FACTORS INFLUENCING ACCESS TO ANTENATAL HEALTH SERVICES BY WOMEN WITH DISABILITIES IN JINJA MUNICIPALITY, JINJA DISTRICT

LIST OF ABBREVIATIONS

AIDS              –           Acquired Immune Deficiency Syndrome

HC                  –           Health Care

HIV                 –           Human Immunodefiency Virus

ICF                  –           International Classification of Functioning

MGLSD          –           Ministry of Gender, Labour and Social Development

MoFPED         –           Ministry of Finance Planning & Economic Development

NAD               –           Norwegian Association for the Disabled

NMHCP          –           National Minimum Healthcare package

PWDs              –           Persons with Disabilities

PWVIs –                       Persons with Visual impairments

UN                  –           United Nations

UNDHR         –           United Nations Declaration of Human Rights

UNICEF         –           United Nations International Children’s Emergency Fund

VHTs              –           Village Health Teams

WHO              –           World Health Organisation

WWDs                        –           Women with disabilities

ABSTRACT

The purpose of the study was to assess the factors influencing access to antenatal health services by women with disabilities in Jinja Municipality, Jinja District. The specific objectives of the study were to; find out the availability of antenatal health services by women with disabilities, explore the accessibility of antenatal health services by women with disabilities, identify the barriers that limit access to antenatal health services by women with disabilities and the experiences of women with disabilities in accessing antenatal health services in Jinja Municipality, Jinja District.

The study employed a cross-sectional research design under qualitative approach and it involved 18 respondents. The respondents were selected using two sampling techniques; purposive sampling that was used for selecting health workers while WWW were selected using simple random sampling. The data was collected using interview guide, observation and focus group discussion which was then analyzed qualitatively.

The majority of the respondents were female who revealed a lot of suffering on the side of WWDs accessing antenatal health service. The most vital challenge limiting access distance to the health facility, lack of enough drugs, lack of awareness, absence of mobility devices. Therefore strategies included provision of assistive devices, immediate attention, empowerment and awareness rising.

The study concluded that distance to the health facility is the major challenge hindering access of healthcare services by WWDs and it has exerted pressure to the health workers and hence making negative attitude inevitable due to the absence of ramps, sidewalks, adjustable labour beds, and this has led to poor quality of life, low life expectancy among WWDs.

The study recommended that the government and other stake holders like NGOs and CBOs should provide mobility appliances to WWDs such as wheel chairs, crutches.  This helps in improving their self esteem and restoration of hope in seeking health care services.

CHAPTER ONE

1.0 Introduction

This chapter presents the background of the study, statement of the problem, purpose of the study, objectives of the study, research questions, and scope of the study and significance of the study.

1.1 Background to the study

Disability refers to difficulties encountered in any or all three areas of functioning. The ICF can also be used to understand and measure the positive aspects of functioning such as body functions, activities, participation and environmental facilitation (WHO, 2011).

Disabled people, irrespective of where they live, are statistically more likely to be unemployed, illiterate, to have less formal education, and have less access to developed support networks and social capital than their able-bodied counterparts. Consequently, disability is both a cause and consequence of poverty

Antenatal health is the care one receives from healthcare professionals during her pregnancy. Antenatal health (ANC) is an important determinant of safe delivery (Bloom et al. 1999). Although certain obstetric emergencies cannot be predicted through antenatal screening, women can be educated to recognise and act on symptoms leading to potentially serious conditions (Bhattia & Cleland 1995); this is one strategy for reducing maternal mortality (Nuraini & Parker 2005). One of the most important functions of ANC is to offer health information and services that can significantly improve the health of women and their infants (WHO & UNICEF 2003). In addition, ANC during pregnancy appears to have a positive impact on the utilization of postnatal healthcare services (Chakraborty et al. 2002).

According to the Uganda Demographic and Health Survey Report (2014), the content of antenatal health consumed in Uganda included the measurement of blood pressure, testing of urine for bacteriuria and proteinuria, and blood tests to detect syphilis and severe anaemia. It also includes taking iron supplements, intestinal parasite drugs, tetanus toxoid injections, weight and height measures, and information about danger signs during pregnancy, and where to go in case of complications. However, according to the World Health Organization (WHO) (2012) not all items included in antenatal health impact on maternal and neonatal health. In a WHO antenatal health randomised trial, a new model was introduced with just a few examinations and tests (blood pressure measurement, testing of urine for bacteriuria and proteinuria, and blood tests to detect syphilis and severe anaemia). Routine weight and height measurement at each visit is considered optional.

In the context of reproductive health, women with disabilities have largely been ignored in reproductive health research and programming (Charles, 2010). For example, Lwanga (2014) concluded that women with disabilities have received little attention. Part of the reason for this neglect is that they are often thought not to be sexually active, and less likely to marry or to have children than women without disability.

Although Uganda has made progress over the last several decades to improve maternal health, maternal mortality is a serious public health concern. According to the World Health Organization’s most recent estimates (2012), Uganda’s maternal mortality ratio stands at 380 per 100,000 live births. Maternal mortality accounts for 14% of deaths among females aged 12–49 years, and are the second largest cause of female mortality after infectious diseases among women of childbearing age. Despite the fact that Uganda has since implemented a free maternal healthcare policy, more than 45% of births still occur at home without any form of skilled care in parts of Uganda. In addition, large and growing gradients of inequalities in skilled care services accessibility and utilisation have been observed in Uganda. It’s upon this background that the researcher intended to explore the factors influencing the accessibility of antenatal health services by women with disabilities.

1.2 Statement of the problem

In Uganda, women with disabilities are confronted with life threatening health risks related to unwanted pregnancies, HIV/AIDS and sexually transmitted infections (STIs) which have been addressed by various organizations. However, other reproductive health programs such as antenatal health have been less successful as indicated by the lower reproductive health indicators in Uganda compared to the region (East Africa)and Sub-Sahara Africa (Ntale, 2013).

In Jinja municipality, among women who come for antenatal health and delivery, few of them are women with disabilities and being a village in Jinja, it contributes to this great problem. It’s upon the above background that researcher picked interest in carrying out a study about the factors influencing the accessibility of antenatal health services by women with disabilitiesin Jinja municipality, Jinja District.

1.3. Purpose of the study

The main purpose of the study was to explore the factors influencing the access to antenatal health services by women with disabilities in Jinja Municipality, Jinja District.

1.4 Research objectives

1. To find out the availability of antenatal health services by women with disabilities in Jinja Municipality, Jinja District.
2. To explore the accessibility of antenatal health services by women with disabilities in Jinja Municipality, Jinja District.

• To identify the barriers that limit access to antenatal health services by women with disabilities in Jinja Municipality, Jinja District.

1. To identify the experiences of women with disabilities in accessing antenatal health services in Jinja Municipality, Jinja District.

1.5 Research questions

1. Are health services available for women with disabilities in Jinja district?
2. Do women with disabilities access antenatal health services in Jinja Municipality, Jinja District?

• What barriers limit access to antenatal health services by women with disabilities in Jinja municipality, Jinja District?

1. What are the experiences of women with disabilities in relation to accessibility of antenatal health servicesin Jinja Municipality, Jinja District?

1.6 Scope of study

1.6.1 Content Scope

The main purpose of the study was to explore the factorsinfluencing access to antenatal health services by women with disabilities in Jinja municipality, Jinja District. Specifically, the study found out whether women with disabilities have access to antenatal health services, the barriers that limit access to antenatal health services by women with disabilities and the experiences of women with disabilities in accessing antenatal health services.

1.6.2 Geographical Scope

The study was carried out in Jinja municipality, Jinja District. This was due to the easy proximately to the area.

1.6.3 Time Scope

The study was carried out for a period of four months in 2017.

1.7 Significance of the study

To women with disabilities, the study would help them acquire information on antenatal health services by women with disabilities and measures they can employ to improve antenatal health services. This was done by holding a session with them after the research which took 30 minutes.

To local leaders, the findings would form a basis upon which appropriate interventions can be devised to improve antenatal health services. This was ensured by the researcher giving a report copy to the local leaders.

The research report would act as a source of literature to other future researchers. This was ensured by putting a copy of the report in the library.

CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter presents the literature review cited by other scholars about accessibility of health services to women with disabilities. The literature was presented according to the objectives of the study.

2.1 Antenatal health services offered to women with disabilities

The right to health relies on a range of services including those that provide health promotion, prevention, screening, and treatment. Access to health maintenance programs in the community e.g. fitness programs, swimming centres is also intrinsically linked to achieving optimal health outcomes (Beer and Faulkner, 2009).

Women with disabilities may need specialty care to address their individual needs. In addition, they need the same general health care as women without disabilities, and they may also need additional care to address their specific needs. However, research has shown that many women with disabilities may not receive regular health screenings within recommended guidelines (Armour, 2009).

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) has specific provisions that recognize the reproductive rights of persons with disability (Art. 23); the right of people with disability to access SRH information and services (Art. 25); and the specific need for empowerment of women with disability (Art. 6) [UN, 2006]. In order for these rights to be achieved, women with disability need to be provided with age appropriate, accessible information on SRH, and to have recognition of their rights to have a sexual relationship, marry, establish a family, enjoy reproductive health, and physical integrity [Schaaf, 2011].

2.2 Accessibility of Antenatal health services by WWDs

According to Winklebly, (2014), education shapes future occupational opportunities and earning potential in developed countries like US. It also provides knowledge and life skills that allow better-educated persons to gain more ready access to information and resources to promote health services such as medical examination.

According to a study by Hannah, (2012) on the factors affecting access to health services by intermarried Filipino women in rural Tasmania, it was found out that cultural beliefs and practices hindered participants’ access to routine medical examinations, particularly those from rural areas. They find it hard to adopt the new health practices. For instance, it was mentioned that ‘their practices have been part of their lives since birth’. Thus, accepting and adopting new health practices affects their accustomed ways of maintaining health and wellbeing, as well as accessing the new health services.

According to a study by Magoma et al., (2010), on the high antenatal care coverage and low skilled attendance in a rural Tanzanian district, it was established that increasing knowledge and awareness of the determinants influencing access to antenatal care services and how they interact can inform effective policy development and improve the availability and accessibility of health care services that fit the needs of different communities in Tanzania. Therefore, increased awareness and knowledge about health issues influences the access to routine medical examination.

According to Mare, (2012), in his study Socio-Economic Careers and Measurement and Analysis of Mortality, he stated that the work status of women has also been linked to knowledge and use of medical examinations. Women who work outside the home have higher rate of accessing routine medical examination than women who do not work outside home (housewives). Working women, particularly, those who earn cash incomes are assumed to have greater control over household decisions and increased awareness of the world outside home.

According to Kinney et al., (2010), the observed variation in medical examination use by place of residence may be attributed to differences in the availability of such social services as education, information about medical examination, access to medical examination and health care services.

Atkinson et al., (2001), religion may affect compliance or access to health services. It is recognised also that in most African countries like Uganda, health professionals put into account these types of religious beliefs and values when communicating with patients or users; this may affect ones access to routine medical examination.

A study carried out by Duong et al., (2004), on measuring client perceived quality of maternity services in rural Vietnam, the study found out that more than ninety percent of women attending antennal clinic but less than half of them frequently did routine medical examination in health facility. The study also found out that a higher number of respondents had a positive attitude towards medical examination implying that majority of them went for routine medical examination.

In a study done by Kyomuhendo, (2003), in Uganda on Low use of rural maternity services in Uganda, the study revealed that quality of care, which only partly overlaps with medical quality of care, is thought to be an important influence on health care-seeking and routine medical examination. Assessment of quality of services largely depends on personal experience with health system.

UDHS, (2011), showed that Ugandan women in the lowest wealth quintile have no access to routine medical examination as those in the highest wealth quintile. Percentage of women in the lowest quintile has no education compared with 38 percent in the highest quintile” shows the obvious fact that wealth and education go hand-in-hand and, together, make the biggest fertility impact. The lower the income levels the higher the access to routine medical examination.

According to Atkinson et al., (2001), argues that the location of health services in developing countries may result in poor access for routine medical examination. Also household financial capacity is one of the major factors in the determinants of routine medical examination, and this depends on occupation of family members.

According to Ross, (2011), household financial capacity is one of the major factors in the determination of routine medical examination in most African Countries. A limited ability to pay and high hospital costs have been identified as the major barriers for the rural poor wishing to access health care, due to economic difficulties in rural areas women are not able to afford costs related to routine medical examination.

According to Link and Phelan, (2010), the inequalities in the apparent circumstances of individual’s lives, like individuals’ access to health care, schools, their conditions of work and leisure, households, communities, towns, or cities, affect people’s ability to lead a flourishing life and maintain health, thus access to routine medical examination.

Women who are working and earning money may be able to save and decide to spend it on a health issues. Several studies find that farming women are less likely to have routine examination than women in other occupations (PHAC, 2011). This may be due to limited financial resources and health services in such areas.

According to a research carried out by Agency for Healthcare Research and Quality (AHRQ) in the US, 2008, lack of access, or limited access, to health services greatly impacts an individual’s health status. For example, when individuals do not have health insurance, they are less likely to participate in preventive care and are more likely to delay medical treatment.

2.3 Barriers that limit access to antenatal health services by WWDs

Women with disabilities are not able to access the health services they need to optimise their health and well-being. They are not involved in decision-making about their own health. There several key socio-economic, policy and practice barriers to achieving this basic human right:

Women with disabilities often encounter physical, attitudinal, and policy barriers in seeking to meet their health care needs. Physical barriers include the unavailability of transportation; stairs and narrow doorways into clinics, doctors’ offices, etc.; written information, such as intake forms and patient education materials, not available in alternative formats (i.e. Braille, tape, large print); high examining tables which prevent transfer by women using wheelchairs; mammogram machines which require patients to stand; and lack of personal assistance to women who need it during clinic visits. These barriers may be remedied through accessibility planning and modifications; availability of written materials in alternative formats; obtaining “adaptable” equipment such as tables which can be raised and lowered, and provision of trained, appropriate assistance in mobility and other personal care needs.

Higher rates of poverty and housing stress and lower levels of education and employment are experienced by women with disabilities, compared with men with disabilities, or women without disabilities. Women living with disabilities are more likely than those without disabilities to experience social and economic disadvantage and poverty. Contributing factors include lower levels of education and employment (46.9% compared with 59.9% for men with disabilities and 64.9% for women without disabilities). Lower income contributes to significantly more housing stress, food insecurity, poorer nutrition and higher rates of obesity and chronic disease (Beer and Faulkner, 2009).

Policy barriers may be imposed by hospital or clinic regulations; by insurance companies; or by other third-party payers such as Medicare and Medicaid. Some insurance providers discriminate against individuals with disabilities, by barring coverage for “preexisting conditions,” or by cost-capping services which may be essential for managing a disability. Another major barrier is that some necessary services — such as in-home personal assistance services, prescription medications, durable medical equipment, holistic health services, assistive technology, preventive care, certain therapies, or abortion services — may not be covered by private or government-funded insurance plans. Government and private policies may also have an “institutional bias” — i.e., they offer services primarily in nursing homes, rehabilitation hospitals, and other large long-term care facilities; but not in the disabled woman’s own home, where she can be part of her family and community. Ending this institutional bias, and securing more support for independent living (IL) and community-based rehabilitation (CBR), is a major focus of disability-rights advocates in many countries (Laura, 2000).

Lower levels of health knowledge among some women with disabilities may contribute to delays in obtaining treatment and lower participation in health promotion and prevention services. Lower levels of literacy and education also impact directly on health. It results in a poorer understanding of the way the body functions and the relationship between prevention and disease and early access to health services for treatment. This may be exacerbated by psychological factors e.g. low self-esteem, depression; cognition problems such as memory and organizational skills (Broughton & Thomson, 2000).

Health information is not provided in a range of accessible formats for women with disabilities. Proactive development of health information is needed using a range of formats (including print and emerging electronic technologies). The delivery of education / information must be paced to match the specific disability needs women have. Education needs to be delivered and repeated, if necessary, through all stages of women‘s lives. Women with disability need to be involved in the development of these resources (Burgen, 2010).

Primary carers and health care providers who do not see beyond the woman‘s disability, who fail to recognise her holistic health needs, or who do not adjust their care and services to meet those needs, exclude women from mainstream health services. Many people with disabilities rely on carers – family members and service providers – for intimate physical care as well as access to services. Women with these needs are in a particularly vulnerable position [Noonan and Heller, 2002]. De-institutionalization has meant that people with disability now have a physical presence in the community, however, access to externally provided support and opportunities is essential and the low expectations of others, including health service providers, can act as significant barriers.

Attitudinal barriers arise from negative societal beliefs about the worth of women with disabilities. These barriers may include the disrespect and/or discomfort of medical professionals; unwillingness to communicate with women whose speech or hearing is impaired; professionals’ lack of knowledge about particular disabling conditions; and focus upon the disability, to the exclusion of other health needs. Some practitioners wrongly believe that disability inevitably diminishes a disabled woman’s value or quality of life. They may therefore fail to explore or offer all treatment options, assuming instead that death is preferable to living with a significant disability. Doctors, nurses, and other clinic and hospital staff people may benefit from training and education in these areas. In addition, women with disabilities should be fully informed about their rights as patients (de Kretser, 2010).

Gender based violence is experienced by women with disabilities up to two to three times more often than women without disabilities, with lower rates of access to justice and health systems. High levels of dependency, cognitive and communication disabilities place women at higher risk of violence. Perpetrators are often known to women, they can be carers, residents or other providers of assistance. They may also be partners or family members [Murray and Powell, 2008]. In addition, Healey (2008) women with high degrees of physical impairment are more likely to perceive themselves as sexually inadequate and unattractive than women with mild impairment‘.

Higher rates of mental health problems co-exist with having a disability and are exacerbated by the higher rates of violence, socio-economic factors and lack of adequate mental health support and prevention services. Women with disability are more vulnerable to mental health problems due to the social and economic disadvantage described above and women with psychiatric conditions are particularly vulnerable to abuse and violence, both within health services and more generally in society. Australia‘s 2007 National Survey of Mental Health and Wellbeing found that 43% of people who had a profound or severe core-activity limitation experienced symptoms of a mental disorder in the 12 months prior to the survey, compared with 20% in the general population [Australian Bureau of Statistics, 2007].

According to Anderson and Kitchin (2000) women with disabilities remain poorly served by health services in relation to their sexual and reproductive health needs and entitlements. Community attitudes and perceptions of disability, sexuality and gender contribute to the lack of appropriate information and accessible services. Mainstream cultural perceptions of disability, sexuality and gender and the intersection of these contribute to the lack of effective reproductive services for women with disability. Current issues (and controversies) with particular resonance for women with disability include sterilization, abortion and fertility. Consideration of the rights of women with disability to have, or not have babies and to raise children is particularly important. There is lack of appropriate information and education about sexual and reproductive health for women with disabilities, including contraceptive choices and compliance, and recognition of the early signs of pregnancy.

Access to health promotion initiatives, including screening is as important for women with disabilities as for women in general. However these programs, including those for mammography and Pap screening, are not currently meeting their service obligations for this group of women. This places women with disabilities at higher risk of delayed diagnoses of breast or cervical cancer [Carlson, 2002].

International, national and state policies enshrine the rights to health, freedom, respect, equality and dignity. However, discrimination on the basis of disability was the most common cause of complaint. These principles need to be translated into equitable and accessible services. Significant practical, attitudinal and organisational barriers to inclusive services for women with disabilities remain. Women with disabilities experience higher levels of disadvantage and discrimination, much of which is based in a lack of knowledge and sensitivity about disability among health care providers; the physical layout and paucity of appropriate equipment in health services; and a lack of appropriate policies, guidelines and information resources [Barr, 2008].

CHAPTER THREE

METHODOLOGY

3.0 Introduction

This chapter presents the research design, target population, sample size, sampling procedures, data collection instruments used, procedure and data analysis.

3.1 Research Design

The study used a cross-section research design. Qualitative method was used to acquire information on the study under investigation; this enabled the researcher to gather a wide range of information required by the objectives of the study.  Hennik et al., (2007) qualitative approach is an approach that allows a researcher to examine peoples experience in detail, by using a specific set of research methods such as interviews, observation, focus group discussion, content analysis. It also allows a researcher to identify issues from the perspective of his participants, and understand the meanings and interpretations that they give.

3.2 Target Population

According to Baron, (2011), population constitutes people-individuals, organizations, groups, communities or other units that provide information for the study. The population included: women with disabilities from 18 to 45years, health workers (health in charge and 3 midwives) with in Jinja municipality.

3.3 Sample size

A sample size is a part of a population methodologically selected for purposes of drawing a conclusion about a population and its characteristics (Allan, 1962). In this case therefore, the sample size was made of 18 respondents.

Table 3.1: Sample size

Women with disabilities were involved in the study because they were the main culprits; Health workers were selected because they are aware of the health issues affecting women with disabilities.

3.4 Sampling Procedure or Technique

A sample technique is a way of gathering statistical information where few elements or individuals were chosen out of the population to present the whole population. The researcher used a simple random sampling technique where the essence was to allow every member of the population to get an equal opportunity to be included in the study and to reduce biases in selecting samples.

Saunders et al, (2012) purposive sampling (also known as judgmental, selective or subjective) is a sampling technique in which a researcher relies on his or her own judgment when choosing members of population to participate in the study. It’s convenient enough because of cost and time effectiveness (Saunders et al, 2012). Purposive sampling was used in selecting knowledgeable participants (information rich participants). Participants are usually selected based on pre-determined criteria (inclusion criteria). This technique was used to select health workers (health in charge and mid-wife).

3.5 Data collection and instruments

Interviews

Cohon and Manioh (1989) qualify interview to be a conservation initiated by the interviewer for specific purpose of obtaining research relevant information and focuses on content specified by research objectives of specific description. Semi-structured interviews were used to generate additional information from the respondents. This method was chosen because it helps in the collection of more data as it allows the interaction of both the researcher and the respondents. It is cheap and does not waste much time.

An interview guide was used for the in-depth interviews with health workers. Unstructured interview guide was developed based on the objectives. They were designed in English language.  It was used because it promotes greater depth of response which is not possible through other means and it allows the researcher to get information concerning feelings, attitudes in relation to research questions. It is also cheap and easy to administer.

Informal observation

Informal observation is usually done when the researcher has little knowledge of a population and its behaviour. The main purpose of informal observation was to create hypotheses to be tested later, in a survey or using for a survey. This method involved watching and listening to people.

Under this method, the researcher included in her observation checklist issues such as; health services available, nature of beds, physical access and also the expertise of the health workers.

Focus group discussions

Focus group discussions were used due to the capacity of the short period of time. Focus group discussions were used on WWDs.  This enabled the WWDs to debate and discuss on the study directed by the few questions set and followed. The instrument used was the focus group discussion guide where questions were set and followed. The study involved 2 focus group discussions (in groups of 5 WWDs) and took about 30 minutes each.

3.6 Data Collection Procedure/ethical consideration

An introduction letter was obtained by the researcher from the university at the Department where it was used to introduce the researcher to the heads of the community where the study took place. The introductory letter was used to seek for permission for the researcher to carry out research in the area. The researcher collected data upon seeking respondents’ consent after revealing the type of information needed and the purpose to avoid potential concealment of vital information. The researcher also maintained confidentiality of respondents’ information; and reported the true findings of the study without any bias.

3.7 Data analysis

Data was qualitatively analyzed using quick impression which was done by summarizing the key findings; content analysis included recording and reviewing of the recorded information in order to understand data better and on a broader context, thematic analysis was also used. Here the researcher identified relevant information and classify it into relevant topics.  These techniques were exploratory in nature since they were highlighted, sorted, scrutinized and reviewed data better to ensure accuracy in the data collected.

CHAPTER FOUR

PRESENTATION AND ANALYSIS OF DATA

4.0 Introduction

This chapter entails the findings of the study. The findings are presented relating to the purpose of the study which was to factors influencing access to antenatal health services by WWDs in Jinja municipality, Jinja district. A total of 18 respondents participated in the study.

4.1 Background Information of the Respondents

This section presents the background on the studied characteristics of respondents used for the study. A total of 18 respondents participated in the study.

Table 1: Background information of the respondents

Respondents were asked information relating to their age and the majority (8/18) revealed that they were between the age of 26-35 years, followed by those who claimed that they were above 36years of age and a few claimed that they were between 18-25years of age.

Table 2: Highest education level of respondents

Relating to the education background, the majority of the respondents were “A” leavers, very few had made it to degree level, certificate level and primary level.

Table 3: Religious affiliation of respondents

Regarding the religious affiliation, most of the respondents were Anglicans, some of them were Catholics and Muslims, and only few were in other religions.

Table 4: Occupation of respondents

Study respondents were asked to give information about their occupation and the majority were not working while a few were working.

4.1 The availability of antenatal health services by women with disabilities

The study aimed at finding out whether women with disabilities have access to antenatal health services and the responses are reflected below.

Table 5: The availability of antenatal health services by women with disabilities

Table above revealed that majority of the respondents (14/18) indicated that antenatal health services are provided by health centres while (4/18) of them said personal clinics. This implies that most women with disabilities get their antenatal health services from health centres.

When the student asked about what antenatal health services are provided to WWD, most respondents indicated that measurement of blood pressure, testing of urine for bacteria and proteins, and blood tests to detect syphilis and severe anaemia.

Other respondents indicated that antenatal includes taking iron supplements, intestinal parasite drugs, tetanus toxoid injections, weight and height measures, and information about danger signs during pregnancy, and where to go in case of complications. One respondent was quoted saying:

            “I always get blood tests at the health centre III”.

4.2 Barriers that limit access to antenatal health services by WWDs

Study were required to identify the barriers that limit access to antenatal health services by WWDs and responses are presented below;

Distance to the antenatal facility

The responses were very varied as were participants, One challenge that was raised by all the participants was the aspect of distance to the existing antenatal facility in the municipality and the available two H/Cs at the parish level which was far away from other four parishes:

‘‘………WWDs face a lot of challenges here because as a municipality, we do not have H/Cs in every parish as compared to some municipality in the district with H/Cs. And therefore, these WWDs have trouble to go there and come back’’ (health worker)

 ‘‘Sometimes one endures the distance to go there and line up but to be disappointed that there are no changes’’ (female WWD)

‘‘you find even WWDs enduring the distance but only to be told to go back home due to many people’’ (WWDs)

Lack of awareness

Another challenge was lack of awareness for both WWDs and health workers. Some of the participants lamented that they are not well informed about the existing antenatal health services in the H/C because most of the antenatal workers do not have adequate knowledge and skills on the needs:

Both WWDs and key informants indicated that antenatal facilities are ill-prepared to address the health needs of WWDs. Most respondents mentioned that antenatal health providers were not trained to handle WWDs and that some antenatal health providers subject females with disabilities to deliver by cesarean section not knowing they can deliver normally like any other human being, thereby minimizing their ability to deliver normally. This is particularly due to lack of skills to handle pregnant females with disabilities, as the following quotations illustrate:

‘‘If we had information on antenatal health services presented in Braille and large print, we would have higher chances to information about our condition and the necessary intervention’’ (WWD)

‘‘We need to appreciate that delivering WWDs requires particular skills and surely we do not have them at the moment…..’’ (Key informant)

Lack of assistive devices

The absence of assistive devices was one of the challenges that the participants mentioned. These appliances would enhance movement of WWDs to access antenatal health services. The participants said that appliances like crutches and wheel chair would be another limb to help them easily access the antenatal health services from the antenatal facility:

The key informants confirmed that most of the WWDs struggle to forge their ways to the H/C by borrowing any passerby to help them who in most cases ask for money which a WWD does not have:

 ‘‘if wheel chairs or tricycles are given to WWDs, there level of movement and access to antenatal health services would be improved’’

Rudeness of nurses

Another WWD also pointed out the aspect of rudeness of nurses in the H/C and this is usually in relation to their slow response especially to hand in the book, dirty clothes always tantamount WWDs being insulted in the H/C. still another participant pointed out the difficulty to access some rooms in the H/C, especially the narrow doorways which are difficult for one who crawls or uses a wheel chair to pass:

‘‘……….why should I go and end up at the door way. It’s better to just buy drugs………’’ noted another WWD

Lack of enough trained medical personnel

The inadequate medical personnel were also raised by the participants. Most of the participants mentioned that this has resulted into VHTs being recruited to work in the H/C to help the few qualified staff. They said the level of the knowledge needed in the H/C especially for WWDs antenatal needs was not appropriate for the VHTs:

 ‘‘these VHTs even cannot read the names of certain medicines but due to few qualified antenatal workers…..’’ (Key informant)

Shyness of WWDs

In addition, another participant said that most WWDs are shy because of their conditions. Citing an example of those who crawl; even when taken to the H/C, they may not get the necessary help because of low self-esteem.

WWDs have low self-esteem to the extent of fearing people like nurses. They always react by seeing their situation as hopeless and therefore refuse to help themselves or to be helped as the quotation illustrates:

‘‘Most of the WWDs are shy most especially those who crawl and it makes it difficult for them to follow lines in the H/C, and also given that there are many people’’

Discrimination

Another participant said that one other challenge WWDs face was the aspect of being treated equally like those who have no any form of disability. Other ‘normal’ people undermine WWDs and are not sensitive to their needs. They are labeled all sorts of names disabled and dump. On this issue one participant said:

 ‘‘Sometimes we are not treated like human beings. People look at us as though we desired to be like that, aren’t we human?’’(WWD)

4.3 Experiences of WWD in accessing antenatal health services

The researcher asked respondents to indicate their experience of accessing antenatal health services. Results were obtained and are presented below;

Table 6: Accessibility of antenatal health services by WWD

Study findings as shown in the table indicate that, most respondents (8) mentioned that some antenatal health services require money, others said WWD find the distance to the health facility long, some health clinics do not have assistive devices to cater for women with disabilities and also rudeness of nurses.

One respondent was quoted:

            “There are some nurses who are very rude whenever I visit the health facility,       sometimes they make me feel small.

CHAPTER FIVE

DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.0 Introduction

This chapter presents a discussion on the major findings of the study, conclusions and gives recommendations. This was done according to objectives as earlier.

5.1 Summary of findings

In Uganda, women with disabilities are confronted with life threatening health risks related to unwanted pregnancies, HIV/AIDS and sexually transmitted infections (STIs) which have been addressed by various organizations. However, other reproductive health programs such as antenatal health have been less successful as indicated by the lower reproductive health indicators in Uganda compared to the region (East Africa)and Sub-Sahara Africa (Ntale, 2013). In Jinja municipality, among women who come for antenatal health and delivery, few of them are women with disabilities and being a village in Jinja, it contributes to this great problem. It’s upon the above background that researcher picked interest in carrying out a study about the factors influencing the accessibility of antenatal health services by women with disabilitiesin Jinja municipality, Jinja District.

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) has specific provisions that recognize the reproductive rights of persons with disability (Art. 23); the right of people with disability to access SRH information and services (Art. 25); and the specific need for empowerment of women with disability (Art. 6) (UN, 2006). In order for these rights to be achieved, women with disability need to be provided with age appropriate, accessible information on SRH, and to have recognition of their rights to have a sexual relationship, marry, establish a family, enjoy reproductive health, and physical integrity (Schaaf, 2011). NAD (2001) citation that most of the WWDs are poor and have no money to afford the special treatment and care from private clinics since most of the rural H/Cs do not have medicine to work on certain disabilities. This challenge leaves WWDs with a wide gap of risk in their health status that leads to low life expectancy. Mensah et al., (2008) who pointed a similar argument which noted that most of the health facilities do not provide disability friendly services making it hard for most WWDs especially wheel chair users to access H/Cs buildings and climb onto examination beds. This challenge has left most of WWDs delivering on the floor.

The study employed a cross-sectional research design under qualitative approach and it involved 18 respondents. The respondents were selected using two sampling techniques; purposive sampling was used for selecting health workers while WWW were selected using simple random sampling. The data was collected using interview guide, observation and focus group discussion which were then analyzed qualitatively.

From findings, the major antenatal services accessed by women with disability in Jinja Municipality health centres are; screening, measurement of blood pressure, testing urine, blood tests, information about danger signs, tetanus injections, weight and height measures and intestinal parasite.

The barriers that limit access to antenatal health services by WWDs included; distance to the antenatal facility, lack of awareness, lack of assistive devices, rudeness of nurses, lack of enough trained medical personnel, shyness of WWDs and discrimination.

The experiences of WWD in accessing antenatal health services included some antenatal health services require money, others said WWD find the distance to the health facility long, some health clinics do not have assistive devices to cater for women with disabilities and also rudeness of nurses affected WWD in accessing antenatal health services.

5.2 Discussion of findings

5.2.1 The availability of antenatal health services by women with disabilities

As indicated in the table 5 in chapter the major antenatal services accessed by women with disability in Jinja Municipality health centres are; screening, measurement of blood pressure, testing urine, blood tests, information about danger signs, tetanus injections, weight and height measures and intestinal parasite. This are the same services that other women in this area access. This implies that women with disabilities in Municipality have a right to and access the same services that are offered to women without disabilities in area. This affirms the fact that both women with disabilities and those without disabilities have the same right to quality and accessible antenatal health services.

In this respect antenatal health services providers with in Jinja municipality make an effort to ensure availability and accessibility of the common antenatal health services required by all women in the area. This is inline with article 25 of UN convection on the rights of PWDs 2006 which stretches the right of PWD to quality, accessible and affordable health services within the main stream of the community. However, not all women with disabilities in were able to access health facilities because of inappropriate walk ways and entrance to buildings where the services could be accessed.

5.2.2 Barriers that limit access to antenatal health services by WWDs

Results in chapter 4, presents a number of barriers that limit access to antenatal health services by WWD in Jinja municipality. One of these challenges was long distances from homes of WWDs to health centres. In the municipality, there are no health centres at village or parish levels, the centres are located long distance from homes of many WWDs. This situation is however different from the GOU (2004) and MOH (1996) that emphasized that all districts should have H/C at all levels and equipped with relevant services. These four parishes seem to be unlucky not to have H/Cs. No wonder long queues, pressure on the health workers leading to abuse of patients among others are some difficulties encountered by WWDs and the general community.

Another finding was that most WWDs are shy or fearful to access health care services. The researcher agrees because most of them are not empowered, and given the influence of negative attitudes in the community especially labeling. NAD (2001) pointed a similar argument which noted that most WWDs lack self-esteem especially crippled, and cerebral pulsed always react by seeing their situation as hopeless and so refuse to help themselves. The issue of low self-esteem of WWDs is a point not to be underestimated especially in rural areas and among children.

In this study, respondents reported rudeness of nurses and other health workers towards them when accessing health care services. The researcher agrees and notes that this scares the people not only WWDs and tend to seek another alternatives. This is in agreement with MOH (1996) citation that most health workers are ignorant of the health needs and expectations of WWDs, and this worsens the situation. It’s not surprising that given the situation in this municipality, more people from other parishes without H/Cs flood to the HC III in the Municipality. this stresses the health workers and hence become rude on patients. This alone has become a significant hindrance to their access to health care services.

Another finding was that WWDs in this Municipality lack mobility devices. This finding reveals the plight of WWDs especially crippled in accessing health care and social services. Participation which is a vital component of development is also significantly affected and this has an effect in the community and the individual. It matches NAD (2007) citation that absence of mobility devices like crutches hinders WWDs access to health care services and public places. This difficulty points to isolation and suffering of WWDs in this community.

Another finding was that the aspect of poverty among WWDs has greatly hampered their access to health care services. The researcher seconds this point because most WWDs do not have economic activities that can help them earn money to meet the minimal costs in the H/C. it lines NAD (2001) citation that most of the WWDs are poor and have no money to afford the special treatment and care from private clinics since most of the rural H/Cs do not have medicine to work on certain disabilities. This challenge leaves WWDs with a wide gap of risk in their health status that leads to low life expectancy.

5.2.3 Experiences of WWD in accessing antenatal health services

In this study, respondents reported that most of the health facilities in the Municipality are not disability friendly which has made it so hard for most WWDs to access health care services. The researcher also agrees because the delivery beds are high and un adjustable to favor WWDs going for labor in the H/C. this is in line with Mensah et al., (2008) who pointed a similar argument which noted that most of the health facilities do not provide disability friendly services making it hard for most WWDs especially wheel chair users to access H/Cs buildings and climb onto examination beds. This challenge has left most of WWDs delivering on the floor.

The researcher  observed  this  during data collection one woman with physical impairment  who was using a wheel chair could not enter a room where  HIV testing was done and she could not  get support  to enable her enter the room. Therefore inaccessibility of the physical environment in the health centres was a great barrier to some WWD access to the services provided.

5.3 Conclusion

The responses given concerning antenatal health services access by WWDs in general reveal a lot of suffering of WWDs. This is because of absence of H/Cs which would have been in other parishes of the Municipality for them and other people to easily access nearer antenatal health care services. This has made most of the people seeking antenatal health care services to move for long distances and those without mobility aids receive double vulnerability which lowers their esteem, life expectancy and worst of it death. WWDs sufferings can be turned to hopefulness of life by the government initiative to establish health centres at all levels in the sub county with special health facilities that are disability friendly. It’s not surprising that aspect of being rude on WWDs and other people by the health workers exist through expression of derogative remarks that scare away WWDs patients seeking health care services. There is need to expand the health centre by requesting addition of health care personnel, create provision of medicine and above all offering guidance and counseling to both WWDs and health workers to be patient and kind to one another.

5.4 Recommendations

The researcher recommends the following:

NGOs and CBOs should come on board and empower WWDs and people in the municipality to demand services from their leaders. This can be through training them and clarifying their rights by advocating dissemination of written rights in various local languages, Braille and also in large print. This improves on their access to information on health care services and thus improving on their access to health care services.

The government and other stake holders like NGOs and CBOs should provide mobility appliances to WWDs such as wheel chairs, crutches.  These mobility appliances can be used as seats by WWDs in the health centre while waiting for medication and also improving on their mobility levels not only to the health centre but also to places of socialization like recreational centres, churches. This helps in improving their self esteem and restoration of hope in seeking health care services.

The government especially the local government of Jinja district under the department of health should ensure that these parishes get health centres under their jurisdictions. The construction of health centres in all parishes tends to bring health care services closer to the WWDs since most of them are unable to afford travelling long distances given their low incomes to seek for medication. This leads to improved quality of life among WWDs.

The Nurses council should include in their curriculum sign language and Braille. This can be learnt by the Nurses and doctors being trained to help them easily communicate with WWDs seeking health care services as they can be able to understand them. This further motivates health workers to attend WWDs health needs and also the WWDs to frequently seek for health care services whenever in need.

WWDs councilors should encourage WWDs to from groups aimed at savings and credit, and also to benefit from other government initiated programs like NAADS, Operation Wealth Creation and NUSAF. This can help WWDs start small businesses that can in turn enable them to afford some of the health care services and human basic needs like food, education, and clothing among others, thus leading to improved quality of life among WWDs.

5.5 Areas for further research

The research recommends the following areas for further research;

• Contributions of societal attitudes towards utilization of health care services.

REFERENCES

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Bankole, K.C. (2006). Special Issues in Contraception: Caring for Women with Disabilities. J Midwifery Women’s Health. Elsevier Science, Inc.

Broughton, N. K., and Thomson, L. (2000). “Reasons for Not Using Contraceptives: An International Comparison” Studies in Antenatal health 15 (2): 92.

Burgen, A. (2010). Components of Unexpected Fertility Decline in Sub-Saharan Africa. Demographic and Health Surveys Analytical Reports no. 5.

Byarugaba, M. (2009). A Global Handbook for Providers, A World Health Organization Antenatal health Cornerstone.

Antenatal health Association of Uganda (2007), Golden Jubilee, 50 Years Moving Generations to Reproductive Health Rights.

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APPENDICES

Appendix I: Letter of Informed Consent

Dear respondent,

I am Namanya Racheal, a student of Kyambogo University pursuing a bachelor degree in Community Based Rehabilitation and as part of the requirement for the fulfillment of the award; I am carrying out a study on “factors influencing access to antenatal health services by women with disabilities in Jinja municipality, Jinja District”.

For the completion of this study, you have been identified as one of the key respondents for this study. Therefore, I request for your cooperation. You will not be forced to answer any question that is against your will, you may not also need to mention your name in case you don’t need to be recognized. The information you will provide was treated with utmost confidentiality and will only be used for academic purposes.

Therefore, I request you to answer the questions that follow.

Thank you for your time.

Appendix II: Interview guide for WWD

Section A: Background Information

Age: ……………………………………

Level of Education:…………………………………………………………..

Religion:……………………………………………………………………….

Occupation

Section: B

1. Who provides antenatal health services to women in this community?
2. Where do you find antenatal health services?
3. What are the antenatal health services in this community?
4. How are they provided?
5. Can you share with me your experience of accessing antenatal health services?
6. Are health services free?
7. What are the costs of antenatal health services in this community?
8. What challenges do you experience in accessing antenatal health services?
9. Any other information?

THANK YOU FOR TIME

Appendix III: Interview Guide for Health Workers

Section A: Background Information

Age: ……………………………………

Level of Education:……………………

Religion:………………………………

Position: ………………………………

Section: B

1. May you share with me antenatal health services available in this health center?
2. Roughly how many women attend antenatal health services weekly?
3. How many of them are women with disabilities?
4. What are the costs of antenatal health services in this health center?
5. What are expected of women receiving antenatal health services in this center?
6. What challenges are you experiencing in providing antenatal health services to women with disabilities?
7. Generally what challenges are experienced by health workers in providing antenatal health services?
8. Any other information?

THANK YOU FOR TIME

Appendix IV: Focus Group Discussions for WWD

1. Who provides antenatal health services to women in this community?
2. Where do you find antenatal health services?
3. What are the antenatal health services in this community?
4. How are they provided?
5. Can you share with me your experience of accessing antenatal health services?
6. Are health services free?
7. What are the costs of antenatal health services in this community?
8. What challenges do you experience in accessing antenatal health services?
9. Any other information?

THANK YOU FOR TIME