ACCESS TO HEALTH CARE SERVICES BY PERSONS WITH DISABILITIES: A CASE STUDY OF ACOWA H/C III, AMURIA DISTRICT.

LIST OF ABBREVIATIONS

UWONET       –           Uganda Women’s Network

PWDs              –           Persons with Disabilities

WHO              –           World Health Organisation

UNDHR         –           United Nations Declaration of Human Rights

HC                  –           Health Care

MOH               –           Ministry of Health

VHTs              –           Village Health Teams

S/C                  –           Sub-county

HSSP               –           Health Sector Strategy Plan

UNHS             –           Uganda National Household Survey

GoU                –           Government of Uganda

ICF                  –           International Classification of Functioning

LRA                –           Lord’s Resistance Army

UBOS             –           Uganda Bureau of Statistics

HIV                 –           Human Immunodefiency Virus

AIDS              –           Acquired Immune Deficiency Syndrome

HQ                  –           HeadQuarters

N.E                  –           North East

NPA                –           National Planning Authority

UNICEF         –           United Nations International Children’s Emergency Fund

NUDIPU        –           National Union of Disabled Persons in Uganda

PWPDs           –           Persons with physical disabilities

WWDs                        –           Women with disabilities

FY                   –           Financial Year

GDP                –           Gross Domestic Product

NAD               –           Norwegian Association for the Disabled

UNAPD          –           Uganda National Association of Persons with disabilities

MGLSD          –           Ministry of Gender, Labour and Social Development

NMHCP          –           National Minimum Healthcare package

UN                  –           United Nations

CAO                –           Chief Administrative Office

DHO               –           District Health Officer

UPHC             –           Uganda Population & Housing Census

MNCH –           Material New Born Child Health

ST                    –           Sexually Transmitted Diseases

NHA               –           National Health Accounts

HSDP              –           Health Sector Development Plan

USDC             –           Uganda Society for the Disabled Children

MoFPED         –           Ministry of Finance Planning & Economic Development

COU               –           Church of Uganda

ABSTRACT

The whole world is grappling with ensuring the health of its population. The aspect of disability and healthy well-being of the people is the matter of concern to all countries and therefore a lot has been documented, discussed and done to improve quality of life. The purpose of this study was to discover or examine access to health care services by PWDs in Acowa H/C III, Acowa S/C Amuria district.

Specifically, the study determined factors that influence access to health care services, found out the attitudes of health workers towards PWDs accessing health care services, also examined the challenges faced by PWDs in accessing health care services and finally suggested strategies for improving on the PWDs access to health care services in Acowa H/C III, Acowa S/C Amuria district.

The study employed a case study under qualitative approach and it involved a number of 15 (fifteen) participants. The participants were selected using two sampling techniques; purposive sampling that was used for selecting health workers and leader whereas, snowball was used for PWDs. The data was collected using interview guide and observation which was then analyzed descriptively.

The majority of the participants were female who revealed a lot of suffering on the side of PWDs accessing health care service. The most vital factor influencing there access was inaccessibility of the H/C environment because of the absence of mobility devices, ramps, and as a result of inaccessible labour beds negative attitude can be helped to access these health care services favourably by providing them assistive devises and establishment of ramps.

In conclusion, high number of patients visiting the H/C remains the most hindering factor to access of healthcare services by PWDs 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 PWDs.

CHAPTER ONE

INTRODUCTION

1.0 Introduction

This chapter includes the purpose of study, objectives, and research questions, statement of the problem, scope of study, its significance, limitations and delimitations.

1.1 Background

The aspect of access to health care services throughout the world has become of a concern to all governments. According to the United Nations Declaration of Human Rights (UNDHR), 1948, access to health services and facilities including treatment and care is a human right and every person regardless of color, age, appearance, status or physical condition is entitled to.

This declaration is seen as a driving force and has prompted all state parties to come up with approaches geared towards the attainment of this right. In 1978 for instance WHO emphasized in its conference in Alma Ata an approach to health care which caters for all people and is accessible; and decreed that gross inequality in health access and care between countries and within countries is politically, socially, and economically unacceptable.

Declaration in Alma Ata conference defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The definition seeks to include social and economic sectors within the scope of attaining health and reaffirms health as a human right. (           WHO, 1978)

Health care services in this case refer to the services provided for promotion of wellbeing, prevention of diseases, treatment and management of illness as well as the general preservation of mental and physical wellbeing (GOU, 2009).

Health according to business dictionary (2017), as defined by WHO, it is a ‘state of complete physical, mental, and social being, and not merely the absence of disease or infirmity’. Health is a dynamic condition resulting from a body’s constant adjustment and adaptation in response to stress and changes in the environment for maintaining an inner equilibrium called homeostasis. Furthermore, health care refers to the act of taking preventive or necessary medical procedures to improve a person’s wellbeing. This may be done with surgery, the administering of medicine. These services are typically offered through a health care system made up of hospitals and physicians.

Disability according to ICF (International Classification of Functioning) ‘Disabled World’ (29^th Jan. 2017 updated), refers to a condition or function judged to be significantly impaired relative to the usual standard of an individual or group. The term is used to refer to individual functioning including physical impairment, sensory, cognitive, intellectual, mental illness and various types of chronic disease. While PWDs according to Equality Act, 2010 defines a PWD as a person who has a physical or mental impairment that substantially limits one or more major life activities.

According to World Bank report on disability 2011, 1 billion people or 15% of the world’s population, experience some form of disability, and the disability prevalence is higher for developing countries. 1/5 of the estimated global total or between 110 million and 190 million people experience significant disabilities and in this number females have higher rates of disability than males. 2-4% of PWDs experience significant difficulties in functioning. The global disability prevalence is higher than previous WHO estimates which date from 1970s and suggested a figure of around 10% and this one arise due to population aging and rapid spread of chronic diseases, poor health, few economic opportunities and higher rates of poverty than people without disabilities.

According to the initial report on the UN convention on the rights of PWDs (24^th/Nov/2011) and other international human rights convention guarantee the fundamental human rights to physical, social, and psychological health. Specifically, the UNCRP guarantees PWDs the right to access ‘the same range, quality, and standard of free affordable health care and programs as provided to other persons, including those in the area of sexual and reproductive health and population-based public health program’. WHO Action Plan ‘Better health for PWDs’ (3^rd sep.2013), emphasizes access to health care services as an important determinant of one’s health, and has particular relevance as a public health and development issue in the low income countries like Uganda. In fact accessibility to healthcare services by PWDs as the most vulnerable and underprivileged population has been recommended by WHO as a basic primary health care concept.

The aspect of health care in this case has also sparked various categories of people to demand since it’s a mandatory human right and therefore women, children, elderly and all categories of people seek these vital services.

However, Ganle J.K et al., 2016, Ghana says ‘available evidence suggests that PWDs still face numerous challenges in accessing and utilizing essential health services and this affects their quality of life. Impediments to accessing the required health services include long distances to the health facility, high cost of services, education level of PWDs, negative attitudes of health workers, poor physical accessibility, health workers not experienced to handle or fear PWDs.

In a study on the health care service access and support for PWDs in Canada, Gibson and Mykitiuk (1994) found that health system policies and practices reflect numerous assumptions about what PWDs can or should do and that PWDs were even discouraged from having children either because of doubts regarding their capacities to provide care or because of concerns regarding the risks of a child inheriting a heredity condition.

These findings above also suggest that despite the call for universal access to health care services including those for reproductive health at the 4^th international conference on population and development in Cairo (1994) and the right to access ‘the same range, quality and standard of free or affordable health care and programs as provided to other persons’ access to health care services by PWDs remains a critical challenge.

Accordingly, access to health services in Uganda is a right according to the constitution of the Republic of Uganda 1995. Therefore to attain this, the government of Uganda has put various frame works to ensure attainment of this right and hence through various policies, the Ministry of Health (MOH) is in place, Health centers (HCs) IV are to be in every district and each S/C has to have HC III, HC II in the parish as well as village Health Team (VHTs) that act as HC1. According to MOH, (2009) at least 73% of all districts in Uganda are covered by various HCs; and access to health services is therefore enhanced. The Disability Act, (2006) part 2 section 7 stresses that PWDs shall enjoy the same rights with other members of the public in all health institutions including general medical carewhere the purchase and importation of health care equipment relating to disabilities are exempted from tax.

According to the 2002 Population and Housing Census, at least 1/25 of every people or 4% of Uganda’s then 24.4 million people are disabled. Later studies have however revealed higher prevalence of disability in Uganda. According to the UNHS, the estimated disability population was 16% or 5,088,000 PWDs out of Uganda’s then estimated 31.7 million people in 2010.

In Uganda, Health Sector Strategy Plan (HSSP) endorsed by government and development partners prioritizes key actions to attain agreed upon sector targets. The 1^st (2000/2005), 2^nd(2006/2010) HSSP periods have focused on ensuring universal access to a minimum health care service package. Universal access is a core strategy for achieving increased health care utilization and reducing disparities there in. In general, access to health care services has improved over both HSSP periods. However, other studies conducted for the same periods suggest that inequalities in the use of the health services like malaria have persisted on the side of PWDs. For example the analysis of the Uganda National Household Survey data (1997/98,1999/2002, and 2002/2003) shows that the reduction in those reported not to seek care was more for the richest compared to the PWDs lowest income earners, this was an increase in reported ‘no care’ for those in the lowest and little income earners respectively. The interdependent factors to access of health care services by PWDs are described in a Health Access Livelihood Frame work. They are related to the health seeking process, the nature and organization of health services and to access livelihood assets. In the process of seeking health care, PWDs will use services if they find them to be acceptable. How acceptable services are is related to the nature and organization of services which includes their availability, accessibility, affordability, and adequacy; this encompasses the health services approach. Livelihood assets include financial capital, physical capital, and natural capital, human and social capital.

In Uganda however, health service delivery particularly in the HCs is hampered by limited resources such as qualified personnel, inadequate medicines and health supplies, health infrastructure development and management and health financing. Issues of unequal opportunities in terms of accessing services have come up in the country with categories such as the PWDs and the elderly being affected (GOU, 2009). According to WHO (2008), a majority of PWDs in Uganda, 14% almost have no access to health services.

Access to health services by PWDs in Amuria district is a challenge as the HCs do not have facilities modified to suit their needs. The mobilization of PWDs to access health services is left to their leaders who also lack information regarding peoples’ life conditions and available resources; and given the fact that the existing HCs are at a distance from most villages. Besides an outcry of inadequate personnel, drugs and facilities is the order of the day in the existing S/C HC III (District Development Plan, 2010/2011). According to UBOS report on UPHC 2014 Amuria district has a number 64,288 PWDs or 24% of the total population. Acowa S/C in particular has about 6,531 or 10% PWDs. This has been attributed to poverty levels, low level of education, poor health. According to the 2003/2004 LRA insurgency in Amuria district (Teso sub-region), it left an increased number of PWDs and this left people with a devastating effect on the lifestyle, health and their wellbeing. This was caused by injuries from landmines and weapons. Amuria district has no Hospital but it has 1 sub-health district with level 4 health unit and 13 level 3 unit and Acowa HC III is one of them with 2 level II units serving 6 parishes with a total population of 270,498 people including PWDs (UBOS, 2014). According to MOH (Annual Sector Performance Report, 2008/2009), health care services available for PWDs include among others; immunization, sexual and reproductive health, basic health and nutrition, health education, guidance and counseling (HIV/AIDs), malaria and STD treatment, health promotion and support to community health workers. However, there is no documented information in the district about rehabilitative health care services.

However, while previous studies have explored the factors affecting access to health care services by PWDs in general, few studies have explored the challenges faced by PWDs in accessing health services. This presents a missed opportunity for understanding the challenges that these people go through in accessing health care services, and impedes our ability to assist them to enjoy the same health services that able-bodied persons enjoy. In this study we will bridge this gap by exploring the challenges faced by PWDs in accessing health care services in Acowa HC III Amuria district, Uganda.

1.2 Statement of the problem

Despite governments’ constitutional provisions for free quality health services in attempts to realize the UNDHR WHO Alma Ata declaration on health (1978) and the essential services and facilities for all people, it’s noted that many PWDs are not accessing these services. For instance, according to WHO (2008), a majority of PWDs in Uganda; 14% almost do not have any access to health services. This inaccessibility has contributed to a lot of health complications including acquisition of secondary disability, low life expectancy and at worse death among PWDs.

It is upon this background that the researcher wants to ascertain factors that impede PWDs from accessing these vital basic services.

1.3 Purpose of the study

The purpose of this study will be to examine the factors that influence access to health care services by PWDs in Acowa HC III in Amuria district.

1.4 Objectives

1. To determine the factors that influence access to health care services by PWDs in Acowa HC III, Acowa S/C Amuria district.
2. To find out the attitudes of health workers towards PWDs accessing health care services in Acowa HC III, Acowa S/C Amuria district.

• To examine the challenges faced by PWDs in accessing health care services in Acowa HC III, Acowa S/C Amuria

1. To suggest possible measures/interventions to improve on PWDs access to health care services in Acowa HC III, Acowa S/C Amuria district

1.5 Research questions

1. What are the factors that influence access to health care services by PWDs in Acowa HC III, Acowa S/C Amuria district?
2. What are the attitudes of health workers towards PWDs while accessing health care services in Acowa HC III, Amuria district?

• What challenges do PWDs always encounter during health care service access in Acowa HC III, Acowa S/C Amuria district?

1. What possible strategies or interventions can be put in place to improve access to health care services by PWDs in Acowa HC III, Acowa S/C Amuria district?

1.6 Significance of the study

The research findings will be of great importance to the stake holders like Amuria district Health Department, UBOS, WHO, NUDIPU, UNICEF, NPA, in addressing the challenges that shall be arrived at in the study.

The study will enable the government to find a way of improving PWDs favourable policies regarding health care service provision and delivery through stipulating stringent measures to improve on accessibility of health care services not only in Acowa HC III, but may be adopted elsewhere in the country.

The research findings will be of great value to academia carrying out further research on the subject.

1.7 Scope of the study

The research will be conducted from February to May 2017 after approval of the research topic. This time is convenient because it favours the researchers’ lecture timetable to enable him prepare enough for University end of semester examinations. The study will be carried out at Acowa HC III in Acowa S/C H/Q Eastern Uganda approximately 290 km by road, N.E of Kampala capital city of Uganda. Acowa HC III is the main health facility in Acowa S/C serving 06 parishes of; Acowa, Amero, angerepo, Akum, Acinga, and Angolebwal together with its 02 level 2 units of Ajeleik and Angerepo. The study will entirely examine the accessibility of health care services by PWDs in Uganda: A case study of Acowa HC III, Acowa S/C Amuria district and it will specifically be focusing on PWDs patients.

1.8 Limitations and delimitations

The researcher anticipates the following problems/challenges during the study;

1. Non-participation of some respondents (non-respondents errors), the researcher anticipates non-participation from some of the respondents. The researcher however, will try all the means possible to convince the respondents by assuring them that information will be confidential and purely academic, and not for any kind of action against them.
2. Time limitation; the time for conducting the research and analyzing findings may not be enough to win the deadline. The May deadline as communicated by the research coordinator poses a serious time constraint on the researchers’ side, reason being the research is being done within the semester packed with activities and schedules like course works, tests, and elections. The researcher will try all that is possible within this time frame to get the most reliable data.

• Financial limitation; high research costs are expected to be incurred during the course of the study. Transport, typing and printing costs and other contingencies will be needed. However, proper budgeting will enable proper execution and spending with the adequate knowledge the researcher has in financial management.

CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter provides review of related literature on PWDs access to health care services, provides review of evidence and knowledge gaps.

2.1 Factors influencing PWDs health care access

According to Beals (2000), cultural beliefs are some of the factors that dictate peoples’ actions and inactions. He argued that some PWDs believe that certain disabilities or inabilities are as a result of a curse and therefore, they are there to stay. This makes them believe that if securing health care from HCs can’t help them. Citing an example where most people believe that crippled PWDs are cursed makes themselves to believe that. It affects them since it erodes or reduces their self-esteem.

J.B. Dhamulira et al., (2014), cited that long queues in the health facilities pose particularly vulnerability to PWDs whose condition as opposed to the able-bodied clients may not stand the waiting time. For instance PWPDs hip bones are not strong enough to stand for a long time and some of them don’t have wheelchairs to sit on as they wait their numbers being called to receive the health care service. He further argued that; the long queues lead to loss of time and getting tired which is also exacerbated by the physical limitation associated with physical disability and lack of positive discrimination by the health workers where PWDs are left to line up with those who don’t have disabilities.

Felix Mutale et al., (2016), argued that physical accessibility to and of HCs services (facilities) impedes PWDs access to health care services; across all disability types, many PWDs face inaccessible physical infrastructure for example poor roads, lack of sidewalks and ramps, inability to use public transportation as well as the social and emotional trauma of being taunted by other riders or drivers or having to pay extra for the assistive appliances on a bus. Citing an example of Kampala taxi drivers do not pick up PWDs instead turn them away because of their disability. He emphasized that travelling with an assistant or guide to help them, but admitted that this brought additional complications due to difficulty of finding someone to give up his/her time and publicly be seen associating closely with a PWD who is totally ill may be because of HIV/AIDS, and the additional transport costs required. He further argued that many of the PWDs regardless of their disability attending health facility visit with an assistant present a challenge of maintaining confidentiality incase diagnosed HIV positive.

Richard Adanu et al., (2012), explained that mobility challenge is linked to another problem that impedes PWDs access to health care services; limited support form family, community members and the health system. Citing an example, these groups tended to be less supportive once a PWD especially WWDs gets pregnant; to access the required basic needs of pregnancy. According to this account, WWDs who gets pregnant are often reminded of their disability situation and the need for them to focus on that rather than getting pregnant. He emphasized that lack of support is particularly pronounced for WWDs as such people often require a direct assistance of others to access immediate basic health care. Similarly most WWDs who are not married repot limited support from family and community members as they seem to be a burden to them. He also further argued that one of the biggest challenges that PWDs especially PWPDs and VI face in accessing skilled care is the unfriendly nature HCs infrastructure. Most HCs currently lack ramps, wheelchairs, disability friendly delivery beds, separate toilets for PWDs and personnel to assist the pregnant WWDs climb stairs, examination tables. These problems often combine to discourage PWDs seeking skilled health care.

According to Shantha Rau Barringa, (2010) Human Rights Watch in Northern Uganda pointed out that PWDs face frequent isolation and discrimination by strangers, neighbors, family members and also health workers making them unable to gain access to improved health medication as one of the basic services of life. B.P. MARTINA et.,(2010) also emphasized that others encountered discriminatory attitude by staff and could not get assistance even from family members due to existence of multiple disabilities.

According to the NHA FY 2010/2012, cited out inadequate expenditure on the health services where Uganda’s health expenditure US $53 per capita which is lower than the minimum WHO recommended standards. In addition the total health expenditure was 1.3% of GDP against a target of 4%. Although efforts have been made to increase national health expenditure the budget allocation of 8.5% remains lower than the 15% that the country assented to in the 2001 Abuja Declaration (German Foundation for World Population 2010: HSDP, 2015). Due to absence of a national insurance scheme and the weak health infrastructure, the private out of pocket spending on health care among PWDs remains higher at 37% way about the WHO recommended Household expenditure of 20% (annual HSP review, 2015). The high out of pocket spending on health care negatively an impact on PWDs household’s income and affects their demand for, and access to health care services. It also predisposes household to catastrophic health expenditure in cases of severe ill health or hospitalization that can lead to secondary disabilities.

WHO ‘Disability and Health’ (2016) pointed that PWDs encounter arrange of barriers when they attempt to access health care. For instance, affordability of health services and transportation are two main reasons why PWDs do not receive needed health care in low income countries 32-33% of able-bodied people are unable to afford compared to 51-53% of PWDs. WHO emphasized that lack of enough appropriate services for PWDs is a significant barrier to health care. Citing an example of a study in Uttar, Pradesh, and Tamil Nadu Indian states found that after the cost, lack of services in the HCs was the 2^nd most significant barrier to using health facilities by PWDs.

However, accordingly lack of rehabilitative services greatly hinders PWDs access to health care services. These services like physiotherapy would help improve on the mobility abilities of Persons with Physical Disabilities. Most of the PWDs given opportunity of rehabilitation and habilitation improve on their attitude as potential persons in the community and this increases their self-esteem with great hopes of a better quality of life. Most of these special habilitation and rehabilitation services are found or located in urban areas not benefiting a majority of PWDs in rural areas like Corsu is located in Entebbe far from most of the PWDs who are unable to afford transport as a result of their meager income since they do not participate actively in most of the community’s economic activities.

2.2 Attitudes of health workers

1. Adanu et al., (2012) argued that health care providers insensitivity to and lack of adequate knowledge of PWDs care needs makes them to give information and advice irrelevant to PWDs. He emphasizes that some of the health workers are not only rude and insensitive but also they appear ill-prepared to address the maternity needs of WWDs. Accordingly most care givers are not trained to understand and provide appropriate care to PWDs when in need and most of them are even nervous or uncomfortable examining them.

J.B. Dhamulira et al.,(2014), emphasized that negative attitude is one of the most important challenges PWDs face while accessing health care services compounded by societal beliefs and expectations that PWDs should not conceive at all; women particularly suffer from societal stigmatization and blankness under the pretext that they should not become pregnant and give birth owing to their disability. WWDs are concerned about constant reminders on how they should be a sexual or abuse related to their appearance which they note to cause stigma and de-motivation from using health facilities. He further cited that some/most of the health workers are not specifically trained to respond adequately to the disability health needs, for instance they subject WWDs to deliver by cesarean section, thereby minimizing their ability to deliver normally mainly due to lack of adequate skills to handle pregnant WWDs.

Uganda Women’s Network, 2011 (UWONET) cited that health workers are a stand block PWDs access to health care services due to their negative attitude. For instance they have denied WWDs to have access to information and services about MNCH, sexual reproductive health and HIV/AIDs that was advocated by NUDIPU. Also in case of WWD failure getting up the high un adjustable beds provided in the health facility, the mid-wives will ask how ‘‘they climbed the bed to have sex and conceive’’. This has claimed many lives of inborn babies as they will take long in labour pain. Medical practitioners sometimes treat PWDs as objects rather than rights holders and do not always seek their free consent when it comes to treatment.

Human Rights Watch, 2010 (As if We Weren’t Human) pointed out that health workers in Northern Uganda practice discrimination of PWDs in health care services as they were sometimes hostile towards them especially WWDs. Nurses made derogatory remarks, including questioning why a woman with a disability would ever engage in sex or have a child. Health care personnel also discouraged PWDs from seeking reproductive health and family planning services; this makes them particularly vulnerable to HIV infections, and especially unlikely to have access to antiretroviral drugs.

However, in normal circumstance negative attitudes towards an individual or a group is a kind of sin because why do you have to be negative to a person who has blood like any other individual, lack knowledge, information and a sympathetic heart of humanity. The practitioners need to be availed with much information through guidance and counseling. In most cases, this happens because of ignorance among health workers, community members, family which has left most of the PWDs with poor health conditions, low life expectancy, malnutrition and even death because of the limited access to health care services.

2.3 Challenges faced by PWDs accessing health care services

MOH (1996), cited lack of awareness for both PWDs and health workers as one of the challenges that inhibit PWDs from accessing health services. PWDs are in most cases no aware of available services in health centers. Health workers on the other hand are ignorant of the health needs and expectations of PWDs and this worsens the situation. Mobility problems limit information access thus making PWDs ignorant of available services. Most nurses and doctors are also insensitive to the needs, for instance they may not know how to handle physically impaired pregnant mothers hence this mother may not get necessary services.

Norwegian Association for the Disabled-NAD (2001), indicates that sometimes PWDs are to blame their situation since most of them lack self-esteem and hence fear people like nurses and especially rippled and cerebral pulsed always react by seeing their situation as hopeless and therefore refuse to help themselves or to be helped. Low self-esteem among PWDs is a point not to be underestimated especially in rural areas and among children.

Isiko (1994) postulated that nature of one’s condition of disability is a big barrier in accessing social services. He argued that when disability condition is severe, the individual becomes immobile and so confined to one place. This therefore means that he/she cannot have health services which tend to be located far away. Giving an example where one’s legs are both amputated, crippled or severely affected this means that a PWD will not manage to go to a health facility to receive the health care services.

Isiko (1994) further noted that negative attitudes that are mostly manifested in the institutions of society area big hindrance to access of health services among others services. This is due to the way other normal people tend to treat PWDs because of their condition which usually is not favourable. WHO (1995) also emphasized that negative community attitudes have worsened the situation in most communities throughout the world. Additionally, most PWDs are regarded as unproductive, unable, useless, cursed among others. These cause PWDs to shy off from public places like health centers, negative attitudes particularly hinder participation in aspects to do with health services. It erodes self-esteem and constitutes to social and physical barriers which aggravate disability.

Poverty among most PWDs is blamed for not allowing PWDs from accessing health services (NAD, 2001). It’s argued that most of rural HCs have no medicine to work on certain disabilities and this means that PWDs need special treatment and care because of their situation. However, most of them are poor and have no incomes to afford these services; this worsens their situation. The indication by NAD is significant in Uganda since most health facilities do not have specialized rehabilitative care needed by PWDs. It’s true that many PWDs are not involved in IGAs.

NAD (2007) in its report noted that most PWDs do not have devices to help them with mobility; it argued that this limits these persons’ access even public places and has rendered them isolated. An appliance like wheelchair, crutch, and hearing aid would be another limb or hearing for a PWD especially amputated and hard-of-hearing respectively; however, their absence means a big challenge to that PWD because he/she may not go to the market, school and HC as well.

Claudine (2004) postulated that inaccessible facilities are a hindrance to most PWDs, she argued that PWDs find it challenging to access services in most rural HCs because of the way they are constructed and they see these facilities as not adaptable to their needs and conditions. UNAPD (2010) also argued that most health units in Uganda are inaccessible to PWDs; this makes them even going to public places including HCs. For instance most HCs which were constructed during colonialism have no ramps and hand rails. This poses a challenge to PWDs and hinders their participation in social services.

Nikolai (1999) in his book noted that loneliness is one factor that hinders PWDs from accessing health services. He argued that loneliness means isolation and therefore limited network. AdjeteySorsey (2000) substantiated that most PWDs are isolated and have no network. This cuts them off from the rest of the society and hence become ignorant of what is going on in the area. It’s true that most PWDs are always abandoned in their buildings, this is common in villages, this renders them stressed and thinking no one likes them and therefore see no reason going to a public place like HC.

Kimberly (2003) also pointed out that HIV/AIDS is one of the challenges that have affected society including PWDs and limits from participating in most programs related to development. WHO (2008) added that HIV/AIDs has rendered most elderly PWDs to have many orphans who are young and dependent and preoccupied with ensuring their wellbeing. It’s worth noting that the impact of HIV/AIDs has penetrated society and all categories of people and therefore PWDs are inclusive. They have the burden of caring for orphans like looking for basic needs and other services to enhance the wellbeing of the children. This leaves them with little time to go to receive health services.

Najjumba (2009) in her report on poverty noted that persistent ill health is in itself one factor that prevents PWDs from accessing health services. She argued that persistent ill health has the effect of draining energy from a person and reach a time when one can no longer engage in activities let alone go to a HC. The situation is then aggravated by the person’s impairment. For example a PWD who develops hypertension, muscular pain drain the energy from the person. This makes a person fear to move long distances to seek services of his/her situation.

Mensah et al., (2008), pointed that challenges to health care service access span from financing, structural and physical environment. Health facilities do not provide disability friendly services making it difficult for most PWDs; especially wheelchair users to access HCs buildings and climb onto examination beds. For instance, the accessibility audit data for some districts of Ghana including; Ajumako-Enyan-Essian, Sekondi-Takoradi, New Juabeng, Ho, Wa, Ashaiman and East Gonja found that 76.6% of medical centers do not have policies that specifically cover access to medical facilities for PWDs (Institute for Democratic Governance, 2011), despite recognition in the Disability Act, 2006 to ensure access to effective health care and adequate medical rehabilitation services. Furthermore, just as physical structures and equipment are inaccessible there are no provisions for sign language in most facilities to respond to the needs of deaf patients. This is likely to result in misinterpretation of sign language by doctors with no knowledge in signing.

However, the PWDs lack access to the health related policies that advocates for their rights towards access to health care services because the information in the policies like the constitution of the Republic of Uganda (1995), Disability Act, (2006) are not disseminated into various local language for easy interpretation by every person regards of their status. This limited access has demoralized or has made them voiceless in pressing on hardly on the right of accessing the same quality affordable range of health care services as like the able-bodied persons. There is also no provision of suggestion boxes even if available are placed high that PWDs cannot be able to reach. They would use this as a platform of raising their concerns about health care services access thus affecting their access to improved medication negatively.

2.4 Strategies to minimize challenges to health care access

According to Wulffsbergg (1995), well packed community awareness should be effectively and efficiently carried out. He argues that society should be cognizant of the needs of the people as well as other PWDs in its structural planning so as to ensure full participation. It should also look at the physically handicapped as its own and be positive about expectation of their social rehabilitation, USDC (2003) also adds that awareness should be encouraged targeting government leaders, health workers and educators as well as the community. This helps in changing peoples’ negative attitudes to positive and hence leads to increase in the number of people seeking assistance for treatment, therapy and surgery. The issue of community awareness raising is important, it should as well include all stake holders including PWDs. This has many advantages but most important it fosters the participation of PWDs and also helps them to come to terms with their situation. It generally opens up opportunities for people and other PWDs to enjoy a wide range of services.

Ministry of Gender, Labour and Social Development (MGLSD), (2005) says that there should be provision of specialized drugs and services for various types of disabilities in the NMHCP in all HCs throughout the country. Thus it will encourage people and other PWDs to access services since they know that the services they need will be got. The proposition by the MGLSD requires commitment on mainly part of government through MOH. It also requires an effective information system for PWs to know that these services are available. However, in Uganda for now most HCs are inadequately stocked and this is still a challenge yet to be addressed.

UN (1992) emphasized advocacy by all stake holders in the development process and more so PWDs. It argued that people esteem themselves and not sit back and must demand for services that promote their health and wellbeing. It’s supported by what MGLSD (2005) pointed out that advocacy must be strengthened by development partners in Uganda for PWDs. It further argues that it should include advocating for community based services including orthopedic workshops for PWDs to improve their wellbeing. The aspect of advocacy is very paramount for PWDs. This can be on a wide range of issues like observing their rights, drugs in health units, modification of environment. This should be spearheaded by PWDs themselves; this prompts other stake holders to come on board. However, most people have not benefited especially those in rural areas despite wide spread advocacy.

UN (2003), in its progress report on Millennium Development Goals in Uganda argues that improving accessibility of health services requires a multi-sectorial approach. It noted that health, education and water sectors play a significant role. It argued that improved educational attainment, improved access to water and nutrition. It also added that giving people nutritional supplements and other items like nets, food can motivate them. The approach suggested by the UN is significant since most social problems need combined effort to tackle; in the same way accessing services. Citing an example where education creates awareness and eliminates ignorance, this improves access of PWDs to health services.

MGLSD (2005) argued that there should be out reach clinics at the grass root level to cater for the majority of PWDs; and those should provide basic health care service like first aid. Ideally it is a wonderful argument and would be of benefit to PWDs if it’s to be initiated in Uganda and not simply being on paper. PWDs would benefit from the services that come at their door steps hence avoiding long distances, however, it needs political will to initiate and strengthen and sustain it if it’s to yield results.

Muyinda et al., (1992) noted that there should be provision of appropriate appliances or devices for PWDs so as to improve on their mobility for various services including health services. Kagonyera et al., (2009) as well agrees with the above author, he notes that providing PWDs assistive devices will help them to be self-supportive and hence independent. Independence of PWDs being the major aims of all rehabilitation attempts, these devices should be provided at subsidized prices or the PWD can be taught to make these services like crutches, head protective gear, long canes among others. This will improve their mobility and general quality of life and hence exposure and therefore social services including health care will not be a problem to access.

Political commitment on health related policies should be worked upon, 2003. It argued that it’s important for the population to receive a clear message from the government regarding aspects like immunization, family planning, antenatal care. This motivates the PWDs to go and utilize theses services. The community usually waits to hear from their leaders that when they act. Besides the leaders should implement policies related to health service delivery in the community.

Ellis (2001) pointed out that monitoring is one aspect that cannot be underestimated in the implementation of government programs. MoFPED, (2008) argued that the government must monitor all its instituted policies to ensure that the nation benefits from its efforts to prevent ill health as well as poverty. Any project to be effective and efficient needs to be monitored so that it yields to the PWDs meant for. As such PWDs and their activities need to be monitored including their access community services like health care services and appropriate step be undertaken.

There should be provision of health care materials easy to use by PWDs (PWDs Act, 2006). It emphasizes that its duty of government in all government owned HCs and private to provide disability related health services. It gives an example of constructing ramps, hand rails and accessible delivery beds for mothers with physical disabilities. The availability of these services act as a motivation to PWDs since they know that it’s easy for them to access health care services, it also limits them from sustaining injuries or even acquiring secondary disabilities.

However, the government agencies and NGO’s, CBOs should come together and draft policies in favour of PWDs followed by adequate implementation of such enacted policies by increasing funding CBR workers on the same note should also come up and advocate inclusion of PWDs and also the health facilities to provide services like suggestion boxes within the reach of PWDs. Furthermore, the enacted policies should also be changed to different local language understood by all people PWDs inclusive; this will enhance easy access to health care service as they get more information about their fundamental rights as human beings in relation to health care services access.

CHAPTER THREE

METHODOLOGY

3.0 Introduction

This chapter entails the research design, population, study sample, sampling procedure, data collection methods, data collection procedures and data analysis procedure.

3.1 Research design

Robinson (1998) observes that a design is all about the style of a researcher’s own preference of ideas on a certain topic. Accordingly, Mouton and Prozesky (2005), a research design is ‘a plan or blue print of how a researcher intends to conduct a study’’. This involves plans for data collection, the instrument for gathering information, how gathered information would be processed and analyzed to give meaning to research finding. The research employed a case study under qualitative approach. 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. This approach was used because the researcher wants to establish the real life experiences of PWD’S while accessing health care services.

3.2 Study area

This study was based in Amuria District, Acowa H/C in Acowa S/C. According to the 2014, UBOS report, Amuria District has 64,288/24% PWDs, Acowa S/C in particular 6,531 or 10% PWDs. Amuria district is found is Eastern Uganda that became independent in 2003 from Katakwii district where most of the population depends on agriculture as a basis of survival alongside small scale businesses under and Acowa S/C is approximately 12 km east of Amuria town with H/C III offering health care services such as HIV/AIDs, health education, immunization, counseling, malaria and STD treatment.

3.3 Study Population

Lokesh (1998) defines study population as any collection of specified group of human beings, non-human entities such as objects, institutions among others. The study population included; PWDs (all impairments), health worker (H/C in charge, nurse, mid-wife) and PWD leaders (councilors) in Acowa S/C. PWDs were chosen because they were the primary consumers while their leaders and health workers were the key players in addressing challenges faced by PWDs.

3.4 Sample size

Mubazi (2008) defines this as part of the population that is deliberately selected to investigate the properties of the parent population. The research involved a sample of 10 (all impairments) PWDs, 03 (in charge, nurse, mid-wife) Health workers, and 02 Leaders (councilors) as shown in the table below.

Table 3.1: Categories of participants

3.5 Sampling

William M.K Trochim, (2006) defines sampling as the process of selecting units (for example, people, and organizations) from a population of interest so that by studying the sample the researcher may fairly generalize findings back to the population from which they it was chosen; when choosing a sample there are two ways such as; random and non-random sampling. For the case of this study, the researcher used non-random sampling using purposive and snowball sampling techniques.

3.5.1 Purposive sampling technique

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 PWDs leaders (councilors) and health workers (in charge, nurse, and mid-wife) because they were the role key players in the S/C who frequently interact with various PWDs as they provide services to them.

3.5.2 Snowballing

Ashley Crossman, (2016) a snowball sample is a non-probability sampling technique that is appropriate to use in research when the member of a population are difficult to locate. A snowball sample is one in which the researcher collects data on a few participants of the target population he can locate, then asks those participants to provide information needed to locate other members of that population whom they know This was only be used in selecting PWDs; the researcher intended to select one PWD well known to him in the area of study and after would lead him to other colleagues from other parishes. This was done mainly to exploit the knowledge of the PWD, his/her colleagues and to save time.

3.6 Data collection methods

3.6.1 Interview

The study used the interview method. This is face to face interaction between two people or more; one being an interviewer and the other interviewee (Everett Angella, 1992). This method included and favoured both literates and illiterates in the study and also enabled the researcher to obtain first-hand information from the respondents.

3.6.2 Observation

Hennik et al., (2007), observation is a data collection method that enables a researcher to systematically observe and record people’s behavior, actions, and interactions. Observation is systematically recorded often using an observation checklist. It allows researcher to obtain detailed description of social settings or events in order to situate people’s behavior within their own socio-cultural context. It involves detailed observation and talk, watching and recording what people say and do. This helped the researcher to obtain data where it is not possible using interviews.

3.7 Data collection tools

3.7.1 Interview guide

This study used interview guides; especially unstructured interview guides. This is an interview in which the researcher will pre-set topics or questions in relation to the purpose of the study. The questions will not be systematically posed to the respondent but it will depend on the format the researcher chooses (Lokesh, 1998). The researcher set the questions in relation to the objectives of the study. This tool had advantage of greater flexibility in the process of interacting with respondents. It also helped in probing for real life experiences by observing facial expression and body language of PWDs.

3.7.2 Observation checklist

Observation checklist is a list of questions that an observer (researcher) will be looking to answer when they are doing a specific observation of a health facility for this case. The researcher in his observation checklist included issues such as; health services available, nature of beds, physical access (hand rails, ramps) and also the expertise of the health workers.

3.8 Data collection procedure

The introduction letter was obtained from the University and used to seek permission from authorities at the district of the study. The researcher then travelled and sought authorization from the CAO Amuria district who stamped the letter and gave direction to the researcher to go to the DHO who in turn also referred the researcher to the health centre in charge of the study area. Given that issues of disability and health are very sensitive, the researcher will always introduce the purpose of the study to his participants. Participants who agreed to participate in this study signed consent form to enhance adequate security of the participants or put a thumbprint for those who were illiterate. Participation in the study was free and voluntary and participants were assured that anonymity would be observed at all times. Confidentiality of participants was also maintained by using numbers on the transcripts and benefits of the research were well explained to the participants like of no pay/salary since the study is totally academical.

3.9 Data analysis

Raw data was collected by recording respondent’s views and noting down the observable information under study by the researcher using a phone, pen and note book which  would then immediately be transcribed to English, compared and contrasted to identify gaps and then it would be listed, coded, compiled accordingly, word processed, typed and edited to make it accurate. Data processing was done using descriptive words, a lot of care, skill and diligence would be taken into consideration to identify the relevant data. Data was then edited to eliminate any incomplete questions. After data processing, the scored data was analyzed using excel spreadsheets into the desired descriptive statistics. Since a descriptive sample survey was used in gathering data, it was prudent for the researcher to use the same descriptive method in analyzing the data that was obtained.

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 examine access to health care services by PWDs in Acowa H/C III, Acowa S/C Amuria district.

A total of 15 respondents participated in the study.

Table 4.1: Background information of participants

The participants within the age bracket 14-21 dominated in the study than any other age bracket. There were few adults seeking health care service as they are less concerned about addressing the disability coupled with the old age.

4.1 Factors influencing PWDs health care services access

All participants were asked about this and responses were varied as there were participants according to their various backgrounds though some cut across participants as discussed below.

4.1.1 Physical accessibility

This was the major factor hindering both the male and female PWDs in trying to access health care services because of unfriendly physical facilities. As indicated in the quotations below, most PWDs pointed out that most health care facilities lack ramps, specialized personnel to assist PWDs such as; helping climb steps, wheel chairs and disability friendly beds in case of delivery or admission.

Consequently, pregnant WWDs seeking ANC and child birth services have difficulties in accessing these services. The limited access to health facilities characterized by lack of ramps, sidewalks coupled with unfriendly facilities such as labor beds and separate toilets for PWDs in the HC was confirmed through key informants, interviews with technical staff at the health facility and PWDs leaders (councilors) as illustrated in following voice:

‘‘almost all the health facilities in our amidst have steps and therefore moving upwards to the rooms is very hard for us. For example, much as Acowa HC III is the main SC hospital and with qualified staff, it is not easy for us to access….’’ (Female PWDs)

‘‘I would have liked to accompany my wife during the ANC visits, but it is just too hard for me to climb steps. Even when health workers are to assist, they usually ignore us (men). May be we are not expected to go there….’’ (Male PWDs)

‘‘Even if you have money, if you are an expecting woman who has physical disabilities particularly us with hip joints or round legs, you may never give birth from the raised labor bed which is safest place to deliver from in Acowa HC III. Climbing there is not easy…’’ (Female PWDs)

‘‘The PWDs are not well catered for in our health Centre. Labor wards lack facilities for PWDs such as adjustable delivery beds and HCs are not easily accessed due to many steps, absence of hand rails or sidewalks, narrow doorways and lack of ramps. Although suggestions have been made on need to make health care facilities disability friendly, the MOH has not yet put (this)into consideration’’ (key informants)

4.1.2 Long queues

This was another factor which seemed pertinent in the HC. Long queues in the HC pose particular vulnerability to PWDs, whose condition as opposed to the able-bodied patients may not stand the waiting time as these female respondents noted:

‘‘If it was not lining up in HCs, I believe more WWPDs would be going there for services. At times when I would go for ANC services, I would line up for a long time and sometimes I would get so tired and give up. Our hip bones are not strong enough to stand for a long time and when we are pregnant, we tend to feel weak and tired most of the time’’ (female PWDs)

‘‘What puts me off is that when I go for ANC and am told to wait until they call my numbers. I do not have a wheel chair and I cannot sit on the bench. I have to sit on the floor’’ (female PWDs.)

4.1.3 Isolation and discrimination

In addition, another participant said that most the PWDs are isolated and discriminated as they trying to access their health care services. They were marginalized by strangers, family, health workers and the public. One of the male respondents lamented about the treatment he received at the health facility as he escorted his spouse for ANC and delivery services.

Narratives from male and female PWDs revealed that it was common for males to be told to leave or wait from outside while their wives are being attended to. This left males with unanswered questions and concerns regarding to the care their and babies would need.

Societal marginalization of PWDs is also reflected in the way they are treated as they travel to seek care. Given the low economic status, most PWDs in this study used public transport-that is taxis-with few being carried with bicycles. Among the respondents on four out of ten use bicycles from their families to travel to seek care. The encounter with bicycle and public transport was described as a nightmare for PWDs characterized by marginalization by both bicycle riders, taxi operators and few passengers as some respondents explained;

‘‘I went to the HC with my wife for pregnancy checkup and because we all have physical disabilities, only my wife was helped to climb the steps. I was told they did not need me and so whatever was done my wife, I was not informed. I could not even get someone to address my condition as a husband expecting a baby’’ (male PWD)

‘‘……even you in your condition with a pregnancy, what are you going to do in the S/C or T/C?’’ (Female PWD)

‘‘as a woman was boarding a taxi that was heading to the ANC Centre, she heard other women complaining loudly ‘…itungalu mam epedoreteaingarakinakecwatepoteaitumorooni’ literally meaning persons who cannot help themselves will delay us’’ (Female PWD)

‘‘had it not because of this sickness, I had to beg a young boy from the family to carry me on a bicycle up to the HC.  When he accepted, he was riding not minding of me as a human being seated behind. Whenever I complain about his speed, he promises to throw me down….’’ (Male PWD)

4.1.4 High costs attached to health care services

Inaccessibility to health care services was another factor associated with high costs of health care services. Most respondents noted that the services were costly and that many PWDs could not afford them given the meager incomes that they earn:

‘‘…….if we had money, our health would be as the same as that of the able bodied people. For example, in the better Acowa HC III, health workers cannot attend to us unless if we pay yet charges are so high such as, gloves, discharge fee among others. Most of us WWDs resort to giving birth from home by the help of ‘amokolia’ literally meaning traditional birth attendants which are not expensive or at times do not charge anything. Even when you do not have all the required money, health worker there are not patient with us’’ (Female PWDs)

4.1.5 Cultural beliefs

In addition, community’s cultural beliefs are one of the factors that dictate people’s action and inactions. Some community members assume that PWDs do not have sexual interest, self pity, and the desire to conform to social expectations, perceptions among PWDs further constrains access to health care services.

Both male and female respondents noted inherent societal expectations and misperception that PWDs do not need health care services including sexual and reproductive health services. Consequently, there is over protection of children with disabilities an especially girl through denial of information.

In such situations, PWDs miss out on opportunities to get health information that could help them make informed decisions. Such denial of information increases PWDs vulnerability to health care problems as the following quotations illustrate;

‘‘Most PWDs know where to find these services but at times they fear to be seen seeking them because the rest of the society thinks we do not need these services. For example, people do not expect a PWD to contract HIV because they assume we are not sexually active. Society forgets that we are normal human beings with feelings as well’’ (Key informant)

‘‘……we are always denied to associate with other members of the community and forced to contraceptives because that; we are not meant to produce. They said if we are to do so, we shall also produce children with disabilities since the situation can be inherited’’ (Female PWDs)

‘‘Girls with disabilities are so much protected by their care takers who assume that they will not engage in sex. They are usually kept away from discussions about sex and reproduction at home and communities. Such PWDs usually get information when it is too late usually at HCs’’ (Key informant)

4.2 Attitudes of health workers towards PWDs accessing health care services

4.2.1 Negative attitudes

A negative attitude of health workers pointed by one of the participants is the most hindrance for PWDs access to health care services in the HC. The most of the health workers are not specifically trained to respond adequately to the PWDs health needs but instead end up insulting them with rude faces.

Another participant cited that, in case of failure to climb the high un adjustable delivery bed provided in the HC, midwives always ask ‘‘how did you climb the man’s bed for sex and conceive?’’ this made us take long in labor pain which has claimed most of the lives of our babies.

Key informant interviews with health care providers yielded the same sentiments, suggesting that negative health workers’ attitude is a major barrier to PWDs access to health care services as illustrated in the following quotations:

‘‘You know it is like WWDs should not conceive at all. When I go for pregnancy checkup, the way midwives look at me; is like I have done something wrong! At times they are too rude to me but I have learnt to ignore them and just aim at getting someone to check the condition of my baby. We do not like the way health care providers treat us…’’ (Female PWD)

‘‘One time I tried to seek for SHR information but the nurse told me that it was not useful for me since in my condition (as a man with a disability), chances of even impregnating a woman seemed limited according to her thinking’’ (male respondent)

‘‘One time I went to the HC to deliver, on reaching the maternity ward the midwife started laughing at me. See this one! Can your legs carry your body up the bed? And because I never had any of the family members escorting me, I gave birthbut my twin children died……’’ (Female PWD)

‘‘I know when PWDs get sick or pregnant for the case of WWDs, they are despised, not expected to conceive due to the assumption that they already have enough problems to deal with. This happens mostly with health care providers’’ (Key informants)

4.3 Challenges faced by PWDs while accessing health care services

4.3.1 Distance to the health 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 health facility in the S/C and the available two H/Cs at the parish level which was far away from other four parishes, over 5km as illustrated in the following voice:

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

4.3.2 Lack of enough drugs

Another difficulty which seemed pertinent in the H/C was the inadequacy of drugs in the H/C. Consequently, due to very many people versing a few number of health workers in the health facility made it difficult for most of the PWDs to access health care services as some respondent explained:

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

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

4.3.3 Lack of awareness

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

Both PWDs and key informants indicated that health facilities are ill-prepared to address the health care service needs of PWDs. Most respondents mentioned that health care providers were not trained to handle PWDs, and that some health care 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 health care services presented in Braille and large  print, we would have higher chances to information about our condition and the necessary intervention’’ (Female PWVI)

‘‘Having ability to talk really opens every door to access whatever you need. We do not have sign language interpreters that would help us be aware of the available services in Acowa H/C III’’ (Male PWHI)

‘‘Service providers are not trained in special skills to handle PWDs. Health care providers get shocked when they receive pregnant PWDs at health facilities. This should not be the case…’’ (Key informant)

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

4.3.4 Lack of assistive devices

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

The key informants confirmed that most of the PWDs 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 PWD does not have:

‘‘We do not have anybody in the our parish a tricycle……even those who received three years ago, when they got spoilt were not repaired. So these people see it as a burden to move to the H/C’’ (Male PWD)

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

4.3.5 Rudeness of nurses

Another PWD 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 PWDs 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 PWD

4.3.6 Lack of enough trained medical personnel

The inadequate medical personnel was 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 PWDs health needs was not appropriate for the VHTs:

‘‘I find myself work in the H/C because of limited number of nurses and doctors as compared to patients who come to seek health care services….’’ (Remarked one VHT)

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

4.3.7 Shyness of PWDs

In addition, another participant said that most PWDs 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.

Both male and female PWDs 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 PWDs 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’’

‘‘If I am having multiple disabilities like this, of what benefit do I need to seek for medication? ‘edariteongatwanare bon’ literally meaning; I am only waiting for death. God has already made this condition permanent’’

4.3.8 Indiscrimination

Another participant said that one other challenge PWDs face was the aspect of being treated equally like those who have no any form of disability.

Other ‘normal’ people undermine PWDs and are not sensitive to their needs. They are labeled all sorts of names like ‘‘egwalas’’, ‘‘ebubu’’ literally meaning disabled and dump. On this issue one participant said:

‘‘Even us we line up, there is no consideration or privileges given to us……..in such a case why do I go where I am not catered for basing on my situation’’ (male PWD)

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

4.4 Strategies to minimize challenges to health care services access by PWDs

Accordingly participants were asked on what they thought would be the likely remedies to the challenges encountered by PWDs while accessing health care services.

Like the above, responses to this objective were numerous and varied across participants. Although some seemed to cut across all participants, all participants said that health care services ought to be brought nearer the people:

‘‘I need these services nearer because other neighboring places around the S/C have health care services. This can favor some of us who are crawling’’ (Male PWD)

4.4.1 Provision of assistive devices

Another participant also requested that wheel chairs should be provided to ease transportation of PWDs seeking health care services from the H/C. Consequently, presence of wheel chairs also enable PWDs with joint problems to spend long time waiting for medication since they can no longer easily get tired as they can sit on their wheel chairs:

The provision of transport means was cited stationed at the H/C. this was cited by one of the PWD’s leader in the S/C:

‘‘Both PWDs and health workers need ways of transportation. For the PWDs to reach the H/C and we as health workers to reach out the PWDs patients in case of emergencies’’ (Key informants)

‘‘In case I am given a wheel chair, I will endure to wait in the long line. This is because I can use a wheel chair for sitting’’ (Female PWD)

‘‘If possible, there would be need to get some bicycles at the H/C such that in case a PWD is sick, it’s possible to use by the help of a care giver. This helps to increase access to health care services by PWDs’’(Key informants)

4.4.2 Immediate attention

Another remedy given by another participant was that PWDs need to be given priority when they reach the H/C. they should be treated as soon as they reach so that they can move back to their places earlier enough. On this still, another participant said that PWDs should be given priority by securing for them their own special room where they receive the health care services:

One participant also suggested that drugs and other items for use in the H/C like mosquito nets should be sent early enough than waiting for them to get over then start requesting for them:

‘‘they should be sympathetic with us because we have no strength to line up……’’

‘‘Medicine should be brought early for us not to go and waste time in the H/C only to be told drugs are over; they should bring them early enough’’ (Female PWD)

4.4.3 Empowerment

Empowerment was one of the remedies to improve PWDs access to health care services. One of the participants said that PWDs should be empowered to help themselves and this would be by bringing them together to form groups that can help them to have a voice and demand for services. And that they can also be trained to start small projects.

Whereas one said that PWDs should be empowered to help themselves than waiting

To be helped as illustrated in the following voice:

‘‘Most of the times ‘normal’ people have high jacked help meant for PWDs here, because they are not empowered and so they have no voice. They should be brought together so that they can be strong….’’ (Key informant)

‘‘………PWDs should do something so that even when help is brought, they can help themselves. They should not sit and expect that government will do everything for them….’’

4.4.4 Awareness raising

In addition, one participant who happened to be a councilor for PWDs said that awareness raising which is well packed needed to be created to help PWDs improve on their knowledge because most of them are not aware of the services available for them in the H/C. He said:

‘‘We still need to create awareness especially in churches so that many people there who come for health care services can facilitate wide spread of information. In churches, there are PWDs, health workers, care givers and also parents of PWDs’’

4.4.5 Networking

Another participant suggested that non- governmental organizations should come up to help PWDs especially by giving PWDs appliances like tricycles wheel chairs, crutches and others. Another said that more nurses and doctors with skills of attending to the PWDs health care needs should be added to the H/C to match the many number of people seeking health care services.In addition, one of the participants said that one person cannot help PWDs and so all stake holders need to come on board to help the people as illustrated in the following quotations:

‘‘PWDs are among the people who are suffering. They cannot even carry water home, even attending social events like weddings, burials is difficult for them and so the family, community, government and PWDs themselves need to come together’’

‘‘……..there are many people in the H/C and for me I think more health workers should be added, all people in the S/C go to the H/C as other two H/C II units make referrals to the very one H/CIII at the S/C. I am tired of going there and coming back without any attention because the nurse is also tired………’’

4.4.6 Organisation of staff meetings

Another participant pointed out that staff meetings for health workers be organized by management of the H/C so as to sensitize health workers about rights and needs of PWDs seeking health care services.One participant also said that meetings like public health education programs meant for PWDs should be done at the villages within their reach because the distance from the villages to S/C alone scares PWDs as expressed by the voice:

‘‘let them help us in our villages than S/C H/Q, we do not have transportation means……’’

‘‘If this is done may be theywill stop being rude to us…………..’’ (Female PWD)

4.4.7 Implementation of initiated programmes

One of the participants cited out that government agency should effectively and efficiently implement any planned initiative for PWDs. This includes provision of disability friendly health facility equipment like adjustable labor beds, establishment of ramps, sidewalks in the H/C so as to improve on their access to health care services:

‘‘If the modification of the H/C facility is undertaken by various stake holders, I will always bring my wife for ANC and deliver from this H/C…’’ (Male PWD)

Additionally stillon this objective, one participant said that the S/C authorities should monitor all government programs concerning all people in the S/C including PWDs as illustrated by the voice:

‘‘It’s the responsibility of the S/C to monitor all programs of government. Even now PWDs are suffering because the S/C doesn’t do anything…….’’ (Key informant)

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 Discussion

5.1.1 Factors that influence access to health care services by PWDs

In this study, most of the participants reported physical inaccessibility of the health facilities like beds, wards, doors and toilets. Many PWDs across disability types have found it difficult to access health care services in the H/C due to poor roads (rough terrain), lack of sidewalks and ramps that has hindered the use of wheel chairs by the crippled and crawling PWDs. This finding is in match with Felix. et al. (2016) cited that physical inaccessibility to and off H/C facilities has been a hindrance to PWDs access to health care services. PWDs as well face the social and emotional trauma besides absence of hand rails, ramps of being taunted by other riders or drivers. The absence of adapted environment has been a big hindrance to PWDs in the S/C, this deprives them a right to health care services. Another research by GoU (2009) pointed a similar argument which emphasizes that most PWDs miss great opportunities to accessing health care services due to poor health infrastructural development. For instance most H/C do not have ramps especially those built during the colonial period, provision of disability unfriendly beds making their dream of having the same range of health care services as other members of the community remain as unachieved dream in their lives.

Another finding was that cultural belief greatly hindered easy accessibility to health care services by PWDs. The community believes, attitudes, norms and perceptions that disability is as a result of God’s punishment, curse that cannot be curable or rehabilitated. Any visit of PWDs to the H/C is thought to be shame to the family and to the clan at large because of believing that PWDs need to be treated locally using local herbs, witch doctors due to high believe in superstitions and this has made most of hopeless. This was in agreement with Beals (2000) citation that people are driven by their actions and inactions. It’s not surprising that most people believe disability or inability is as a result of a curse and therefore they are there to stay and hence no need to seek for medication and this has lowered the self esteem of PWDs. Another research also by Gibson and Mykitiuk (1994) in Canada cited a similar argument which noted that the health system policies and practices discourage PWDs from having children because of doubts regarding their capacities to provide care or because of concerns regarding the risk of a child inheriting a hereditary condition all of these were because of false assumptions.

In this study, participants reported isolation and discrimination towards access to health care services. The researcher agrees and notes that this has scared PWDs from accessing the services because whenever they get sick there is none to attend, neither be next to them as a result of disability being perceived as contagious to the extent during eating or any social event they are separated from the rest of members. Health workers also practice high level of isolation and discrimination in that they don’t mix up patients and instead of attending PWD first, they attend the able-bodied persons and this has increased social stigmatization among PWDs. This is in line with Shantha Rau Barringa (2010) Human Rights Watch citation that most PWDs are left alone and never allowed to be nearer other people mostly by strangers, family members, and also health workers making them unable to gain inadequate access to improved medication as one of basic services of life. Another research in Northern Uganda by B.P. MARTINA et al., (2010) also in line argued that discriminatory attitude by the health workers could not earn PWDs assistance even at the family level due to the existence of multiple disabilities.

Another finding was that the absence of mobility devices impedes greatly access to health care services by PWDs.The researcher agrees that mobility challenge among PWDs leads them to another hindrance towards accessing health care services; limited support from the family, community members and the health system because in case of a pregnant WWD wants to deliver, supporters see it as a burden for them to carry her up to the H/C and also help her climb the unfriendly labor beds. Because of this ‘‘burden’’, most of them tend to hide away from PWDs in such scenarios. This was in line with Richard Adanu et al., (2012) citation that argued that PWDs who currently lack mobility aids need special attention from the family, community and also health workers but this has turned to be a nightmare as most PWDs totally lack support to access immediate basic care because they are unable to anywhere. Another research by Felix Mutale et al., (2016) citation was also in match which argued that though some PWDs have mobility devices, they need to be escorted or accompanied to seek medical care in the H/C since most of the H/C facilities are not disability friendly thus accessing improved health care services remains unachieved dream among PWDs.

In this study, participants reported long queues in the H/C as a discouragement to most of them due to long waiting time for health care services.The researcher agrees because most of the PWDs are prone to vulnerability compared to the able-bodied persons with hard bones to withstand long awaiting hours for health care services. Most of the PWDs with hip problems find it hard waiting long coupled with absence of wheelchairs that they would be sitting on while waiting for medication and also health workers do not have a sympathetic heart to PWDs by attending their medication needs first but rather consider able-bodied persons because of their well-being. J.B. Dhamulira et al., (2014) pointed a similar argument which noted that long waiting hours poses vulnerability particularly to PWDs whose condition because of weak bones and joints cannot be able to withstand that kind of hours. For instance PWPDs hip bones are not strong enough to stand for a long time and some of them do not have wheelchairs to sit on as they wait their numbers being called to receive medication and also most health workers lack positive discrimination by leaving PWDs lining with those who do not have disabilities making access to health care services as a nightmare to them.

5.1.2 Attitudes of health workers towards PWDs

Accordingly, a negative attitude of health workers towards PWDs remains a standing block to access of health care services. They used derogatory words like why did you also conceive and this usually reminds them of their situation rather than focusing on medication since they have been de-motivated by the health workers. This is all because of inadequate specialized knowledge of personnel to respond the special health care needs of PWDs compounded by societal beliefs and expectations. This was in line with J.B. Dhamulira et al., (2014) which pointed that negative attitudes among health workers remains a critical challenge to PWDs while accessing health care services. They impede stigmatization to PWDs especially WWDs seeking antenatal health care services, this has constantly reminded them how they have become an abuse related to their appearance causing stigmatization and de-motivation among PWDs seeking health care services. Another research by Ganle J.K. et al., (2016) in Ghana cited a similar argument which emphasizes that available evidence suggests that PWDs face a serious challenge in accessing and utilizing essential health care services as most of the health workers shout at them mostly those with hard off-hearing due to fear to attend to PWDs and lack of adequate specialized experience on PWDs health needs.

In this research, the researcher agrees that most of the health care providers are not only insensitive to PWDs health care needs but also lacks knowledge. This is because most of them have ended up delivering irrelevant information to PWDs not in line with their respective health care needs and this has made most of them appear unready to attend PWDs patients when in need since most of them are uncomfortable examining PWDs due to their appearance. This is in match with R. Adanu et al., (2012) citation which argues that insensitivity and lack of knowledge among the health care personnel has made them at all times rude, ill-prepared and uncomfortable attending PWDs especially WWDs seeking health care services in the health facility.

In this study, consistent negative attitude of health workers like unfavorable moody faces of health workers especially when WWD fails to climb up the labor bed, it’s coupled with expression of depressing words describing them as non-living humans with any right to access or utilize the same range of affordable medical care. They impose orders, for instance administering family planning methods to WWDs without seeking their ideologies about it. This is in agreement with UWONET (2011) citation which explains that health workers especially midwives because of their negative feelings towards PWDs, have denied them access to information and services of MNCH, sexual reproductive health and HIV/AIDs as it was advocated by NUDIPU. They treat PWDs as objects they can toss in any way they feel like rather than rights holders and do not always seek their free consent at times of medication.

In addition, health workers discriminate and isolate PWDs seeking health care services. The researcher agrees that because most of health workers are too hostile towards PWDs especially in Northern Uganda due to the multiple disabilities that has distorted their physical appearance. They always practice a look down attitude and this makes them to view PWDs as a missed call to them with a lot of derogatory remarks to WWDs seeking antenatal health care services. Another research in Northern Uganda Human Rights Watch, (2010) pointed a similar argument which noted that most of the health workers are too hostile towards PWDs as they are not human needing the same quality of health care services like any other person. They also discourage PWDs from seeking reproductive health and family planning services through expression of antagonizing statements of why would ever PWD engage in sex, how they climb beds for sex and conceive. This lowers their morale of seeking health care services hence making them particularly vulnerable to HIV/AIDs, and especially unlikely to have access to antiretroviral drugs.

5.1.3 Challenges faced by PWDs in accessing health care services

In this study, absence of H/Cs in some other parishes was a critical finding. It’s not surprising that PWDs as well as the whole community crowd in the H/C III. 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 PWDs and the general community.

Another finding was that most PWDs 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 PWDs 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 PWDs is a point not to be underestimated especially in rural areas and among children.

In this study, participants 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 PWDs 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 PWDs, and this worsens the situation. It’s not surprising that given the situation in this S/C, more people from other parishes without H/Cs flood to the HC III in the S/C. 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 PWDs in this S/C lack mobility devices. This finding reveals the plight of PWDs 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 PWDs access to health care services and public places. This difficulty points to isolation and suffering of PWDs in this community.

Another finding was that the aspect of poverty among PWDs has greatly hampered their access to health care services. The researcher seconds this point because most PWDs 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 PWDs 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 PWDs with a wide gap of risk in their health status that leads to low life expectancy.

In this study, participants reported that most of the health facilities in the S/C are not disability friendly which has made it so hard for most PWDs 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 PWDs 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.

5.1.4 Strategies to improve access to health care services

In this study, provision of mobility appliances as suggested by respondents is vital. The government and other stakeholders should provide appliances like wheel chairs especially for the crippled so as boost and enhance their access to health care services and public places. The preposition agrees with GOU on PWD Act (2006) where it stated that it’s the duty of the government in all government owned H/Cs and private H/Cs to provide special disability-related health services like wheel chairs, delivery beds. This can act as a motivation to pregnant mothers and other PWDs to seek these services.

In this study, the difficulty of negative attitudes depicted in the form of rudeness of health workers, the researcher proposes well packed awareness to be continually conducted. This is critical to PWDs and health workers. This is because information is power and can cause change of attitudes. Wulffsberg (1995) agreed that community awareness should be effectively and efficiently carried out to ensure that the society is cognizant of the needs of PWDs. This can help PWDs and health workers realize their rights and needs as well as responsibilities to the benefit of PWDs.

Another finding was that activities that take place in all sectors of the S/C should be monitored and supervised effectively and efficiently including health services. This is true even Ellis (2001) who pointed out that monitoring shouldn’t be underestimated in promoting programs especially government projects. This is in line with MoFPED (2008) which argued that government must monitor all its instituted policies to ensure benefits by citizens. The researcher agrees with this idea of supervision. This is because it helps to identify gaps in the program and in this case monitoring ensures that all categories of people are benefiting from the services rendered.

In this study, the researcher proposes strengthening of services rendered by VHTs. This can be by including special services that PWDs can desire so as to ease the long distances they always suffer with. This is in line with the MGLSD (2005) which pointed that special services be availed for all categories of disabilities. This indication assures PWDs the presence of health care services.

The only solution to minimize the challenges and one that can satisfy PWDs, councilors, health workers, and the general community should be to construct H/Cs in all parishes. This can help reduce the burden of long distance, congestion, and easy access to health care services, when services are far it de-motivates the PWDs and other people seeking health care services. Another study by the GOU (2004) and MOH (1996) pointed that all districts should have H/Cs offering equitable affordable health care services at all levels. This means that even these parishes are subject to this indication and it’s the only way the researcher seems to see their difficulties being solved.

5.2 Conclusion

The responses given concerning health care services access by PWDs in general reveal a lot of suffering of PWDs. This is because of absence of H/Cs which would have been in other parishes of the S/C for them and other people to easily access nearer health care services. This has made most of the people seeking 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. PWDs 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.

There is a lot of pressure exerted on the existing health care services and health workers are stressed. This is due to having one HC III and two HC IIs in the whole of the S/C with six parishes. It’s not surprising that aspect of being rude on PWDs and other people by the health workers exist through expression of derogative remarks that scare away PWDs 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 PWDs and health workers to be patient and kind to one another.

5.3 Recommendations

The researcher recommends the following:

The government especially the local government of Amuria district under the department of health should ensure that these parishes get H/Cs under their jurisdictions. The construction of health centres in all parishes tends to bring health care services closer to the PWDs 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 PWDs.

NGOs and CBOs should come on board and empower PWDs and people in the S/C 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 H/C authorities should conduct meetings through seminars, workshops, refresher courses on disability specialty needs where health workers are sensitized about the needs of PWDs. This can be done by experts that deal with disability and the community like Rehabilitation Officers from the MOH. In addition, PWDs also need to be sensitized about their needs and rights.

The government and other stake holders like NGOs and CBOs should provide mobility appliances to PWDs such as wheel chairs, crutches.  These mobility appliances can be used as seats by PWDs 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 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 PWDs seeking health care services as they can be able to understand them. This further motivates health workers to attend PWDs health needs and also the PWDs to frequently seek for health care services whenever in need.

Accordingly the researcher had to recommend that PWDs councilors should encourage PWDs 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 PWDs 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 PWDs.

5.4 Areas for further research

The research recommends the following areas for further research;

Impact of IGAs on health care access by PWDs.

Contributions of societal attitudes towards utilization of health care services.

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APPENDIX I

INTRODUCTORY LETTER

APPENDIX II

INTERVIEW GUIDE FOR PWDS (ALL IMPAIRMENTS)

INFORMATION SHEET

I, OLUPOT BENJAMEN a student from Kyambogo University undertaking a course of Bachelor of Community Based Rehabilitation.Am in this community conducting research on “Access to health care services by PWDs”. You have been identified as one of the participants in the study, your details will not be disclosed to anyone without your consent and your identity will be kept anonymously using letters or numbers. The interview will be conducted within your friendly natural environment convenient to your privacy.And above all, you as an individual is free to withdraw from this study any time you wish to do so and you are have adequate freedom to seek clarification where necessary. I kindly request you to answer the following questions.

Questions:

1. Please, tell me about yourself? (Status, Education, Occupation)
2. Which services do you usually seek for at Acowa H/C III?
3. What are the factors that influence your access to health care services at Acowa H/C III? (Probing for health care services available, relationship of PWDs and health workers)
4. What is your opinion on the health workers attitude towards you?

Why?

5. What challenges do you encounter when accessing health care services in Acowa H/C III?
6. In your own opinion, what do you think can be done to improve your access to health care services at Acowa H/C III?
7. Please, do you have any thing you would like to tell me about health care services access by PWDs in Acowa H/C III, Acowa S/C?

THANK YOU SO MUCH FOR OFFERING YOUR TIME

APPENDIX III

INTERVIEW GUIDE FOR PWDS LEADRES (COUNCILORS)

INFORMATION SHEET

I, OLUPOT BENJAMEN a student from Kyambogo University undertaking a course of Bachelor of Community Based Rehabilitation. Am in this community conducting research on “Access to health care services by PWDs”. You have been identified as one of the participants in the study, your details will not be disclosed to anyone without your consent and your identity will be kept anonymously using letters or numbers. The interview will be conducted within your friendly natural environment convenient to your privacy. And above all, you as an individual is free to withdraw from this study any time you wish to do so and you are have adequate freedom to seek clarification where necessary. I kindly request you to answer the following questions.

Questions:

1. Please, tell me about yourself.
2. What kind of health care services do they offer to PWDs at Acowa H/C III, Acowa S/C?
3. Please kindly tell me what factorsdo you think influence access to health care services by PWDs mentioned above at the Acowa H/C III?
4. In your own view, how do health workers behave towards PWDs when accessing health care services at Acowa H/C III, A cowa S/C Amuria district?

Why?……………

5. According to you, what challenges do PWDs often encounter while accessing these health care services at Acowa H/C III, Acowa S/C Amuria district?
6. According to you, what do you think can be done to improve on PWDs access to health care services at Acowa H/C III, Acowa S/C Amuria district?
7. Please, do you have anything you would like to tell me about health care services access by PWDs?

THANK YOU SO MUCH FOR OFFERING YOUR TIME

APPENDIX IV

INTERVIEW GUIDE FOR HEALTH WORKERS (IN CHARGE, NURSE, MID-WIFE)

INFORMATION SHEET

I, OLUPOT BENJAMEN a student from Kyambogo University undertaking a course of Bachelor of Community Based Rehabilitation. Am in this community conducting research on “Access to health care services by PWDs”. You have been identified as one of the participants in the study, your details will not be disclosed to anyone without your consent and your identity will be kept anonymously using letters or numbers. The interview will be conducted within your friendly natural environment convenient to your privacy. And above all, you as an individual is free to withdraw from this study any time you wish to do so and you are have adequate freedom to seek clarification where necessary. I kindly request you to answer the following questions.

Questions:

1. Please, tell me about yourself
2. What health care services do you often offer to PWDs at Acowa H/C III, Acowa S/C Amuria district?
3. In your own view, what factors do you think influence access to health care services by PWDs provided at Acowa H/C III, Acowa S/C Amuria district?
4. In your own opinion, how do you relate with PWDs when rendering a health care service to them?

Why?…………..

5. In your own opinion, what do you think are the challenges PWDs encounter when accessing health care services at Acowa H/C III, Acowa S/C Amuria district?
6. In your own opinion, what do you think can be done so as to improve access to health care services by PWDs at Acowa H/C III, Acowa S/C Amuria district?
7. Please, do you have anything you would like to tell me about health care access by PWDs at Acowa H/C III, Acowa S/C Amuria district?

THANK YOU SO MUCH FOR OFFERING YOUR TIME

APPENDIX V: MAP OF UGANDA SHOWING AMURIA DISTRICT (4)