant women, including health days and other initiatives for promoting integration, equal health services, and health competence. Policy- and decision-makers and service providers from both governmental institutions and non-governmental organizations will use the study findings in their FGM/C-related work (e.g., planning, prioritization, and resource allocation) and help disseminate the results and experiences to other organizations and users.
Denne studien vil gi oppdatert og godt fundert kunnskap om utbredelse og risiko for kjønnslemlestelse i Norge. Fordi kjønnslemlestelse medfører fysiske, psykiske og seksuelle helseplager, har mange utsatte jenter og kvinner behov for helsehjelp. De som ikke er utsatt må beskyttes fra kjønnslemlestelse og derav følgende helseplager. For at tjenestene skal kunne ivareta utsattes behov for helsehjelp, trenger vi kunnskap om antallet berørte, deres alder, landbakgrunn, type kjønnslemlestelse og dermed type helseplager, og i hvilken kommune de er bosatt. Tilsvarende trenger forebyggende tjenester å vite antallet som er i risiko, hvem de er, hvor de bor og hvilke faktorer som hindrer eller fremmer risiko for kjønnslemlestelse. Tilsvarende kunnskap fra 2013 er utdatert og bør oppdateres og forbedres med bedre metoder. Prosjektet er delt i to work packages og kombinerer kvalitative og kvantitative metoder. I første work package vil det først gjennomføres en litteraturstudie for å identifisere faktorer som påvirker holdning og adferd knyttet til kjønnslemlestelse i en migrasjonskontekst. Disse faktorene vil så diskuteres i en faglig ekspertgruppe med brukerrepresentanter. Deretter vil vi sette sammen fire ekspertpanel fordelt på landbakgrunn som gjennom en «Delphi-tilnærming» vil justere listen, og vekte effekten av de ulike faktorene med en total poengsum for alle faktorer på 10, og begrunne dette. Deretter vil de få en anonymisert oversikt over de andre paneldeltakernes vekting og begrunnelse og mulighet til å justere sin egen. Dette vil gjentas inntil det er nådd tilnærmet enighet innen hvert enkelt panel, basert på en statistisk analyse. I andre work package vil vi estimere antall utsatte og i risiko, fordelt på type kjønnslemlestelse og bosetting i Norge. Vi vil ekstrapolere tall fra befolkningsstudier om utbredelse i opprinnelseslandene (Demographic Health Survey (DHS) og Multiple Indicator Cluster Surveys (MICS)) på befolkningsdata fra SSB, og kontrollere for effekten av faktorer som påvirker holdning og adferd knyttet til kjønnslemlestelse estimert i første work package. For å ta høyde for endringer i innvandrerbefolkningen vil vi bruke SSB sin befolkningsstatistikk per 1/1 2022 og siste tilgjengelige tall for hvert opprinnelsesland. Prosjektet vil bidra til forhinding av kjønnslemlestelse og ivaretakelse av nylig identifiserte helsebehov, bl.a. psykoseksuell rådgivning. Det vil føre til bedre fysisk og psykisk helse og dermed livskvalitet for berørte jenter og kvinner, og på lang sikt komme samfunnet til gode gjennom økt integrering og samfunnsdeltakelse. Resultatene fra prosjektet er også nyttig for frivillige organisasjoner som arbeider med innvandrerhelse og integrering, og særlig for N.K.S. betydningsfulle innsats med å fremme seksuell og reproduktiv helse blant innvandrerkvinner. Prosjektet vil også imøtekomme rapporteringskravet om kjønnslemlestelse i FNs bærekraftmål. Videre den forbedrede metoden vil være nyttig i andre migrasjonsland.