Testing of the hypothesis using multiple linear regression statistics to determine the influence of each of the predicting variables revealed a Constance 5.219, and calculated t-values of– 2.594* for stigmatization;-3.156* for abandonment and 1.558 for social isolation. Of these, – 2.594* and - 3.156* were found to be greater, while the value 1.558 was lower than the critical t-value of 1.968 needed for significance at .05 alpha level with 118 degrees of freedom. Hence, the null hypothesis was rejected (Coping strategies of VVF women = 5.219 -3.156 abandonment, +1.558 social isolation, –2.594 stigmatization). This implied that the VVF women who were abandoned and those who experienced stigmatization found coping very difficult, hence they tend to be more passive in their coping than their counterparts who were not (denoted by the negative coefficient), while social isolation exerted less influence on their coping strategies. Whether sick or healthy, normal or abnormal, Nigerian people are known for developing various strategies to manage whatever unfortunate situations they find themselves. It is not surprising that Victims of VVF in the study area also developed survival strategies in the face of their calamity.
Findings from the quantitative analyses were in line with the themes that emerged from the in-depth interview (qualitative), where most of the respondents abandoned traced the rejection by their spouses to inactive sexual life due to painful coitus and occasional leakage of urine even after surgical repairs. They expressed difficulties in coping due to lack of support (emotional and financial), so they tend to be withdrawn, frustrated and resorted to spirituality and resigned to fate, living on charity and even begging. Some resorted to menial jobs like farming and fetching firewood for people for survival. One of the respondents, during the study survey told her story as thus:
“----seeing that my situation is not improved, my husband rejected me and choose another wife and little by little, the entire village turn its back on me. Since then I and my mother have lived in a hut at the edge of the village. We subsist on charity, but my health was becoming a little more precarious every day. When it became obvious that my life was at stake, the Rev. Sister is the Catholic Church my mother worships, brought me to this hospital for treatment. They are the ones providing for my care and treatment since then. That is how we have been coping”. (oral interview – 23yr old VVF victim).
Another respondent said:
“I believe my condition is the will of god”
In support of this, one of the key informants reported:
“For those abandoned patients while in hospital, the hospital take charge of them from donated items by philanthropic organization and women groups from the Catholic Churches….Also some patients from the communities are brought to the centre by good Samaritans. They overstay after discharge, they lack money to feed and become dependent on the nurses
To corroborate the views of other victims who beg for alms in order to survive the hardship of VVF, one of the respondents recounted:
“It has been very difficult for me but I must survive, so I beg for money sitting at a busy road and church corners. Begging is easy for me and I don’t have to walk up and down” (27yr old VVF woman).
These findings are highly in consonance with the findings of study by Wall [25
], which revealed that more than 60% of VVF affected women are abandoned or divorced for the reason that they can hardly satisfy the conjugal and consummative obligations of marriage. Consequently they are pushed away to their parents’ homes or to seek refuge in churches or VVF centres. In support of their coping strategies, study by Fasakin [6
] on VVF and psychosocial wellbeing of women in Nigeria revealed that most VVF women in trying to cope found begging easy for their condition. They sit at a junction and those who are kind drop some coins for them. Same source (p48) revealed that most of them reported finding solace in being active in the church, for that was where they were shown love, prayed for, given gifts and not treated as outcasts even when their problem is known. However, VVF women who were not abandoned could cope better and very actively too. A respondent under this category reported thus:
“-----my husband supports me. He brought me to this hospital and do visit always. I use pad, change always and bath at all times to minimize odour. I also use good scented body cream, soap and spray” (30yr old VVF woman).
In support of this, an analysis of patients at the Addis Ababa Fistua Centre, Muleta and Fantanhun [26
] found that women who are influential and rich are usually not abandoned, instead they are pampered supported and encouraged to stay in intact homes so that her wealth will be used in sustaining the other family members. Coping becomes easier for these ones.
The findings that stigmatization greatly influenced the coping strategies of VVF women though with a negative coefficient implies that the more they were stigmatized, the less their coping abilities. This finding correlates with the findings from the in-depth interview where some respondents from (Ebonyi, Kogi States and the Cameroun) sought treatment and care far from home to avoid stigmatization. One of them verbally expressed her experience as thus:
“Everybody says it is because I committed adultery that I have fistula. Some make fun of me. I could not bear remaining there… I had to seek treatment elsewhere (oral interview: 32yr old woman from the Cameroun).
Some hide their condition from people thereby shying away from treatment thus prolonging the duration of the condition. One of the respondents said:
“I hide my problem from people so that they do not mock at me---“
Nevertheless, others still withdrew from social gatherings and tend to hide themselves from others due to stigmatization. About 10% of the women interviewed, confirmed they benefitted from the free machine donated to them from the VVF centre and the skills taught them, which served as their source of livelihood since discharge. Some verbalized being very happy at the centre meeting others of their likes, sharing their stories and learning to cope by forming groups where they assisted one another.
A respondent recounted:
“The hospital helps me from the donations from churches and other charitable organizations. I can’t tell my end” (38 years old VVF woman, Yala – Cross River State – (oral interview).
In support, another had this to say:
“I want to have friends.I want to share my story” (19 years old girl Ebonyi State: Oral interview).
Nearly all the women who were stigmatized but had gone through a successful repairs described feeling like a “normal human being” and were able to return to their ordinary lives. Some indicated the ability to re-engage in economic activities and perform daily chores with little difficulty, with improved self-esteem; as they could now attend community and family gatherings. Others claimed having served as community level educators for the prevention and treatment of VVF and promoters of maternal health and safe delivery. A respondent interviewed verbalised thus:
“I tell them what I have been through so they don’t have to suffer as I have” (30 years old woman Kogi State oral interview).
These findings are consistent with findings of Akpan [27
], in her work “early marriage in Eastern Nigeria and health consequences of VVF among mothers”, which revealed that VVF is a shameful and degrading condition and women affected are highly stigmatized. When they discover they are many, they soon cope with their lives by forming association of Sisterhood, which helps them cope and cater for one another. Some of them loose hope of getting well again, so to cope, they seek refuge in churches, Non- Governmental Organizations (NGOs) and centres managed by missionaries for care and support.
From the regression analyses result, it could be inferred that social isolation exerted less influence on the coping strategies of VVF women (as reflected in their regression coefficient +1.558). This implies that other psychosocial factors must have contributed to the influence of social isolation on the coping strategies of VVF women. From the findings of this study, it became obvious that other psychosocial factors precede social isolation. For instance, majority of the respondents were married before the occurrence of VVF, only to be rejected, abandoned and some divorced by their husbands. They faced stigmatization from the so called “normal” people and even ostracized out of their communities. For these reasons they withdrew to themselves, stayed away from social functions, feeling very lonely and sad. Some respondents confessed that being isolated served as a motivator for them to devise ways of coping and getting on with their lives. Isolation is based on the superstitious belief that VVF is caused by either evil forces or a curse for the level of promiscuity purportedly engaged by the victim. The researcher during the in-depth interview captured these facts verbalism as thus:
“There is no joy anymore in being with others, loneliness takes over. I lose my habit for cooking, visiting others – and all these make me sad (38 years old VVF woman).
“I sleep in separate bed from my husband; I don’t feel comfortable having sex. I refuse my husband sometimes” (30 years old VVF woman).
They expressed different ways of coping with the situation to include: “resigning to fate’’, “withdrawing from others”, “accepting it as the will of God or punishment from God”, “ forming groups of sisterhood”. Some resorted to living on the margins of the society due to the smell for fear of embarrassment and ostracism from the community. Some tend to depend on charitable bodies like churches and NGOs.
One of the respondents who saw social isolation as a motivator to her coping had this to say:
“It is better to be on your own than to be with people who will constantly remind you of your problems” (29years old VVF woman).
Another respondent recalled:
“If I need to be with anyone, it is better with those we share the same condition. They understand how I feel. Since I came to this centre, I feel better because we share the same story” (VVF woman-34years).
A respondent who still enjoy some form of relationship confessed thus during the oral interview:
“My friends and relatives relate with me from a distance. With the little money I have, I try to change my sanitary pad regularly, wash my cloths and wrappers very clean and also use perfumes and good scented body creams to be able to say close to people” (30 years old VVF woman, Uyo).
Results of survey studies by Beuching and Jeter and Verdell [28
], is in congruence with these findings. The studies revealed that there is a high tendency in these women to exhibit avoidance behaviours in trying to cope passively due to social embarrassment, hence personal isolation which may end up in extreme depression, suicidal tendencies and even death. Also findings of study by Fasakin [6
] revealed that VVF victims feel happy and relaxed being with their likes. They organized themselves into “sisterhood of suffering” which enables them to survive the unwelcoming and anti-social attitude of the “normal” people towards them.
On the whole, the findings of this study strongly agree with the findings of earlier reviewed studies. Physical consequences of VVF lead to severe psychosocial stigmatization for various reasons. In most African communities, people believe that fistula occurs as a divine punishment or a curse for disloyal or disrespectful behavior [29
]. Most cultures in Nigeria view offspring as an indicator of a family's wealth and any woman who is unable to successfully produce children as assets for her family is believed to make her and her family socially and economically inferior [27
]. A patient's incontinence and pain render her unable to perform household chores and childrearing as a wife and as a mother, thus devaluing her worth. Other misconceptions about VVF are that it is caused by venereal diseases or that it is divine punishment for sexual misconduct [30
]. As a result, many girls are divorced or abandoned by their husbands and partners, disowned by family, ridiculed by friends, and even isolated by health workers [4
]. According to McKinney [31
], some women have formed small groups and resorted to walking by foot covering long distances to seek medical help. Same source posit that women are sometimes forced to turn to begging, hawking as a means of survival because the extreme poverty and social isolation that result from VVF eliminate all other income opportunities.