Removing barriers to fistula care: Applying appreciative inquiry to improve access to screening and treatment in Nigeria and Uganda

Figures & data

Figure 1. Reducing barriers to fistula treatment in Nigeria and Uganda using appreciative inquiry.

Table 1. Barriers to and enablers of fistula treatment identified through qualitative research.

Barriers to fistula treatment

Enablers of fistula treatment

Psychosocial Depression/low self-esteem Shame/hopelessness Stigma Self/society blame due to obstetric fistula Fear for repeat surgeries Paranoia/anxiety/anger Political/structural Challenges/gaps in available programs/resources Lack of political or policy will Socio-cultural Myths and misconceptions Gender-based violence and household dynamics Rejection/isolation/outcast/resented Abandonment by family, spouse, and/or community Transportation Distance Transportation cost Road conditions Health system/quality of care Facility shortages Perceived poor quality care Provider shortage, availability, knowledge, and practice Providers’ behaviors Poor referral linkages Awareness of fistula causes and repair services Described causes of fistula – actions of TBAs, delivery-related surgeries, prolonged labor Lack of information around prevention, treatment, referral, and follow-up care Obstetric fistula information sources/channels Lack of information/ignorance of causes of fistula and risk factors Financial/socioeconomic Poverty/lack of basic needs Perceived cost of repair (actual and ancillary) Opportunity cost due to obstetric fistula condition Cost of welfare/care at home

Enablers Free repair services Available information on OF Appropriate referral from facilities Support/caring behaviors by spouse, friends, and/or community networks Good quality and satisfaction on services received Preferred communication channels for increased awareness Use of mass media advertisements Use of repaired fistula clients as ambassadors for awareness creation Church and community platforms Coping mechanisms for care Borrowed money for transport and other welfare Family relatives paid for/supported in the transport Alternative treatments/concoctions for OF treatment Initiatives by OF patient personally Initiatives by well-wishers/community Family/others relinquished roles to support for care Trust and hope

Figure 2. Factors affecting fistula repair access.

Table 2. Intervention partners.

Partner type	Ikwo LGA (Ebonyi, Nigeria)	Katsina LGA (Katsina, Nigeria)	Kalungu District (Central, Uganda)
Primary health care (PHC) facilities	48 PHC workers trained across 19 facilities	46 PHC workers trained across 22 facilities	42 PHC workers trained across 21 facilities
Community agents	Daughter of Virtue and Empowerment Initiative (DOVENET) CBO ** 46 volunteers trained across 15 administrative wards	Federation of Muslim Women of Nigerian (FOMWAN) CBO ** 36 volunteers trained across 12 administrative wards	Village Health Teams (VHTs) ** 275 volunteers trained across 33 administrative parishes
Transportation provider	National Union of Road Transport Workers (NURTW)	Aba Jamil Car Hire Services	Lukaya Taxi Operator Cooperative Society Limited (LUTOCs)
Fistula treatment facility	National Obstetric Fistula Center (NOFIC), Abakaliki	NOFIC, Babbar Ruga	Fistula Clinic at Kitovu Mission Hospital
Digital health platform	VOTO Mobile (now Viamo)
Research and evaluation	FC+/Population Council
Management and supervision of intervention and fistula treatment partnerships	FC+/EngenderHealth

Figure 3. Intervention pathways.