Examensarbete i omvårdnad Malmö högskola
Nivå 61-90 p Hälsa och samhälle
Sjuksköterskeprogrammet 205 06 Malmö
Hälsa och samhälle
HUR SVENSKA
SJUKSKÖTERSKOR KAN
BEMÖTA ÄMNET KVINNLIG
KÖNSTYMPNING
EN LITTERATURSTUDIE
NANDI ZULU
LINDA ÖBERG
HUR SVENSKA
SJUKSKÖTERSKOR KAN
BEMÖTA ÄMNET KVINNLIG
KÖNSTYMPNING
EN LITTERATURSTUDIE
NANDI ZULU
LINDA ÖBERG
Zulu, N & Öberg, L. Hur svenska sjuksköterskor kan bemöta ämnet kvinnlig könsstympning. En systematisk litteraturstudie. Examensarbete i omvårdnad, 15
högskolepoäng. Malmö högskola: Hälsa och samhälle, Utbildningsområde
omvårdnad 2010.
Abstrakt
Bakgrund: Enligt WHO beräknas uppskattningsvis tre miljoner flickor vara i
riskzonen att utsättas för kvinnlig könsstympning varje år. Om man tittar på migrationen i det mångkulturella landet Sverige finns det uppskattningsvis 28 000 kvinnliga invånare som kommer från länder där kvinnlig könsstympning
förekommer. Syftet: Är att beskriva hur svenska sjuksköterskor kan hantera och ta hand om kvinnor som har utsatts för kvinnlig könsstympning. Resultat: Visade att vårdpersonal inte har tillräcklig kunskap gällande dessa kvinnor. Kvinnornas möten med sjukvård i ett främmande land var både positiva och negativa, i relation till hur mycket kunskap personalen hade om kvinnlig könsstympning.
Slutsats: I enlighet med flertalet granskade artiklars slutsats finns ett behov av en
bredare kunskap i ämnet kvinnlig könsstympning för att hälso- och sjukvårdspersonal ska kunna ge bästa möjliga vård.
Nyckelord: Bemötande, litteraturstudie, kvinnlig könstympning, kvinnor,
HOW SWEDISH NURSES CAN
ADDRESS THE SUBJECT OF
FEMALE GENITAL
MUTILATION
A LITERATURE STUDY
NANDI ZULU
LINDA ÖBERG
Zulu, N & Öberg, L. How Swedish nurses can address the subject of female genital mutilation. Degree project, 15 Credit Points. Nursing Programme, Malmö University: Health and Society, Department of Nursing 2010.
Abstract
Background: According to the WHO it is estimated three million girls are at risk
of undergoing female genital mutilation every year. Looking at the migration in the multicultural country of Sweden there is an estimated 28 000 women inhabitants that originate from countries were female genital mutilation occurs.
Aim: To describe how Swedish nurses can address and care for women who have
been exposed to female genital mutilation. Result: Showed that health care personnel do not have sufficient knowledge on how to address these women. The women‟s encounters with health care in a foreign country were both positive and negative and this related to how much knowledge the personnel had about FGM.
Conclusion: As many of the articles reviewed stated a broader knowledge on the
subject of FGM is needed in order for health care personnel to give the best possible care.
Key words: Addressing, female circumcision, literature study, nursing, Sweden,
TABLE OF CONTENT
INTRODUCTION 5 BACKGROUND 5 Different types of FGM 5 History 6 Cause 6 Prevalence 6 FGM practise in Sweden 6 Health consequences 7 Nursing in Malmö 8 Holistic view 8 Laws 8 AIM 9 METHOD 91. Specify the Assessment Problem 9 2. Specify Inclusion Criteria for Studies 9 3. Formulate Plan for Literature Search 9 4. Conduct Literature Search and Retrieval 10 5. Interpret the Study Evidence 11
6. Integrate the Evidence 11
7. Formulate Recommendations Based upon
Evidence Quality 11
RESULT 11
Addressing FGM 12
Experience of health care in a foreign country 13
Adapting to a new culture 14
DISCUSSION 14 Method Discussion 14 Result Discussion 16 CONCLUSION 19 REFERENCES 20 ATTACHMENTS 23 Attachment 1: Appendix 1 24 Attachment 2: Bedömningsmall för kvalitativa artiklar 34
INTRODUCTION
Female genital mutilation (FGM) is a practise that affects a number of women worldwide, due to migration some of these women now reside in Sweden (WHO, 2008). There is an estimated 28 000 women in Sweden that originate from countries where FGM occurs (Berggren & Franck, 2008). FGM has no health benefits, and may lead to severe short term and/or long term complications (ibid). Therefore Swedish nurses need to have an awareness of the subject and need to know how to approach the subject when addressing women who have undergone FGM (Gebru & Willman, 2001).
BACKGROUND
There has been an increase in migration worldwide (WHO, 2008). This has resulted in a large number of girls and women living in countries other than their country of birth. Some of these women may have come from countries where they had been subjected to female genital mutilation or may have been at risk of being subjected to the practice (ibid). The terms female circumcision or female genital cutting (FGC) can also be used to describe the practise of FGM.
According to the WHO (2010a) female genital mutilation harms and kills girls and women, and leads to a lifetime of suffering due to immediate and long term health complications after the procedure. It is however important to note that not all women suffer from complications after the procedure (Berggren & Franck, 2008). This subject is one that affects women worldwide and therefore it is important as a nurse to have sufficient knowledge when encountering these women (Kangoum et al., 2004).
Different types of FGM
The practice of FGM causes severe pain and involves removing and damaging healthy and normal female genital tissue. This interferes with the natural function of girl‟s and women‟s bodies (Momoh, 2005).
Type I: Also known as clitoridectomy or Sunna, consists of partial or total removal of the clitoris and/or the prepuce (WHO, 2008; Jaeger et al., 2009). Type II: Also known as excision, consists of partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (WHO, 2008). Type III: Also known as infibulation or Pharonic, consists of narrowing the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (WHO, 2008; Jaeger et al., 2009).
Type IV: All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, branding, piercing, incising, scraping and cauterization (WHO, 2008).
According to Anuforo et al. (2004) there is not a clear distinction between the above categories because the actual procedure carried out depends on the sharpness of the instrument used, the degree of struggling by the child, and the skill as well as eyesight of the person that performs the procedure.
History
According to Momoh (2005) the history of genital surgery on women dates back at least 2000 years but is not well documented. Texts originating from Greece have been found dating back as early as 163 B.C. mentioning girls undergoing FGM when receiving their dowries (Anuforo et al., 2004). The history of FGM in Africa can be traced back to ancient Egypt as early as the 5th century B.C. (ibid) and there have been reports of traces of infibulations found on Egyptian mummies (Momoh, 2005).
It is important to be aware that FGM is not a religious practice but rather a cultural one and is practiced by various religions such as Jews, Christians, Muslims and other indigenous religious groups in Africa (Rahman & Toubia, 2000).
Cause
FGM is performed on girls as a rite of passage into womanhood and is most commonly performed between the ages of four to twelve years old. In some cultures however it is practised on infants or as late as prior to marriage or after the first pregnancy (Rahman & Toubia, 2000).
Since FGM is seen as a rite of passage into womanhood it represents an act of socialization into cultural values and a connection to family community members and previous generations (Rahman & Toubia, 2000). Through the practise of FGM the communities affirm their relationship with the beliefs of the past by continuing the tradition and therefore maintaining community customs and preserving cultural identity (ibid). In some societies a woman‟s ability to be married is of great importance, therefore FGM is practised as a way of
maintaining a woman‟s virginity and reputation before marriage (Anuforo et al., 2004).
In some cultures where FGM is practised it is believed to reduce the sexual urges of women and directing it to a desirable moderation to benefit the men, thus allowing him to have several wives (Momoh, 2005). It is also believed that FGM has health benefits and will improve the health of children born to women who have undergone FGM (Anuforo et al., 2004).
Prevalence
FGM has been reported to take place in all parts of the world, Asia and the Middle East (for example by some Iraqi Kurds), and among certain immigrant
communities in North America and Europe but is most prevalent in: the western, eastern, and north-eastern regions of Africa (Jaeger et al., 2009).
According to the WHO (2010a), it is estimated that 100 to 140 million girls and women have undergone FGM and 3 million girls are estimated to be at risk of undergoing this sort of procedure every year.
FGM practise in Sweden
In the multicultural country of Sweden there is an estimated 28 000 female inhabitants that originate from countries were FGM occurs (Berggren & Franck, 2008). Many of the minors included in this number are at risk of undergoing FGM
even though they are no longer living in a country where FGM is part of the culture (Berggren & Franck, 2008).
In Sweden Somali natives are the biggest group that has the tradition of practising FGM. Consequently when Somali refugees started coming to Sweden in the late 1980‟s FGM on girls was revealed. Eritreans, Ethiopians and Gambians are also visible groups that practise FGM frequently in their country of birth
(Socialstyrelsen, 2005 a).
Nursing in Malmö
As Malmö is a multicultural city there is a need to understand people from other cultures and have other values and lifestyles. The health care personnel need to have a mutual understanding for these aspects to avoid misunderstandings between them and the patients; as misunderstandings can lead to obstacles in curing, supporting and helping these patients in different health situations (Gebru & Willman, 2001).
Health consequences
To aid preventative work efforts and to help identifying those women who suffer from long-term complications as a result of FGM, there is a great need for more research and evidence based knowledge concerning the risks and complications of FGM. When girls and women who have undergone FGM come in contact with health care professionals they might acquire care for other symptoms or problems and are afraid to talk about what has happened to them (Berggren & Franck, 2008).
What is known is that FGM complications include damage to blood vessels and nerves. Some of the immediate complications are pain and haemorrhage, which can cause the girl to lose consciousness. During the days following the procedure, the wounded area makes it virtually impossible for the girl to urinate and this can lead to urine retention. The wound can become infected, and this may lead to sepsis and in the worst cases death (Berggren & Franck, 2008).
The long-term complications are a more prominent risk of post traumatic stress disorder and other psychological disorders. Repeated urinary tract infections, infertility, urinary incontinence/dripping can also be seen in women who have undergone infibulations and complications related to childbirth such as tears, haemorrhaging and the need of a caesarean section (Berggren & Franck, 2008). According to Rushwan (2000) women who have been subjected to infibulation are highly susceptible to chronic infections of the pelvis. Due to the occlusion of the vagina and the urinary canal caused by FGM the effectiveness of natural
mechanisms of protection are diminished, which leads to and increases the likelihood of infection. These infections may spread inwards to affect the reproductive system or other internal organs and may become chronic (ibid). In cases when labour is prolonged due to unavailability of trained assistance during labour, infibulation could contribute to obstetric fistulae (Rushwan, 2000). The fistulae develops when the baby‟s head causes constant pressure on nearby organs such as the bladder or the rectum, which then leads to a necrosis of the tissue of the vaginal wall leading to a vesico-vaginal fistulae, and/or recto-vaginal fistulae (ibid). The consequences of these fistulae are severe, the woman may
become incontinent of urine and/or faeces and they become outcasts in their community, rejected by their husbands and family (Rushwan, 2000). Other long-term complications may include chronic pain and decreased sexual enjoyment for these women (WHO, 2008). The WHO (2010b) adds the need for later surgery to the list of complications mentioned above.
According to the WHO (2008) babies born to women who have undergone FGM suffer a higher rate of neonatal death compared with babies born to women who have not undergone the procedure.
Holistic view
Leininger (2002) believes that people are affected by culture when it comes to how they view the world, make decisions and act. The definition of culture is learned and shared values, beliefs and life patterns of a group, and is generally transferred between generations and influence one individual thought and action (ibid).
Transcultural nursing is defined as an area for study and experience in nursing with a focus on holistic care, disease patterns and health of individuals and groups. It requires respect for differences and similarities existing cultural values, beliefs and practice with the objective of providing cultural congruent, well-adjusted and skilled nursing care to people from different cultures. Because of rapid global migration transcultural nursing is central to nurses and other health care personnel (Leininger, 2002).
It is important for nurses to discover and understand that cultures have their emic views and knowledge about their culture (Leininger, 2002). These emic ideas are often viewed as secrets within the culture and are not willingly shared with others outside their culture. Through transcultural nursing the nurse hopes to gain the patients trust and through this, the emic knowledge. In contrast, the etic
knowledge such as the professional ideas of the nurse may be different from the emic views and experiences. It‟s important for a nurse‟s thinking and decision making concerning assessment of patients to have knowledge of both the cultures emic as well as etic (ibid).
Laws
Communities that practice FGM worldwide report a range of social and religious reasons why this practice is continued (WHO, 2008). From a human rights perspective the practice reflects a deeply rooted inequality between the sexes and constitutes an extreme form of discrimination against women (ibid).
To protect girls and women at risk of undergoing the practice of FGM the government of Sweden enforced a law in 1982 (SFS-nr: 1982:316 modified in 1998:407) that makes it illegal. This law has been changed several times since and makes it possible to penalize people that have been involved in the FGM practise in Sweden, but also when girls have been taken to their native country to undergo FGM (Berggren & Franck, 2008). This law has also made it possible for social services to intervene and protect girls at risk of undergoing FGM (ibid). It is of outmost importance for people that work within healthcare, social service, schools or other professions to come in contact with people that have FGM in his/her culture, to have knowledge about FGM (Socialstyrelsen, 2005a). Also as a nurse
it is crucial to have a good knowledge and understanding about this matter for the preventive work as well as caring of survivors of FGM (ibid).
HSL 1982:763 says that care must be independent of, for example, ethnic
background and religion, as both are strong cultural variables. The same law states that you must have a holistic approach to patients and that he or she must be involved and be able to influence their care. The goal for HSL 1982:763 is a care on equal conditions and with respect for all human beings‟ equal value and for separate dignity.
FGM is always performed on minors and is therefore a violation of the
Convention on the right of the children (WHO, 2008). It also violates the right of security and physical integrity of the person as well as right to health, the right to be free from torture and cruel, inhuman or degrading treatment, and the right to life when the procedure results in death (ibid).
AIM
The aim was to describe how Swedish nurses can address and care for women who have been exposed to female genital mutilation.
1) How have these women who have undergone FGM experienced health care in a foreign country?
2) What knowledge is necessary for a nurse to have in order to address the subject of FGM from the women‟s point of view?
METHOD
The approach is a descriptive literature study and the working process was
inspired by Goodman‟s (1993) seven steps of searching and interpreting evidence.
1. Specify the Assessment Problem
Through discussing the subject the aim for this study was formulated. To answer the aim the goal was to find as much relevant information as possible therefore a literature search was performed.
2. Specify Inclusion Criteria for Studies
Inclusions criteria were all articles discussing FGM from the women‟s and men‟s as well as nurses, midwife‟s or obstetrics‟ point of view.
Exclusion criteria were articles older than 10 years, meta-analysis and review articles. A decision was made not to order any articles.
3. Formulate Plan for Literature Search
For the timeframe of ten weeks in total to compile this litterateur study the limitation to literature search was made to following three databases: PubMed, CINAHL and PsycINFO.
PubMed is the leading health science database and its huge citation list often overlaps with the other foremost databases. PubMed comprises more than 19 million citations for biomedical articles from MEDLINE and life science journals. CINAHL is an index of English articles and selected articles in other languages about nursing, allied health, biomedicine and healthcare. PsycINFO is a database
containing abstracts of literature in the field of psychology. This literature is comprised of journal articles, books, book chapters, dissertations and technical reports.
To find the accurate words to answer the aim for the literature search, a primary search was made in Swedish MeSH (2010) to find the corresponding English MeSH terms. The MeSH terms used were Circumcision Female, Nursing, Sweden, Social support, Communication.
4. Conduct Literature Search and Retrieval
A literature search was conducted in the three separate databases following the formulated plan for the literature search (Table 1, Table 2, Table 3).
Table 1. PubMed search and selection of articles relating to Female
Circumcision/FGM.
MeSH term Result Read titles Reviewed abstract Read articles Used articles Female circumcision AND social support 3 3 3 2 0 Female circumcision AND Nursing 33 33 25 9 5 Female circumcision AND Sweden 22 22 12 4 2 Female circumcision AND communication* 20 20 20 1 1 Total 78 78 60 16 8 Limits: *Published 2000-2010
Table 2. CINAHL search and selection of articles relating to Female
Circumcision/FGM.
Headings Result Read titles Reviewed abstract Read articles Used articles Female circumcision AND social support 9 9 3 0 0 Female circumcision AND Sweden 30 30 8 1 1 Female circumcision AND Sweden* 23 23 20 0 0 Total 62 62 31 1 1 Limits: *Published 2000-2010
Table 3. PsycINFO search and selection of articles relating to Female
Circumcision/FGM.
Keywords Result Read titles Reviewed abstract Read articles Used articles Female circumcision AND social support 28 28 8 1 0 Female circumcision AND Sweden 10 10 5 2 1 Total 38 38 13 3 1 Limits: *Published 2000-2010
The total amount of titles read was 177, a total of 102 abstracts were reviewed and a total of 20 articles were read. The result that was compiled to answer the aim of this study was based on a total of ten articles.
5. Interpret the Study Evidence
The articles were reviewed after quality and relevance, using the protocols for qualitative and quantitative reviews by Willman & Stoltz (2006). The articles were graded using percent. All the articles used in this study had to surpass 60 per cent. For each question in the protocol every answer that resulted in a “yes” equalled one point, all the questions in the protocol signified 15 points equalling 100 per cent. The articles surpassing 60-70 percent ended up in category III, the ones passing 80-90 in category II and 90-100 percent were put in category I. In the course of doing so it was possible to divide the articles according to the quality of the articles. The articles in category I-II were used in the result (ibid).
6. Integrate the Evidence
The articles were chosen initially by reading the available abstracts through the conducted searches. All the articles were read separately by both of the authors taking separate notes, which were compared and discussed. Themes of interest were identified from the results of the chosen articles, and together the authors discussed and agreed on which themes were relevant to constitute the result.
7. Formulate Recommendations Based upon Evidence Quality
To determine the adequacy of the articles a process of interpreting the content was made inspired by Britton (2000), shown in Appendix I.
RESULT
The result of this literature study consists of ten scientific articles, nine of these were qualitative studies and one was a combined qualitative and quantitative study. The result was divided into three themes used to present the results and answer the study aim. The themes are Addressing FGM, Experience of health care in a foreign country and Adapting to a new culture.
Addressing FGM
Both Thierfelder et al. (2005) and Elise & Johansen (2006) found that health care personnel avoid addressing the subject of FGM when dealing with women from countries where FGM is frequently practiced. Out of the health care personnel
interviewed only 8% stated that they addressed the prevention of FGM during relevant consultations (Thierfelder et al., 2005). Reasons stated why health care personnel avoid the subject are cultural, gender related and social reasons, the language barrier, time constraints and an inappropriate setting (ibid).
Health care personnel also explained their silence and avoidance as an expression of respect for a subject that they perceived being taboo in the practising cultures (Elise & Johansen, 2006). They wanted to appear “professional” and not let their personal emotions affect the situation, they had the notion it was best to “pretend nothing was wrong” (Elise & Johansen, 2006, p 523). These expectations are based on a belief that the women that have undergone FGM are ashamed of their FGM and share the health care personnel‟s negative understanding of the practise (Elise & Johansen, 2006). In fact, this perception of FGM being a taboo subject was generally taken as self-evident and was rarely investigated (ibid). The midwives in Widmark et al. (2002) study performed in Sweden seemed unsure how to communicate with the women concerning FGM and approached it differently. To talk directly to the women about FGM would point out her as different (ibid). On the contrary to this belief, the health care personnel from both Norway and Sweden who brought the issue up with the women found an
eagerness and ease of the following conversation (Elise & Johansen, 2006; Widmark et al., 2002).
In both of the studies by Leval et al. (2004) and Elsie & Johansen (2006) the interviewed midwives made some ethnocentric comments during the interviews. Many of the Swedish midwives expressed notions regarding to cultural practices and a belief that their own culture was well informed compared to the cultures were FGM was practiced which were perceived as ignorant (Elsie & Johansen, 2006). The ethical and emotional challenges that health care personnel deal with linked to FGM have a tendency to lead to silence and over interpretation of culture, which can affect the care procedure in a negative way (ibid).
Even though there was a sense of pity for the women, there were feelings of anger towards the culture, the men and the patriarchal structure that was regarded as responsible for the practice (Elsie & Johansen, 2006). Many of the midwives blamed the men for the practise of FGM and often describing them as “raping oppressors” (Leval et al., 2004, p 753). When meeting the boyfriends/husbands of women with FGM in care-giving situations, a different view of a power sharing, tender and caring men was shown (Leval et al., 2004). This goes to show that the midwives‟ idea of the men concerning FGM is not based on experience, rather on preconceived ideas of FGM and its tradition (ibid).
Experience of health care in a foreign country
There was an unwilling attitude from the health care personnel which many of the women recalled (Berggren et al., 2006). There was a lack of interpreters, which the women related to an attitude from the health care personnel stating that the women had been in Sweden long enough to know the Swedish language (ibid). The women stated that language barrier was a big issue and talked about how difficult it was to express what they needed to say to health care personnel when their knowledge of Swedish or English was poor (Ahlberg et al., 2004).
Thierfelder et al. (2005) found that some women were disappointed that the subject of FGM was not brought up during their contact with health care, while
others felt grateful it was not. During Berggren‟s et al. (2006) interviews with Eritrean, Somali and Sudanese women, many of the women said it was the first time, outside their ethnic group, that anyone had talked to them about FGM. The women described that the contact with native Swedes were scarce and these encounter‟s consisted of work relations and health care personnel (ibid). Elise & Johansen (2006) and Thierfelder et al. (2005) found that the women showed great interest in discussing the consequences of being subjected to FGM so that they could learn about what was ”normal” concerning women in their new country of residence. They wished for care that was more empathetic, and that doctors would take their time and allow discussions during consultations (Elise & Johansen, 2006). The Somali women preferred that the care provider be a woman, as discussing the issue with a man would be very difficult (ibid). More privacy and less “crowds of doctors” eager to see their specific anatomy was something these women requested as well (ibid). Berggren et al. (2006) found that the women in their study had similar experiences of feeling disrespected, looked down upon and stared at by doctors, nurses and midwives at the same time without being asked. They experienced health care personnel talking about them with each other without involving the women in the conversation (ibid). By observing the facial expressions, sometimes expressing disgust from the health care personnel the women could understand that the personnel saw something strange (ibid). Some of the women felt dissatisfied and badly supported by the health care personnel in their country of residence (Thierfelder et al., 2005). All the women in Lundberg et al. (2008) study stated that they had a good impression of the Swedish health care system. The women linked their positive experiences to the encounters with health care personnel who possessed
knowledge concerning FGM. This knowledge of FGM made the women feel confident (ibid).
Adapting to a new culture
According to Berggren et al. (2006) and Upvall et al. (2009) some women stated that they thought that FGM was practiced everywhere before leaving their country of birth. They expressed a double shame of feeling different because FGM in their birth countries was not perceived as shameful, and because FGM was perceived as shameful in Sweden (Berggren et al., 2006; Ahlberg et al., 2004; Lundberg et al., 2008).
Some of the women in Lundberg et al. (2008) and Thierfelder et al. (2005) study stated that they felt lonely due to the distance to their relatives and did not feel that they got the support that they would have received in their birth country. They expressed knowledge that FGM was harmful and had terrible consequences for childbirth (ibid). According to Thierfelder et al. (2005) FGM and related complications are not commonly talked about amongst the women themselves or to their husbands.
The tradition of FGM was something that the women did not want to subject their daughters to (Berggren et al., 2006; Lundberg et al., 2008; Johnsdotter et al., 2009). Instead they wanted to protect their daughters from the painful experience that they themselves had been subjected to (ibid). The women explained that because of migration, the pressure of continuing FGM decreased (ibid). Some of the young women admitted that if they would have been in their country of birth
they would not have been able to protect their daughters, and felt that the Swedish law protected their daughters further from FGM (ibid). The women also stated that they had not received the information about the law against FGM from authorities; instead the information came from friends and the media (Berggren et al., 2006).
Although Morison et al. (2004) found a connection in the aspiration to have their daughters undergo FGM linked to the age of the man or woman when migrating from their country of birth. The men and women who had migrated at an older age were more likely to want their daughter/daughters to undergo FGM. There was a larger amount of men (43%) compared to women (18%) that aspired to have FGM performed on their daughter/daughters (ibid).
DISCUSSION
The discussion is divided into to two categories one where the method of this study will be discussed and one where the study result will be discussed linked to Leininger‟s theory of transcultural nursing.
Method Discussion
The choice of method of this study was a systematic literature study inspired by Goodman‟s (1993) seven steps. The reasons for choosing to conduct this sort of study were that it was possible to gather a large amount of material in a short period of time and to get an overview of the subject of FGM. Since a literature study was conducted no new knowledge was revealed.
The reasons for not conducting an empirical study were the difficulties which might have arisen in finding women that had undergone FGM as well as nurses who had encountered FGM and would be willing to take part in an empirical study. Another reason why a literature search was chosen was that there was a lack of literature written about how nurses could approach these women. From the beginning there was a clear idea of what the aim of the study should be, though it had to be defined and shortened. By using Goodman‟s (1993) seven steps as inspiration there was a clear structure to follow as well as it gives the reader a view of the process behind this study.
Inclusions criteria were all articles discussing FGM from the point of view of women and men, as well as nurses, midwives or obstetricians. Since there was a lack of articles written from a nurse‟s perspective articles that have a midwife‟s or obstetrician‟s point of view were included; as the focus was information that could be used to answer the aim of this study. Though this study includes articles with a midwife‟s point of view it is believed that these articles can be applied to nurses as well, since a midwife in Sweden is a specialized nurse (Lunds
Universitet, 2010). No exclusion was done of the articles that didn‟t have an abstract published on the database, as they could be found and reviewed where they were published. The selection of articles was done systematically and preceded by discussion after reading the abstracts. Chosen articles were believed to contain information that could answer the aim of the study. Further, to ensure usage of scientific articles the criteria in Hanson (2005) were met. However, there is a possibility that useful articles have been overlooked.
Exclusion criteria were articles older than 10 years, this aided in finding relevant articles that were not outdated. When conducting a literature study the information
from a basic source was to be included in the study result, consequently an exclusion of meta-analysis and review articles was made. When taking into
account the time for searching, analyzing and gathering information the amount of articles found was sufficient to answer the aim of the study. A few of the articles found through searches were not available for view unless they were ordered; reason why this exclusion was made was based on financial grounds. This may have lead to an absence in valuable information that possibly could have changed part of the result in the present study.
Through using Swedish MeSH (2010) the word “Könsstympning” was translated into the MeSH term “Circumcision, Female”. It was desired to use the term “Female Genital Mutilation”. When performing a search via PubMed/MeSH using the term “Female Genital Mutilation” the result turned out to be the same, “Circumcision, Female”, due to this it was concluded that the term “Circumcision, Female” had to be used when conducting the search.
There was a wish to use the Swedish word “bemötande” in the aim of this study, however the English word “addressing” was an appropriate word to use, since a direct translation was not available. When conducting a search via PubMed there was no MeSH term for “addressing”, therefore other words needed to be taken in consideration that could include the information needed to answer the aim of the study. The words “social support” and “communication” were used to be
representative of the word “addressing”. Using these terms may have lead to a lack of valuable information in relation to the study aim. A limit due to MeSH terms not thought of might have occurred.
A few of the different searches gave a result that included the same articles; this indicated that there was not a lot written on the subject. Consequently a decision was made not to apply more limits to the searches. Even without applying limits to the searches the majority of the articles were found to have been written in the last 10 years. The decision was made not to use a large number of exclusion criteria as this could lead to a possibility of missing relevant information. The databases were chosen due to their vast content and were thought to answer the aim of the study. Information previously received from Malmö University on how to conduct a search via these databases influenced the choice of databases. A limitation to three databases was made due to time constraints; this may however have lead to a limited result of articles used in the study.
The literature search was primarily conducted via PubMed since it is one of the largest databases in the world with a vast content of scientific articles. The following searches were done in CINAHL and PsycINFO. This resulted in some of the same articles being found as part of the search result in several databases chosen.
Trough dividing the articles into categories the quality of the articles could be reviewed. As this had previously not been done this may have lead to some misinterpretation of how to conduct this quality review. Consequently there is a possibility that the accuracy of the quality review may be of question. Ten of the twenty articles that were read were chosen as they were thought to answer the aim of the study. The articles that were not chosen to be included in this study‟s result were oriented on midwives‟ and obstetricians‟ profession only.
Since the result of this literature study was based on qualitative studies the transferability is questionable hence the lack of quantitative studies. Therefore it has not been possible to formulate recommendations based on this study‟s result. Since qualitative studies are only transferable to a setting that resembles the study population.
Result Discussion
FGM is thought to be a taboo subject, linked to shame and guilt, which health care personnel try to avoid addressing for numerous reasons. Berggren et al. (2006), Lundberg et al. (2008) and Ahlberg et al. (2004) bring up the double shame of having FGM and many of the women quoted in several of the articles spoke of the difficulties they encountered when in contact with health care personnel.
Health care personnel stated many reasons why they avoided bringing up the subject of FGM (Thierfelder et al., 2005). These reasons were: cultural, gender related and social reasons, as well as the language barrier, time constraints and an inappropriate setting (ibid). In an attempt to appear professional the health care personnel avoided to address the subject (Elsie & Johansen, 2006), this may contribute to the women receiving care of less quality which violates HSL
1982:763. Since health care personnel avoid the subject they contribute to making FGM more taboo (Gebru & Willman, 2001; Leininger, 2002; Thierfelder et al., 2005). In having good knowledge about the subject of FGM the nurses will have a broader perspective on how to address these women. Through having a more holistic view, nurses can increase the respect for differences and similarities in existing cultural values with the objective of providing cultural congruent, well-adjusted and skilled nursing care (Leininger, 2002). Having the expectation that the women were ashamed of their FGM and share the health care personnel‟s negative understanding of the practice and the perception of FGM being taboo was generally taken as self-evident and rarely investigated (Elise & Johansen, 2006; Widmark, 2002). This goes to show that there is a lack of knowledge concerning FGM, the long-term complications and how the women perceive FGM. Nurses need to be aware of patient history, earlier experiences with the health care system, respect and adapt to the needs of such patient in a sensitive and culturally appropriate way (Gebru & Willman, 2001; Leininger, 2002; Thierfelder et al., 2005). There is a need for nurses to acquire time to educate themselves on the subject of FGM and how these women want to be addressed. In knowing how these women want to be approached, nurses can get an emic
perspective, and combining this information with the nurses etic may lead to a more culturally adapted care (Leininger, 2002). It is important to know that even though there are some women that do not want to be approached about the subject of FGM, there are some that feel the contrary. By asking if a woman has
undergone FGM the subject will be brought in to the daylight, and this may aid the woman to talk more freely about this subject.
It is also important not to take a judgmental position in condemning traditional values and practices, but rather offer an informed discussion to the harmful effects of FGM and alternative options (Thierfelder et al., 2005). By not having an open dialogue with patients, the possibility of finding out what the patient‟s point of view considering health and illness are, the best way addressing the patient gets lost (Leininger, 2002).
A nurse‟s work should always be characterized by an ethical approach and knowledge built on science and best practices, conducted in accordance with current regulations; laws, ordinance and other guidelines (Socialstyrelsen, 2005 b). How nurses act should be based on fundamental values with its foundation in a humanistic view of human beings, show care and respect for patient‟s autonomy, integrity and dignity, display openness and respect for different values and beliefs, applying current research ethics conventions (Leininger, 2002). Nurses can
contribute to health care personnel‟s education and use their knowledge and experiences to benefit a holistic approach to patients (Socialstyrelsen, 2005b). Midwives believed their own culture to be well informed compared to the cultures where FGM is practiced, which were perceived as ignorant (Leval et al., 2004). The same problem may occur when nurses encounter women subjected to FGM. Through the ethnocentrical view the emic perspective gets lost and with it the transcultural care of these women (Leininger, 2002). The holistic view is an important tool for nurses when approaching these women and their families. This view can give nurses a sense of comfort and ease which will affect the care in a positive way. The holistic view needs to have a central role in all nursing care since it is not just one part of the body that a nurse cares for but the whole human being.
The women in Ahlberg et al. (2004) study talked about the language barrier being a big issue since it made it hard for the women to express themselves when their knowledge in Swedish or English was poor. The unwilling attitude that the women experienced from health care personnel stating that the women had been in Sweden long enough to know the Swedish language combined with the lack of interpreters (Berggren et al., 2006) does not belong in health care. Nurses need to put their own opinions aside and focus on nursing. There needs to be an
understanding of other cultures (Leininger, 2002) and to aid these women an interpreter should be provided that can mediate and help the women to express themselves. The women in Elise & Johansen‟s (2006) study wished for care that was more empathetic, as they felt the health care lacked empathy when caring for them. An important part of a nurse‟s work is to care for the patients in an
empathetic and receptive way (Socialstyrelsen, 2005b; Leininger, 2002). Women who have undergone FGM and now reside in Sweden may contact the health care facilities with symptoms from long term complications due to FGM. According to Thierfelder et al. (2005) and Berggren & Franck (2008) such complications may be urinary tract infections, local obstetric complications as well as difficulties with sexual intercourse and menstruation. When contacting health care the women and girls might be afraid to bring up the subject of FGM and acquire care for other symptoms or problems (Berggren & Franck, 2008). When encountering women that may have undergone FGM it is of outmost importance to have enough knowledge to address the subject of FGM. This need for knowledge can be put in relation to the women in Lundberg et al. (2008) who linked their experience of good health care to the personnel possessing knowledge of FGM.
The practice of FGM is a way to affirm the relationship with the beliefs of the past by continuing the tradition and therefore maintaining community customs and preserving cultural identity (Rahman & Toubia, 2000). Even though it is stated that FGM is part of the cultural identity of the men and woman exposed to FGM,
through migration the need of continuing this tradition is lessened (Morison et al., 2004). Many of the men and women interviewed made it clear that the practice of FGM was nothing they wanted to subject their daughters to after moving to Sweden (Johnsdotter et al., 2009; Lundberg et al., 2008; Berggren et al., 2006). In addressing FGM with patients it is important to have this knowledge,
subsequently not lecturing the patients about the Swedish law against FGM or the health consequences of the practice. Instead this knowledge can be used to have a dialogue with patients concerning their point of view on the subject, hence not having preconceived notions that everyone from FGM practicing countries wants to maintain to practice of FGM (Johnsdotter et al., 2009; Gebru & Willman 2001). According to Johnsdotter et al. (2009) having a structure that is prepared to deal with suspected cases of FGM needs to be combined with a high level of
awareness. To have knowledge about the law (SFS: 1983:316) assists in avoiding that a mistake will be made (Johnsdotter et al., 2009). It is also important to have a healthy sceptical attitude toward exaggerations of risk estimates of immigrants subjecting their daughters to FGM (ibid).
Some women stated that they had received the information about the law against FGM from friends and the media, instead of the Swedish authorities (Berggren et al., 2006). Nurses need to have sufficient knowledge about the law concerning this subject, since it has serious consequences and may lead to penalization (SFS: 1982:316). By possessing knowledge regarding the law a nurse can feel secure in giving the patient information, and what to do when encountering woman and children who may be at risk of undergoing FGM or have already undergone FGM (ibid).
All women are unique, so are the way they view FGM and their own bodies. It is not possible to predict if the women a nurse meets on a specific day may or may not want to talk about FGM, the only way to find out, is to address the subject without anticipation of how the woman may react.
At Malmö University the aim of the nursing education is to educate nurses to be well prepared so that they can take part in present and future health care and work both nationally and internationally (Gebru & Willman, 2001). The Swedish nurses will meet many people from different cultures and it is therefore of outmost importance that they are well prepared for the multicultural society that they will be working in (Gebru & Willman, 2001; ICN, 2006). More research has to be done about the nurses‟ encounters with these women and how to address the subject.
CONCLUSION
Knowledge about FGM among health care personnel seems to be scarce. Therefore a broader knowledge on the subject of FGM is needed in order for health care personnel to give the best individual and scrutinized care. Guidelines and a plan of action on how to handle this sensitive matter combined with
continuous education for all health care personnel is needed. FGM is a subject that awakens many emotions, it is also important to be aware of these emotions and educate oneself on FGM so as to give best care possible. The health care
personnel interviewed in the articles used to answer the aim of this study, spoke frankly about their emotions and preconceived notions in regards to FGM, this gives an insight of how FGM influences the health care in Sweden. Because there
seem to be a lack of a distinct description on how Swedish nurses can address and care for women who have been exposed to FGM more research is needed about how nurses can encounter these women and how to address the subject. It is the authors‟ hope not only to gain more knowledge when writing this literature study, but also to educate others on the subject of FGM.
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ICN (2006) The ICN Code of ethics for nurses. Geneva: International council of nurses
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Momoh, C (2005) Female genital mutilation. Oxford; Seattle: Radcliffe publishing limited
Morison, L et al. (2004) How experiences and attitudes relating to female circumcision vary according to age on arrival in Britain: A study among young Somalis in London Ethicity & Health 9, 74-100
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ATTACHMENTS
Attachment 1: Appendix 1Examensarbete i omvårdnad Malmö högskola
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Attachement 1
Appendix I. Overview of chosen referee judged articles which the result in this literature study is built on.
Author/Year/Title /Country
Objective/Aim Design/Method/Analysis Population /Selection /Setting
Result Comment Quality
Ahlberg, B et al. (2004) ‟It‟s only tradition‟: making sense of eradication interventions and the persistence of female ‟circumcision‟ within a Swedish context. Sweden Why female circumcision (FC) persists despite eradication
interventions and the migration of people to non-practicing countries and discusses the reasoning of Somali immigrants on female circumcision.
A qualitative study. Key informants, interviews and focus group discussions. Thematic analysis.
Somali men, women, young girls and boys were recruited by snowball sampling. A total of 110 people were interviewed, 30 men, 50 women, 10 girls, 5 boys and 15 different professionals. Interviews were conducted in Somali and English. Conducted in two towns in Central Sweden with large numbers of immigrants from Eastern Africa, between 1997 and 1999.
Female
circumcision was described, as just „a tradition‟ that had little to do with Islam. The fear of bringing up an uncircumcised daughter in the liberal sexual morality of Sweden was mentioned as a dilemma. Circumcised
women said that the health care they received during pregnancy and childbirth was poor while the law failed to take account of the experiences of the Somali people.
Easy to follow. Gave insight on how some Somali people perceive health care and the Swedish culture.
87% Category II
Author/Year/Title /Country
Objective/Aim Design/Method/Analysis Population /Selection /Setting
Result Comment Quality
Berggren, V et al. (2006)
Being different and vulnerable:
Experiences of immigrant African women who have been circumcised and sought maternity care in Sweden. Sweden To explore the encounters with the health care system in Sweden of women from Somalia, Eritrea, and Sudan who have been genitally cut.
A qualitative study with an explorative design, interviewing immigrant women.
Latent content analysis.
Interviews with twenty two women from Eritrea, Somalia and Sudan who have been genitally cut. The women were recruited from three different cities in Sweden. The women were selected using snowball sampling or network sampling.
Indicates a need for more
individualized, culturally adjusted care and support and a need for systematic education about FGC for Swedish health care workers.
Made it clear that more knowledge about FGM is necessary to give good care to these patients. 87% Category II
Author/Year/Title /Country
Objective/Aim Design/Method/Analysis Population /Selection /Setting
Result Comment Quality
Elise, R & Johansen, B (2006) Care for infibulated women giving birth in Norway. Norway Norwegian health care workers experience and management of birth care of women who have undergone infibulations.
An anthropological , content analysis.1/3 were General in-depth
interviews and the remaining 2/3 were case interviews.
A total of 40 health care workers: 25 midwives, 12 medical doctors and three nurses were interviewed. Most health care workers volunteered to be interviewed.
The infibulated women were treated and viewed
differently than Norwegian women by health care workers.
Shed light on the lack of
knowledge in the health care system. Since this was a study conducted in another Scandinavian country the transferability is high. 87% Category II
Author/Year/Title /Country
Objective/Aim Design/Method/Analysis Population /Selection /Setting
Result Comment Quality
Johnsdotter, S et al. (2009) “Never My Daughters”: A Qualitative study regarding attitude change toward Female Genital Cutting among Ethiopian and Eritrean families in Sweden. Sweden To investigate the logic of discussions on FGC in these groups; to gain deeper insight into „traditional,‟ locally based understandings of this practice as well as changes in views due to migration to Sweden. How Eritrean and Ethiopian Swedes look upon FGC after some time in exile is an issue hitherto under-researched.
A qualitative study. A basic interview guide was used, designed by the interview group before launching the study. This guide was slightly
changed during the process, however, to allow for the possibility of further elaborating some of the themes that were presented by the interviewees in the initial stage of the study. Content analysis.
Thirty-three taped semi-structured interviews were made with Eritrean and Ethiopian men and women in several Swedish cities during 2003-2004. Snowball sampling was used as well as contacts with immigrant
organizations in some places were initial contacts were scarce. Most interviews took place in the
interviewees homes when preferred by them, some of the interviews took place in public places.
The practice of FGC is redundant to Eritrean and
Ethiopian residents in Sweden; that is, it is socially
accepted to let a girl grow up uncircumcised. The predominant collective self-image among Ethiopian and Eritrean residents in Sweden is that of a group having abandoned this tradition. A changing attitude toward FGM after migrating to Sweden is revealed. Gives a clear picture of the interviewee‟s opinion through use of quotations. 87% Category II
Author/Year/Title /Country
Objective/Aim Design/Method/Analysis Population /Selection /Setting
Result Comment Quality
Leval, A et al. (2004)
The encounters that rupture the myth: contradictions in midwives‟ decisions and explanations of circumcised woman immigrants‟ sexuality. Sweden To analyze how Swedish midwives discuss sexuality in circumcised African women patients.
A qualitative study with focus group discussions and three individual interviews. Content analysis.
A multi-stage sampling procedure was used, selecting midwives in labour wards as well as two ANCs in three Swedish cities.
Twenty-six midwives, all women, aged 37-53 years, and all but one was born in Sweden. Experience as
midwives ranged from five to thirty-three years. The midwives reported different levels of exposure to and experience of caring for circumcised women. A total of 11 interview sessions in eight focus groups were held. Ethnocentric projections of sexuality, a knowledge paradox regarding circumcision and sexuality, the view of the powerless circumcised
women, and the fact that maternity wards function as meeting places between gender and culture where the encounters with men allow masculine
hegemonic norms to be ruptures.
The results were clear, the
quotations enhanced this. Bringing an unknown subject for the authors to light. Interesting contradiction relating to the man‟s role in FGM. 87% Category II
Author/Year/Title /Country
Objective/Aim Design/Method/Analysis Population /Selection /Setting
Result Comment Quality
Lundberg, P et al. (2008) Experiences from pregnancy and childbirth related to female genital mutilation among Eritrean immigrant women in Sweden. Sweden To explore Eritrean immigrant women‟s experience of female genital mutilation (FGM) during pregnancy, childbirth and the postpartum period.
A qualitative study semi-structured interview and open-ended questions were used. The interviews were tape recorded, transcribed verbatim and then analyzed using an ethnographic approach.
Fifteen Eritrean women living in and around Uppsala, Sweden were selected by use of purposive sampling with snowball technique.
All the women in the study felt fear and anxiety during pregnancy and childbirth. Some suffered of long-term complications. They had both positive and
negative experience of the health care in Sweden. A better understanding about both women and men‟s view of FGM and their experience of health care in their country of birth as well as in Sweden. 87% Category II
Author/Year/Title /Country
Objective/Aim Design/Method/Analysis Population /Selection /Setting
Result Comment Quality
Morison, L et al. (2004) How experiences and attitudes relating to female circumcision vary according to age on arrival in Britain: A study among young Somalis in London. Great Britain To examine the association between age on arrival to Britain and experiences and attitudes relating to FGM among young, single Somalis in London. A quantitative and a qualitative approach. Quantitative data was collected using a cross-sectional survey.
Qualitative was collected from in-depth interviews. Thematic content
analysis. The qualitative data were analysed by looking for common themes and expectations, with the particular aim of illustrating aspects of experience or attitudes that could not be obtained from quantitative data.
A collaboration between a non-governmental
organisation, the Black Women‟s Health and family support group, and the London school of hygiene. Unmarried Somalis between the ages 16 and 22 who were living in the Greater London area. Quantitative data was collected from self-completed
questionnaires aiming for 100 males and 100 females. Qualitative data were collected from in-depth interviews with 10 males and 10
infibulated females.
Quantitative data for 94 females and 80 males was obtained. Living in Britain from a younger age was associated with increased assimilation in terms of language, dress and socializing. Seventy per cent of the females reported that they had undergone circumcision.
Those that were living in Britain before the usual age range for FGM (before age six) were less likely to have undergone FGM than those who arrived after the usual age range for FGM (11 or older).
87% Category II
Author/Year/Title /Country
Objective/Aim Design/Method/Analysis Population /Selection /Setting
Result Comment Quality
Thierfelder, C et al. (2005) Female genital mutilation in the context of migration: experience of African women with the Swiss health care system. Switzerland
To analyze how
immigrant women with FGM experience
gynaecological/obstetrical care in the Swiss health care system, and to investigate if physicians and midwives treat and counsel FGM related complications adequately.
A qualitative study, including focus group discussions and telephone interviews based on semi-structured, open-ended questions. All discussions were tape-recorded, transcribed and analyzed using the software MAXQDA.
Purposeful sampling was used to select women of
reproductive age who had undergone FGM before migrating to Switzerland, and health care who had received such
patients. Twenty-nine women from Somalia and Eritrea were interviewed using focus group
discussions. In-depth telephone interviews with 37 health care professionals, a structured questionnaire with open-ended questions was used. A lack of knowledge of FGM in Swiss health care was apparent by the health care personnel as well as the women form countries where FGM is prevalent FGM is no adequately addressed and the situations could be easily improved by taking into consideration the fairly simple measures
suggested by the women and health care providers.
87% Category II
Author/Year/Title /Country
Objective/Aim Design/Method/Analysis Population /Selection /Setting
Result Comment Quality
Upvall, M et al. (2009) Perspectives of Somali Bantu refugee women living with circumcision in the United States: A focus group approach. USA
1. What are the Somali Bantu women‟s perceived healthcare needs related to circumcision? 2. What culturally acceptable interventions can be developed in
providing care for these women based upon their self-identified needs?
A qualitative study with focus group interviews. Thematic analysis, using the software Atlas.
Purposive, inclusive sample of twenty-three Somali refugee women over the age of 18 was identified by a local non-profit organization assisting in the resettling of Somali refugee families. Including 23 women who had resettled in South-western Pennsylvania, USA.
Circumcision is considered a normal part of everyday life for the Somali Bantu refugee woman. Communication skills are fundamental in providing culturally competent care for these women. Health care
providers must take responsibility for acquiring
knowledge of the Somali women‟s challenges.
Gave insight that there was a difference of view of FGM amongst women from different African countries. 87% Category II
Author/Year/Title /Country
Objective/Aim Design/Method/Analysis Population /Selection /Setting
Result Comment Quality
Widmark, C et al. (2002) A study of Swedish midwives‟ encounters with infibulated African women in Sweden. Sweden To investigate Swedish midwives‟ perception and attitude towards infibulated and infibulated women, midwives‟ experience of providing care for them and the training the midwives
describe having received to enable them to care for and deliver infibulated women. A qualitative design, open-ended questionnaire. Content analysis.
Three hospitals were selected. A multi-stage sampling procedure was used. A self-administered
questionnaire was used in labour wards, returned by 86 of the midwives. Thirty-nine of these had cared for circumcised women. Twenty-six agreed to participate in the study. Midwives in two ANCs were also included, five agreed to participate. Twenty-six midwives, all women, participated in a total of 11
interview sessions in eight focus groups. Individual interviews were held when needed. Three major themes: (a) emotions and communicational challenges entailed the care of infibulated women, (b) knowledge and skills needed for caring and (c) the midwives‟ reliance on the Swedish law when dealing with the dilemmas they face in their interactions with the women and their families. Good information concerning how to address these women. Highlights the importance of culturally sensitive professional care and the importance of communication. 87% Category II
Examensarbete i omvårdnad Malmö högskola
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Attachement 2
BEDÖMNINGSMALL FÖR KVALITATIVA
ARTIKLAR
Efter Willman & Stoltz (2006)
Beskrivning av studien
Tydlig avgränsning/problemformulering? Ja Nej Vet ej
Patientkarakteristika Antal ………...
Ålder ……….. Man/kvinna ……….
Är kontexten presenterad? Ja Nej Vet ej
Etiskt resonemang? Ja Nej Vet ej
Urval
–Relevant? Ja Nej Vet ej
– Strategiskt? Ja Nej Vet ej
Metod för
– urvalsförfarande tydligt beskrivet? Ja Nej Vet ej – datainsamling tydligt beskriven? Ja Nej Vet ej – analys tydligt beskriven? Ja Nej Vet ej Giltighet
– Är resultatet logiskt, begripligt? Ja Nej Vet ej
– Råder datamättnad? Ja Nej Vet ej
– Råder analysmättnad? Ja Nej Vet ej
Kommunicerbarhet
– Redovisas resultatet klart och tydligt? Ja Nej Vet ej – Redovisas resultatet i förhållande
till en teoretisk referensram? Ja Nej Vet ej
Genereras teori? Ja Nej Vet ej
Huvudfynd
Vilket/-n fenomen/upplevelse/mening beskrivs? Är beskrivning/ analys adekvat? ……… ……… ……… ……… ………
Sammanfattande bedömning av kvalitet: Bra Medel Dålig
Kommentar ……….
……… ………
