Development and Pilot Test of a Multi-Component Intervention to Support Women’s Recovery from Female Genital Fistula

Introduction and hypothesis We evaluated a pilot multi-component reintegration intervention to improve women’s physical and psychosocial quality of life after genital fistula surgery. Methods Twelve women undergoing fistula repair at Mulago Specialized Women and Neonatal Hospital (Kampala, Uganda) anticipated in a 2-week multi-component intervention including health education, psychosocial therapy, physiotherapy, and economic investment. We assessed feasibility through recruitment, retention, and adherence, acceptability through intervention satisfaction, and preliminary effectiveness through reintegration, mental health, physical health, and economic status. We collected quantitative data at enrollment, 6 weeks, 3 months, and 6 months. We conducted in-depth interviews with six participants. Quantitative data are presented descriptively, and qualitative data analyzed thematically. Results Participants had a median age of 34.5 years (25.5–38.0), 50% were married/partnered, 42% were separated, 50$ had completed less than primary education, and 67% were unemployed. Mean number of sessions received was 12 for health education (range 5–15), 8 for counseling (range 8–9), and 6 for physiotherapy (range 4–8). Feasibility was demonstrated by study acceptance among all those eligible (100%); comfort with study measures, data collection frequency and approach; and procedural fidelity. Acceptability was high; all participants reported being very satisfied with the intervention and each of the components. Participant narratives echoed quantitative findings and contributed nuanced perspectives to understanding approach and content. Conclusions Our results suggest that the intervention and associated research were both feasible and acceptable, and suggested certain modifications to the intervention protocol to reduce participant burden. Further research to determine the effectiveness of the intervention above and beyond surgery alone with regard to the health and well-being of women with fistulas is warranted. Supplementary information The online version contains supplementary material available at 10.1007/s00192-024-05814-3


Introduction
Female genital fistula is a debilitating birth injury affecting an estimated 500,000 women, mostly in sub-Saharan Africa [1,2].Primarily due to prolonged obstructed labor combined with a lack of high-quality emergency obstetric care access or iatrogenic etiologies, up to 100,000 new cases occur each year globally.In Uganda, 1.4% of women of reproductive age (regional range 0.5% to 4.3%) report having experienced female genital fistula symptoms in their lifetime and approximately 1,900 new cases occur per year [3].
Fistula is associated with significant physical, psychosocial, and economic consequences.Physical symptoms include uncontrollable urine and/or fecal leakage and associated odors, pain, weakness, and mobility impairments [4][5][6][7].Fistula-causing births have high stillbirth rates [8].Women with fistula are often stigmatized, unable to participate in social, economic, or religious activities [6,8] and report high psychiatric morbidity [9][10][11].Surgery Handling Editor: Catherine Matthews Editor in Chief: Maria A. Bortolini Extended author information available on the last page of the article is often transformative; however, persistent post-repair symptoms may substantially lower psychosocial health [12,13].These factors limit women's ability to resume their previous roles despite successful surgery, particularly in conjunction with economic hardship [14].
Owing to the significant physical and psychological disabilities that women with fistula experience, targeted rehabilitation efforts may substantially impact recovery and quality of life.Despite the need and recognition that holistic approaches to fistula care may improve recovery, most fistula services incorporate little complementary or follow-up care [15][16][17][18].Few studies report on the development and implementation of holistic fistula care or on the effectiveness of interventions provided as an adjunct to fistula surgical care, leaving a knowledge and practice gap [13,19].Studies from Nigeria, Eritrea, and Tanzania support short-term facility-based psychological intervention for improving mental health [20][21][22][23], and evidence from the Democratic Republic of the Congo and Benin supports health education and physiotherapy for improved pelvic floor strength and reducing post-repair incontinence [24][25][26][27].Economic empowerment lacks robust evidence, yet is theoretically and anecdotally considered an important adjunct to fistula programming [13,28] and is a primary focus of social programming outside of health care settings.
Our study sought to address the gap in evidence-based practice for reintegration following female genital fistula surgery through the development and pilot test of a multi-component intervention including health education, psychosocial counseling, physiotherapy, and economic empowerment.Intervention domains and delivery structure were informed by existing evidence and our team's experience in surgical fistula care and research on optimizing recovery from female genital fistula surgery [29].The objectives of this pilot study were to assess the feasibility and acceptability of the multi-component reintegration intervention in conjunction with fistula surgery in a Ugandan referral hospital and to explore its preliminary effectiveness on women's physical and psychosocial quality of life.

Study Design and Site
We employed a quasi-experimental (pre/post) mixed-methods design to assess feasibility and acceptability, and to explore the preliminary effectiveness of a multi-component reintegration intervention among women accessing care for female genital fistula at Mulago Specialised Women and Neonatal Hospital in Kampala, Uganda.

Study Participants
Eligibility criteria included being confirmed for urogenital fistula surgery, age 18 or above (or emancipated minor), and able to provide consent to study participation.Twelve study participants were enrolled in our study between October 2021 and February 2022.We invited a nested sub-sample of six study participants for in-depth interviews between December 2021 and March 2022 to understand their experience participating in the intervention and its impact.Quantitative and qualitative sample sizes were based on feasibility.

Participant Recruitment and Enrollment
Potential participants were identified through surgical registry review and discussion with fistula care providers.After screening for eligibility, the research team described the study goals and procedures, ensured understanding of study procedures and risks, and ascertained women's interest in participating.Written confirmation of informed consent was obtained from all study participants.

Intervention
Standard fistula surgical care at Mulago Hospital includes a 2-week post-surgical hospitalization during which patients receive unstructured health education and counseling on post-repair behaviors, including instruction on pelvic floor muscle strengthening exercises.Women with significant psychiatric or physiotherapy needs are referred to specialist care.
Our pilot intervention targeted four domains to support women to overcome the physical, psychological, and economic consequences of fistula: health education, psychosocial therapy, physiotherapy, and economic empowerment (Table 1; detailed schedule in Table S1, session objectives outlined in Appendix 1).These components were selected because of their importance in the fistula literature [12,13].Intervention activities were planned for ~75 min per day for small group delivery (e.g., 4-8 participants).Health education sessions (n = 15) delivered by nurse-midwives communicated comprehensive information about the development, treatment, and rehabilitation of fistula, contraception, and birth planning for subsequent deliveries, identification of obstetric emergencies, and nutrition.Psychosocial

Health education
Development: health education activities were adapted from materials developed for health education and reproductive health counseling for women with fistula [30] and other low-literacy populations, including counseling components developed by EngenderHealth's FistulaCare project, which were previously implemented in Eritrea [21,30].We have modified these materials for relevance, understandability, and acceptability to our target population as well as in consideration of participant burden for intervention participation Facilitator: facility nurses/midwives Content and rationale: health education sessions focus on educational and behavioral messages designed to improve women's understanding of fistulas and important reproductive health topics including comprehensive information about the development, treatment, and rehabilitation of fistulas, family planning and birth plans for subsequent deliveries, identification of obstetric emergencies, and nutrition (Table S1, Appendix 1).This information is intended to help women to make informed decisions during the post-repair period and beyond.Partners and/or caregivers who are helping or visiting women at the facility are included as they share the burden of fistulas with their afflicted family member are critical sources of social support, and may serve as links between the afflicted woman and other community members Setting: group Sessions: during their stay at the health facility for fistula repair, each participant receives daily health education sessions: 15 sessions; no session on the day of surgery or the day after; each session lasts ~30 min; one session includes partners and/or caregivers Psychosocial counseling Development: short-term facility-based psychological intervention has resulted in improved mental health among women with fistulas [20,21].Psychosocial counseling activities build on therapeutic strategies previously developed for women with fistulas [20,21,31] and treatment modalities demonstrated to be efficacious for the treatment of depressive, anxiety, and traumatic stress disorders among similar populations, and that may be delivered both individually and within-group-administered therapy, including delivery by trained lay persons [32][33][34][35][36][37][38] Facilitator: facility social worker Content and rationale: each session addresses an important component for helping women to accurately frame their fistula experience, and to prepare for returning home by developing plans for positive coping and development of social support (  [6,24,25].This intervention component is based on programming developed by pelvic floor physiotherapists with expertise in the treatment of women with fistula [39] Facilitator: facility physiotherapists supported by facility nurses/midwives Content and rationale: the program comprises a sequential series of exercises focused on recovering mobility, balance, and strength, and building and maintaining pelvic floor musculature.A low-literacy brochure including home exercise descriptions is provided to participants at hospital discharge to guide them through walking, range of motion, and strength-building exercises, including lumbopelvic stability and pelvic floor muscle exercises (Table S1, Appendix 1) Setting: group and individual sessions Sessions: during their stay at the health facility, each participant engages in pre-surgical PT evaluation; daily physiotherapy exercises, per stage; pre-discharge PT evaluation + home treatment plan; 6-week follow-up evaluation and home treatment plan Economic empowerment Content and rationale: many women with fistula lack skills or investment funds to build home businesses, and many have depleted savings or incurred debt by seeking fistula care.Qualitative research suggests that small businesses, animal husbandry, or skills training might be desired [38], and supporting women in achieving their economic goals is necessary for well-being.Livelihood development programs are broadly accessible in Uganda [40,41], and women often have prior business experience that they would like to develop further; thus, investment funding combined with a short informational session on financial literacy was seen to be the optimal strategy to meet the individual needs of women Facilitator: facility social worker Setting: individual Sessions: at the 6-week post-surgical visit, the participant meets with the facility social worker for the following: a short informational session covering the basics of financial literacy is done on an individual basis; 525,000 Ugandan Shillings (equivalent of US$ 150) in investment funding, in cash; follow-up by the social worker to provide additional support/advice (by phone) counseling sessions (n = 8) delivered by a social worker sought to help women to reframe their fistula experience and prepare for returning home by developing plans for positive coping and social support development.Physiotherapy sessions delivered by physiotherapists comprised evaluation (pre-surgery, pre-discharge, and at 6 weeks following surgery) and a sequential series of facilitated exercises focused on recovering mobility, balance, and strength, and building and maintaining pelvic floor musculature (daily).Economic empowerment included a short financial literacy session by the social worker and provision of 525,000 Ugandan Shillings (equivalent to US$ 150) in investment funding.

Data Collection
Mixed-methods data on intervention implementation was captured through process tracking, discussions with intervention implementers, and observation.Quantitative data were collected at enrollment (prior to fistula surgery), hospital discharge (14 days following surgery), and 6 weeks, 3 months, and 6 months following fistula repair surgery.Participants were provided with phones and monthly airtime to facilitate study communication and for remote follow-up data collection at 3 and 6 months.Qualitative data were collected between 3 and 6 months following surgery.

Study Measures
Our primary study outcomes were feasibility and acceptability.Intervention feasibility was assessed through recruitment, retention, and fidelity/adherence.Intervention acceptability was assessed quantitatively through participant satisfaction with the intervention overall and with each intervention component using a five-point Likert-type scale.Qualitative acceptability assessment included open-ended questions on participant experiences and perspectives with the intervention overall, and with each intervention component, including perspectives on appropriateness (perspectives on fit and relevance of the innovation to the patient, problem, and setting) [42,43].Quantitative feasibility and mixed-methods acceptability assessment were supplemented by discussions with intervention moderators regarding challenges and adaptations required to the original intervention plan.Preliminary effectiveness assessment was based on participant self-reported reintegration as a primary outcome [12], and secondary outcomes: physical health (incontinence [44] and level of disability [45]), mental health (i.e., depression [46], and a one-item self-esteem measure), economic stability (i.e., earnings and food security), empowerment (measured through input into household decision-making across varied domains), and stigma (enacted and internalized).Most measures were collected at each time point; however, to reduce participant burden, incontinence was assessed at baseline and at 6 weeks only, and stigma at baseline and at 6 months only.Outcome assessment was implemented at 6 months owing to our study timeframe and because this is the time point at which prior research has identified reducing gains over time [13].Qualitative assessment included participant perspectives of intervention effectiveness.
Covariates captured and used to describe the study sample included sociodemographic characteristics (age, education, marriage/partnership status, labor force participation, income, and wealth) and duration of time with fistula), all collected at baseline.

Data Analysis
Quantitative data on feasibility, acceptability, and preliminary effectiveness were descriptively analyzed using medians and standard deviations, medians and inter-quartile ranges, and proportions-per variable distribution.We explored trends over time using mixed-effects linear and logistic regression models, accounting for within-person clustering.Qualitative data were analyzed thematically across intervention and research components using an implementation science orientation focused on content, approach, acceptability, appropriateness, and feasibility [42].A codebook was developed iteratively including deductive codes from our framework and interview guide and inductive codes emerging organically from the data.The codebook included a detailed description of each code, inclusion and exclusion criteria, and examples of the code in use.Transcripts were coded by three research team members a Ugandan researcher and qualitative interviewer (HN), an American mixed-methods researcher (AE) and an American Master of Public Health Student (SA).Coded data were analyzed thematically to understand participant experiences and perspectives across intervention components, and major findings and interpretation were reviewed by the co-author team.Change in economic status over time was analyzed through review of mixed-methods data.

Study Participants
Study participants had a median age of 34.5 years (IQR 24.5-38.0;Table S2).Half had not completed primary education (6 out of 12; 50%) and half were married or in a domestic partnership (6 out of 12, 50%).Many were not employed (5 out of 12, 42%) and median monthly income was 0 (IQR 0-95,000 Ush, ~US$ 25).None had health insurance.Time with fistula varied substantially across the sample, ranging from 1 month to 23 years.

Intervention Feasibility
The pilot reintegration intervention was considered feasible.Recruitment and retention were successful despite fewer patients seeking fistula care during the COVID-19 pandemic.Among 13 eligible individuals, 12 agreed to participate.One declined participation owing to concerns with follow-up data collection.All 12 participants were retained throughout the 6-month study.
Intervention fidelity was good, with most but not all intended sessions received.The mean number of sessions attended by intervention component was 12 for health education (range 5-15), 8 for counseling (range 8-9), and 6 for physiotherapy (range 4-8).All participants received the economic incentive.Few family members attended the final counseling session on fistula prevention and management.
Data collection, including outcome measurement, was feasible and question comprehension was good.Participants reported that the interviews were not burdensome, with only 1 suggesting shortening the quantitative survey.
Study intervention implementation was largely feasible.Participants were generally ready to engage per plan; however, a few participants preferred to postpone physiotherapy exercises for the first few days following surgery.Some counseling topics were difficult to engage with owing to their sensitive nature; however, participants reported feeling supported to discuss challenging topics.Some participants suggested that fewer sessions would be easier.

Intervention Acceptability
Acceptability of the intervention to patients was high overall.All participants reported being very satisfied with the intervention (12 out of 12) and that each of the components were very useful (12 out of 12, for each component).Intervention moderators reported high acceptability in team discussions.Participant perspectives on the content, approach, satisfaction, appropriateness, and suggestions for each of the four components are described below, with selected quotations in Table 2.

Health Education
Study participants generally reported understanding the health education content well and recalled key content areas such as how a fistula occurs and primary discharge instructions (e.g., delaying post-repair sexual intercourse, avoiding heavy work, drinking enough water, eating healthily, and doing exercises).Participants also reported being counseled on postponing post-repair pregnancy and the importance of cesarean section for subsequent births.One participant reported some difficulty with understanding the cause of their fistula, and 2 participants particularly appreciated the family planning information given their lack of prior knowledge.Participants reported that the educational content was very useful for them, met their needs, and was understandable, and thus was considered appropriate.Participants generally appreciated the approaches used within the health education sessions.One participant specifically mentioned enjoying the handouts shared by the moderators.Most participants preferred group versus individual sessions owing to the social support provided by individuals with the same problem; however, one participant who had participated individually voiced potential confidentiality concerns with a group format.

Counseling
Participants felt that counseling covered important topics for overcoming fistula-related challenges.The counseling content was useful for them, motivated them, and met their needs (appropriateness).Some participants preferred the group counseling approach whereas others preferred individual counseling.Participants who preferred group counseling believed that the group facilitated greater learning.Participants who preferred individual counseling prioritized confidentiality.Overall, participants were satisfied with counseling.They expressed being comforted during counseling and trusted the counselor.

Physiotherapy
Participants appreciated the physiotherapy content, including exercise training.The physiotherapy was considered helpful and appropriate for fistula patients, and participants appreciated physical improvements after initiating physiotherapy, with some respondents also noting stress relief.Some participants, mainly those who underwent abdominal surgery, reported that certain exercises were painful, particularly early after surgery.Some suggested that physiotherapy exercises might be delayed by a few days or weeks to minimize the pain and allow the surgical wound to heal.
Preferred physiotherapy session mode (approach) varied, with some participants preferring individual sessions and others preferring group sessions.Some respondents feared being made fun of doing exercises, exposing their private parts, or failing to do some exercises.Others preferred group sessions for social support and encouragement.
All respondents expressed satisfaction with the exercises mainly because they believed that they helped them heal faster.However, certain exercises were more painful or difficult.Many respondents reported continuing the physiotherapy exercises beyond their hospital stay for fistula repair in order to heal.Some participants failed to continue with the exercises at home, simply because they forgot the exercises that they were meant to do, and a few missed getting discharge cards describing the different exercises.

Economic Incentive
All participants appreciated and were satisfied with the economic incentive they received as a start-up fund, and most did not expect it.Most started small businesses and reported that the amount given to them ($150) was adequate.Some participants suggested adding vocational skills training (e.g., hairdressing or baking).Most preferred money versus vocational skills training as it did not guarantee employment, whereas money met immediate family needs.Others suggested adding follow-up via phone or visits to check on business progress and well-being.The small businesses included roadside food stalls, general trading, animal rearing or farming, and crafts.They focused on a range of commodities including charcoal, rice, and groundnuts, coffee beans, pigs, silverfish, chicken, and clothing.One participant reported investing in a popcorn machine and now makes and sells popcorn.Another participant brewed and sold alcohol.Two participants described using the funds to support other family members or household expenses such as school fees, rent, clinical care, or family funeral expenses.One participant stayed with family post-surgically and saved the money to start a restaurant after she returned home.

Research
Participants found the research approach acceptable.Some participants perceived the survey as short, whereas others noted that it was long; however, participants reported no difficulty with the questionnaire and interview length or returning to the health facility for follow-up data collection.They appreciated facilitation of their return transportation for data collection.
At baseline, all participants were leaking urine (n = 12, 100%); at 6 weeks post-surgery, only 1 person (8.3%) reported ongoing urine leakage (not shown).Median impact of urine leakage interference on everyday life reduced from the scale maximum of 10 (IQR 9-10) at baseline to the scale minimum of 0 (IQR 0-0) at 6 weeks.Respondent input into household decision making exhibited little change over time, except for food crop and livestock farming (80% to 86% from baseline to 6-month follow-up, p = 0.006) and nonfarming economic activities (75% to 100%, marginal p = 0.091).
We observed important reductions in stigma experiences and increases in social support.From baseline to 6 months, enacted stigma reporting decreased from 6 to 2, reporting being treated differently than before fistula, 5 to 1 reporting being treated badly, and 6 to 1 reporting abandonment owing to the fistula.Internalized stigma reduced from 9 at baseline to 2 at follow-up, and similar numbers reported choosing to avoid others or join social activities owing to the fistula (6 to 1).Over the study follow-up, consistency in emotional support increased from 6 to 10 and informational support increased from 4 to 7, yet tangible support decreased from 6 to 5 (Table 3).
Changes in living status, relationship status, individual financial status, and household financial status over the study period are described in Table 4. Change in living status was reported by most participants at 6 weeks (8 out of 12) and 3 months (8 out of 12) post-surgery, most of which was positive and focused on stigma reduction; fewer participants endorsed changes in relationship status, yet comments in this domain were similarly focused on stigma reduction.Most participants reported positive changes in individual employment, income, savings, and debt at 3 (8 out of 12) and 6 months (10 out of 12), and positive household changes reported largely reflected changes in individual income.
Within 3 months of receiving the incentive, participants created small businesses (see acceptability), saved the money, used it for household essentials, or paid debt and taxes.By 6 months, many participants were involved in income-generating activities.Assets did not change over time but investments improved household income and savings.Some participants experienced an improvement in the quality of their living environment.They expressed better living conditions such as sleeping well in clean beds, working, and buying what they needed.

Discussion
Establishing feasibility and acceptability of an intervention and the surrounding research are key foundational components required before moving forward with robust assessment of intervention effectiveness.We found that a multi-component fistula reintegration intervention incorporating health education, psychosocial counseling, physiotherapy, and an economic incentive delivered within a public Ugandan referral hospital setting at the time of fistula surgery was demonstrated to be feasible and acceptable to both implementers and recipients.Furthermore, the research structure around the intervention for assessing effectiveness was also considered feasible and acceptable to implementers and participants.Research findings informed important adjustments to the original intervention protocol to reduce participant burden and improve engagement.Our research contributes to the limited evidence based on holistic fistula care, which supports the need for reintegration programming addressing the unique physical, psychosocial, and economic needs of women recovering from a fistula and fistula surgery [2].
Implementing fistula care has its own unique challenges, which are structured by the relatively low incidence but broad geographic distribution of patients, the constellation of physical and social sequelae experienced by individuals with the condition, in conjunction with traditionally siloed care models for these needs, the low socioeconomic status and health literacy of this population, and the lower-resource settings in which a fistula more commonly occurs.These challenges, relevant to both fistula surgery and reintegration programming, Table 3 Change in primary and secondary outcomes across pilot study participants, and trends over time a β from linear regression and b odds ratio from logistic regression Scale ranges were reintegration 0-100, disability 12-60, depressive symptoms 0-27, self-esteem 1-5, incontinence impact (0-10), enacted stigma (1-4), and internalized stigma (1)(2)(3)(4) Different sample sizes (n) across involvement in some household decision-making: Definitions of different categories: food crop: crops or livestock grown primarily for house or for household food consumption; cash crop: crops grown primarily for sale in the market; nonfarming economic activities: small business, self-employment, buy and sell; wage and salary: in kind of monetary work, both agricultural and other wages Mean (SD) a , median (IQR)  were considered by our research team and have similarly influenced the scope of other reintegration interventions reported in the literature.Other programs providing reintegration support have tested health education, psychosocial counseling, physical rehabilitation, social immersion, and livelihood improvement, alone or paired-and largely at the fistula repair facility [13,47,48].We sought to be comprehensive in our reintegration programming approach through addressing physical and psychosocial health and economic status, employing group delivery strategies to capitalize on shared experiences and build social support, extending certain sessions to family members to strengthen communitybased support, and providing an economic incentive for women to use as they desired; however, certain limitations to our design should be explored in future research and implementation.Optimal reintegration programming should extend facility-based services to community settings given the important role of the unique community environments of each individual to accommodate their individual needs, and facilitators and barriers to reintegration, which include social support networks and resources.We implemented our intervention within the fistula surgical facility to exploit the 2-week facilitybased recovery period and because of service provision challenges across large distances.Building community networks and programming within this model was not possible within the scope of our small grant mechanism, but a systems approach should be prioritized for countrylevel reintegration program developers and implementers.Broad engagement of community health workers has been feasible within the Fistula Foundation's Fistula Treatment Network in Kenya for surgical mobilization and followup [47], and other models for expanding care continuity through existing community-based services are needed.Finally, most existing reintegration programming supporting economic stability offers vocational training, with or without added financial support; owing to the referralfacility base of our intervention and geographic diversity of participant residence, we chose not to coordinate further vocational programming.This design increased implementation feasibility within our clinical setting, but further consideration should be given to connecting women with existing vocational training programs as needed to improve economic status.
Our preliminary effectiveness results identified improving trends across time within key domains of interest; however, our pilot study was not designed to test the effectiveness of the reintegration intervention components separately from the impact of fistula surgery, which we know has significant impact on improving women's physical and psychosocial health [49,50].The findings of the current research confirm that the research structure around our intervention is both appropriate and feasible, but cannot be considered evidence of intervention effectiveness.
Key limitations to this study include our implementation within one site, small sample size, and lack of a comparison group; although appropriate for a pilot study such as ours, these factors did not allow us to explore feasibility and acceptability differences across diverse settings and populations and limited our ability to formally assess intervention effectiveness.Pilot study implementation and data collection occurred during the COVID-19 pandemic.Local mitigation measures included travel restrictions, reduced medical capacity, and limitations on elective surgery provision, which influenced our ability to implement this study as planned.Finally, although our study evaluated outcomes at 6 months, which is the time point at which prior longitudinal research has identified reducing physical and psychosocial gains, a longer evaluation period may be more appropriate to fully capture this impact, as well as any economic impact [13].

Conclusion
Holistic approaches to genital fistula programming are important for supporting women to overcome the significant physical and psychological disabilities associated with this condition in conjunction with surgery, yet the evidence base is limited.Our facility-based multicomponent intervention, built on prior literature, theory, and field experience, was found to be both feasible and acceptable within pilot research.Further research to determine the effectiveness of this intervention above and beyond surgery on the health and well-being of women with fistulas is warranted.Future research should employ study designs capable of evaluating the value added of reintegration components on key fistula outcomes.Quality of research design and reporting has been limited for many fistula interventions [2,13], and integrating robust research structures with ongoing and new reintegration programming is an important strategy for improving the quality of this evidence base so that others can learn from this body of literature, including attention to implementation considerations such as human resources and costs, to meet the needs of policy makers and program leadership, and ultimately improve women's recovery from fistula.

Table 1
Specific components of post-surgical reintegration intervention

Table 2
Example participant narratives on intervention content, approach, appropriateness, feasibility, satisfaction, and recommendations across components

Table 4
or proportion by time since surgery Trend over time Changes reported in living status, relationship status, individual financial status, and household financial status over time To introduce the patient to the cognitive-behavioral model 60 min Day 6 (post-operatively) Group To begin the teaching patient how to reframe negative or unhelpful thoughts Review key emotions Identify negative and problematic thoughts Link thoughts to resulting emotions Begin practicing reframing problematic thoughts To manage the emotions associated with their situation 5. Develop coping strategies to maximal pelvic floor muscle exercises Exercises for the abdominal, hip, and low back muscles Stretching areas of scar tissue and muscle and joint tightness (or contracture) WHODAS World Health Organization Disability Assessment Schedule, ICIQ International Consultation of Incontinence Questionnaire