ACCESSIBILITY OF HEALTH SERVICES TO WOMEN WITH DISABILITIES IN BUGEMBE TOWN COUNCIL,

JINJA DISTRICT

LIST OF ABBREVIATIONS

AIDS              –           Acquired Immune Deficiency Syndrome

HC                  –           Health Care

HIV                 –           Human Immunodefiency Virus

ICF                  –           International Classification of Functioning

MGLSD          –           Ministry of Gender, Labour and Social Development

MoFPED         –           Ministry of Finance Planning & Economic Development

NAD               –           Norwegian Association for the Disabled

NMHCP          –           National Minimum Healthcare package

PWDs              –           Persons with Disabilities

PWVIs –                       Persons with Visual impairments

UN                  –           United Nations

UNDHR         –           United Nations Declaration of Human Rights

UNICEF         –           United Nations International Children’s Emergency Fund

VHTs              –           Village Health Teams

WHO              –           World Health Organisation

WWDs                        –           Women with disabilities

ABSTRACT

The study was carried out in Bugembe town council, Jinja District with the purpose of assessing the accessibility of health services to women with disabilities in Bugembe town council. The specific objectives of the study were to; identify health services offered to women with disabilities, identify the challenges faced by women with disabilities in accessing health services and identify strategies of improving access of health services to women with disabilities in Bugembe town council.

The study employed a case study under qualitative approach and it involved 20 respondents. The respondents were selected using two sampling techniques; purposive sampling that was used for selecting CDO and leader whereas, convenient was used for WWDs. The data was collected using interview guide and observation which was then analyzed descriptively.

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

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

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

CHAPTER ONE

INTRODUCTION

1.1 Background to the study

Disability is a decrement in functioning at the body, individual or societal level that arises when an individual with a health condition encounters barriers in the environment (WHO, 2001). Disabled people comprise approximately 10% of the world’s population, 75% of whom live in developing countries, and constitute one of the most poor, marginalised and socially excluded groups in any society (Barron & Amerena, 2007).

Access is being able to get what one needs (Joshua, 2011). Health is the care one receives from healthcare professionals such as antenatal care, normal treatments. One of the most important functions of accessing health services is to offer health information and services that can significantly improve the health of women and their infants (WHO & UNICEF 2003). For instance, access to health services during pregnancy appears to have a positive impact on the utilization of postnatal healthcare services (Chakraborty et al., 2002).

According to the Uganda Demographic and Health Survey Report, the content of health consumed in Uganda included the measurement of blood pressure, testing of urine for bacteriuria and proteinuria, and blood tests to detect syphilis and severe anaemia. It also includes taking iron supplements, intestinal parasite drugs, tetanus toxoid injections, weight and height measures, and information about danger signs during pregnancy, and where to go in case of complications.

Although Uganda has made progress over the last several decades to improve maternal health, maternal mortality is a serious public health concern. According to the World Health Organization’s (WHO, 2014) most recent estimates, Uganda’s maternal mortality ratio stands at 380 per 100,000 live births. Maternal mortality accounts for 14% of deaths among females aged 12–49 years, and are the second largest cause of female mortality after infectious diseases among women of childbearing age. Despite the fact that Uganda has since implemented a free maternal healthcare policy, more than 45% of births still occur at home without any form of skilled care in parts of Uganda. In addition, large and growing gradients of inequalities in skilled care services accessibility and utilisation have been observed in Uganda.

Bugembe town council is a town in Jinja district in the eastern region. It is the seat of the kingdom of Busoga, one of the four constitutional monarchies in Uganda, which is conterminous with the Busoga sub-region.In Bugembe town council, women with disability are more likely to be poorer and have lower social and economic status than their counterparts who have no disability. In the context of reproductive health, women with disabilities have largely been ignored in reproductive health research and programming. For example, women with disabilities have received little attention. Part of the reason for this neglect is that they are often thought not to be sexually active, and less likely to marry or to have children than women without disability (Nyakubega, 2010).

1.2 Statement of the problem

Bugembe town council has several health centers with services that are accessible by women with disabilities such as antenatal care services, measurement of blood pressure, testing of urine for bacteriuria and proteinuria, and blood tests to detect syphilis and severe anaemia and many others. However, some services such as reproductive health programs including family planning have been less successful as indicated by the lower reproductive health indicators in Uganda compared to the region (East Africa)and Sub-Sahara Africa (Mukisa, 2009).

Despite the Government of Uganda, being a signatory to international laws and policies; implemented policies to ensure that women with disability enjoy their rightsincluding having access to health facilities like the rest. There is still high number of women with disabilities that do not have access to health services and Bugembe being a village in Jinja, it contributes to this great problem. It’s upon the above background that that researcher picked interest in carrying out a study about the accessibility of health services by women with disabilities in Bugembe town council, Jinja District.

1.3 Purpose of the study

The main purpose of the study was to assess the accessibility of health services to women with disabilities in Bugembe town council.

1.4 Specific objectives

1. To identify health services offered to women with disabilities in Bugembe town council.
2. To identify the challenges faced by women with disabilities in accessing health services in Bugembe town council.

• To identify strategies of improving access of health services to women with disabilities in Bugembe town council.

1.5 Scope of study

The study was carried out in Bugembe town council, Jinja District. The main purpose of the study is to assess the accessibility of health services to women with disabilities in Bugembe town council. Specifically, the study identified health services offered to women with disabilities, challenges faced by women with disabilities in accessing health services and suggest strategies to improve access of health services to women with disabilities. The study was carried out for a period of four months from May to August, 2017.

1.6 Significance of the study

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

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

To policy makers, the findings would help them form appropriate strategies to improve access to health services to women with disabilities.

1.7 Limitation of the study

High expectations and suspicion by the local people. Respondents expected money and other materials of the kind from the researcher while others were suspicious that the researcher had come to spy on them. And some respondents deliberately refused to give information related to the study.

Time scheduled for data collection was not enough and the uncertain changes and increase in costs like transport as compared to the expected costs.

1.8 Delimitations of the study

The area covered is familiar to the researcher. And communication is effective since the researcher knew the language spoken in the area of the study.

Time was budgeted to ensure the research is done in the stipulated period of time.

The respondents were assured of confidentiality of the information they gave at all levels.

CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

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

2.2 Health services offered to women with disabilities

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

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

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

2.3 Challenges faced by women with disabilities in accessing health services

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

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

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

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

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

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

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

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

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

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

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

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

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

2.4 Strategies of improving access of health services to women with disabilities

Tarletonand Ward (2007) states that removing cost as barrier to access of services through providing supports such as the free, accessible transport.

According to Carlson[2002] argues that more accessible health services require physical access including ramps, clear signage to assist navigating the environment, the building and the office, disability accessible facilities and examination table.

Parish (2006) argues that there is need for effective communication, informed and competent staff who are knowledgeable about the additional burdens that women with disabilities may face. Talking directly to the woman and where women do not have the capacity involving a designated family member or carer.

Additional time and resources, including flexible, longer and multiple appointments if necessary to gain a full understanding of the information and health needs of women, particularly those with intellectual and communication disabilities (Llewellyn, 2003).

Acknowledging the important role of carers, family and friends, but not to the exclusion of primary decision-making resting with women themselves (except if this not possible).

A holistic approach to health care for women with disabilities requires services that recognise women‘s broader health needs beyond those related to their specific impairment, and the recognition of their rights to live full sexual and reproductive lives.

Further research about the barriers faced by women with disabilities in accessing health services. This includes data collection describing women‘s use of health services and research protocols that mandate the inclusion of women with disabilities.

Professional development for health service providers that addresses attitudes and prior assumptions. Gaps in knowledge and skills have been shown to result in a reluctance to provide health services to women with disabilities. Evidence demonstrates that training by women with disabilities is most effective in improving knowledge and skills.

Health information which is clear and concise with appropriate health messages about treatment, screening and lifestyle issues. Multimedia methods of disseminating health information are required. Use of reminders, recall systems or other mechanisms to ensure women receive the necessary information and feel included as part of the program are also required.

Multi-disciplinary teams and cooperation between services, practice nurses, social workers, disability workers and others can facilitate continuity of care and advocacy. This may require the development of inter-agency policies and procedures such as domestic violence, sexual assault, justice, housing and health services (treatment and preventative), which respect the privacy of clients.

CHAPTER THREE

METHODOLOGY

3.0 Introduction

This chapter presents the methodology to be used in the study and includes the research design, area of the study, study population, sample size, sample techniques, the data collection methods and instruments, the procedures of data collection, validity and reliability, data processing and analysis and ethical considerations.

3.1 Research Design

The research employed a case study under qualitative approach. Its main objective is to describe the variation in a phenomenon, situation or attitude like description of an observed situation, or opinions. Qualitative research design helps to capture qualitative data, based on qualitative aspects that cannot be quantified. It aids in discovering the motives and desires or what people think and how they feel about a given subject or situation. The research used qualitative research design because it allows flexibility in all aspects of the research process and it is more appropriate to explore the nature of a problem, issue or phenomenon without quantifying it.

3.2 Area for study

The study was carried out in Bugembe town council which is a town in Jinja district in the eastern region.

3.3 Population of the Study

According to Baron, (2011), population constitutes of individuals, organizations, groups, communities or other units that provide information or to collect information about the study. This included women with disabilities, local leaders and community development officer.

3.4 The Sample

The sample refers to a few items selected from the universe or population for study purposes, (Baron, 2011). The study used a total of 20 respondents to provide a manageable volume of data and allowed the researcher to make accurate estimates of thoughts and behavior of a larger population. The sample included 15WWDs, 4 local leaders and 1 community development officer (CDO).

Table 3.1. Showing Sample of the study

WWDs was selected because they know the challenges they face in accessing health services as WWDs, health workers and community leaders was chosen because they are assumed to have broader knowledge of the study area and also they are the implementer of government programs hence valuable information for the study is needed from them.

3.5 Sampling Procedures

The study used purposive sampling which is the deliberate selection of respondents. In this study, WWD was selected purposively because the researcher chose the sample based on who she thought was appropriate for the study. The local leaders (Chairperson LC III, LC III councilor for PWDs) and CDO was selected using convenient sampling because it involved selecting them by virtue of their positions.

3.6 Data collection methods and instruments

Interviews

The main method in data collection was interview.

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

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

Informal observation

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

Focus group discussions

Focus group discussions were used due to the capacity of the short period of time. Focus group discussions were used on WWDs.  This enabled the WWDs to debate and discuss on the study directed by the few questions set and followed. The instrument used was the focus group discussion guide where questions were set and followed. The study involved 1 focus group discussions (in groups of 5 WWDs) and took about 30 minutes each.

3.7 Procedures of Data Collection

The researcher ensured the approval of the research proposal and instruments especially the interview guide to test their effectiveness in carrying out the study;

• The researcher got a letter of introduction from the head of department for introducing her to the area of study;
• The letter was presented to the town council authorities to seek for permission to collect data from the area;
• She prepared other letters to individual respondents requesting their willingness to participate in the study;
• The researcher also presented herself to the area of the study and gave respondents their consent letters;
• Then actual data collection on arrival to the area was carried out;
• The researcher arranged with the local leader and explained her visit and carried on with interviews with each interview lasting between 15 to 30 minutes.

3.8 Validity and reliability of research instruments

Reliability

The reliability of research instruments was ensured by the researcher throughout the study, discussing them with the supervisor when seeking expert opinion, taking great care in the choice of section, order and proper structure of questions. The researcher developed instruments that were easy to understand.

Validity

Validity refers to the degree to which a test measures what it is supposed to measure and consequently permits appropriate interpretation of scores. As suggested by (Kathari, 2003), content and construct validity was determined by expert judgment. The researcher thus used the help of the supervisor who examined and confirmed content validity by checking the items’ and content coverage, relevance, clarity of questionnaire, persistency and ambiguity.

3.9 Data processing, presentation and analysis

Data Processing

Data collected was sorted, edited and coded so as to obtain a reasonable judgment. Data was edited to check the completeness of the respondents’ responses with the purpose of detecting and eliminating errors and identifying vital information that is essential in coding and tabulation and finally data was entered.

Data Presentation

The data was presented using percentages and tables according to objectives of the study to come up with the conclusions and recommendations basing on the findings.

Data Analysis

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

3.10 Ethical Considerations

The researcher considered the research values of voluntary participation, anonymity and protection of respondents from any possible harm that could arise from participating in the study. Thus the researcher; introduced the purpose of the study as a fulfillment of a bachelors’ Study programme and not for any other hidden agenda. Request was made to the respondents to participate in the study on a voluntary basis and refusal or abstaining from participating was permitted. The researcher also assured the respondents of confidentiality of the information given and protection from any possible harm that could arise from the study since the findings were used for the intended purposes only.

CHAPTER FOUR

DATA ANALYSIS AND PRESENTATION

4.0 Introduction

This chapter presents 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 WWDs in Bugembe town council, Jinja district.

A total of 20 respondents participated in the study. There characteristics is given in the table 4.1 below;

Table 4.1: Background information of respondents

The respondents within the age bracket 14-21 were the majority (20%) as indicated in the table above. Respondents in the age bracket of 45-52yrs and 53-60yrs were next in number each with 15%.

4.2 Health services offered to WWDs

The study sought to identify the health services offered to women with disabilities. Results were obtained and are presented below;

Table 4.2: Shows response on if WWD in the area have access to health services

Table shows that majority of the respondents (100%) mentioned that WWDs have access to health services in the various health facilities in Bugembe.

Table 4.3: Shows response on if WWD in the area have access to health services

Results as shown above indicate that, majority of respondents (16) mentioned that there are facilities that have been designed to accommodate the health needs of women with disabilities. Only 30% of the study respondents mentioned no. This implies that in Bugembe town council, most health centres are equipped to provide health services to WWDs.

Table 4.4: Health services available

Majority of the study respondents (100%) as indicated in table above mentioned measurement of blood pressure, blood tests to detect syphilis, antenatal care services, family planning and HIV/AIDs. Respondents indicated that testing for urine, weight and height measures with 95%. 75% of the respondents indicated taking iron supplements, 65% of the study indicated intestinal parasite drugs and only 55% mentioned tetanus toxoid injections.

From the above observation, women with disabilities have access to most of those services.

4.2 Challenges faced by WWDs while accessing health services

The study sought to identify challenges faced WWDs while accessing health services in Bugembe town council. Responses are presented below;

Table 4.5: Challenges faced by WWDs while accessing health services

From table above, most respondents (100%) indicated distance to the health facility implying that most WWDs move long distance to access health services. Respondents (65%) who said lack of assistive devices were second in number, while 55% of them said lack of enough drugs, 50% mentioned lack of enough trained medical personnel to handle issues of women with disabilities, 45% of the respondents indicated lack of awareness. Others 35% mentioned discrimination, 30% of them mentioned rudeness of nurses and only 20% of the respondents who were the minority said shyness of WWDs.

Distance to the health facility

The responses were very varied as were respondents, One challenge that was raised by all the respondents was the aspect of distance to the existing health facility in the town council 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:

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

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 WWDs 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’’ (WWD)

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

Lack of awareness

Another challenge was lack of awareness for both WWDs and health workers. Some of the respondents 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 WWDs and key informants indicated that health facilities are ill-prepared to address the health care service needs of WWDs. Most respondents mentioned that health care providers were not trained to handle WWDs, 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 Bugembe town council’’ (WWHI)

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

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

Lack of assistive devices

The absence of assistive devices was one of the challenges that the respondents mentioned. These appliances would enhance movement of WWDs to access health care services. The respondents 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 WWDs struggle to forge their ways to the H/C by borrowing any passerby to help them who in most cases ask for money which a WWD does not have:

‘‘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’’ (WWD)

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

Rudeness of nurses

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

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

Lack of enough trained medical personnel

The inadequate medical personnel was also raised by the respondents. Most of the respondents mentioned that this has resulted into VHTs being recruited to work in the H/C to help the few qualified staff. They said the level of the knowledge needed in the H/C especially for WWDs 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)

Shyness of WWDs

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

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

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

Discrimination

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

Other ‘normal’ people undermine WWDs and are not sensitive to their needs. They are labeled all sorts of names such as disabled and dump. On this issue one respondent 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’’ (WWD)

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

4.3 Strategies to minimize challenges to health care services access by WWDs

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

Like the above, responses to this objective were numerous and varied across respondents. Although some seemed to cut across all respondents, all respondents (100%) said that health care services ought to be brought nearer the people:

‘‘I need these services nearer because other neighboring places around the town council have health care services. This can favor some of us who are crawling’’ (WWD)

Provision of assistive devices

Other respondents (90%) also requested that wheel chairs should be provided to ease transportation of WWDs seeking health care services from the H/C. Consequently, presence of wheel chairs also enable WWDs 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 WWD’s leader in the town council:

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

Another respondent was quoted:

 ‘‘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’’ (WWD)

Also,

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

Immediate attention

Another remedy given by respondents (85%) was that WWDs 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 respondent said that WWDs should be given priority by securing for them their own special room where they receive the health care services:

One respondent 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……’’

Another respondent was quoted:

 ‘‘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’’ (WWD)

Empowerment

Empowerment was one of the remedies to improve WWDs access to health care services. One of the respondents said that WWDs 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 WWDs 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 WWDs 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)

Another respondent was quoted:

‘‘………WWDs 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….’’

Awareness raising

In addition, one respondent who happened to be a councilor for WWDs said that awareness raising which is well packed needed to be created to help WWDs 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 WWDs, health workers, care givers and also parents of WWDs’’

Networking

Another respondent suggested that non- governmental organizations should come up to help WWDs especially by giving WWDs appliances like tricycles wheel chairs, crutches and others. Another said that more nurses and doctors with skills of attending to the WWDs 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 respondents said that one person cannot help WWDs and so all stake holders need to come on board to help the people as illustrated in the following quotations:

‘‘WWDs 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 WWDs themselves need to come together’’

Another respondent was quoted:

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

Organisation of staff meetings

Another respondent 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 WWDs seeking health care services. One respondent also said that meetings like public health education programs meant for WWDs should be done at the villages within their reach because the distance from the villages to town council alone scares WWDs as expressed by the voice:

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

Another respondent was quoted:

 ‘‘If this is done may be they will stop being rude to us…………..’’ (WWD)

Implementation of initiated programmes

One of the respondents cited out that government agency should effectively and efficiently implement any planned initiative for WWDs. 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:

Additionally still on this objective, one respondent said that the town council authorities should monitor all government programs concerning all people in the town council including WWDs as illustrated by the voice:

‘‘It’s the responsibility of the town council to monitor all programs of government. Even now WWDs are suffering because the town council doesn’t do anything…….’’ (Key informant)

Conclusion

Finding about health care services access by WWDs in general reveal a lot of suffering of WWDs. This is because of absence of H/Cs which would have been in other parishes of the 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. WWDs sufferings can be turned to hopefulness of life by the government initiative to establish health centres at all levels in the sub county with special health facilities that are disability friendly. There is need to expand the health centre by requesting addition of health care personnel, create provision of medicine and above all offering guidance and counseling to both WWDs and health workers to be patient and kind to one another.

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 Health services offered to WWDs

As indicated in the table 4.4 in chapter the major services accessed by women with disability in Bugembe town council, health centres are;

• Testing for HIV/ AIDS
• intestine parasites
• Antenatal care
• Guidance on family planning
• Weight, height and blood pressure
• And testing for a variety of common infections.

These are the same services that other women in the community in this area access. This implies that women with disabilities in Bugembe have a right to and access the same services that are offered to women without disabilities in area. This affirms the fact that both women with disabilities and those without disabilities have the same right to quality and accessible health services.

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

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

5.1.2 Challenges faced by WWDs in accessing health care services

Table 4.5 in chapter 4 presents a number of challenges that hinder access to health services by WWD in Bugembe town Council. One of these challenges was long distances from homes of WWDs to health centres. In Bugembe, there are no health centres at village or parish levels, the centres are located long distance from homes of many WWDs. This situation is however different from the GOU (2004) and MOH (1996) that emphasized that all districts should have health centre at all levels and equipped with relevant services. These four parishes seem to be unlucky not to have health centres. No wonder long queues, pressure on the health workers leading to abuse of patients among others are some difficulties encountered by WWDs and the general community.

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

In this study, respondents reported rudeness of nurses and other health workers towards them when accessing health care services. The researcher agrees and notes that this scares the people not only WWDs and tend to seek another alternatives. This is in agreement with MOH (1996)citation that most health workers are ignorant of the health needs and expectations of WWDs, and this worsens the situation. It’s not surprising that given the situation in this S/C, more people from other parishes without health centres 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 WWDs in this health centre lack mobility devices. This finding reveals the plight of WWDs especially crippled in accessing health care and social services. Participation which is a vital component of development is also significantly affected and this has an effect in the community and the individual. It matches NAD (2007) citation that absence of mobility devices like crutches hinders WWDs access to health care services and public places. This difficulty points to isolation and suffering of WWDs in this community.

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

In this study, respondents reported that most of the health facilities in the health centre are not disability friendly which has made it so hard for most WWDs to access health care services. The researcher also agrees because the delivery beds are high and un adjustable to favor WWDs going for labor in the health centre. this is in line with Mensah et al., (2008) who pointed a similar argument which noted that most of the health facilities do not provide disability friendly services making it hard for most WWDs especially wheel chair users to access health centres 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 Government of Uganda on WWD Act (2006) where it stated that it’s the duty of the government in all government owned health centres and private health centres to provide special disability-related health services like wheel chairs, delivery beds. This can act as a motivation to pregnant mothers and other WWDs 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 WWDs 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 WWDs. This can help WWDs and health workers realize their rights and needs as well as responsibilities to the benefit of WWDs.

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 village health team (VHTs). This can be by including special services that WWDs 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 WWDs the presence of health care services.

The only solution to minimize the challenges and one that can satisfy WWDs, 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 WWDs and other people seeking health care services. Another study by the Government of Uganda (GOU, 2004) and Ministry of Health (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 WWDs in general reveal a lot of suffering of WWDs. This is because of absence of health centres which would have been in other parishes of the town council 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. WWDs sufferings can be turned to hopefulness of life by the government initiative to establish health centres at all levels in the sub county with special health facilities that are disability friendly.

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 WWDs and other people by the health workers exist through expression of derogative remarks that scare away WWDs patients seeking health care services. There is need to expand the health centre by requesting addition of health care personnel, create provision of medicine and above all offering guidance and counseling to both WWDs and health workers to be patient and kind to one another.

5.3 Recommendations

The researcher recommends the following:

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

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

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

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

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

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APPENDICES

APPENDIX I: INTERVIEW GUIDE FOR LOCAL LEADERS AND CDO

Dear Respondent:

My name is Ayebare Damary, a student of Kyambogo University pursuing a Bachelor degree in Community Based Rehabilitation. I am carrying out research on “the accessibility of health services to women with disabilities in Bugembe town council as part of the requirements by the University for this Award. I humbly request you to take part by answering the questions below. All information was treated with confidentiality and used for academic purposes.

Section A.  Bio data

1. Gender……………………………………………………………………
2. Age of Respondents………………………………………………………….
3. Education level……………………………………………………………….
4. How long have you been in this area………………………………………..

Section B: Health services offered to women with disabilities

1. Do women with disability in the area have access to health services?
2. Are there facilities that have been designed to accommodate the health needs of women with disabilities?
3. If yes, which health services are those?
4. How accessible are those health services?

Section C: Challenges faced by women with disabilities in accessing health services

1. What challenges are faced by women with disabilities in accessing health services?
2. What cause those challenges being faced?

Section D: Strategies of improving access of health services to women with disabilities

1. What can government do to improve access to health services by women with disabilities?
2. What can families do to improve access to health services by women with disabilities?
3. What other strategies/measures can a community take to improve access to health services by women with disabilities?

THANK YOU FOR YOUR TIME

APPENDIX II: FOCUS GROUP DISCUSSION GUIDE FOR WWDS

1. Do women with disability in the area have access to health services?
2. Are there facilities that have been designed to accommodate the health needs of women with disabilities?
3. If yes, which health services are those?
4. How accessible are those health services?
5. What challenges are faced by women with disabilities in accessing health services?
6. What cause those challenges being faced?
7. What can government do to improve access to health services by women with disabilities?
8. What can families do to improve access to health services by women with disabilities?
9. What other strategies/measures can a community take to improve access to health services by women with disabilities?

THANK YOU FOR YOUR COOPERATION