Using locational data in a novel mixed-methods sequence design: Identifying critical health care barriers for people with disabilities in Malawi.

The primary aim of this study was to determine which health care barriers were most important for people with disabilities in Malawi. To accomplish this, we devised a sequential mixed-methods research design that integrated locational survey data and qualitative data from field studies. Our secondary aim was to evaluate this research design not only as a design-solution to our particular research objective, but as a tool with more general applicability within social sciences. Malawi has one of the most underserved health service populations in the world with chronic resource shortages and long travel distances where people with disabilities are at a particular disadvantage. Nevertheless, our results show that even in a resource scarce society such as Malawi it is the interpersonal relationships between patients and health service providers that has the largest impact on the perception of access among patients. Our results also suggest that the sequential mixed-methods design is effective in guiding researchers towards models with strong specifications.

Predictors of negative beliefs toward the sexual rights and perceived sexual healthcare needs of people with physical disabilities in South Africa.

Background: Although sexuality is a ubiquitous human need, recent empirical research has shown that people without disabilities attribute fewer sexual rights and perceive sexual healthcare to benefit fewer people with disabilities, compared to non-disabled people. Within a global context, such misperceptions have tangible, deleterious consequences for people with disabilities (e.g., exclusion from sexual healthcare), creating an urgent need for effective strategies to change misperceptions.Methods: To lay the groundwork for developing such strategies, we examined predictors of the recognition of sexual rights of people with physical disabilities within the South African context, derived from three key social psychological literatures (prejudice, social dominance orientation and intergroup contact), as well as the relationship between sexual rights and beliefs about sexual healthcare. Data were obtained through a cross-sectional survey, given to non-disabled South Africans (N = 1989).Results: Findings indicated that lack of recognition of the sexual rights for physically disabled people predicted less positive beliefs about the benefits of sexual healthcare. In turn, high levels of prejudice (both cognitive and affective) toward disabled sexuality predicted less recognition of their sexual rights, while prejudice (both forms) was predicted by prior contact with disabled people and possessing a social dominance orientation (cognitive prejudice only). Evidence was also obtained for an indirect relationship of contact and social dominance orientation on sexual healthcare beliefs through prejudice, although these effects were extremely small.Conclusion: Results are discussed in terms of their implications for rehabilitation, as well as national-level strategies to tackle negative perceptions of disabled sexuality, particularly in contexts affected by HIV.Implications for rehabilitationFindings demonstrate an empirical link between prejudice toward disabled sexuality, lack of recognition of sexual rights and viewing sexual healthcare of less benefit for disabled people.Consequently, there is need for increased attention to these dimensions within the rehabilitative context.Contact with disabled people, including dedicated interventions, is unlikely to meaningfully impact beliefs about the benefits of sexual healthcare.

Dating persons with physical disabilities: the perceptions of South Africans without disabilities.

There is good reason to believe that the attitudes of persons without disability towards dating a person with a physical disability might be unfavourable. However, in general, and in the Global South in particular, there is a dearth of research in this area. This study sought to take the first step in addressing this lack of enquiry, by surveying the attitudes of a general population sample in South Africa towards dating people with physical disabilities, using a vignette. Data from 1723 survey respondents were analysed thematically. Findings reveal largely negative attitudes towards people with physical disabilities. Respondents without disability perceived numerous barriers to dating a person with a physical disability, including social stigma, anxiety and concerns about the burden of care they believed such a relationship would place upon them. However, there was some evidence to suggest that some positive attitudes do exist, and a few respondents were open to dating a person with physical disabilities. Findings contribute to a nuancing and expanding of the 'myth of asexuality' among physically disabled people by showing that people with physical disabilities are actively desexualised by persons without disability. Future research is needed to explore how the inclusive attitudes, of which we did find evidence here, can be further cultivated.

Intimacy, intercourse and adjustments: Experiences of sexual life of a group of people with physical disabilities in South Africa.

There is a growing recognition of the sexual and reproductive rights of people with disabilities, and since the World Health Organisation's World Report on Disability, increased international attention has been given to these issues. Past research, however, suggests that this group encounter barriers to sexual and reproductive rights, which are both physical and attitudinal. Against this backdrop, this article employs a sequential mixed qualitative methodology to explore the practical and subjective experiences of 13 people with physical disabilities in South Africa, with regard to their sexual lives and experiences of sexuality. These experiences were marked by concerns about their 'fitness' as sexual beings and indicated that social forces were key in shaping their expectations for their own sexual life.

The sexual and reproductive rights and benefit derived from sexual and reproductive health services of people with physical disabilities in South Africa: beliefs of non-disabled people.

There is a body of theoretical work, and some empirical research, which suggests that non-disabled people assume people with physical disabilities are not suitable romantic partners, do not have sexual drives or desires, or are not sexually active. It has also been proposed that people with physical disabilities face barriers to sexual healthcare access which are structural as well as social. The present paper explores non-disabled South Africans' beliefs concerning the degree to which non-disabled respondents enjoy sexual and reproductive rights, and benefit from sexual and reproductive healthcare, compared to people without disability. Using a survey, we asked 1989 South Africans to estimate the degree to which people with physical disabilities and people without disability have sexual rights, and benefit from sexual and reproductive healthcare services, respectively. Respondents were more likely to support the idea that the population without disability were deserving of sexual rights compared to people with physical disabilities. Respondents were more likely to rate the degree to which people with physical disability benefit from sexual and reproductive healthcare as less than that for people without physical disabilities. These findings provide some of the first empirical support that non-disabled people perceive people with physical disabilities as having fewer sexual and reproductive rights, and deriving less benefit from sexual and reproductive health services, than the population without disability. To have diminished sexual rights, and benefit less from sexual and reproductive healthcare, we suggest, evinces a negation of the sexual and reproductive needs and capacity of people with physical disabilities.

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

BACKGROUND: Although approximately 80% of the global population of people with disabilities reside in low- and middle-income countries (LMICs), very little is known about their sexual lives due to a lack of empirical data. We aimed to provide a scoping review of English-language research conducted on disability and sexuality in LMICs. OBJECTIVE: Our research questions concerned what topics in disability and sexuality have (and have not) been investigated, where this research has been carried out, and how this research has been conducted. METHODS: A scoping review was conducted to examine the published English-language research literature on disability and sexuality within LMICs. We searched three electronic databases (PsycINFO, Web of Science, and PsycARTICLES) for research meeting these criteria published between 2000 and 2016 (inclusive). Through this search, we identified 103 articles. RESULTS: It is concluded that: (a) disability and sexuality research in African countries has focused predominantly on sexual abuse and violence or HIV, (b) the sexuality of people with disabilities within many LMICs has received little or no empirical investigation, and (c) there have been very few experimental studies on disability and sexuality conducted in LMICs in general. CONCLUSIONS: Much remains unknown about the sexual health and sexual lives of the majority of people with disabilities, globally. Moreover, what has been done in certain contexts has tended to focus predominantly on vulnerabilities rather than emancipatory practices. Thus, urgent action is needed within LMICs on issues related to disability and sexuality to meet the goal of global optimal sexual health.

Beyond the checklist: understanding rural health vulnerability in a South African context.

BACKGROUND: Vulnerability in the past has sometimes been measured and understood in terms of checklists or common understanding. It is argued here that vulnerability is a more complex issue than this. Although checklists of vulnerable groups are important, they do not capture the essence and dynamics of vulnerability. OBJECTIVE: The case of rural health vulnerability in South Africa is discussed to show that classifying people into vulnerable groups does not portray the complexity and intricacies of what it means to have vulnerability. We also wish to show that there are different kinds of vulnerabilities, and the difference between access vulnerability and illness vulnerability is highlighted. METHODS: As part of a larger study, this case study is presented to show how vulnerability in a poor rural community in South Africa has to be understood in a contextual and dynamic manner as opposed to a static manner. RESULTS: Family and social dynamics can influence health. For example, fractured families were seen as a vulnerable issue within the community, while being a person with a disability can lead to isolation and callous attitudes towards them. It is these family and social dynamics that lead proximally to vulnerability to ill health. CONCLUSIONS: A contextual approach can assist in giving a more layered understanding of vulnerability than a checklist approach can do. Interventions to change health cannot be addressed simply by medical means. Social conditions need to be changed, and part of changing social conditions is the process of assisting those who are isolated or experience themselves as vulnerable to reconnect with others in the community. Poverty leads to social exclusion; social and family inclusion may be key to well-being.

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

BACKGROUND: Equitable access to health care is a challenge in many low-income countries. The most vulnerable segments of any population face increased challenges, as their vulnerability amplifies problems of the general population. This implies a heavy burden on informal care-givers in their immediate and extended households. However, research falls short of explaining the particular challenges experienced by these individuals and households. To build an evidence base from the ground, we present a single case study to explore and understand the individual experience, to honour what is distinctive about the story, but also to use the individual story to raise questions about the larger context. METHODS: We use a single qualitative case study approach to provide an in-depth, contextual and household perspective on barriers, facilitators, and consequences of care provided to persons with disability and HIV. RESULTS: The results from this study emphasise the burden that caring for an HIV positive and disabled family member places on an already impoverished household, and the need for support, not just for the HIV positive and disabled person, but for the entire household. CONCLUSIONS: Disability and HIV do not only affect the individual, but the whole household, immediate and extended. It is crucial to consider the interconnectedness of the challenges faced by an individual and a household. Issues of health (physical and mental), disability, employment, education, infrastructure (transport/terrain) and poverty are all related and interconnected, and should be addressed as a whole in order to secure equity in health.

Access to tuberculosis services for individuals with disability in rural Malawi, a qualitative study.

Tuberculosis occurs in all populations, but with higher prevalence in poor contexts. Vulnerable groups, including individuals with disability, run a particular risk due to poorer access to information and health services. Studying access to tuberculosis services for vulnerable groups in poor contexts may provide useful insight into the quality of such services in low-income contexts. This article aims to present a contextual understanding of access to tuberculosis services for people with disabilities in one district in southern Malawi. A qualitative method with semi-structured interviews and site observations was applied. In all, 89 participants were interviewed: 47 persons with disability, 11 parents/guardians of youths with disability, and the remaining 31 comprising eight health workers, four community rehabilitation assistants and volunteers, and 19 leaders in the community.Our main findings are that lack of information and knowledge, and considerable confusion related to tuberculosis, its cause and how to protect oneself, are major barrier to accessing services. Disease awareness and personal risk perception are key factors in this regard. Further findings concerns the pathways to tuberculosis related health services, in particular having a test and completing the treatment. The combination of lack of knowledge and barriers in accessing tests implies substantial availability and access problems.It is of importance to understand the combined impact of individual, social, contextual, and systems barriers to fully address the complexity of accessing tuberculosis services for vulnerable groups in poor populations. Lack of disability specific strategies in the local health services may be part of the reason why individuals with disability to not access such services.

"I just answer 'yes' to everything they say": access to health care for deaf people in Worcester, South Africa and the politics of exclusion.

OBJECTIVE: To explore whether there are other factors besides communication difficulties that hamper access to health care services for deaf patients. METHODS: Qualitative methodology using semi-structured interviews with 16 deaf participants from the National Institute for the Deaf in Worcester and 3 Key informants from the Worcester area, South Africa. RESULTS: Communication difficulties were found to be a prominent barrier in accessing health care services. In addition to this interpersonal factors including lack of independent thought, overprotectedness, non-questioning attitude, and lack of familial communication interact with communication difficulties in a way that further hampers access to health care services. CONCLUSION: These interpersonal factors play a unique role in how open and accepting health services feel to deaf patients. PRACTICE IMPLICATIONS: Health care services need to take cognizance of the fact that providing sign language interpreters in the health care setting will not necessarily make access more equitable for deaf patients, as they have additional barriers besides communication to overcome before successfully accessing health care services.

Understanding the local context for the application of global mental health: a rural South African experience.

BACKGROUND: The global mental health movement has supplied ample evidence of treatment gaps for mental health care in low and middle-income countries. It is also clear that substantial progress has been made in developing an evidence base for innovative treatments which have been shown to work. It is only through rich and detailed understandings of local contexts and individual experiences that the challenges global mental health faces can be fully appreciated. METHODS: In this article, we use a single, qualitative case study from one context and of one family affected by mental disorder. This is to elucidate core issues which we regard as key to further developments in the global mental health agenda. RESULTS: Core issues are poor mental health literacy, transport and lack of outreach, limitations of formal health care, challenges at the interface with indigenous health care and lack of follow-up and rehabilitation. CONCLUSION: We propose shifting the focus of mental health care from cure to promotion and prevention, using an interdisciplinary team of lay and trained health workers from the professional, folk and popular sectors. The challenges are complex, as this small study shows, but it is only by looking closely at local conditions that it is possible to develop interventions which are contextually appropriate and make optimal use of local resources.

Accessing community health services: challenges faced by poor people with disabilities in a rural community in South Africa.

Poor people with disabilities who live in poor rural societies experience unique problems in accessing health services. Their situation is influenced by multiple factors which unfold and interplay throughout the person's life course. The difficulties do not only affect the person with a disability and his or her family, but also impact on the relevant care unit. The barriers are rooted in a life in poverty, upheld and maintained by poverty-reinforcing social forces of the past and the present, and reinforced by the lack of the person's perspective of the health services. This article explores how difficulties may interact and influence access to and utilisation of health services, and how this may render health services out of reach even when they are available. The study reveals that non-compliance is not necessarily about neglect but could as well be a matter of lived poverty. The study was based on in-depth interviews with people with disabilities and family members, and semi-structured interviews with health personnel. The data analysis is contextual and interpretive. When offering health services to people with disabilities living in resource-poor settings, services should take into consideration the person's history, the needs, and the resources and abilities of the family group. Rethinking access to health services should transcend a narrow medical institutionalisation of health professional's training, and include a patient's perspective and a social vision in understanding and practice. Such rethinking requires health service models that integrate the skills of health professionals with the skills of disabled people and their family members. Such skills lie dormant at community level, and need to be recognised and utilised.

Accessing community health services: challenges faced by poor people with disabilities in a rural community in South Africa

Poor people with disabilities who live in poor rural societies experience unique problems in accessing health services. Their situation is influenced by multiple factors which unfold and interplay throughout the person's life course. The difficulties do not only affect the person with a disability and his or her family, but also impact on the relevant care unit. The barriers are rooted in a life in poverty, upheld and maintained by poverty-reinforcing social forces of the past and the present, and reinforced by the lack of the person's perspective of the health services. This article explores how difficulties may interact and influence access to and utilisation of health services, and how this may render health services out of reach even when they are available. The study reveals that non-compliance is not necessarily about neglect but could as well be a matter of lived poverty. The study was based on in-depth interviews with people with disabilities and family members, and semi-structured interviews with health personnel. The data analysis is contextual and interpretive. When offering health services to people with disabilities living in resource-poor settings, services should take into consideration the person's history, the needs, and the resources and abilities of the family group. Rethinking access to health services should transcend a narrow medical institutionalisation of health professional's training, and include a patient's perspective and a social vision in understanding and practice. Such rethinking requires health service models that integrate the skills of health professionals with the skills of disabled people and their family members. Such skills lie dormant at community level, and need to be recognised and utilised

HIV/AIDS and disability in Southern Africa: a review of relevant literature.

Purpose. HIV/AIDS has grown to become the biggest epidemic in modern history. Southern Africa is at the epicentre of the global epidemic, with just of a third of the world's HIV-positive population living here. It is known that HIV/AIDS affect vulnerable population groups. It is surprising then, that persons with disabilities, one of the world's most vulnerable population groups, particularly in southern Africa, have been largely overlooked with regards to HIV/AIDS. This review sought to establish the state of the knowledge at present. Method. This article reports on findings of a literature review conducted as an initial step in a research project currently underway in South Africa. This article focuses on HIV/AIDS as it affects persons with disabilities in southern Africa, as it is in this region that the majority of people living with HIV live. However, as fewer studies exist that have as its focus southern Africa (particularly looking at HIV/AIDS and persons with disabilities), relevant articles from the international literature were used as indications of what we may find through future research also in the southern African countries. Given the paucity of published literature dealing with HIV/AIDS and persons with disabilities, the review looked at various risk factors associated with HIV infection, and how it affects persons with disabilities. Results. Findings from the literature review suggest that persons with disabilities, particularly in southern Africa, are at significant risk for HIV infection. Conclusions. There is an urgent need for more research on HIV/AIDs and sexuality among persons with disabilities in Africa.

"I thought . . . maybe this is my chance": sexual abuse against girls and women with disabilities in Malawi.

This article is based on a pilot study conducted in Malawi in 2006 that intended to uncover episodes of violence and abuse against women and girls with disabilities and furthermore to explore the mechanisms behind such acts. The stories of 23 women with disabilities were obtained through in-depth semistructured interviews that covered, among other topics, aspects of sexual abuse experienced by or known to these women. None of the informants reported having been sexually abused during childhood. In adulthood, several had experienced what they themselves defined as sexual abuse: Men came and wanted to "marry" them. When the woman became pregnant, the man disappeared and left her alone. The interviewees were very opinionated regarding this theme and sought both social and political action in this matter, especially a means to enforce men to take economic responsibility for their biological children. The informants stressed that adapted education for women with disabilities would allow them to become more economically independent and be better able to refuse the advances of unserious suitors.