Rehabilitation and reintegration programming adjunct to female genital fistula surgery: A systematic scoping review

Abstract Background Female genital fistula is associated with significant physical, psychological, and economic consequences; however, a knowledge and practice gap exists around services adjunct to fistula surgery. Objectives To examine rehabilitation and reintegration services provided adjunct to genital fistula surgery, map existing programming and outcomes, and identify areas for additional research. Search strategy We searched the published and grey literature from January 2000 to June 2019. Two reviewers screened articles and extracted data using standardized methods. Selection criteria Research and programmatic articles describing service provision in addition to female genital fistula surgery were included. Data collection and analysis Of 3047 published articles and 2623 unpublished documents identified, 26 and 55, respectively, were analyzed. Main results Programming identified included combinations of health education, physical therapy, social support, psychosocial counseling, and economic empowerment, largely in sub‐Saharan Africa. Improvements were noted in physical and psychosocial health. Conclusions Existing literature supports holistic fistula care through adjunct reintegration programming. Improving the evidence base requires implementing robust study designs, increasing reporting detail, and standardizing outcomes across studies. Increased financing for holistic fistula care is critical for developing and supporting programming to ensure positive outcomes.

to pain and general weakness, 8 women may experience nerve damage, uterine cervix injuries, and pelvic bone trauma that present as secondary infertility and gait disorders. 9 Most babies involved in fistula-causing deliveries do not survive. 10 Women with fistula are stigmatized, restricted in social and economic participation, 8,10 and report high psychiatric morbidity including depression, which may persist even after surgical repair. [11][12][13][14] Access to genital fistula surgery has improved in sub-Saharan Africa and many women experience improvements in physical and mental health following fistula repair alone; however, numerous women face continued physical and psychological challenges to resuming prior roles or adjusting to new circumstances. They may require further medical care depending on injury severity and surgical outcomes, and medical support for subsequent pregnancies and births. Longitudinal studies from sub-Saharan Africa have identified concerning adversity following fistula surgery, including fistula recurrence, persistent fistula-related symptoms, subsequent fertility challenges, and adverse perinatal outcomes. [15][16][17][18][19] In Guinea, 16% experienced fistula recurrence by 24 months. 17 In Uganda, by 12 months following repair, one-third had persistent urinary incontinence, 17% weakness, and 9% general pain. 20 In Malawi, only one-fifth of women with reproductive potential became pregnant in the year following surgery. 16 Experience of persistent physical adversity correlates with substantially lower psychosocial health. 20 Such factors limit women's ability to resume previous roles despite successful surgery, particularly in conjunction with economic hardship, 21 resulting in additional reintegration needs. 22,23 A knowledge and practice gap exists around women's postsurgical reintegration programming. Preliminary evidence supports short-term facility-based psychological intervention. 24,25 Physical therapy has also been recommended, 26 as has improvement of economic independence. 27,28 Research synthesis on the reintegration process, evaluation, and service provision is important for developing evidence-based service prioritization to meet the health needs of women recovering from genital fistula. Thus, the objective of this scoping review was to examine the range of rehabilitation and reintegration services provided as adjunct to genital fistula surgery, map the existing programming and outcomes, and identify areas where additional research is necessary.

| MATERIALS AND METHODS
Four research questions were specified to meet these objectives: and Levac et al. 30 frameworks and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) guidelines. 31 The full protocol for this review is published in detail elsewhere and summarized herein. 32 We searched the published and unpublished ("grey") literature to broadly capture reintegration programming data. The search strategy was developed collaboratively with a medical librarian (JBW) with training and experience in systematic reviews using an iterative process including term harvesting, text and MeSH term extraction, and testing. 33 The final search strategy was peer reviewed by a second librarian following Peer Review of Electronic Search Strategies guidelines. 34 We searched reference lists of included articles and contacted authors for additional detail. Titles and abstracts of published articles were independently screened by two reviewers (AE and CP) followed by full-text screening and data extraction. A third reviewer (AD) was available to resolve discrepancies; however, none arose. In accordance with established scoping review frameworks, 29,30 critical appraisal of study quality was not performed. Inclusion and exclusion criteria are detailed in Table 1.
Data from eligible studies were systematically extracted ( Table 2).
Where articles were eligible but lacked detail, data were summarized narratively. Unpublished studies and reports were screened by one of four reviewers (AE, CP, RB, LL); results are reported following a simplified PRISMA sequence in narrative format 35

| Published articles and program reports
Our database search identified 3242 articles. Excluding duplicates, 2197 articles were screened; 25 were found eligible and one related article was identified during web searching of article PDFs. The modified PRISMA flow diagram for selection of available studies is given as Figure 1. Twenty-six articles were analyzed. Among these, 11 articles representing seven different studies or programs were considered "primary," including a meaningful level of detail on program components and outcomes, and are presented in the data extraction table (Table 2). Fifteen articles representing 10 different studies or programs were considered "supplementary," meeting the eligibility criteria but lacking detail, and are summarized within a separate narrative section.
Results from the same study or program are presented together in table and narrative. One program had one primary 36 and one supplementary 37 article; both are described within the primary results.

| Rehabilitation and reintegration intervention components and delivery
Two studies tested a combined health education and physiotherapy program. [38][39][40][41] In Benin, Castille et al. 38 ioral therapy intervention on mental health. Improvements in depression, anxiety, post-traumatic stress disorder (PTSD), and self-esteem from baseline to follow-up were not significantly different by intervention group, but feasibility and intervention satisfaction were high.
One report, by Pollaczek et al. 45 from Kenya, described an intervention comprising psychosocial counseling, social support, and economic empowerment. Individual counseling was followed by community-based peer support group linkage for social support and economic empowerment through income-generating activities. Most participants reported improvements in emotional well-being and fistula-related knowledge, and high intervention satisfaction; however, economic gains were modest.
One report described an intervention combining health education and social support. 36,37 In Guinea, women lived in a supportive group home or host family while recovering from surgery, and received health education sessions and public speaking and interpersonal communication training. The program sought to facilitate women's transition to family life while ensuring postoperative care access and prepared them as community educators. No outcome data were provided; however, anecdotally, participants experienced increased confidence, selfesteem, and emotional health.

| Health education and psychosocial counseling
Outcomes from combined health education and psychosocial counseling interventions included self-esteem (n=3) and depression (n=2).
All three studies identified significant improvements in self-esteem; in the only controlled study, no differential self-esteem increase was found between intervention and control groups. Significant decreases in depression were identified by Johnson et al. 25 and Watt et al. 42-44 ; again, intervention differences were not significant. Other outcomes included increased fistula knowledge and healthy behavioral intentions, 25 and significant reductions in severe suicidal ideation, 24 anxiety, and PTSD symptoms. 45 No difference between intervention and control groups was found for anxiety and PTSD symptom reduction. 44 T A B L E 1 Population, concept, and context for identification of eligible studies.

| Outcomes by fistula etiology
Outcomes of reintegration programming were not reported by etiology of genital fistula.

| Authors' recommendations
The authors' recommendations from primary articles supported holistic programming at genital fistula surgery and extending to community, despite most study outcomes measured at short term.
Most articles recommended increasing women's access to incorporated intervention components given formal or anecdotal findings.
Psychosocial counseling for women 36

| Supplementary articles
Fifteen additional articles representing 10 studies or programs were eligible but limited in information; most were conference abstracts.
Bangser and Haile-Mariam 46 reported on the effectiveness of the USAID Ethiopia program, which included transport home, followup, and cash or in-kind support, and was valued by stakeholders.

Recommendations (authors' recommendations based on findings/experiences)
Summary of components: Psychosocial counseling and health education Location: Hospital Implementer: Trained community health nurse Duration: 6 individual psychotherapy sessions over a 2-wk period (2 presurgery, 4 postsurgery) Mechanism: An intervention based on CBT and coping skills will lead to effective coping and improved mental health, further resulting in social well-being and general functioning, and improving ability to reintegrate Structure: Session 1: Normalize patient's experience, acknowledge fistula impact, explore fistula influence on self-perception, generate therapy goals, and learn relaxation exercise (to practice daily). Session 2: Practice relaxation exercise, review any other assignments, cognitively reframe fistula experience through education, counsel on fistula surgery, discuss treatment hopes/anxieties/questions. Patients assigned relaxation practice and asking healthcare provider questions. Session 3: Introduce to cognitive model, begin teaching how to reframe negative/unhelpful thoughts, teach 'serenity prayer' and relate to individual coping. Patient assigned relaxation practice and practice reframing negative thought. Session 4: Help patient recognize and respond to stressors using appropriate and effective coping skills, create behavioral plan for coping with negative stressors. Patient assigned coping strategy practice. Session 5: Examine the effect of social relationships on patient's life, generate specific strategies to strengthen social relationships, role play potential discussions about fistula, facilitate call between patient and support person to facilitate return home. Patient assigned consideration of thoughts and feelings about going home. Session 6: Prepare the patient to return home, discuss patient thoughts/emotions, problem solve how to handle circumstances and cope with potential stressors, develop a detailed action plan, facilitate second phone call with support person to share reintegration plans and solidify support, share summary of postsurgery medical recommendations (e.g. 3 mo of sexual abstinence, no heavy work), review goals, achievements, and plan      The existing literature supports holistic fistula care including meeting postrepair physical, psychosocial, and economic needs of women through reintegration programming targeting short-and long-term outcomes. However, the evidence base lacks robust research designs and systematic detailed reporting of intervention components and outcomes. We strongly encourage researchers and service providers to implement more robust evaluation designs and to broadly disseminate the results of their work so that the global fistula community can benefit through the development of best practices in reintegration.

CONFLICTS OF INTEREST
The authors have no conflicts of interest.