From words to actions: systematic review of interventions to promote sexual and reproductive health of persons with disabilities in low- and middle-income countries

Barriers and facilitators to perinatal care of women with disabilities in lower- and middle-income countries: a study protocol for scoping review of qualitative studies

BACKGROUND

The Sustainable Development Goals have put emphasis on equitable healthcare access for marginalised groups and communities. The number of women with disabilities (WWD) to marry and have children is rapidly increasing in low- and middle-income countries (LMICs). However, these women experience multifaceted challenges to seeking perinatal care in LMICs. The objective of this scoping review is to document key facilitators and barriers to seeking perinatal care by WWD. We also will propose strategies for inclusive perinatal healthcare services for women with disabilities in LMICs.

METHODS

We will conduct a scoping review of peer-reviewed and grey literature (published reports) of qualitative and mixed-methods studies on facilitators and barriers to seeking perinatal care for women with functional disabilities from 2010 to 2023 in LMICs. An electronic search will be conducted on Medline/PubMed, Scopus and Google Scholar databases. Two researchers will independently assess whether studies meet the eligibility criteria for inclusion based on the title, abstract and a full-text review.

ETHICS AND DISSEMINATION

This scoping review is based on published literature and does not require ethics approval. Findings will be published in peer-reviewed journals and presented at conferences related to reproductive health, disability and inclusive health forums.

Building disability-inclusive health systems

Health systems often fail people with disabilities, which might contribute to their shorter life expectancy and poorer health outcomes than people without disabilities. This Review provides an overview of the existing evidence on health inequities faced by people with disabilities and describes existing approaches to making health systems disability inclusive. Our Review documents a broad range of health-care inequities for people with disabilities (eg, lower levels of cancer screening), which probably contribute towards health differentials. We identified 90 good practice examples that illustrate current strategies to reduce inequalities. Implementing such strategies could help to ensure that health systems can expect, accept, and connect people with disabilities worldwide, deliver on their right to health, and achieve health for all.

Principles for Service Delivery: Best Practices for Cervical Screening for Women with Disabilities

Background

Cervical cancer screening is an important public health priority, yet many marginalized groups are not reached by existing programs. The nearly 700 million women with disabilities globally face substantial barriers in accessing cervical cancer screening and have lower coverage, yet there is limited evidence on what would support enhanced uptake among this population.

Methods

We updated a systematic review to estimate the disparity in screening uptake for women with disabilities. We conducted a scoping review to understand key barriers and the inclusion of disability in existing screening policies and possible solutions to improve screening uptakes amongst women with disabilities. We then formulated key principles for improved service delivery for this group, targeted predominantly at clinicians.

Results

Our updated review identified an additional five new studies, and confirmed that women with disabilities were less likely to be screened for cervical cancer (RR=0.65, 0.50-0.84). Disability-specific barriers to accessing screening pertained to: (1) knowledge and autonomy; (2) logistics; and (3) stigma and fear. Few guidelines included specific considerations for women with disabilities. Our scoping review showed that improving access to care must focus on improving (1) autonomy, awareness, and affordability; (2) human resources; and (3) health facility accessibility.

Conclusion

Screening programmes and health providers must ensure women with disabilities are included in cervical cancer screening programmes and thereby help to achieve their right to health and eliminate cervical cancer as a public health issue.

Access to general health care among people with disabilities in Latin America and the Caribbean: a systematic review of quantitative research

In Latin America and the Caribbean (LAC), there are 85 million people with disabilities (PwD). They often experience barriers accessing healthcare and die, on average, 10-20 years earlier than those without disabilities. This study aimed to systematically review the quantitative literature on access to general healthcare among PwD, compared to those without disabilities, in LAC. A systematic review and narrative synthesis was conducted. We searched in EMBASE, MEDLINE, LILACS, MedCarib, PsycINFO, SciELO, CINAHL, and Web of Science. Eligible articles were peer-reviewed, published between January 2000 and April 2023, and compared healthcare access (utilization, coverage, quality, affordability) between PwD and without disabilities in LAC. The search retrieved 16,538 records and 30 studies were included, most of which had a medium or high risk of bias (n = 23; 76%). Overall, the studies indicated that PwD use healthcare services more than those without disabilities. Some evidence indicated that women with disabilities were less likely to have received cancer screening. Limited evidence showed that health services affordability and quality were lower among PwD. In LAC, PwD appear to experience health inequities, although large gaps exist in the current evidence. Harmonization of disability and health access data collection is urgently needed to address this issue.

Sexual and reproductive health (SRH) of women with mental illness (WMI) - An integrative mixed-method study

Background

Women with mental illness (WMI) are more likely to experience unreported sexual and reproductive health (SRH) problems. Mixed-method research studies with the strengths of quantitative and qualitative approaches provide deeper insight into SRH issues of WMI.

Methods

A sequential explanatory mixed-method design was used to understand better the SRH problems of WMI attending tertiary care psychiatry hospital. In phase 1, a survey was conducted to identify if they have SRH problems. Women who were identified to have SRH problems were part of Phase II. In this phase, in-depth interview was conducted to explore their lived-in experiences. Integration at the method level was adopted by connection through sampling. Using a narrative approach, integration was accomplished at the level of interpretation and reporting.

Results

Among the users, 261 (64.6%) female sterilization, 244 (93%) was the most common, and the other methods like coitus interruptus, male condoms, and intrauterine devices were reported less. Of the non-users, 137 (33.9%) WMI 100 (73%) were unaware of the best family planning approach. Most of them, 377 (93.3%), were ignorant about sexually transmitted infection (STI) symptoms. WMI reported 62 (15.3%) unusual foul-smelling vaginal discharge and 58 (14.4%) genital ulcers, with poor treatment-seeking behavior. Sexual dysfunction in desire, arousal, lubrication, orgasm, satisfaction, and pain were also reported. The findings were described in a single report based on the quantitative data followed by themes obtained from qualitative interviews using weaving techniques under the headings of contraceptive use and its awareness, prevalence of STI symptoms and its treatment, and sexual health experiences.

Conclusion

Data integration demonstrated that one-fourth of WMI had inadequate awareness of contraceptive use, were ignorant of STI symptoms, and experienced sexual dysfunction.

Feasibility study of a menstrual health behaviour change intervention for women and girls with intellectual disabilities and their caregivers for Vanuatu's humanitarian responses

The Veivanua campaign is a menstrual health intervention for people with intellectual disabilities and their caregivers in Vanuatu's humanitarian setting. The campaign was adapted from the Bishesta campaign delivered in Nepal's development setting. This feasibility study is designed to assess the feasibility and acceptability of the Veivanua campaign to understand if efficacy testing is warranted. The Veivanua campaign was delivered to a preselected group of 30 young people (individuals with intellectual disabilities) and 35 caregivers (males and females). Data were collected through several qualitative tools to allow for methods triangulation: process monitoring, post-intervention in-depth interviews with caregivers and nine young people, observation of young persons, photovoice and ranking with two young people, campaign resource ranking, and key informant interviews with staff involved in the intervention. Data were analysed thematically using Nvivo 12. Results show that the Veivanua campaign is feasible. Male and female caregivers reported an increased ability to support young people's menstrual health and greater preparedness for the next emergency. Young people understood the training and applied their learning. Key informants want to scale up the intervention in their humanitarian responses. Several changes were made to the adapted campaign, but similar outcomes were recorded in Nepal and Vanuatu. All target behaviours improved, and campaign resources were used, but many caregivers found the menstrual calendar confusing. The intervention was not delivered with fidelity but responded to the context. The campaign cost more than the Bishesta campaign because procurement was more expensive in Vanuatu. In conclusion, this is the first intervention globally, so it begins to fill a substantial gap, but more must be done. As the Veivanua campaign is feasible, it requires efficacy testing in Vanuatu. It should also be adapted to humanitarian crises in other countries to support the menstrual health of this previously excluded population.

Improving access to family planning for women with disabilities in Kaduna city, Nigeria: study protocol for a pragmatic cluster-randomized controlled trial with integrated process evaluation

BACKGROUND

Globally, women with disabilities are less likely to have access to family planning services compared to their peers without disabilities. However, evidence of effective interventions for promoting their sexual and reproductive health and rights remains limited, particularly in low- and middle-income settings. To help address disparities, an inclusive sexual and reproductive health project was developed to increase access to modern contraceptive methods and reduce unmet need for family planning for women of reproductive age with disabilities in Kaduna city, Nigeria. The project uses demand-side, supply-side and contextual interventions, with an adaptive management approach. This protocol presents a study to evaluate the project's impact.

METHODS

A pragmatic cluster-randomized controlled trial design with surveys at baseline and endline will be used to evaluate interventions delivered for at least 1 year at health facility and community levels in comparison to 'standard' state provision of family planning services, in the context of state-wide and national broadcast media and advocacy. Randomization will be conducted based on the health facility catchment area, with 19 clusters in the intervention arm and 18 in the control arm. The primary outcome measure will be access to family planning. It was calculated that at least 950 women aged 18 to 49 years with disabilities (475 in each arm) will be recruited to detect a 50% increase in access compared to the control arm. For each woman with disabilities enrolled, a neighbouring woman without disabilities in the same cluster and age group will be recruited to assess whether the intervention has a specific effect amongst women with disabilities. The trial will be complemented by an integrated process evaluation. Ethical approval for the study has been given by the National Health Research Ethics Committee of Nigeria and London School of Hygiene & Tropical Medicine.

DISCUSSION

Defining access to services is complex, as it is not a single variable that can be measured directly and need for family planning is subjectively defined. Consequently, we have conceptualized 'access to family planning' based on a composite of beliefs about using services if needed.

TRIAL REGISTRATION

ISRCTN registry ISRCTN12671153. Retrospectively registered on 17/04/2023.

"God is my only health insurance": a mixed-methods study on the experiences of persons with disability in accessing sexual and reproductive health services in Ghana

Background

Access to sexual and reproductive health (SRH) services is a fundamental human right, but people with disabilities (PwDs) in low-and middle-income countries often face multiple barriers to utilisation. This study aimed to assess the level of SRH services utilisation and the enabling and inhibiting factors among PwDs in Ghana's Ashanti region.

Methods

A sequential explanatory mixed-methods study design was employed, involving quantitative (n = 402) and qualitative (n = 37) data collection from PwDs. Quantitative data were analysed using descriptive and inferential statistics, while qualitative data were analysed using inductive thematic analysis.

Results

The study found that only 33.8% of the PwDs had ever used SRH services. Utilisation was associated with sex, marital status and travel duration to health facility. The qualitative data revealed that factors at the individual, family/community and health facility levels influenced utilisation of SRH services, acting as both enablers and barriers.

Conclusion

PwDs had relatively low utilisation of SRH services in Ghana's Ashanti region. To increase utilisation, it is recommended to address the stigma and discrimination towards PwDs, provide more training for healthcare providers, improve the accessibility of healthcare facilities, and strengthen the national health insurance scheme. Further research could explore PwDs' SRH outcomes and strategies to improve these outcomes in Ghana.

Barriers and facilitators to accessing sexual health services for older LGBTQIA+ adults: a global scoping review and qualitative evidence synthesis

The number of older adults identifying as lesbian, gay, bisexual, transgender and other sexual and gender diverse identities (LGBTQIA+) is growing as populations age and social environments become more accepting. This study uses a global evidence synthesis to understand perceived barriers and facilitators to access to sexual healthcare globally for older LGBTQIA+ adults. We used a scoping review and qualitative evidence synthesis. Embase, PubMed and PsycInfo were searched with terms related to LGBTQIA+ populations, adults aged 45years, and sexual health care. We used the Cochrane Handbook and the review protocol was registered. Primary and secondary textual data were coded and grouped into themes using PRISMA-SCR and the Minority Stress Model. The certainty of review findings was assessed using the GRADE-CERQual approach. We identified 19 studies and 15 were included in the qualitative evidence synthesis. All studies were from high-income countries. Heterocentricity and male-centricity of sexual healthcare services contributed to feelings of exclusion for older LGBTQIA+ adults. Both anticipated and enacted stigma from healthcare providers resulted in older LGBTQIA+ adults, especially those with chronic conditions, avoiding health services (seven studies each, low certainty). Older LGBTQIA+ adults have unique sexual health needs and may feel their age empowers them to access appropriate care (four studies, low certainty). This review highlights the need for additional research and interventions to improve sexual health services for older LGBTQIA+ adults. Practical strategies to make sexual health less heterocentric (e.g. gender neutral signage) may increase uptake of essential sexual health services.

Barriers and Enablers to Health-Seeking for People Affected by Severe Stigmatising Skin Diseases (SSSDs): A Scoping Review

People affected by severe stigmatising skin diseases (SSSDs) often live in the poorest communities, within the poorest countries, and experience a range of barriers to seeking timely, quality care. This scoping review analyses the available literature on health-seeking for patients affected by SSSDs, to identify enablers and barriers to health-seeking. We searched MEDLINE complete, CINAHL, Global Health databases for suitable articles published between 2010 and 2020. Search strings were compiled for health-seeking, SSSDs and lower middle-income countries (LMIC). Our search returned 1004 studies from across three databases. Of these, 136 potentially relevant studies were identified and full texts were reviewed for eligibility against the inclusion criteria, leading to the inclusion of 55 studies. Thematic narrative analysis was used, with results framed around the Levesque framework to analyse barriers and enablers to health-seeking along the continuum of the patient pathway. This scoping review has revealed barriers across the patient pathway, from both supply and demand aspects of health services. Spiritual beliefs emerged strongly relating to care-seeking and underlying stigma. Curative care was a focus for the majority of studies, but few papers emphasised holistic care (such as physical rehabilitation and psychosocial support). From our analysis, greater community engagement is needed to reduce barriers along the patient-care pathway.

Positive Influences and Challenges for the Deaf Community Navigating Access to HIV Information, Testing, and Treatment in Kampala, Uganda: A Qualitative Study

Although sub-Saharan Africa has the highest HIV burden globally, few studies have investigated disabilities and HIV in this region. We conducted a secondary analysis of text data from in-depth interviews (2014-2015) to describe HIV perceptions among a subsample of 73 deaf individuals participating in the Crane survey, Kampala, Uganda. Being deaf was defined as being profoundly or functionally deaf, having deafness onset 5 + years ago, and preferring sign language to communicate. Among participants ever tested for HIV (47%), most (88%) had a negative test. Thematic analysis revealed overcoming challenges/barriers followed by socioeconomic status, support systems, HIV, stigma, abuse, and health conditions as major themes. An unanticipated finding was the role of sex work to support basic living needs. The data showed related themes among participants, suggesting a complex context in which deaf participants experience HIV prevention and treatment. It is important to tailor HIV interventions for deaf and disabled persons.

Influence of education on sexual and reproductive health service utilization for persons with disabilities in nationwide Bangladesh: an explanatory sequential mixed-methods study

Background

Persons with disabilities comprise more than one billion people in the world, yet they are one of the most discriminated groups and face significant health disparities. Particularly in developing countries, which contain 80% of the entire population with disabilities, these individuals experience major barriers in accessing sexual and reproductive health (SRH) services. Education is an important factor that greatly affects individuals’ SRH service utilization. Hence, we sought to investigate the relationship between education and SRH service utilization for persons with disabilities in Bangladesh.

Methods

Using an explanatory sequential mixed-methods design, a total of 5000 persons with disabilities were surveyed for the quantitative component and 15 mini-ethnographic case studies were conducted with persons with disabilities for the qualitative component. Chi-squared tests and logistic regression analyses were performed on the survey data, while the qualitative interviews were coded and their SRH themes synthesized accordingly.

Results

Our quantitative findings show that education statistically significantly increases persons with disabilities’ SRH service utilization of antenatal care, delivery care, postnatal care, and family planning (P < 0.05). Interestingly, for persons with disabilities, primary education shows increased adjusted odds of family planning use but is likely not enough to increase antenatal care, delivery care, or postnatal care use; secondary or post-secondary education may be required to improve utilization of these latter services. Qualitative findings support the association between higher education levels and greater SRH service use. Persons with disabilities of lower educational attainment held misinformation and distrust in SRH services and experienced mistreatment by SRH healthcare providers, discouraging them from seeking future SRH services.

Conclusions

We report that higher formal education level is associated with greater SRH service use for persons with disabilities in Bangladesh. Formally educating persons with disabilities expands their SRH knowledge and familiarity with SRH services, as well as leads to more economic opportunities so they can afford SRH services. Increasing formal education levels for persons with disabilities, paired with integrating comprehensive sexuality education (CSE) in their schools, will likely help close the gap in SRH health disparities for this vulnerable population.

Experience of Primary Care Nurses of Sexuality Care for Persons with Disabilities: A Qualitative Study

(1) Background: Disability is a dynamic interaction between a person's health conditions and personal and environmental factors. Disability is an evolving concept, which can be improved by intervening in the barriers that prevent disabled people from functioning in their daily life and enjoying a satisfactory sexual life. Sexuality is an important dimension of life that affects people's well-being. The aim was to describe and understand the experiences of primary care nurses regarding care for the sexuality of persons with disabilities. (2) Methods: A descriptive qualitative study was designed. Twenty-one in-depth interviews were conducted with nurses. A thematic analysis was used to analyse the data. (3) Results: three main themes emerged: (1) Initial assessment of the patient: competencies for a nurse-patient therapeutic relationship; (2) A comprehensive approach to nursing care for persons with disabilities: the importance of sexuality; and (3) Sex counselling in nursing consultations. (4) Conclusions: Nurses have the skills to develop a good therapeutic relationship with patients. Planning of nursing interventions is required in order to promote individual coping, emotional support, and sex education. Sex counselling is essential to promote autonomy, with the figure of the sex therapist emerging for this purpose.

Disparities in Accessing Sexual and Reproductive Health Services at the Intersection of Disability and Female Adolescence in Tanzania

Despite at times having greater needs for sexual and reproductive health (SRH) services, adolescents with disabilities often face challenges when trying to access them. This inaccessibility is further exacerbated during female adolescence. The qualitative study examines how SRH services respond to the characteristics of Tanzanian adolescent females with disabilities. We used the method of empathy-based stories to investigate the perceptions of 136 adolescent females with disabilities of their access to SRH services in Tanzania. The study used thematic content analysis and the Levesque model of health care access was applied as an analytical framework. The results demonstrate that discrimination affects access at different phases of care-seeking, that affectionate behaviour of providers is a central enabler of access, and that for this population access relies on a collective effort. We propose that affection, as an enabler of access, is as an additional provider dimension of access to SRH services for adolescents with disabilities, serving as a “reasonable accommodation” to the health care systems in southern contexts and beyond.