EXPLORING ACCESSIBILITY OF ANTENATAL HEALTH SERVICES OF PHYSICALLY DISABLED PREGNANT WOMEN IN RUYONZA

SUB COUNTY, KYEGEGWA DISTRICT

CHAPTER ONE

1.0 Introduction

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

1.1 Background to the study

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

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

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

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

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

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

1.2 Statement of the problem

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

In Ruyonza Sub County, among women who come for antenatal health and delivery, few of them are physically disabled pregnant women and being a village in Kyegegwa, it contributes to this great problem. It’s upon the above background that researcher has picked interest in carrying out a study about the factors influencing the accessibility of antenatal health services by physically disabled pregnant womenin Ruyonza sub county, Kyegegwa District.

1.3. Purpose of the study

The main purpose of the study will be to explore the factors influencing the access to antenatal health services by physically disabled pregnant women in Ruyonza sub county, Kyegegwa District.

1.4 Research objectives

To establish the availability of antenatal health services by physically disabled pregnant women in Ruyonza sub county, Kyegegwa District.
To explore the accessibility of antenatal health services by physically disabled pregnant women in Ruyonza sub county, Kyegegwa District.
To assess the barriers that limit access to antenatal health services by physically disabled pregnant women in Ruyonza sub county, Kyegegwa District.
To establish the experiences of physically disabled pregnant women in accessing antenatal health services in Ruyonza sub county, Kyegegwa District.

1.5 Research questions

Are health services available for physically disabled pregnant women in Kyegegwa district?
Do physically disabled pregnant women access antenatal health services in Ruyonza sub county, Kyegegwa District?
What barriers limit access to antenatal health services by physically disabled pregnant women in Ruyonza sub county, Kyegegwa District?
What are the experiences of physically disabled pregnant women in relation to accessibility of antenatal health servicesin Ruyonza sub county, Kyegegwa District?

1.6 Scope of study

1.6.1 Content Scope

The main purpose of the study will be to explore the factorsinfluencing access to antenatal health services by physically disabled pregnant women in Ruyonza sub county, Kyegegwa District. Specifically, the study found out whether physically disabled pregnant women have access to antenatal health services, the barriers that limit access to antenatal health services by physically disabled pregnant women and the experiences of physically disabled pregnant women in accessing antenatal health services.

1.6.2 Geographical Scope

The study will be carried out in Ruyonza sub county, Kyegegwa District. This will be due to the easy proximately to the area.

1.6.3 Time Scope

The study will be carried out for a period of four months in 2018.

1.7 Significance of the study

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

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

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

1.8. Definitions of some key terms

Antenatal health is the care one receives from healthcare professionals during her pregnancy.

Disability refers to difficulties encountered in any or all three areas of functioning.

CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter presents the literature review cited by other scholars about accessibility of health services to physically disabled pregnant women. The literature will be presented according to the objectives of the study.

2.1 Antenatal health services offered to physically disabled pregnant women

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).

Physically disabled pregnant women 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 physically disabled pregnant women may not receive regular health screenings within recommended guidelines (Armour, 2009).

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

2.2 Accessibility of Antenatal health services by physically disabled pregnant women

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

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

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

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

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

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

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

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

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

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

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

According to Link and Phelan, (2010), the inequalities in the apparent circumstances of individual’s lives, like individuals’ access to health care, schools, their conditions of work and leisure, households, communities, towns, or cities, affect people’s ability to lead a flourishing life and maintain health, thus access to routine medical examination. Women who are working and earning money may be able to save and decide to spend it on a health issues. Several studies find that farming women are less likely to have routine examination than women in other occupations (PHAC, 2011). This may be due to limited financial resources and health services in such areas.

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

2.3 Barriers that limit access to antenatal health services by physically disabled pregnant women

Physically disabled pregnant women 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:

Physically disabled pregnant women 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 physically disabled pregnant women, 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 physically disabled pregnant women 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 physically disabled pregnant women. 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 physically disabled pregnant women. 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, physically disabled pregnant women should be fully informed about their rights as patients (de Kretser, 2010).

Gender based violence is experienced by physically disabled pregnant women 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) physically disabled pregnant women 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 physically disabled pregnant women, including contraceptive choices and compliance, and recognition of the early signs of pregnancy.

Access to health promotion initiatives, including screening is as important for physically disabled pregnant women 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 physically disabled pregnant women 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 will be 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 physically disabled pregnant women remain. Physically disabled pregnant women experience higher levels of disadvantage and discrimination, much of which is based in a lack of knowledge and sensitivity about disability among health care providers; the physical layout and paucity of appropriate equipment in health services; and a lack of appropriate policies, guidelines and information resources [Barr, 2008].

CHAPTER THREE

METHODOLOGY

3.0 Introduction

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

3.1 Research Design

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

3.2 Target Population

According to Baron, (2011), population constitutes people-individuals, organizations, groups, communities or other units that provide information for the study. The population will include: physically disabled pregnant women from 18 to 45years, health workers (health in charge and 3 midwives) with in Ruyonza sub county.

3.3 Sample size

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

Table 3.1: Sample size

Category	No. of respondents
Physically disabled pregnant women	14
Health workers	4
Total	18

Physically disabled pregnant women will be involved in the study because they are the main culprits; Health workers will be selected because they are aware of the health issues affecting physically disabled pregnant women.

3.4 Sampling Procedure or Technique

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

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

3.5 Data collection and instruments

Interviews

Cohon and Manioh (1989) qualify interview to be a conservation initiated by the interviewer for specific purpose of obtaining research relevant information and focuses on content specified by research objectives of specific description. Semi-structured interviews were used to generate additional information from the respondents. This method will be 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 will be used for the in-depth interviews with health workers. Unstructured interview guide will be developed based on the objectives. They were designed in English language. It will be 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 will be to create hypotheses to be tested later, in a survey or using for a survey. This method will involve watching and listening to people.

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

Focus group discussions

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

3.6 Data Collection Procedure/ethical consideration

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

3.7 Data analysis

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

Letter of Informed Consent

Dear respondent,

I am Biregyeya Sam, a student of Kyambogo University pursuing a bachelor degree in Social Work and Community Development and as part of the requirement for the fulfillment of the award; I am carrying out a study on “accessibility of antenatal health services of physically disabled pregnant women in Ruyonza sub county, Kyegegwa District”.

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

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

Thank you for your time.

Interview guide for physically disabled pregnant women

Section A: Background Information

Age: ……………………………………

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

Religion:……………………………………………………………………….

Occupation

Section: B

Who provides antenatal health services to women in this community?
Where do you find antenatal health services?
What are the antenatal health services in this community?
How are they provided?
Can you share with me your experience of accessing antenatal health services?
Are health services free?
What are the costs of antenatal health services in this community?
What challenges do you experience in accessing antenatal health services?
Any other information?

THANK YOU FOR TIME

Interview Guide for Health Workers