This week Harena Randrianasolo, our Social Media Specialist, interviewed our Community Engagement Coordinator, Rovahasina Ralaindimby, about Operation Fistula’s community outreach and engagement work.
Rova has been working with Operation Fistula since 2020, and leads and manages our community outreach officers in their mission to visit communities and find patients in need of care. In the below Q&A, she shares some insights into what this work entails, and what it means to her.
Tell us about the typical journey our outreach workers take in order to reach a community. What are the challenges?
Typically, we spend the first two days traveling by taxi-brousse — Madagascar’s public transportation system. This gets us as far as we can go on the main roads. You’re sharing space on a bus with lots of other people, other animals — some sheep, usually!
Once we get as far as the taxi-brousse goes, we either hop on the back of a motorbike or finish out the rest of the journey on foot. This might be a full day of walking — 20 kilometers or so. And in rainy season, that means walking through knee-high “puddles” or trudging through mud. Motorbikes can’t pass through on those conditions, so we use our feet! Sometimes we will hitch a ride on a little pirogue — a wooden raft that floats on empty plastic canisters.
We don’t pack much gear, because we know that everything we bring we’ll have to carry on our backs. Most of the communities we work in lack electricity, or even small hotels, so we rely on the generous hospitality of community leaders. We bring sleeping bags and stay in the little wooden huts some people have next to their houses.
In your experience, why is community engagement such an important part of our program?
Our approach to community engagement has been designed to address the following basic barriers to care:
- Women with fistula do not know that their suffering is caused by an injury that can be treated.
- Communities do not know what fistula is or why it happens. They see women with the injury as cursed, or unclean, shunning them from society, and they don’t know the actions that can be taken to prevent fistula.
- Most women with fistula live in very isolated places that are unmapped, very difficult to reach, and far from the health system.
These barriers are pervasive in Madagascar. We know that because women with fistula experience such deep ostracism — affecting their family, social, and economic lives — they often do not trust outsiders, or believe that anyone wants to help them. In order for us to improve lives, we have to travel to them, not expect them to come to us. We need to engage directly with these women and all their neighbors, offering our help and building relationships. It’s face-to-face communication and contact that usually persuades them to trust us.
What is it like to meet with community members to talk about fistula? How do they react?
In 2020, when we were testing our outreach strategy, we encountered a lot of resistance, or confusion. It was such a new topic for most of them. They were used to community health workers talking about HIV or malnutrition or malaria, but not fistula.
Another challenge is that nearly everything we need to talk about, in order to help people understand what we do, is taboo in Malagasy culture. Entire categories — menstrual hygiene, sexual health and STDs — are off-limits, usually.
But in the last two years, it’s gotten much better. People are starting to know us, and we’ve implemented radio campaigns across entire regions, so that people are hearing about fistula before we even arrive in their communities. We’re still combating rumors — that fistula is a kind of curse, or a punishment for bad behavior, for example — but insisting on more open conversation has really helped.
It’s always going to be difficult to convince people to go to the hospital, either to give birth (and thus hopefully prevent a fistula) or to get treated for a fistula once it’s happened. Women want to do what their mothers and their grandmothers did. They want to do what’s trusted, and give birth at home with a matron (a traditional birth attendant). It makes sense — you trust the people you know, the people who are close to you.
But part of what Operation Fistula does is engage with those matrons, too, so that they understand the benefits of pre-natal care and learn how to spot a potential obstructed labor that may need professional medical intervention.
A big part of what we do during our time in the communities is finding these trusted people and asking for their help. We spend time with all sorts of influential people, including mayors, chefs de village, and religious leaders. It is completely logical to trust your own neighbors more than outsiders. So, relationship-building is key.
Finally, speaking purely from a logistics point of view, you have to get up really early to talk to people! We sometimes go door-to-door in a community, but people work during the day, so daytime hours aren’t convenient. So we are accustomed to starting our days at 5AM and catching people before they go to the field, and later in the evening as well. We work long days. We will use the time when the community members are at work to travel on to our next destinations, or to meet with community leaders, who hold normal office hours during the day.
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