A household perspective on access to health care in the context of HIV and disability: a qualitative case study from Malawi

"These attitudes are a pressure": women with disabilities' perceptions of how stigma shapes their sexual health choices

Women with disabilities face numerous barriers to achieving sexual health on an equitable basis to others, including stigma about disability and sexuality. Yet, how specific stigmatising beliefs about disability and sexuality influence the choices women with disabilities make about their sexual health has not been studied widely. The present study sought to address this gap in the context of Sierra Leone. Semi-structured interviews were conducted with women with disabilities (N = 32) and women without disabilities (N = 10). Societal stigma of disability linked with witchcraft was seen as a deterrent to accessing sexual and reproductive health services. Stigma about women with disabilities as burdens and about childless women with disabilities as pitiable were perceived as sources of pressure on disabled women's reproductive choices. Concurrently, women with disabilities rejected common stigmatising beliefs held about their lives. Results are discussed in terms of practical implications for healthcare providers and policymakers in Sierra Leone.

A review of the framework and strategy for disability and rehabilitation services in South Africa

Background

Rehabilitation is imperative for the successful integration of persons with disabilities into their social environments. The Framework and strategy for disability and rehabilitation services (FSDR) in South Africa, 2015-2020.was developed to strengthen access to rehabilitation services and ensure the inclusion of persons with disabilities in all aspects of community life. Despite the FSDR being commissioned, access to rehabilitation is a challenge for persons with disabilities and further compounded in rural communities.

Objective

The study aimed to describe the barriers and facilitators that influenced the process of development, implementation and monitoring of the FSDR.

Method

This qualitative study employed a single case study design. Data was collected through document analysis and in-depth interviews utilising the Walt & Gilson policy analysis framework that outlines the context, content, actors and process of policy development and implementation. In-depth interviews were conducted with twelve key informants (N=12) who were selected purposively for the study. Data obtained from the in-depth interviews were analysed using inductive thematic analysis.

Results

We found many factors that influenced the implementation of the framework. Actor dynamics, insufficient resources, the rushed process, poor record-keeping, inappropriate leadership, negative attitudes of staff members and the insufficient monitoring impeded the successful implementation of the framework. While positive attitude, mentorship and support amongst the task team facilitated the implementation process, albeit with challenges.

Conclusion

There is a need to address implementation gaps so that the FSDR is responsive to the current rehabilitation needs of persons with disabilities in South Africa.

Contribution

This study may inform future disability policy, and can be used as a tool to advocate for the rights for persons with disabilities.

Transport Poverty with Special Reference to Sustainability: A Systematic Review of the Literature

The aim of this work is to analyse the state of the art of scientific research related to transport poverty with special reference to sustainability and to identify new research needs. To this end, a methodology has been used in line with the objective set out, choosing the systematic review of the literature as the most suitable method. The results show that transport poverty is an under-exploited issue and is not well articulated by researchers, and there are great differences between the different areas of knowledge studied. The subjects related to health and medicine have more publications, almost 58%, with the rest distributed among 11 different subjects. Of the works analysed, only 26.69% refer to the topic of sustainability, and therefore this is a branch which is little studied in the literature in this field. Another relevant finding is that all the articles analysed highlight the vulnerability and inequality of the groups affected by transport poverty, with the elderly being the least studied in the research work.

"We can't handle things we don't know about": perceived neurorehabilitation challenges for Malawian paediatric cerebral malaria survivors

BACKGROUND

We sought to identify perceptions of neurorehabilitation challenges for paediatric cerebral malaria (CM) survivors post-hospital discharge at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi.

METHODS

An exploratory approach was used to qualitatively investigate the perceived neurorehabilitation challenges for paediatric CM survivors. Data were collected through semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs). Eighteen data-gathering sessions were conducted with 38 total participants, including 3 FGDs with 23 primary caregivers, 11 IDIs with healthcare workers at QECH, and 4 IDIs with community-based rehabilitation workers (CRWs).

RESULTS

FGDs revealed that caregivers lack important knowledge about CM and fear recurrence of CM in their children. Post-CM children and families experience substantial stigma and sociocultural barriers to integrating into their community and accessing neurorehabilitative care. At a community-level, rehabilitation infrastructure, including trained staff, equipment, and programmes, is extremely limited. Rehabilitation services are inequitably accessible, and community-based rehabilitation remains largely unavailable.

CONCLUSIONS

There is an urgent need to establish further training of rehabilitation personnel at all levels and to build accessible rehabilitation infrastructure in Malawi for post-CM patients. Additional work is required to expand this study across multiple regions for a holistic understanding of neurorehabilitation needs.

Access to health care for people with disabilities in rural Malawi: what are the barriers?

Background

People with disabilities experience significant health inequalities. In Malawi, where most individuals live in low-income rural settings, many of these inequalities are exacerbated by restricted access to health care services. This qualitative study explores the barriers to health care access experienced by individuals with a mobility or sensory impairment, or both, living in rural villages in Dowa district, central Malawi. In addition, the impact of a chronic lung condition, alongside a mobility or sensory impairment, on health care accessibility is explored.

Methods

Using data from survey responses obtained through the Research for Equity And Community Health (REACH) Trust’s randomised control trial in Malawi, 12 adult participants, with scores of either 3 or 4 in the Washington Group Short Set (WGSS) questions, were recruited. The WGSS questions concern a person’s ability in core functional domains (including seeing, hearing and moving), and a score of 3 indicates ‘a lot of difficulty’ whilst 4 means ‘cannot do at all’. People with cognitive impairments were not included in this study. All who were selected for the study participated in an individual in-depth interview and full recordings of these were then transcribed and translated.

Results

Through thematic analysis of the transcripts, three main barriers to timely and adequate health care were identified: 1) Cost of transport, drugs and services, 2) Insufficient health care resources, and 3) Dependence on others. Attitudinal factors were explored and, whilst unfavourable health seeking behaviour was found to act as an access barrier for some participants, community and health care workers’ attitudes towards disability were not reported to influence health care accessibility in this study.

Conclusions

This study finds that health care access for people with disabilities in rural Malawi is hindered by closely interconnected financial, practical and social barriers. There is a clear requirement for policy makers to consider the challenges identified here, and in similar studies, and to address them through improved social security systems and health system infrastructure, including outreach services, in a drive for equitable health care access and provision.

Inter- and intra-household perceived relative inequality among disabled and non-disabled people in Liberia

Evidence suggests that people with disabilities are the most marginalised and vulnerable group within any population. However, little is known about the extent of inequality between people with and without disabilities in contexts where the majority of persons experience extreme poverty and hardship. This includes in Liberia, where very little is understood about the lives of disabled people in general. This study uses a multidimensional wellbeing framework to understand perceived relative inequality associated with disability by assessing several facets of wellbeing across and within households containing disabled members (N = 485) or households with no disabled members (N = 538) in Liberian communities (Total individuals surveyed, N = 2020). Statistical comparisons (adjusted for age, sex, education and wealth differences and clustered at the household, village and county level) reveal that disabled Liberians are managing similarly to non-disabled Liberians in terms of income and education, but experience many perceived relative inequalities including in life satisfaction, transport access, political participation and social inclusion. Our results further suggest that disability may lead to perceived relative inequality at the household level in terms of trust held in neighbours. However, they also show that being the head of a household may protect against perceived relative inequality in certain dimensions (e.g. healthcare and transport access, political participation) irrespective of disability status. Results are discussed in terms of practical implications for development efforts in Liberia and for disabled people in other low- and middle-income settings.

The Association of Material Hardship with Medication Adherence and Perceived Stress Among People Living with HIV in Rural Zambia

The intersection of poverty and HIV/AIDS has exacerbated socioeconomic inequalities in Zambia. For example, the downstream consequences of HIV/AIDS are likely to be severe among the poor. Current research has relied on multidimensional indicators of poverty, which encompass various forms of deprivation, including material. Although comprehensive measures help us understand what constitutes poverty and deprivation, their complexity and scope may hinder the development of appropriate and feasible interventions. These limitations prompted us to examine whether material hardship, a more practicable, modifiable aspect of poverty, is associated with medication adherence and perceived stress among people living with HIV (PLHIV) in Zambia. We used cross-sectional data from 101 PLHIV in Lundazi District, Eastern Province. Data were collected using a questionnaire and hospital records. Material hardship was measured using a five-item scale. Perceived stress was measured using the ten-item perceived stress scale. Adherence was a binary variable measured using a visual analog scale and medication possession ratio (MPR) obtained from pharmacy data. We analyzed the data with multivariable linear and logistic regressions using multiply imputed datasets. Results indicated that greater material hardship was significantly associated with MPR nonadherence (odds ratio = 0.83) and higher levels of perceived mental distress (β = 0.34). Our findings provide one of the first evidence on the association of material hardship with treatment and mental health outcomes among PLHIV. The findings also draw attention to the importance of economic opportunities for PLHIV and their implications for reducing material hardship and improving adherence and mental health status.

"Even the fowl has feelings": access to HIV information and services among persons with disabilities in Ghana, Uganda, and Zambia

Background: Persons with disabilities have often been overlooked in the context of HIV and AIDS risk prevention and service provision. This paper explores access to and use of HIV information and services among persons with disabilities.Methods: We conducted a multi-country qualitative research study at urban and rural sites in Uganda, Zambia, and Ghana: three countries selected to exemplify different stages of the HIV response to persons with disabilities. We conducted key informant interviews with government officials and service providers, and focus group discussions with persons with disabilities and caregivers. Research methods were designed to promote active, meaningful participation from persons with disabilities, under the guidance of local stakeholder advisors.Results: Persons with disabilities emphatically challenged the common assumption that persons with disabilities are not sexually active, pointing out that this assumption denies their rights and - by denying their circumstances - leaves them vulnerable to abuse. Among persons with disabilities, knowledge about HIV was limited and attitudes towards HIV services were frequently based upon misinformation and stigmatising cultural beliefs; associated with illiteracy especially in rural areas, and rendering people with intellectual and developmental disability especially vulnerable. Multiple overlapping layers of stigma towards persons with disabilities (including internalised self-stigma and stigma associated with gender and abuse) have compounded each other to contribute to social isolation and impediments to accessing HIV information and services. Participants suggested approaches to HIV education outreach that emphasise the importance of sharing responsibility, promoting peer leadership, and increasing the active, visible participation of persons with disabilities in intervention activities, in order to make sure that accurate information reflecting the vulnerabilities of persons with disabilities is accessible to people of all levels of education. Fundamental change to improve the skills and attitudes of healthcare providers and raise their sensitivity towards persons with disabilities (including recognising multiple layers of stigma) will be critical to the ability of HIV service organisations to implement programs that are accessible to and inclusive of persons with disabilities.Discussion: We suggest practical steps towards improving HIV service accessibility and utilisation for persons with disabilities, particularly emphasising the power of community responsibility and support; including acknowledging compounded stigma, addressing attitudinal barriers, promoting participatory responses, building political will and generating high-quality evidence to drive the continuing response.Conclusions: HIV service providers and rehabilitation professionals alike must recognise the two-way relationship between HIV and disability, and their multiple overlapping vulnerabilities and stigmas. Persons with disabilities demand recognition through practical steps to improve HIV service accessibility and utilisation in a manner that recognises their vulnerability and facilitates retention in care and adherence to treatment. In order to promote lasting change, interventions must look beyond the service delivery context and take into account the living circumstances of individuals and communities affected by HIV and disability. Implications for RehabilitationPersons with disabilities are vulnerable to HIV infection but have historically been excluded from HIV and AIDS services, including prevention education, testing, treatment, care and support. Fundamental change is needed to address practical and attitudinal barriers to access, including provider training.Rehabilitation professionals and HIV service providers alike must acknowledge the two-way relationship between HIV and disability: people with disability are vulnerable to HIV infection; people with HIV are increasingly becoming disabled.Peer participation by persons with disabilities in the design and implementation of HIV services is crucial to increasing accessibility.Addressing political will (through the National Strategic Plan for HIV) is crucial to ensuring long-term sustainable change in recognizing and responding to the heightened vulnerability of people with disability to HIV.

Chronic pain as a human rights issue: setting an agenda for preventative action

Background: Historically, chronic pain has been viewed primarily as a medical issue, and research has been focused on the individual and predominantly on pain sufferers in high-income countries.

Objectives: This article argues the need for a broader understanding of the context of chronic pain and its complex aetiologies and maintenance. It is suggested that the interaction between chronic pain and social context has been inadequately explored.

Methods: A single case study is used of a man living in a violent urban environment in South Africa accessing a pain clinic at a tertiary hospital. Following the case-study approach, as used in the chronic traumatic stress field by Kaminer et al., the case material is utilised to develop an argument for a new research agenda.

Results: Analysis of the case material demonstrates the complex interplay between bodily and psychological experiences, with chronic pain being contextually maintained and exacerbated by very difficult life circumstances, ongoing violence, and marginalisation.

Conclusions: It is suggested that a research agenda be developed which explores the links between chronic pain and ongoing chronic traumatisation in contexts of continuous violence, oppression, and disempowerment – common features of much of the contemporary majority world.

Exploring the interaction of activity limitations with context, systems, community and personal factors in accessing public health care services: A presentation of South African case studies

Background

There are many factors that influence access to public health services, such as the context people live in, the existing health services, and personal, cultural and community factors. People with disabilities (activity limitations), through their experience of health services, may offer a particular understanding of the performance of the health services, thus exposing health system limitations more clearly than perhaps any other health service user.

Aim

This article explores how activity limitations interact with factors related to context, systems, community and personal factors in accessing public health care services in South Africa.

Setting

We present four case studies of people with disabilities from four low-resource diverse contexts in South Africa (rural, semi-rural, farming community and peri-urban) to highlight challenges of access to health services experienced by people with activity limitations in a variety of contexts.

Methods

One case study of a person with disabilities was chosen from each study setting to build evidence using an intensive qualitative case study methodology to elucidate individual and household experiences of challenges experienced by people with activity limitations when attempting to access public health services. In-depth interviews were used to collect data, using an interview guide. The analysis was conducted in the form of a thematic analysis using the interview topics as a starting point.

Results

First, these four case studies demonstrate that equitable access to health services for people with activity limitations is influenced by a complex interplay of a variety of factors for a single individual in a particular context. Secondly, that while problems with access to public health services are experienced by everyone, people with activity limitations are affected in particular ways making them particularly vulnerable in using public health services.

Conclusion

The revitalisation of primary health care and the introduction of national health insurance by the Health Department of South Africa open a window of opportunity for policy makers and policy implementers to revisit and address the areas of access to public health services for people with activity limitations.

The sexual lives of people with disabilities within low- and middle-income countries: a scoping study of studies published in English

BACKGROUND

Although approximately 80% of the global population of people with disabilities reside in low- and middle-income countries (LMICs), very little is known about their sexual lives due to a lack of empirical data. We aimed to provide a scoping review of English-language research conducted on disability and sexuality in LMICs.

OBJECTIVE

Our research questions concerned what topics in disability and sexuality have (and have not) been investigated, where this research has been carried out, and how this research has been conducted.

METHODS

A scoping review was conducted to examine the published English-language research literature on disability and sexuality within LMICs. We searched three electronic databases (PsycINFO, Web of Science, and PsycARTICLES) for research meeting these criteria published between 2000 and 2016 (inclusive). Through this search, we identified 103 articles.

RESULTS

It is concluded that: (a) disability and sexuality research in African countries has focused predominantly on sexual abuse and violence or HIV, (b) the sexuality of people with disabilities within many LMICs has received little or no empirical investigation, and (c) there have been very few experimental studies on disability and sexuality conducted in LMICs in general.

CONCLUSIONS

Much remains unknown about the sexual health and sexual lives of the majority of people with disabilities, globally. Moreover, what has been done in certain contexts has tended to focus predominantly on vulnerabilities rather than emancipatory practices. Thus, urgent action is needed within LMICs on issues related to disability and sexuality to meet the goal of global optimal sexual health.