2.1 Study design
A longitudinal before and after study using the standard WHOQOL-BREF tool for assessing quality of life of study participants before and after fistula repair was conducted between November 2019 and August 2020.
2.2 Study setting and study participants
The data collection for quality of life before surgical repair of study participants was conducted at the national center for obstetric fistula repair in Zimbabwe. Women who had come for obstetric fistula repair at the hospital were the participants of this study. The diagnosis of fistula was first suspected at health facilities in the women’s communities by nurses based on signs and symptoms using the community fistula screening tool (Additional file 1). The women were referred to the fistula center where physical per vagina and speculum examinations including dye tests were conducted to verify the presence, site and extend of the fistula. The second phase of data collection was conducted 6 months after repair, per telephone for the majority of the participants and through home visits for three participants.
2.3 Inclusion criteria
Women who had obstetric fistula of any type and any duration and who had come for fistula care at the fistula repair center were the participants of the. Those women who were willing to participate and gave written informed consent for both the baseline and the follow-up interviews, were eligible for the study.
2.4 Exclusion criteria
Obstetric fistula survivors who were not willing to participate in the study.
2.5 Data collection
Data collection for the “before” part of the study was conducted between 18 November and 6 December 2019. To allow adequate time for preparations for surgery, obstetric fistula patients are admitted at the center about 3 days prior to the actual day of operation. It was during this waiting time that participants were recruited into the study and data for assessing quality of life before repair was collected. The purpose of the study and procedures were explained to all the twenty-nine women who had come for fistula repair. Written information about the study was also distributed to all the women for them to read and understand. On the day of actual data collection for each participant, all aspects of the study were again explained to each individual woman, including procedures, benefits, advantages, disadvantages and need for follow-up data collection. The need for the follow-up interview, which would be conducted at least 4 months after fistula repair when they come for their review consultations, through home visits or per telephone was also explained.
Informed written consent for participation in the study was obtained from all participants. Data was collected using the WHOQOL_BREF questionnaire. The WHOQOL-BREF is a short version of the WHOQOL-100 for measurement of the impact of disease and impairment on daily activities and behavior. The WHOQOL-100 was piloted in 15 centers and field trials were conducted in 18 countries. Zimbabwe participated in both [8], so translations in Shona for Zimbabwe are available.
The WHOQOL-BREF comprises of 26 items in four domains. These items are a subset of items derived from the World Health Organization WHOQOL-100 tool for the assessment of quality of life.
The WHOQOL-BREF consists of two parts. The first part evaluates the patient’s subjective assessment of her quality of life and satisfaction with her health while the second part assesses four domains.
The first domain is on physical health. This domain looks at activities of daily living, dependence on medicinal substances and medical aids, energy and fatigue, mobility, pain and discomfort, sleep and rest and work capacity. The second domain assess psychological health and look at bodily image and appearance, negative feelings, positive feelings, self-esteem, spirituality/religion/personal beliefs, thinking, learning, memory and concentration. The third domain assesses social relations and specifically personal relationships, social support and sexual activity. Lastly the fourth domain assesses the person’s environment and looks at financial resources, freedom, physical safety and security, health and social care accessibility and quality, home environment, opportunities for acquiring new information and skills, participation in and opportunities for recreation/leisure activities, physical environment (pollution/noise/traffic/climate) and transport. Participants’ responses were recorded on a Likert scale of 1–5 on the WHOQOL-BREF tool.
The follow-up interviews were conducted mainly through telephone except for 3 participants who had home visits done between 17 June and 30 August 2020.
2.6 Data analysis
The quality of life data collected using the WHOQOL-BREF instrument were analyzed using the associated SPSS syntax files.
The SPSS syntax file automatically checks for missing data, recodes data and computes domain scores. The four domain scores denote an individual’s perception of quality of life in each particular domain. Domain scores are scaled in a positive direction (i.e. higher scores denote higher quality of life). The mean score of items within each domain was used to calculate the domain score. The mean score in each domain was obtained by computing the mean of transformed scores converted to a 0-100 scale for each domain [8]. These were compared with the mean scores in each domain 6 months after successful fistula repair.
For the purposes of this study, a mean score of < 40 in each domain denotes poor, 41–60 indicates moderate and > 60 indicates good quality of life [5].
Results were presented in median plus interquartile ranges and mean ± standard deviation (SD). The paired t test was used to compare the means of scores in pretreatment and post treatment period. A p-value < 0.05 was considered to be statistically significant. Significance analyses were conducted using SPSS version 16.0.
2.7 Ethical considerations
Permission to use the WHOQOL-BREF tool was sought and granted by WHO, Geneva. This study was approved by the national research council under license number MRCZ A2525.
All study participants gave written consent after the study processes were explained to them and their questions and concerns had been addressed. Confidentiality was maintained throughout the study.