Negotiating situational abstinence and moderation: a study of regular and heavy-drinking young Nigerians.

Studies that have examined young people's drinking behaviour, particularly how they abstain from alcohol or drink lightly and their motivations, have focused on Western contexts. Currently, studies on how and why young Africans abstain from alcohol or drink moderately are lacking. Therefore, there is a need to examine young people's drinking behaviours/practices on the continent to facilitate health promotion interventions. This study, which uses qualitative data elicited from 53 participants, explores how young Nigerian men and women who consume alcohol and drink heavily enact and negotiate abstinence and moderate drinking and the factors that motivate their choices. Some participants constructed situational abstinence, while others participated in temporary light drinking in their friendship networks, but these attracted some consequences. Peers pressured them, but some deployed the ability to offer 'valid' explanations and express self-determination and agency to ward off such pressures and negotiate situational abstinence or moderate drinking. Additionally, the fear of public embarrassment, negative publicity on social media due to intoxication and parental influences motivated some participants' occasional sobriety. Others relied on previous personal or friends' negative experiences of drunkenness or the consequences of heavy drinking represented in movies and books to construct occasional light drinking. The findings demonstrated how enacting and rejecting particular forms of masculinity and embodied gendered drinking practices, more generally, in some friendship groups, facilitated situational abstinence and moderation. Policymakers should partner with young people to design interventions that encourage abstinence or moderation and mitigate the current drinking practices in Nigeria, which will enhance health promotion.

Alcohol industry-sponsored music festivals, alcohol marketing and drinking practices among young Nigerians: Implications for policy.

INTRODUCTION: The global alcohol industry sponsors social/music events targeting young people; however, existing literature focuses on Westernised contexts. Given the decline in young people's drinking in many Western countries, it appears that multinational alcohol companies are importing the strategies they have used in high-income countries to the Global South countries like Nigeria to recoup profits. This study aims to examine the Guinness Show- a free one-month annual music festival, alcohol marketing at the festival and the extent to which the event encourages diverse drinking practices among its attendees. METHODS: We observed the music festival before collecting data through 53 interviews and 3 focus groups (N = 26). Data were analysed to generate themes with the aid of NVivo 12 software. FINDINGS: Over 6000 participants attend the Guinness Show daily, and participants gave detailed descriptions of the music festival, alcohol marketing activities that occur in it and the drinking practices of attendees, indicating that they were highly knowledgeable of the event. The Guinness Show attracts famous music artistes and other entertainers. Therefore, young people attend to see them perform free of charge. However, diverse alcohol promotions (e.g., quantity deals, low prices, giveaways) that happen daily, the strategic use of young women as 'beer promoters', and the pleasure the event induces by fusing music/entertainment into alcogenic environments, encourage drinking and drunkenness. All the attendees drank alcohol, and some engaged in impulse buying, while many consumed excessively due to promotions (e.g., buy-two-get-one free), which facilitated intoxication and the loss of control. CONCLUSIONS: Guinness Nigeria organises the event for strategic brand communication, generating brand capital, and encouraging alcohol purchases and consumption among young people. Policymakers should reconsider self-regulation and implement national alcohol control policies and other public health interventions to restrain the alcohol industry from sponsoring such events.

Journey for a cure: Illness narratives of obstetric fistula survivors in North Central Nigeria.

Obstetric fistula is a life transforming event resulting in embodied biographical disruption. Survivors suffer myriad long-term physical and emotional consequences. This paper is an account of a narrative inquiry, conducted with 15 fistula survivors in North-central, Nigeria, who described how their identities had been transformed by their condition. A narrative therapeutic approach, using Frank's 'chaos, restitution and quest' typology, was used to map their recovery narratives. 'Chaos', described by Frank as the opposite of restitution, dominated, with women losing hope of recovery. Women's shift towards 'restitution' began with treatment, but inadequate health-care access often delayed this process. In their quest narratives, women's life and identify changes enabled them to derive meaning from their experience of obstetric fistula within the context of their own lives. The findings highlight socio-structural factors raising the risk of obstetric fistula, which in turn causes biographical disruption and hampers sufferers' treatment and recovery. Rehabilitation should include income-generating skills to bring succour to survivors, particularly those whose incontinence persists after repairs.

Community voices on alcohol harm in Sierra Leone: Perceptions of prevention needs.

Objective: The research purpose is to determine alcohol prevention needs in Sierra Leone. Methods: We analyzed a cross-sectional survey from fall 2020, distributed by the West African Alcohol Policy Alliance to their partners across nine West African countries. The survey included questions on perceptions of alcohol harm, research priorities, and capacity and reach of the organizations represented. Only participants from Sierra Leone were included (n = 33). Results: When asked if they thought measures taken to prevent alcohol-related harm in their country have been adequate, 66% answered inadequate (n = 32). Asked if heavy drinking of commercial alcohol is a concern in their community, 96% said yes (n = 25), and 92% said heavy drinking of traditional brew or distilled spirits is a concern in their community (n = 24). Finally, 91% said that their organization would be interested in implementing an alcohol counter-marketing campaign (n = 23). Conclusions: Based on the perception of survey participants, efforts to prevent alcohol-related harm thus far are inadequate in Sierra Leone where heavy drinking is a critical concern. CBOs and NGOs already engaged in alcohol harm prevention are eager to support and adopt new strategies. Innovation: This is the first research to seek direct input from CBOS and NGOs about alcohol harm prevention in Sierra Leone.

Decline in youth drinking in high-income settings: Implications for public health in low-income countries.

Declining drinking among youth in many high-income countries has attracted scholarly attention and debates. Still, researchers are yet to globalize such research or examine its public health implications for low-resource settings. This commentary has two interrelated purposes. First, using evidence from Nigeria, it highlights how declining youth drinking in high-income countries may impact public health in low-income countries. Second, it highlights the necessity for research to examine youth drinking behaviours simultaneously worldwide. The declining drinking trends among young people in high-income countries have occurred simultaneously with global alcohol corporations being more aggressive in low-income countries like Nigeria. Relatedly, alcohol corporations may employ evidence regarding declines in drinking to argue against implementing stringent policies or other effective interventions in Nigeria (and other low-income settings), claiming their apparent success in the falling drinking trends in high-income settings. The article argues that research on the drinking decline among young people should be globalized because without commensurate attempts to examine their drinking behaviours/trends worldwide simultaneously, public and/or global health may be harmed for the reasons explored in this article.

Developing an alcohol harm prevention research agenda in West Africa: a mixed methods approach.

Research on alcohol use and its associated harm is scarce in West Africa. To mitigate the knowledge gap and to build momentum for future research, we determined research priorities for alcohol prevention among stakeholders across nine countries in West Africa. We analyzed a cross-sectional survey conducted in the fall of 2020, distributed by the West African Alcohol Policy Alliance (WAAPA). Respondents represented members of the WAAPA, members of intra-country alliances on alcohol and other stakeholders reached by snowball sampling. Quantitative and qualitative survey measures, adapted from the WHO's readiness assessment for the prevention of child maltreatment or developed by the research team, assessed research priorities, awareness of alcohol-related harm, risk factors and data availability. We mapped the qualitative answers into general themes and conducted descriptive analysis on the quantitative responses. Participants outlined two general themes to focus on: (i) alcohol use among children and youth and (ii) the health-related impact of alcohol. The most commonly listed types of alcohol-related harms pertained to acute consequences, such as gender-based violence, injuries, traffic crashes and child maltreatment. Risk factors for alcohol-related harm included limited enforcement of alcohol policies, cheap alcohol, and limited knowledge. Strengthening the capacity for addressing these research priorities will be key in reducing alcohol-related harm in West Africa. The goal of these research priorities is to drive research that informs advocacy, programs and policy. In addition to research, an awareness campaign of the health effects of alcohol is urgently needed.

Doing gender, doing alcohol: The paradox of gendered drinking practices among young Nigerians.

Previous research on alcohol and gender identity constructions has primarily focused on Western countries. Studies from non-Western contexts can make crucial contributions to understandings of the impact of social constructions of masculinities and femininities on drinking behaviours and health. In traditional Nigeria, consumption norms prohibited women's and young people's alcohol use. Nowadays, young men and women use alcohol, and many enact identities with heavy drinking. This study uses gender performance theory and interviews/focus group data from 72 young Nigerian men and women to explore their masculinity performance and resistance to traditional femininity codes through drinking practices. Profiling women as vulnerable agents and the only gender that provides care and affective labour, most men reinscribed the consumption norms proscribing women's drinking while some recommended sweetened or flavour brands for women. Citing gender equality and criticizing/resisting local norms, the women argued that alcohol consumption should not be the prerogative of men. The men used competitive heavy drinking rituals and drunkenness to enact masculinity. Most of the women constructed counter-traditional/normative femininity with heavy drinking bouts, while others, who maintained the traditional femininity to avoid stigmatization, enacted secret, or solitary drinking with potential health impacts. The findings demonstrate how distinct social norms promote socio-structural constraints and power relations that suppress women's agency and encourage gender inequality with potential health impacts.

Research Capacity and Needs for Alcohol-Related Harm Prevention in West Africa: Findings From a Cross-Sectional Survey of Stakeholders.

OBJECTIVE: The purpose of this study was to determine capacity and resource needs for alcohol prevention research among stakeholders across nine countries in West Africa. METHOD: We analyzed a cross-sectional survey conducted in the fall of 2020, distributed by the West African Alcohol Policy Alliance to their member alliances and stakeholders across nine countries in West Africa. Fifteen survey questions assessed research capacity and priorities related to alcohol prevention and harm locally and in the region. Overall, 140 persons participated in the survey, predominantly representing community-based organizations (CBOs) and nongovernmental organizations (NGOs). RESULTS: Only 42% of the respondents reported that their organizations have conducted research with a university or a research institution (with percentages ranging from 13% in Burkina Faso to 68% in Nigeria). The survey respondents indicated greater capacity for "upstream" research tasks (e.g., monitoring and evaluation, online survey tools, and data collection) compared with "downstream" research tasks (e.g., data analyses, translating research for community use, and preparing policy briefs and briefing decision makers). Less than half (48%) of the respondents were familiar with the World Health Organization (WHO) SAFER initiative. CONCLUSIONS: Given the low proportion of stakeholders in alcohol-related work who have worked with universities and research institutions, a clear priority is to facilitate and strengthen future collaborations. In addition, improving capacity for downstream research tasks is needed to inform policy. Finally, increasing familiarity with SAFER among key stakeholders involved in alcohol harm prevention in the region is a tangible short-term priority.

Impact of the COVID-19 Pandemic on Alcohol Treatment Access and Harm Prevention in West Africa: Reports from NGOs and Community-Based Organizations.

BACKGROUND: Recent research highlights how the COVID-19 pandemic has significantly impacted alcohol consumption patterns, yet research thus far has largely overlooked the experience in West Africa. Research also has not addressed how the COVID-19 pandemic has affected access to alcohol treatment, support, and alcohol harm prevention. This study addresses this research gap in West Africa, a low-resource setting with a very high burden of alcohol harm. OBJECTIVES: To understand the impact of the COVID-19 pandemic on alcohol use, access to alcohol, treatment access, and alcohol harm prevention activities in West Africa. METHODS: This study analyzed data from a cross-sectional online survey conducted in August and September of 2020 and distributed by the West Africa Alcohol Policy Alliance to their member alliances and stakeholders across nine countries (N = 140 participants) to understand their perceptions on COVID-19 and alcohol-related topics. RESULTS: Our findings convey a significant adverse impact on alcohol-focused NGOs and community-based organizations in West Africa. Overall, 94% of participants indicated that the COVID-19 pandemic adversely impacted their organizations' work. In addition, 71% of participants reported reduced access to alcohol treatment or support in their communities. Lastly, 44% of the respondents indicated that people in their community drank less alcohol than usual, and only 33% answered that they perceived it to be harder to get alcohol. CONCLUSIONS: These data underscore the significant impact of the COVID-19 pandemic across West Africa with respect to accessing alcohol treatment and organizational capacity to address alcohol harm. With the lack of infrastructure to address alcohol harm, this impact could exacerbate the high level of alcohol use and harm in the region.

A readiness assessment for the prevention of alcohol-related harm in West Africa: A new methodological approach to inform practice and policy.

OBJECTIVE: Alcohol-related harm is a growing concern globally and particularly in West Africa. However, tools for assessing the readiness for prevention of alcohol-related harm in low-resource settings have been lacking. We modified the WHO tool, the Readiness Assessment for the Prevention of Child Maltreatment Short Form (RAP-CM), to assess readiness for the prevention of alcohol-related harm across West Africa. METHODS: We conducted a cross-sectional survey in the fall of 2020, distributed by the West Africa Alcohol Policy Alliance to their member alliances and stakeholders, predominantly community-based organizations (CBOs) and non-governmental organizations (NGOs), across 7 countries in West Africa (N = 140). The survey included modified measures from the RAP-CM short form. RESULTS: In terms of general readiness, the overall adjusted aggregate score for West Africa was 45.0% (ranging from 42.9% in Liberia to 52.7% in Senegal). Of the ten domains assessed (on a 0-10 scale), across all countries, knowledge of alcohol-related harm prevention (8.3) and legislation, mandates, and policies (6.7) received the highest readiness scores. The lowest readiness scores were observed for human and technical resources (2.5), attitudes toward preventing alcohol-related harm (2.7), and the will to address the problem (2.9). CONCLUSIONS: Our results demonstrate substantial variability across domains in the readiness to address alcohol-related harm with clear strengths and limitations for future priority setting and capacity building. The barriers to progress include attitudes toward alcohol-related harm prevention, lack of willingness to address the problem, and limited human and technical resources available. These barriers need to be mitigated to address the high burden of alcohol-related harm in the region and to inform both practice and policy.

Making sense of ''drink responsibly'' messages: Explorations of the understanding and interpretations of young Nigerians who use alcohol.

BACKGROUND: Nigeria ranks first for per capita consumption and heavy episodic drinking prevalence in Africa. Yet, there are no alcohol policies, standard drink measurements, or low-risk drinking guidelines (LRDG) in the country. METHODS: This study explored the awareness and understanding/interpretations of the alcohol industry-sponsored 'responsible drinking message' (RDM) among Nigerian youth. Data were elicited through 53 semi-structured interviews and 3 focus groups (N=26), and we also observed product labels and industry websites. FINDINGS: Undergraduate participants were aware of ''drink responsibly'' (one of the RDMs), but some out-of-school participants with low-level education did not know it existed. This is likely because drink responsibly message is promoted in English language without any indigenous language alternatives. It is embedded in conventional advertisements that glamorize drinking without stand-alone public health messages encouraging low-risk drinking behaviours. Participants shared divergent but subjective interpretations of drink responsibly, but none associated it with abstinence. Some associated drink responsibly with the ability to hold one's drink, stating that it means: 'drinks very well, but don't get drunk', and 'drink to your satisfaction, but don't misbehave'. Other interpretations included: 'know your limit' and 'drink in moderation'. Drink responsibly was also understood to mean 'drink in excess but respect yourself'. Alcohol companies in Nigeria redirect consumers to Drinkaware's and DrinkIQ's websites in the UK but use inconspicuous fonts to inscribe 'drink responsibly' on product labels. CONCLUSION: By design, alcohol companies frame RDMs to promote drinking and individual responsibility. Thus, it engenders subjective interpretations, including high-risk drinking behaviours. Policymakers should jettison self-regulation, implement alcohol policies, and introduce LRDG to encourage low-risk drinking. Stand-alone public health interventions that promote abstinence or low-risk drinking behaviours should be developed, while Drinkaware's and DrinkIQ's websites should be avoided. To be effective, all RDMs should include the indigenous language versions.

'I just drink to feel abnormal for some time': Reconfiguring heavy drinking and intoxication as pleasurable.

BACKGROUND: The sociocultural norms moderating alcohol consumption in Nigeria were more permissive for men than women in the traditional era. Alcohol use among young people was taboo, and intoxication among men who occupy drinking spaces was punished. In contemporary Nigeria, heavy drinking and the 'culture of intoxication' are reified features of some young people's leisure lives. METHODS: Drawing on the intersections of pleasure and intoxication, this study explores the interplay between deliberate heavy drinking and the positioning of intoxication experiences as pleasurable. We conducted 53 semi-structured interviews and 3 focus groups (N = 26) with 18-24-year-old youths in Benin City, Southern Nigeria. RESULTS: Participants deliberately pursued heavy drinking and intoxication to experience 'altered bodily effects', to know the feelings of intoxication, and to master extreme drinking levels. Other explanations given for 'determined drunkenness' included fun and excitement. Participants sought pleasurable experiences of drinking through repeated deliberate drunkenness or by taking large quantities of spirits. 'Loss of control' experiences were described as fun and exciting, and participants laughed when friends showed them videos of their 'passing out' experiences. Gendered alcohol 'providing' rituals in peer networks that facilitated intoxication and loss of consciousness were used to enact friendships. Providing drinks for friends and consuming large quantities conferred a higher status on the buyer and drinker, respectively. Friendship networks performed double-edged roles by instigating heavy drinking and providing care for inebriated members. CONCLUSION: The emerging drinking culture in Nigeria suggests that the cultural prohibitionist approach to young people's drinking should be reconsidered. Policymakers should implement public health interventions that promote low-risk drinking practices to mitigate the risks of heavy drinking and intoxication.

Adolescent Health Series - Alcohol, tobacco, and other drug use among adolescents in sub-Saharan Africa: A narrative review.

Alcohol, tobacco, and other drug (ATOD) use by adolescents are major contributors to death and disability in sub-Saharan Africa (SSA). This paper reviews the extent of adolescents' ATOD use, risk and protective factors, and studies evaluating prevention interventions for adolescents in SSA. It also describes the harms associated with adolescents' ATOD use in SSA, which mainly include interpersonal violence, sexual risk behaviours, and negative academic outcomes. We use the socio-ecological model as our framework for understanding ATOD use risk and protective factors at individual, interpersonal, peer/school, and societal/structural levels. We used two strategies to find literature evaluating ATOD interventions for adolescents in SSA: (a) we sought systematic reviews of adolescent ATOD interventions in SSA covering the period 2000-2020; and (b) we used a comprehensive evidence review strategy and searched for studies that had evaluated ATOD interventions in all SSA countries between 2000 and 2020. Only two community interventions (a brief intervention and an HIV prevention intervention), out of four that were identified, were partially effective in reducing adolescent ATOD. Furthermore, only one school-based intervention (HealthWise), out of six that we uncovered, had any effect on ATOD use among adolescents. Possible reasons why many interventions were not effective include methodological limitations, involvement of non-evidence-based education-only approaches in some studies, and shortcomings in adaptations of evidence-based interventions. The scale of ATOD and related problems is disproportionate to the number of evaluated interventions to address them in SSA. More ATOD interventions need to be developed and evaluated in well-powered and well-designed studies.

Enhancement motivations for using prescription drugs among young adults in Nigeria.

BACKGROUND: The desire for enhancement is a common motive for non-medical use of prescription drugs in Western countries. Little is known about the factors that motivate use in non-Western contexts. METHODS: The study explores access to prescription drugs and the motivations for using them among educated young adults in a city located in Anambra State, South-Eastern Nigeria. Semi-structured interviews were conducted with 23 participants aged 23-29 years. Data were thematically analysed using NVivo 12 Software. RESULTS: The data indicate that prescription drugs are widely available and easy to access without a prescription in the unregistered 'pharmacies' and medicine shops that form part of Nigeria's informal healthcare system. Social networks are also a source of drugs. Participants shared detailed perspectives on their use of prescription drugs, revealing that codeine, Rohypnol, and high doses of tramadol are used to enhance performance in several social life domains. These drugs were described as enhancing performance and productivity in the workplace, and were taken by participants working as labourers and sales representatives. Male participants also shared accounts of using high doses of tramadol to improve stamina and skill in sports. Some participants took Rohypnol to enhance their creative and academic performance. Participants stated that drug use enabled them to meet the pressures associated with work, academia, and parental expectations. CONCLUSION: The findings suggest that prescription drugs are being strategically and instrumentally deployed by users to enhance different domains of social life. This is driven by users' experiences of the drugs' bodily effects, and it is supported by a context in which self-medication and informal healthcare are common. Participants' reasons for seeking drug-induced enhancement reflect sociocultural factors within Nigeria and some West African countries, such as employment scarcity and the championing of sporting prowess. The findings can be used to inform the design of tailored approaches to reduce the harms presented by the non-medical use of pharmaceuticals among young adults.

Effects of alcohol warning labels on alcohol-related cognitions among German adolescents: A factorial experiment.

There is evidence that alcohol warning labels (AWL) can have preventive effects on alcohol-related cognitions and behavior, but it is less clear how children and adolescents react to AWL. A total of 9260 German students aged 10-17 participated in a three-factorial experiment, embedded in a health survey. The first experimental factor was the position of the AWL on the questionnaire (before vs. after alcohol items). The second factor was the type of AWL (text only vs. text plus picture). The third factor was the content of the AWL (one out of a pool of ten). Dependent variables were knowledge about alcohol-related risks, self-reports of alcohol use, and negative emotions. Regression analyses revealed that exposure to an AWL significantly increased knowledge about alcohol-related risks. AWL exposure did not influence self-reports of alcohol use in the total sample, but a significant interaction for PositionXAge indicated that older students (15+ years) less frequently reported lifetime (79.8% vs. 84.2%) and current (50.5% vs. 56.6%) use of alcohol if they were exposed to an AWL. Overall, text-only AWL elicited less negative emotions than text-and-picture based AWL. The experiment indicates that exposure to an AWL affected alcohol-related cognitions of children and adolescents. This was true for both, text-based or picture-and-text-based labels. Pictorial messages seem to be more potent to elicit emotions, at least for recipients that already have experience with alcohol use. Future research needs to further explore the long-term effects of repeated exposure to the same message contents.

Alcohol Labeling Regulations and Industry Compliance in Nigeria: Evidence to Guide Policy Implementation.

OBJECTIVE: Alcohol labeling raises consumers' awareness of a product's composition and the risks associated with alcohol consumption. We identified mandatory elements and health warnings in alcohol regulations in Nigeria and evaluated selected product labels on alcoholic beverages produced in Nigeria to determine their compliance with the requirements. METHOD: A descriptive case study was used. Labeling requirements were extracted from two alcohol regulations and one related document retrieved from the website of the National Agency for Food and Drug Administration and Control (NAFDAC). The information on the product labels of 59 selected beers and spirit drinks produced in Nigeria was assessed based on six mandatory elements: list of ingredients, allergens, nutritional information, percentage of alcohol by volume (ABV), "drink responsibly" statement, and age restrictions. Five health warnings were also assessed: standard drinks per container, drinking guidelines, link to an alcohol education website, a "drinking during pregnancy" logo/text, and drink driving logo/text. RESULTS: Different regulations exist for beer and spirit drinks in Nigeria. Health warnings are not mandatory on labels of alcoholic beverages. No single product label included all six mandatory elements. Four mandatory elements--list of ingredients, ABV, drink responsibly statement, and age restrictions--were present on 61% of the product labels examined. CONCLUSIONS: The alcohol labeling regulations in Nigeria fall short of the World Health Organization labeling recommendations. The alcohol industry does not fully comply with labeling requirements in Nigeria. Enhanced labeling inclusive of health warnings should be mandatory as a strategy to create awareness of alcohol-related risks while monitoring industry-labeling practices to ensure compliance.

Alcohol consumption, harms and policy developments in sub-Saharan Africa: The case for stronger national and regional responses.

ISSUES: Sub-Saharan Africa (SSA) has long been characterised as a region with weak alcohol policies, high proportions of abstainers and heavy episodic drinkers (among drinkers), and as a target for market expansion by global alcohol producers. However, inter-regional analyses of these issues are seldom conducted. APPROACH: Focusing mainly on the period 2000-2016, we compare alcohol consumption and harms, alcohol policy developments and alcohol industry activities over time and across the four sub-regions of SSA. KEY FINDINGS: Per-capita consumption of alcohol and alcohol-related disease burden have increased in Central Africa but stabilised or reduced in other regions, although they are still high. Most countries have implemented tax policies, but they have seldom adopted other World Health Organization 'best buys' for cost-effective alcohol control policies. Countries range from having minimal alcohol controls to having total bans (e.g. some Muslim-majority countries); and some, such as Botswana, have attempted stringent tax policies to address alcohol harm. Alcohol producers have continued their aggressive marketing and policy interference activities, some of which have been highlighted and, in a few instances, resisted by civil society and public health advocates, particularly in southern Africa. IMPLICATIONS: Increased government support and commitment are needed to be able to adopt and implement effective alcohol policies and respond to pressures from alcohol companies to which SSA remains a target market. CONCLUSION: SSA needs effective alcohol control measures in order to reverse the trajectory of worsening alcohol harms observed in some countries and reinforce improvements in alcohol harms observed in others.

Insights from birthing experiences of fistula survivors in North-central Nigeria: Interplay of structural violence.

Obstetric Fistula is an abnormal opening between the vagina and rectum resulting from prolonged and obstructed labour. Studies indicate that delays in accessing maternal care and home birth contribute to the development of fistula. Survivors are usually women of low socioeconomic status residing in rural locations. This study explores the birthing experiences of 15 fistula survivors through a narrative inquiry approach at a repair centre in North-central Nigeria. Using structural violence as a lens, it describes the role of social, political and health systems in the inequitable access to care for women. For women opting for home births, preference for home delivery was mainly due to lack of finances, poor health systems and cultural practices. Rural location inhibited access as women seeking facility delivery faced transfer delays to referral centres when complications developed. Inequitable maternal health services in rural locations in Nigeria are inherently linked to access to health care, and these contribute to the increased incidence of fistulae. Structural intervention is a health policy priority to address poor health systems and achieve universal health coverage to address maternal health issues in Nigeria.

Reflections on Identity: Narratives of Obstetric Fistula Survivors in North Central Nigeria.

Obstetric fistula is a condition that affects women and can lead to identity changes because of uncontrolled urinary and/or fecal incontinence symptom experiences. These symptoms along with different emerging identities lead to family and community displacement. Using narrative inquiry methodology that concentrates on the stories individuals tell about themselves; interviews were conducted for 15 fistula survivors to explore their perception of identities of living with obstetric fistula. Within a sociocultural context, these identities consist of the "leaking" identity, "masu yoyon fitsari" (leakers of urine) identity, and the "spoiled" identity, causing stigmatization and psychological trauma. The "masu yoyon fitsari" identity, however, built hope and resilience for a sustained search for a cure. Identity is a socially constructed phenomenon, and the findings reveal positive community involvement which reduces obstetric fistula stigmatization and improves women's identity. Sexual and reproductive health issues remain of grave concern within a contextualized societal identity of women's role.