Experiences of Internalized and Enacted Stigma among Women with Obstetric Fistula in Tanzania

Background: Obstetric fistula is the development of a necrosis between the bladder and the vagina and/or the bladder and the rectum as a result of prolonged obstructed labor, resulting in urinary or fecal incontinence. In Tanzania surgical repair for obstetric fistula is provided freely by the government but it is estimated that there are over 25,000 women living with an untreated fistula. These women experience high degrees of psycho-social stresses exacerbated by the stigma surrounding their condition. There is a dire need to explore stigma within this population in order to better understand its impact, as stigma affects both treatment seeking behavior as well as long term recovery of those who access surgical repair.

Study Aims: This study aims to understand the experiences of stigma among women with obstetric fistulas by examining both internalized and enacted stigma, and by identifying pertinent correlates of internalized stigma.

Methods: This mixed-methods study utilized both quantitative and qualitative data collected in two related studies at a single hospital in Moshi, Tanzania. All study participants were women receiving surgical repair for an obstetric fistula. In the quantitative portion, cross-sectional survey data were collected from 52 patients. The primary outcome was fistula-related stigma, measured using an adaptation of the HASI-P stigma scale, which included constructs of both internalized and enacted stigma. In the qualitative portion, 45 patients participated in a semi-structured in-depth interview, which explored topics such as stressors caused by the fistula, coping mechanisms, and available support. The transcripts were analyzed using analytic memos and an iterative process of thematic coding using the framework of content analysis.

Results: Expressions of internalized stigma were common in the sample, with a median score of 2.1 on a scale of 0 – 3. Internalized was significantly correlated with negative religious coping, social participation, impact of incontinence and enacted stigma. Qualitative analysis was consistent and demonstrated widespread themes of shame and embarrassment. Experiences of enacted stigma were not as common (median score of 0), although some items, like those pertaining to mockery and blame, were endorsed by up to 25% of the study sample. Themes of anticipated stigma (isolation and non-disclosure due to the possibility of stigmatization) were also evident in the qualitative sample and may explain the low enacted stigma scores observed.

Conclusion: In this sample of women receiving surgical repair for an obstetric fistula, stigma was evident, with internalized stigma resulting in psychological impacts for patients. Experiences of both anticipated and enacted stigma were also observed. There is a need to explore interventions that would decrease stigma while also increasing support for these women, as stigma may be a barrier towards accessing surgical repair and reintegration following surgery.

Keywords: Tanzania, obstetric fistula, stigma, maternal health

Women in the Global Clothing and Textile Industry

This paper examines the current role of women in the clothing and textile industry through oral history of South African union members. I argue that the industry’s particularly exploitative environment is directly related to both gender and globalization, acting together to worsen conditions in factories. Additionally, I argue that the more recent addition of an increasingly consumer-driven industry structure also impacts its abusive environment. Unionization, along with public and private regulation, have the potential to be catalysts for change in the industry. To be most effective, these organizations need to take into account both gender and globalization, and recognize the equal impacts both have when making decisions.

When Consumption Embraces Faith: How Religious Beliefs and Practices Influence Consumption

Marketers have long looked for observables that could explain differences in consumer behavior. Initial attempts have centered on demographic factors, such as age, gender, and race. Although such variables are able to provide some useful information for segmentation (Bass, Tigert, and Longdale 1968), more recent studies have shown that variables that tap into consumers’ social classes and personal values have more predictive accuracy and also provide deeper insights into consumer behavior. I argue that one demographic construct, religion, merits further consideration as a factor that has a profound impact on consumer behavior. In this dissertation, I focus on two types of religious guidance that may influence consumer behaviors: religious teachings (being content with one’s belongings), and religious problem-solving styles (reliance on God).

Essay 1 focuses on the well-established endowment effect and introduces a new moderator (religious teachings on contentment) that influences both owner and buyers’ pricing behaviors. Through fifteen experiments, I demonstrate that when people are primed with religion or characterized by stronger religious beliefs, they tend to value their belongings more than people who are not primed with religion or who have weaker religious beliefs. These effects are caused by religious teachings on being content with one’s belongings, which lead to the overvaluation of one’s own possessions.

Essay 2 focuses on self-control behaviors, specifically healthy eating, and introduces a new moderator (God’s role in the decision-making process) that determines the relationship between religiosity and the healthiness of food choices. My findings demonstrate that consumers who indicate that they defer to God in their decision-making make unhealthier food choices as their religiosity increases. The opposite is true for consumers who rely entirely on themselves. Importantly, this relationship is mediated by the consumer’s consideration of future consequences. This essay provides an explanation to the existing mixed findings on the relationship between religiosity and obesity.