Petronella T Mhindo ZOU

FACULTY OF APPLIED SOCIAL SCIENCES DEPARTMENT OF DEVELOPMENT STUDIES MSDS516/MSDS520/MSSD520 HARARE REGION CAMPUS FACULTY OF APPLIED SCIENCES DEPARTMENT OF DEVELOPMENT STUDIES ACCESS TO HEALTHCARE AND REPRODUCTIVE SERVICES BY WOMEN WITH DISABILITIES. A CASE OF DOMBOSHAVA & GOROMONZI DISTRICTS A RESEARCH BY PETRONELLA T MHINDO (P2316893A) TO THE ZIMBABWE OPEN UNIVERSITY, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE MASTER OF SOCIAL SCIENCE DEGREE IN DEVELOPMENT STUDIES HARARE, ZIMBABWE 2024 RELEASE FORM NAME OF AUTHOR: PETRONELLA TATENDA MHINDO TITLE OF RESEARCH PROJECT: ACCESS TO HEALTHCARE AND REPRODUCTIVE SERVICES BY WOMEN WITH DISABILITIES. A CASE OF DOMBOSHAVA & GOROMONZI DISTRICTS DEGREE FOR WHICH RESEARCH PROJECT WAS PRESENTED: Master of Social Science in Development Studies YEAR THIS DEGREE WAS GRANTED: 2024 Permission is hereby granted to the Zimbabwe Open University Library to produce single copies of this research project and to lend or sell such copies for private, scholarly, or scientific research purposes only. The author reserves other publication rights and neither the dissertation nor extensive extracts from it may be printed or otherwise reproduced without the author’s written permission. SIGNED PERMANENT ADDRESS: 1334, Dunowen, Arlington, Hatfield, Harare APPROVAL FORM The undersigned certify that they have read and recommended to the Zimbabwe Open University for acceptance; a research project entitled ACCESS TO HEALTHCARE AND REPRODUCTIVE SERVICES BY WOMEN WITH DISABILITIES. A CASE OF DOMBOSHAVA & GOROMONZI DISTRICTS submitted by PETRONELLA MHINDO in partial fulfilment of the requirements for the Master of Social Science in Development Studies SUPERVISOR(S) ……………………………. ………………………………………………………………… PROGRAMME/ SUBJECT COORDINATOR ………………………………………… EXTERNAL EXAMINER DATE: ………….. DECLARATION ABSTRACT The study examined healthcare access for women with disabilities in rural Zimbabwe, specifically in Domboshava and Goromonzi. With about 16% of the global population living with disabilities, these individuals often experience poorer health outcomes. In Zimbabwe, inadequate primary healthcare systems in peri-urban areas lead many to overcrowded central hospitals, which often lack accessibility and sensitivity to the needs of disabled women. The research aimed to investigate healthcare and reproductive service access, while secondary objectives included assessing service utilization, identifying barriers and enablers, and evaluating existing initiatives. Utilizing the Andersen-Newman model and the Levesque model, the study employed a pragmatic, mixed-methods approach through a cross-sectional survey with structured questionnaires and interviews. Key findings revealed that 73% of women lived over 45 minutes from health centres, facing significant accessibility challenges due to uneven facility distribution influenced by political factors. Transportation issues further complicated access, with many women dependent on assistance and facing higher costs. Staff shortages and inadequate equipment hindered care, while communication barriers led to missed appointments. Despite free maternal care, over 34% reported additional charges. Provider attitudes, including gender and experience, affected service acceptability. The government was recommended to enhance healthcare accessibility by investing in infrastructure and ensuring equitable facility distribution based on population needs. Consistent implementation of free healthcare services for disabilities is vital, along with providing disability training for healthcare workers. Increasing the representation of people with disabilities in health professions is recommended. Healthcare providers should adopt patient-centric approaches, improve communication, and ensure respectful care. Community organizations should empower Female Community Health Volunteers to advocate for women with disabilities and raise awareness about their rights and healthcare needs. TABLE OF CONTENTS RELEASE FORM i APPROVAL FORM ii DECLARATION v ABSTRACT vi TABLE OF CONTENTS vii LIST OF TABLES xi LIST OF FIGURES xii CHAPTER ONE 1 INTRODUCTION TO THE STUDY 1 1.1 Introduction 1 1.2 Background to the Study 1 1.3 Statement of the Problem 6 1.4 Research Objectives 7 1.4.1 Main Research Objective 7 1.4.2 Secondary Research Objectives 7 1.5 Research Questions 7 1.5.1 Main Research Question 7 1.5.2 Secondary Research Questions 8 1.6 Significance of the Study 8 1.6.1 Significance to Practice 8 1.6.2 Significance to Academia 10 1.7 Limitations 10 1.8 Delimitations 10 1.8.1 Conceptual Delimitations 10 1.8.2 Theoretical Delimitations 10 1.8.3 Geographical Scope 11 1.8.4 Time Delimitations 11 1.8.5 Methodological Delimitations 11 1.9 Dissertation Outline 11 1.10 Definition of Key Terms 12 1.11 Chapter Summary 12 CHAPTER TWO 13 LITERATURE REVIEW 13 2.0 Introduction 13 2.1 Theoretical Framework 13 2.1.1 The Andersen-Newman Model 13 2.1.2 Levesque’s Model 16 2.1.3 The Zimbabwe National Disability Policy (2021) 18 2.2 Conceptual Framework 19 2.3 Reproductive and Health Services Utilization by Women with Disabilities in Marginalised Communities 20 2.4 The Enablers of Access to Healthcare and Reproductive Services by Women with Disabilities 22 2.4.1 Approachability 22 2.4.2 Acceptability 24 2.4.3 Availability and Accommodation 25 2.4.4 Affordability 27 2.4.5 Appropriateness 28 2.5 Barriers Faced by Women with Disabilities from Accessing Healthcare and Reproductive Services 29 2.5.1 Lack of Transparent Information 29 2.5.2 Lack of Outreach and engagement: 31 2.5.3 Physical Inaccessibility 32 2.5.4 Communication Accessibility 32 2.5.5 Stigmatisation 33 2.5.6 Gender-Based Influences 35 2.6 The Effectiveness of the Existing Initiatives Designed to Improve Healthcare and Reproductive Services Access to People with Disabilities 37 2.7 Empirical Literature Review 39 2.7.1 American Context 39 2.7.2 European Context 40 2.7.3 Asian Context 41 2.7.4 African Context 42 2.7.5 Southern-African Context 43 2.7.6 Zimbabwean Context 43 2.8 Research Gaps 44 2.9 Chapter Summary 46 CHAPTER 3 47 RESEARCH METHODOLOGY 47 3.0 Introduction 47 3.1 Research Philosophy 47 3.2 Research Design 48 3.3 Research Approach 48 3.4 Population 49 3.5 Sampling Approach 50 3.6 Data Collection Instruments 52 3.6.1 Instrument Design and Structure 54 3.7 Data Collection Procedure 55 3.8 Ethical Considerations 56 3.9 Variables and Operationalisation 57 3.10 Data Analysis 57 3.11 Chapter Summary 58 CHAPTER FOUR 59 DATA PRESENTATION AND ANALYSIS 59 4.1 Introduction 59 4.2 Sample Characteristics 59 4.2.1 Response Rate 59 4.2.2 Characteristics of Surveyed Respondents 60 4.2.2.1 Distribution by Disability Status 60 4.2.2.2 Distribution by Age 61 4.3 Accessibility 64 4.3.1 Location and Distance to Health Facility 64 4.3.2 Road and Transport 68 4.3.3. Travel Time and Cost 68 4.4 Availability 71 4.4.1 Staff Adequacy and Availability 71 4.4.2 Time Spent by the Providers 72 4.4.2 Waiting Time 73 4.4.3 Equipment, materials and drugs. 74 4.4.4 Information Communication 75 4.5 Affordability 76 4.5.1 Cost for Services, Medicine and Supplies 76 4.5.2 Income 78 4.6 Acceptability 79 4.7 Accommodation 84 4.7.1 Physical Infrastructures and Access 84 4.7.2 Internal Arrangement and Space Availability 85 4.7.3 Opening Times 86 4.8 Discussion 86 4.8.1 Level of Access 86 4.8.2 Enablers 88 4.8.3 Barriers 89 4.8.4 Effectiveness of Zimbabwe National Disability Policy 90 CHAPTER FIVE 94 SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 94 5.1 Summary 94 5.2 Conclusions 97 5.2.1 Level of Access 97 5.2.2. Enablers of Access 98 5.2.3 Barriers 99 5.2.4 Policy Effectiveness 100 5.3 Recommendations 100 5.4 Areas of Further Study 101 REFERENCES 102 APPENDICES 115 LIST OF TABLES Table 4.1 Response Rate 59 Table 4.2 Distribution by Disability Status 60 Table 4.3 Age in Years 61 Table 4.4 Rural Residence 62 Table 4.5 Highest Educational Level 62 Table 4.6 Employment Status 63 Table 4.7 Income Status 64 LIST OF FIGURES Figure 2.1 The Andersen Model for Health Services Use Adapted from (Andersen and Newman, 1995) 14 Figure 2.2 The Levesque’s Model (Adapted from Levesque et al., 2013 pp.5) 16 Figure 2.3 Conceptual Framework (Modified from Andersen-Newman and Levesque et al., 2013 models) 19  CHAPTER ONE INTRODUCTION TO THE STUDY 1.1 Introduction Efforts to improve and provide equitable reproductive healthcare and treatment of people continue to improve across the world although gaps remain visible regarding access to health facilities and information to the marginalized and special groups which include people with disabilities. Much as healthcare technology and infrastructure continues to advance, questions can be raised as to whether the disabled people have ease of access and if their needs are met in the same manner as those of the non-disabled group. Whilst reproductive healthcare has been spoken and written about immensely, it should be noted that it later dawned on people that children and disabled women were not being provided with the same privileges in accessing that healthcare. It was realized that the extent to which people with disabilities are able to access healthcare and reproductive systems is still very limited especially for those residing in remote communities of less developed countries even though they have the same needs as other women regarding reproductive healthcare. There is thus a need for ongoing research on why women with disabilities are still not able to access healthcare and reproductive services at the same rate as non-disabled women so that the gap is narrowed. It was also discovered that there are a lot of assumptions that disabled people do not require access to reproductive services as people tend to associate disability with inability to partake in sexual relations. The study thus sought to examine access to healthcare and reproductive services by women with disabilities in Harare peri-urban communities so as to identify areas that require urgent attention to enable the formulation of effective frameworks that can influence policy changes for the betterment of healthcare provision and access to the disabled population. This chapter served as an introduction to the study and consists of the background to the study, the statement of the problem, research objectives and questions, significance of the study, delimitations, as well as other sections. 1.2 Background to the Study The Center for Disease Control (2024) defines disability as any physical or mental impairment that makes it harder for the person to perform certain activities or engage with their surroundings. In other words, a disability is a condition that creates limitations in a person’s abilities and restricts their full participation in society. It encompasses a wide range of conditions, including blindness, deafness, physical disabilities, intellectual impairments, and mental health-related disabilities (Gomez, 2021). Globally, it is estimated that 16 percent of the world population (or close to 1.3 billion people around the globe) are living with disabilities (World Health Organization, 2023). It is also estimated that the statistics rose from the estimated figure of 15% in 2011 to the current figure due to an increase in chronic health conditions and aging populations. A rise in chronic conditions as well as the growth of aging population implies that demand for health and reproductive services has likely risen putting healthcare systems to meet the increased demand. Moreover, people with disabilities tend to have poorer health, higher mortality rates, and more limitations in their daily functioning as compared to those who live normal lives (World Health Organization, 2023). Various academic studies (Rade et al., 2023) have revealed that when the HIV/AIDS global pandemic began around 1981, disabled people were never the focus area of study and neither were they considered as a vulnerable group in sexual matters at the time. In America, it is reported that other special populations such as homosexuals and commercial sex workers were prioritized since HIV/AIDS was associated with gay practices and commercial sex work (prostitution). During the 1980s period, a lot of stigma was attached to HIV/AIDS issues and a lot of fear and myths surrounded the issue. This was made worse by the lack of information on HIV/AIDS hence a lot of discrimination ensued. The disabled group being an already discriminated group would therefore endure the double tragedy of being excluded and being viewed as asexual beings. Based on this, it is evident in various studies that the disabled have been left out for a long time even at the height of sex education, reproductive health promotion and HIV/AIDS. The period around the 1980s saw reproductive health issues being combined into HIV/AIDS initiatives whereby disabled people were not seen as a target group as nobody treated their needs in the same way as the need of non-disabled people were being handled. The World Bank (2023) has reported a ratio of 1 to 20 in all females as the proportion of females with disabilities. Furthermore, women generally experience slightly higher rates of disability compared to men as reported by the Department of Labour (2021) thus increasing their vulnerability to a greater extent. Moreover, women with disabilities face the same challenges as women without disabilities, but they also encounter additional forms of discrimination and environmental obstacles that further leave them vulnerable and unable to access essential services and information like their non-disabled counterparts. (The World Bank,2023). This implies the need for inclusive programs that recognize that disabled women are human beings who have feelings just like other women, only that they may have challenges in fulfilling their urges due to their disabilities which may limit mobility and reduce their potential to access reproductive health services and critical information. Furthermore, women with disabilities often face multiple challenges and discrimination regarding HIV and sexually transmitted infections as well as access to treatment. This is largely because they are considered as being asexual and incapable of wanting to partake in sexual relations or becoming parents and in some cases would depend on the assistance of another person for mobility in order to access such services. The fear of another person judging them thus contributes to their failure to access reproductive health services as they fear being ridiculed. Moreover, World Health Organization (2023) noted that HIV education had been hyped around the globe during the 1980s to 1990s period but currently has been overtaken by the prioritization of Non-Communicable Diseases such as cancer, heart diseases, diabetes and chronic respiratory disease. The COVID 19 pandemic also greatly shifted attention from HIV and reproductive health with focus being placed on coronavirus. The effect of this shift saw the disabled community being thrust at a further disadvantage as their needs remained far from being prioritized. WHO (2023) estimates that, women with disabilities are 2.2 times at risk of getting HIV than women without disabilities. Furthermore, women with disabilities are less likely to know their HIV status and access treatment than people without disabilities mainly because it is especially hard for disabled persons to access HIV services and information. The cultural and religious beliefs within various global societies do not enable sexual matters to be discussed openly. The taboo attached to sexual and reproductive health in the cultural domain therefore make it especially difficult for the disabled to come out and express sexual needs where non-disabled counterparts are even shying away from openly declaring their needs. Moreover, disabled persons tend to be excluded from sex education and education in general where they could possibly learn and understand more on reproductive education. To make it worse, disabled persons are usually stigmatized and discriminated against and in some cases are abused and violated. There is need for recognition of the challenges faced by persons living with disabilities by further assessing and evaluating what has been done and what can still be done so as to ensure equitable and inclusive programs are initiated. The Convention on the Rights of Persons with Disabilities further obligates member states to ensure that people with disabilities have access to the same high-quality and affordable healthcare services as the general population. Additionally, the World Health Assembly Resolution WHA74.8 calls on member states to guarantee that people with disabilities receive effective and comprehensive healthcare services as part of universal health coverage. It further advocates for the provision for equal protection and support for people with disabilities during emergencies and crises; as well as ensuring equal access for people with disabilities to public health initiatives and interventions across different sectors. According to the National Disability Authority (2024) The Convention on Rights of Persons with Disabilities has been ratified to date by 164 signatories as well as 191 parties. On the other hand, there has been unanimous resolution by 194 member states on “Strengthening Rehabilitation in Health Systems” as of May 2023 (World Rehabilitation Alliance, 2023). In a similar vein, the 2030 Agenda for Sustainable Development makes a commitment to guarantee that no one is left behind and to eradicate poverty for all people. Reducing and avoiding the risk of disasters as well as guaranteeing inclusion for all will be necessary to achieve the Sustainable Development Goals. That said, considerations have to be made regarding differences in geographical terrain especially in the global south where environmental conditions alone are enough to inhibit access to healthcare to the disabled. A lot of gaps are still present in the access to healthcare and reproductive services by women with disabilities across the globe and these need to be explored. Nevertheless, despite the ADA’s efforts, there are still a lot of obstacles that prevent persons with disabilities from exercising their freedom of reproductive and sexual health rights (Long-Bellil, 2022). There are still preconceived notions that people with disabilities are asexual, incapable of giving informed permission for sexual activity, and unfit to parent effectively or sustain a pregnancy to maturity. For certain disabled people, there are extra obstacles in the form of inadequate transportation, physically inaccessible locations, and equipment like examination tables (ibid). People with disabilities were more likely than those without disabilities to have encountered hurdles when trying to get reproductive health care (69.0% vs. 43.0%). The most common barriers were access (49.9%) and logistical (50.7%) (Biggs et al., 2023). In Europe, about 101 million persons, or 27% of the European Union’s population over the age of 16, were estimated to have a disability in 2022 (European Council, 2024). Despite European Union’s efforts, there are still obstacles in the way of many disabled persons getting access to healthcare. Compared to 18.3% of those without impairments, 28.8% of people with disabilities faced poverty as well as social isolation in 2022. Due to many reasons including cost, location, and lengthy wait periods, the likelihood of unmet healthcare requirements among those with disabilities was four times higher when compared to those without impairments. Furthermore, 17% of people who have impairments experienced violence as victims compared to 8% of persons without impairments (European Council, 2024). While challenges are persistent in developed and in developing countries, it is evident that marginalization of people with disabilities is more prevalent in developing countries. The key challenges revolve around poverty, lack of economic and social inclusion, discrimination, and the disconnect between policy frameworks and actual implementation to improve the lives of people with disabilities. In Asian countries, it was evident that the poverty rate among people with disabilities is greater than that of the overall populace; variations in this percentage among nations range from 3.9% to 20.6% (UN ESCAP, 2021). People with disabilities face a wide range of accessibility requirements; many solely consider physical mobility, ignoring other limitations. In several nations, healthcare and disability benefits for people with disabilities only amount to 30% and 28% of total social protection insurance, respectively (UN ESCAP, 2021). Approximately one-third of children with impairments do not receive early intervention programs, and when they go from primary to secondary school, their enrolment decreases by more than 50% (UN ESCAP, 2021). In addition to facing more work challenges than males, women and girls with disabilities also face limited access to reproductive healthcare. Only 12 nations have passed pertinent anti-discrimination legislation, despite the fact that several have accepted the Convention on the Rights of Persons with Disabilities. In Africa, the issue of healthcare access for individuals with disabilities is multifaceted and impacted by a range of variables as reported by the World Bank (2024). When it comes to getting healthcare, those with disabilities who live in rural locations face more obstacles than those who live in urban areas. For example, Gabon was recorded having 11% living in rural with close to 6% in the urban, Botswana had close to 6% in rural and only 3% in urban. Zimbabwe on the other had had 2% in rural and close to 1% in the urban (World Bank, 2024). Significant barriers include the distance from remote areas to healthcare facilities and the lack of funding for such travel. Disability rates are higher among women than among males. For example, Lesotho had close to 9% females with close to 4% males. However, differences were not much significant in Zimbabwe (World Bank 2024). Disability rates are greater among women due in part to disparities in rights and precautions. Many low-income families may decide to put their male children’s economic prospects first, putting their health first. More impairments are reported by older adults. Insufficient availability of healthcare can worsen over time in addition to limits on movement, aging-related changes in vision and hearing, and difficulties focusing. Individuals who are disabled tend to have less schooling. Children with disabilities leave the public school system at a faster pace than their classmates without impairments because schools frequently lack facilities to accommodate them. For people with disabilities, entering the workforce presents additional difficulties. The degree of a handicap increases the barriers to accessing healthcare. The quality of care is hindered by a lack of patient-centeredness. Patients are marginalized during clinical encounters due to poor communication. 1.3 Statement of the Problem Zimbabwe’s peri-urban communities struggle with access to reproductive services and other healthcare issues. Weaknesses in Primary Healthcare Delivery is one of the issues. The primary healthcare delivery systems are frequently inadequate, particularly those that serve peri-urban areas. Due to this, the majority of people (especially women) are forced to seek care in central hospitals, which require accessing transport in order to access healthcare. This may not be as easy for disabled women who may already face mobility challenges owing to the nature of their disabilities (UNICEF, 2022). There are fewer alternatives for women with disabilities to get basic healthcare services closer to their homes since peri-urban areas lack effective primary healthcare facilities. They may find it more difficult and time-consuming to go to central hospitals, which might not be as accessible or sensitive to their unique needs, as a result. Furthermore, Zimbabwe’s peri-urban areas frequently lack resources that provide ease of access to the blind and immobile. In some cases, their disabilities may also hinder communication as health personnel may not be trained to communicate in sign language thus making it harder to access accurate medical attention. Moreover, youths and adolescents in these areas frequently lack access to essential services related to sexual and reproductive health, including family planning, counseling, psycho-social support, and information on SRH. The problem is even worse when the youths are also disabled as it now presents multiple challenges that hinder easy access to healthcare. This may result in higher prevalence of HIV, STIs, and unintended pregnancies. The healthcare personnel themselves may not even recognize that the disabled women and youths require the same services provided to non-disabled persons hence worsening their predicament in accessing treatment and information. In addition, the existence of negative perceptions of health personnel towards women with disabilities coupled with disability-unfriendly infrastructure at the health facilities has greatly inhibited access to these health facilities for the disabled. Moreover, the absence of personnel skilled in sign language has also presented a challenge for the deaf and mute women wishing to access reproductive healthcare. Based on this information, it becomes necessary to further research so as to find out if any adjustments have been made to improve access of reproductive healthcare services to special groups such as that of disabled women in particular. The government itself has also failed to promote those policies which facilitate access to sexual and reproductive services by women with disabilities. 1.4 Research Objectives 1.4.1 Main Research Objective The main aim of the study was to investigate the access to healthcare and reproductive services by women with disabilities in Harare peri-urban 1.4.2 Secondary Research Objectives The secondary research objectives of the study were: To examine the extent of utilization of reproductive health services by women with disabilities in Harare peri-urban To determine the barriers to access of healthcare and reproductive services by women with disabilities in Harare peri-urban To determine the enablers of access of healthcare and reproductive services by women with disabilities in Harare peri-urban To assess the effectiveness of existing initiatives designed to improve healthcare and reproductive services access for women with disabilities 1.5 Research Questions 1.5.1 Main Research Question Why is access to healthcare and reproductive services by women with disabilities still limited? 1.5.2 Secondary Research Questions Secondary research questions of the study were: To what extent are reproductive health services utilized by women with disabilities in the peri-urban areas of Harare? What are the barriers that women with disabilities in the peri-urban areas of Harare face in accessing healthcare and reproductive services? What are the enablers that facilitate access to healthcare and reproductive services for women with disabilities in the peri-urban areas of Harare? How effective are the existing initiatives designed to improve healthcare and reproductive services access for women with disabilities? 1.6 Significance of the Study The successful conduct of the study realized benefits to various stakeholder groups as discussed below. Engaging the key stakeholders throughout the research process ensured that the study’s findings were relevant to drive positive change towards access to healthcare and reproductive service landscape for women with disabilities in the Harare peri-urban area. 1.6.1 Significance to Practice The study served as an opportunity for women with disabilities to directly share the lived experiences, challenges, and needs in relation to access to healthcare and reproductive services. The study shared insights to women with disabilities in advocating more effectively for their rights as well as improved access to healthcare and reproductive services. This helped empower them in making informed decisions concerning their health and wellness. The study was also significant to disability rights organisations and advocacy groups such as the Jairos Jiri Association and the National Association Agency for Disability and other various disability-focused non-governmental organizations (NGOs). The study’s insights and recommendations helped such organisations in strengthening their advocacy efforts. This was possible through the provided evidence in supporting their demand for more inclusive and accessible healthcare systems. Ultimately, this enhanced capacity to represent the specific healthcare and reproductive service needs of women with disabilities. The organizations can leverage the study’s findings to collaborate on the development of targeted interventions and policies. The study was also relevant to healthcare professionals through the study’s recommendations for improving the accessibility and responsiveness of their services. The study advocated for tailored training programs that can enhance disability-inclusive practices of healthcare providers. The study further informs healthcare facilities to make the necessary operational changes to cater to the unique needs of women with disabilities. Advocating for the improvement of accessibility to quality of healthcare services though such facilities can contribute to increased utilization and better health outcomes for women with disabilities. Policymakers at the national and local government levels, such as the Ministry of Health and Child Care and the Harare City Council, can be informed about the existing gaps and barriers in healthcare and reproductive service access for women with disabilities. The study’s recommendations can guide the development and implementation of inclusive programs, and resource allocation to address accessibility disparities. Government authorities can use the evidence to evaluate the effectiveness of existing initiatives, as well as to inform the design of new, targeted interventions to improve healthcare access and outcomes for this population. International development organizations, and other donors can use the study’s evidence for informing their funding priorities and program design. The insights generated can allocation resources more effectively, targeting areas and interventions that are most likely to improve the accessibility and utilization of healthcare and reproductive services for women with disabilities. Donor organizations can also leverage the study’s findings to advocate for increased investment and prioritization of disability-inclusive healthcare programs within the broader development agenda in Zimbabwe. The study is very important for several Sustainable Development Goals (SDGs). First, it directly addresses SDG 3 which is focused on good health and well-being. This is because improving access to important healthcare services is fundamental to the overall health and well-being of women with disabilities. The focus on differences in access between men and women aligns with SDG 5 on achieving equality between men and women. This is because the study examines the unique challenges faced by women with disabilities in this area. Additionally, the research done in the area around Harare can provide important insights to help make cities and communities more inclusive and accessible for people with disabilities. This links to SDG 11 on building sustainable cities and communities. 1.6.2 Significance to Academia The study adds to literature by providing evidence on access to healthcare and reproductive services by women with disabilities in Harare’s peri-urban areas. This adds to literature in the context of marginalized societies in developing communities. The study further builds upon the Andersen and Newman Framework, thereby testing the model’s applicability in unique Zimbabwean context such as the Harare’s peri-urban areas. 1.7 Limitations The study encountered the following limitations: The study was conducted in Domboshava and Goromonzi rural only. This limited full inclusion of other rural communities in Zimbabwe. However, this limitation was overcome by a thorough literature review that presented the findings of other studies that were conducted in other rural contexts in Zimbabwe. Another limitation was that the study was cross-sectional, and it focused on data collected in early 2024. A longitudinal design would have provided a broader perspective on how access to healthcare have evolved. To overcome the limitation, the background of the study together with literature examined the trends of healthcare access for various time periods overcoming the limitation. 1.8 Delimitations The study was delimited by concepts, theory, geographical boundaries, as well as methodological scope: 1.8.1 Conceptual Delimitations The study was delimited to the concepts of access to healthcare services, access to reproductive services, women with disabilities, and any other related concepts. 1.8.2 Theoretical Delimitations The study relied on the Andersen and Newman Framework for health services utilization as the theoretical framework of the study. The Health Belief Model as well as the Social Cognitive theory were however used as supporting theories. These were chosen due to their relevance to the study in explaining enablers, and barriers to accessing healthcare and reproductive services. However, reference was made to other theories to explain findings. 1.8.3 Geographical Scope The study was delimited within the Zimbabwean context with a focus on Harare’s peri-urban areas for data collection. More specifically, the areas considered were Domboshava and Goromonzi rural communities. Such areas were noted by the UNICEF (2022) as having weak primary healthcare services and facilities. Furthermore, people travel very long distances to access essential services such as health services. This justified their selection in the study so as to understand how women with disabilities coped in such contexts. 1.8.4 Time Delimitations The study was cross-sectional, and data collection was conducted in early 2024. Empirical literature focused on studies published from 2018 so as capture emerging findings on access to healthcare and reproductive services by women with disabilities. However, theoretical literature was not delimited by time. 1.8.5 Methodological Delimitations The study was qualitative by nature grounded in the interpretivist research philosophy. The population of the study consisted of all the women with disabilities in Domboshava and Goromonzi. 1.9 Dissertation Outline The dissertation is organised in five chapters. Chapter 1 serves as an introduction to the study, offering a background and context for the research. It defines the research problem and identifies the research objectives and questions. Additionally, it provides a justification for undertaking the research. Chapter 2 focuses on reviewing relevant literature and previous work conducted by other scholars in the field. This section aims to provide a comprehensive understanding of the existing knowledge and research gaps. Chapter 3 outlines the methodology and philosophical approach adopted in the research. It discusses various aspects such as sampling methods and data collection techniques that were employed during the research exercise. Chapter 4 presents and discusses the research findings and results obtained from the study. Finally, Chapter 5 summarizes the study by drawing upon the results presented in Chapter 4. It includes concluding remarks, managerial recommendations, and suggestions for future research that can build upon the findings of the current study. 1.10 Definition of Key Terms The following the study’s key terms and how they were used in the study: Disability - a condition that substantially restricts an individual's physical, mental, cognitive, or sensory abilities, which can hinder their ability to carry out tasks, engage in activities, or take part in everyday life (CDC, 2024). Access to Healthcare Services - the capacity of individuals to access timely, affordable, and suitable medical care as required (Levesque et al., 2013).  Access to Reproductive Services - the accessibility and cost-effectiveness of medical care pertaining to reproductive health (Levesque et al., 2013). Women with Disabilities - individuals who identify as female and experience chronic physical, mental, intellectual, or sensory disabilities. 1.11 Chapter Summary The chapter introduced the study aimed at investigating access to healthcare and reproductive services for women with disabilities in Domboshava and Goromonzi. The research objectives and questions have been presented together with significance of the study, delimitations, as well as other key aspects. Aim was to solve problems pertaining to barriers to health access. The following chapter is a review of literature. CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This chapter is a review of literature on access to healthcare and reproductive services by women with disabilities based on a case of Domboshava and Goromonzi district communities. The chapter contains the theoretic framework that was used to guide analysis of results, theoretical literature that was used in the study to partially address the research questions, as well as empirical literature which was used to compare the studies findings relative to other similar academic studies. 2.1 Theoretical Framework The study adopted the Anderson-Newman model as the core theory supported by the Levesque model as part of the study’s theoretical framework. The Zimbabwe National Disability Policy was also used in the study as part of the theoretical framework. 2.1.1 The Andersen-Newman Model The Andersen Model of Health Service Use (sometimes called the Andersen-Newman Framework), is a theoretical construct designed to comprehend and elucidate the reasons behind people’s utilization of particular health service categories. Andersen first presented the concept in 1968, and he and Newman later built on it in 1973. The concept contends that a person’s propensity, circumstances that facilitate or impede access to amenities, and their need for treatment all influence how they use health services (Chen and Gu, 2021). Figure 2.1 The Andersen Model for Health Services Use Adapted from (Andersen and Newman, 1995) Figure 2.1 illustrates the relationship between the environment, population characteristics, health behaviour, and outcomes. This study employed the Andersen-Newman model to comprehend the factors that influence the utilization of healthcare and reproductive services, as well as the accessibility of these services for women with impairments. The environment and healthcare system are portrayed as influential factors that influence population characteristics, health behaviour, as well as outcomes. The environment could include socio-economic, cultural, and physical aspects, while the healthcare system refers to the structure and resources available for healthcare. Population characteristics are influenced by the environment and the healthcare system. This includes predisposing characteristics, such as genetic factors, age, and gender, as well as enabling resources. These are socio-cultural characteristics of individuals that exist prior to their illness. The need for healthcare service usage, which could be an illness or injury, is influenced by population characteristics. Health behavior is then influenced by this need and is divided into personal health practices, such as diet, exercise, and substance use, as well as the use of health services for prevention, treatment, or management of health conditions. The outcomes of these health behaviors include perceived health status, which is how individuals perceive their own health, evaluated health status, which is a more objective measure of health often assessed by healthcare professionals, and consumer satisfaction, which measures the extent to which the healthcare services meet the patient’s expectations. The Andersen and Newman framework for healthcare utilization has been used in several studies to understand healthcare access. For example, Tang et al., (2021) used the model to understand the determinants of emergency department utilization among older adults. Kwaitana et al., 2023 also applied the Andersen-Newman framework to assess factors affecting access to primary healthcare for older adults in low- and middle-income countries Lastly, (Pujolar et al., 2022) used the framework as a guide to synthesize available knowledge on changes in access to healthcare for non-COVID-19 conditions during the pandemic. These studies demonstrate the continued relevance and application of the Andersen-Newman framework in understanding the determinants of healthcare utilization, particularly among vulnerable populations. Several studies have also applied the model in testing its applicability in assessing access among people with disabilities. For example, Kim and Ho (2023) employed Andersen’s model to investigate factors associated with the lack of health screening among individuals with disabilities. Similarly, Kim et al. (2022) used the model to explore the service demand and awareness for a primary healthcare pilot project targeting this population. Medeiros et al. (2021) applied Andersen’s framework to analyse the use of rehabilitation services by persons with disabilities in Brazil, while Maltais et al. (2020) utilized Andersen’s model to compare healthcare services utilization between people with intellectual disabilities and the general population. Fujiura et al. (2018) also employed the model to investigate health services use and costs for Americans with intellectual and developmental disabilities. Finally, Evans and Randle-Phillips (2018) used Andersen’s framework to systematically review and synthesize the experiences of people with intellectual disabilities in psychological therapy. The studies demonstrate that the model is adjustable to various contexts, and they further demonstrate its applicability in examining healthcare utilization and experiences among people with disabilities. The model’s ability to capture the multifaceted factors influencing service use, its adaptability to different contexts, and its potential to inform policy and practice decisions make it a valuable framework in this study to comprehend the factors that influence the utilization of healthcare and reproductive services, as well as the accessibility of these services for women with impairments in the context of Domboshava and Goromonzi districts. While the model is generally applicable to the study’s context, other scholars criticise the model’s inability to take into account cultural and psychosocial factors (Lerdele et al., 2021). Cultural and psychosocial factors are important in understanding access to healthcare services for women with disabilities because they can significantly influence individuals’ beliefs, attitudes, and behaviors towards healthcare utilization. These factors shape the social context in which women with disabilities navigate and experience the healthcare system, which can create barriers or facilitators to accessing appropriate and responsive care. Additionally, the model is criticized for prioritizing need over social structure and health ideals which limits the ability to explicitly capture the complexities the surround of health service use (Lerdele et al., 2021). To overcome these limitations, the study combined the model with the Levesque’s model described in the following section. 2.1.2 Levesque’s Model The Levesque was developed in 2013 by Levesque, Harris and Patient. It incorporates five related capacities of people and communities such as perceiving, seeking, reaching, paying, and engaging in healthcare (Levesque et al., 2013). It does this by taking into consideration the socioeconomic determinants of a community. Regarding access, the framework can equally consider the viewpoints of medical systems and the consumer (Cu et al., 2021). This is illustrated in figure 2.2 below. Figure 2.2 The Levesque’s Model (Adapted from Levesque et al., 2013 pp.5) Figure 2.2 above shows that Levesque et al (2013) conceptualized accessibility of services by how they are approachable, acceptable, available or how they are accommodating, affordability, as well as how they are appropriate. The top portion illustrates how the five dimensions interact with different specified dimensions. Access is created through the interaction of five related human abilities with the accessibility characteristics. The abilities as shown in bottom part are perception, seeking, reaching, paying, and engagement (Levesque et al., 2013). The framework depicts access as the opportunity to identify healthcare needs, seek healthcare, reach, obtain, and use healthcare services, and have needs fulfilled. Access emerges from the dynamic interaction between the dimensions of accessibility and the corresponding abilities of populations. This conceptualization of access highlights the multidimensional and interactive nature of access, capturing both supply-side and demand-side factors that shape a person’s ability to access and benefit from healthcare services. It provides a comprehensive lens to understand and address barriers to access across different levels, from the health system to the individual. The model enables researchers to investigate impediments to access that result from individuals’ perceptions, searches, reach, payments, or engagements, rather than solely from the shortcomings of the health system (ibid). Access is conceptualised as the capacity to recognize, seek, reach, get, or use healthcare services and to guarantee that the demands for these services are met (Cu et al., 2021). A range of studies have utilized the Levesque et al. (2013)’s model among people with disabilities to explore various aspects of healthcare access and use. For examples, Bright and Kuper (2018) and Hameed et al. (2020) both used the model to examine access to general healthcare services and sexual and reproductive health interventions for people with disabilities in low and middle-income countries, respectively. Casebolt (2020) and Gubbels (2020) applied the model to identify barriers to reproductive health services and to discuss the use of healthcare services by young people with disabilities. Liang et al. (2017) and Lima-Castro et al. (2020) used the model to understand online health information use and health-related quality of life among people with physical disabilities. Lastly, Furlan (2018) and Furlan et al. (2018) utilized the model to compare rehabilitation service models for people with mental and/or physical disabilities in low and middle-income countries. The studies collectively highlight the importance of the Model in understanding and addressing the healthcare needs of people with disabilities. The model was used in this particular study to comprehensively assess the dimensions of accessibility and the abilities of populations in relation to healthcare and reproductive services for women with disabilities. The dimensions of accessibility examined included approachability, acceptability, availability and accommodation, affordability, and appropriateness. The study looked at how well health services and information reach out to and are made known to women with disabilities, whether services and providers are respectful and responsive to their needs and preferences, if there are enough accommodating services available, the financial barriers they face in accessing care, and whether the services provided are relevant and effective in meeting their specific healthcare and reproductive needs. Additionally, the study evaluated the different abilities of the population of women with disabilities. This included their ability to perceive their healthcare needs and the availability of appropriate services, their ability to actively seek out and access services, their ability to physically reach the services based on geographical, organizational, and social factors, their individual and community-level economic resources that affect affordability, and their knowledge, skills, attitudes and autonomy to engage in their own healthcare. 2.1.3 The Zimbabwe National Disability Policy (2021) The Zimbabwe National Disability Policy has been reported as Zimbabwe’s comprehensive framework to promote the full inclusion and active participation of persons with disabilities in the country’s social, economic and political life. The policy aims for inclusive health to people with disabilities through four key policies to people with disabilities in Zimbabwe which are mainly on ethics and rights, service provision, health care settings, as well as orientation of health workers toward people with disabilities (Kuper et al., 2021). In this study, the policy was used to assess the extent to which its policies have been so far implemented especially to marginalised communities such as Domboshava and Goromonzi rural settings. The policy aims to ensure comprehensive and equitable healthcare for people with disabilities. It requires that: People with disabilities have access to both general health services and specialized disability-specific services. Rehabilitation and habilitation programs be available and accessible. Health services in public facilities be provided free of charge to people with disabilities. The quality and standard of care for people with disabilities be on par with that provided to the general population. The policy also has provisions to protect the rights and ethical treatment of people with disabilities in the healthcare system: Discrimination against people with disabilities in healthcare settings is prohibited. Informed consent standards must be upheld for any medical treatment. Additionally, the policy sets goals to: Increase the representation of people with disabilities among health profession students to 15%. Ensure healthcare workers receive training on disability-related issues. Make healthcare facilities, services, and public health initiatives accessible and locally available for people with disabilities. These policies were used in this study as a benchmark of assessment on the extent to which its policies have been so far implemented especially to marginalised communities such as Domboshava and Goromonzi rural settings. 2.2 Conceptual Framework Figure 2.3 below shows the schematic representation of interaction between barriers and enablers of health and reproductive services use by people with disabilities. Figure 2.3 Conceptual Framework (Modified from Andersen-Newman and Levesque et al., 2013 models) The study’s conceptual framework on the use of health and reproductive services by women with disabilities is based on Andersen-Newman and Levesque’s models. The models have been merged to overcome the limitations of either model. Figure 2.3 further shows that the model incorporated the Zimbabwe’s National Disability Policy to assess the extent to which it is facilitating or hindering the use of health and reproductive services by women with disabilities in Domboshava and Goromonzi. The Andersen model has been modified to be specific on how health systems may hinder or enable facilitation through Levesque’s conceptualisation of access. The same has also been done with predisposition factors. 2.3 Reproductive and Health Services Utilization by Women with Disabilities in Marginalised Communities Healthcare utilization refers to the consumption of healthcare services, procedures, devices, or pharmaceutical drugs to maintain health and wellbeing, prevent and treat health issues, or obtain information about health status and prognosis (Carrasquillo 2013). It can be categorized as discretionary or non-discretionary based on who (the patient or provider) controls the decision to use the service. For instance, if an individual decides to visit an emergency department, it is discretionary, whereas a provider deciding to admit a patient to a hospital is non-discretionary (Mkanta and Uphold 2006). Operational definitions of healthcare utilization vary, often including the number of outpatient visits, hospital admissions, length of hospital stays, emergency visits, prescription drug use, and associated costs (Corrao and Mancia 2015). Healthcare utilization involves complex behaviors influenced by various factors beyond health and illness. Sociodemographic characteristics, culture, economics, personality, perceptions, access to services, attitudes, beliefs, and social roles all affect decisions to seek healthcare, the types and volumes of services used, and health outcomes (Linden et al. 1997). Additionally, significant structural differences between healthcare systems in different regions limit generalizations about healthcare utilization across systems (Welzel et al. 2017). The Andersen model as well as the Levesque model may explain why there is much utilisation from people with disabilities. From the Andersen Behavioral Model perspective, disability status is a key predisposing factor that can increase an individual’s propensity to use healthcare services, as they may have a greater perceived need for care. Furthermore, based on need factors, individuals with disabilities typically have greater levels of perceived and evaluated need for healthcare services to manage their condition, impairments, and any related complications. This may drive use of services. However, they may have limited access due to enabling resources. Factors like insurance coverage, income, and access to transportation that facilitate or hinder service utilization may differ for people with disabilities. The Levesque’s model depicts access to healthcare as the opportunity to identify healthcare needs, seek healthcare, reach and obtain services, and have those needs fulfilled. People with disabilities may be more likely to utilize healthcare services in some ways, but could also face barriers that make it more difficult for them to fully access and utilize services. Individuals with disabilities have been reported as generally having higher rates of healthcare utilization compared to those without disabilities. Stransky et al. (2018) revealed that adults with communication disabilities were more likely to have chronic conditions, report fair or poor health, and use healthcare services more frequently. Furthermore, the systematic review by Bright and Kuper (2018) found that people with disabilities tended to use healthcare services more and had higher healthcare expenditures. Similarly, the study by Maltais et al. (2020) found that people with intellectual disabilities used some healthcare services, such as general medicine, psychiatry, and PSA blood tests, more than the general population, while they accessed services like optometry, physiotherapy, and Pap tests significantly less. Finally, the study by Verlenden et al. (2021) indicated that young adults with disabilities were more likely to visit the emergency room, delay medical care due to cost, and have unmet medical needs compared to their non-disabled counterparts. However, they were also more likely to have a usual source of care when sick (Verlenden et al., 2021). The utilisation of reproductive services by women with disabilities in marginalised communities has however produced mixed evidence. Some studies suggest that people with disabilities seek more reproductive services due to greater needs and higher odds of receiving certain types of care, while other studies indicate they face barriers and are less likely to seek infertility-related care. For example, Ha and Martinez (2021) discovered that women with disabilities had a higher likelihood of experiencing infertility and were less inclined to seek reproductive care for this issue. Similarly, a study by Mahmood et al. (2022) in Pakistan found that women with disabilities were less likely to utilize skilled antenatal care, skilled birth attendance, and skilled postnatal care. In contrast, a scoping review by Bhattarai et al. (2023) found that people with disabilities in Nepal were seeking sexual and reproductive healthcare, but faced multiple barriers in accessing these services. In contrast, a study by Obasi et al. (2019) found that the majority of students with disabilities in Ghana had good knowledge of sexual and reproductive health. This indicates a general awareness and interest in reproductive health among this population, which could translate to higher utilization of service. 2.4 The Enablers of Access to Healthcare and Reproductive Services by Women with Disabilities Access has been conceptualized in different ways by models of healthcare access. The Andersens’ Model regards access as a combination of healthcare need, enablers and obstructing variables to utilization, and the propensity to utilize medical services (Chen and Gu, 2021). Access is conceptualised in Penchansky-Thomas’ model as a “match” between users’ requirements and healthcare institutions’ capabilities (Zandam et al., 2017). Another often used theory is the Frenk’s Model which characterizes access as the capacity of the population to seek and then get care. In addition, Frenk’s paradigm evaluates the effectiveness of health systems and cites resistance, usage power, and resource availability as access factors (Bally and Cesuroglu, 2020). The study however relied on the comprehensive conceptualisation of access from the Levesque’s model. Levesque et al (2013) conceptualized accessibility of services by how they are approachable, acceptable, available or how they are accommodating, affordability, as well as how they are appropriate. The Levesque framework depicts access as the opportunity to identify healthcare needs, seek healthcare, reach, obtain, and use healthcare services, and have needs fulfilled (Cu et al., 2021). From this perspective, access emerges from the dynamic interaction between the dimensions of accessibility and the corresponding abilities of populations (Levesque et al., 2013). This conceptualization of access highlights the multidimensional and interactive nature of access, capturing both supply-side and demand-side factors that shape a person’s ability to access and benefit from healthcare services. It provides a comprehensive lens to understand and address barriers to access across different levels, from the health system to the individual (Cu et al., 2021). The model depiction of access enables this study to investigate impediments to access that result from individuals’ perceptions, searches, reach, payments, or engagements, rather than solely from the shortcomings of the health system. 2.4.1 Approachability The concept of approachability pertains to the capacity of individuals with health challenges to recognize that there are resources available, that they may be accessed, and that these services can affect their own health (Levesque et al., 2013). Services might become more or less well-known within certain social or physical demographics. The degree of approachability of the services can be affected by a number of factors, including outreach initiatives, openness, and knowledge about treatments and services that are offered (Levesque et al., 2013). In addition to the idea of services being approachable, the idea of a population’s capacity to recognize the need for service is also important and is influenced by things like health understanding, medical knowledge, and attitudes about health and illness (Levesque et al., 2013). Research indicates that outreach initiatives, such as mobile healthcare services and community-based programs, can successfully reach and provide services to people with disabilities living in rural and marginalized areas, potentially improving their utilization of essential healthcare. For example, Trotignon et al. (2022) found that the Sightsavers eye health outreach program in Kasungu district, Malawi successfully reached people with disabilities, with 27.5% of participants reporting a functional disability (Trotignon et al., 2022). The study also showed that the program reached the poorest individuals, with 9% of participants belonging to the poorest wealth quintile compared to 4% in the general population. Their observation was comparable to the one they observed in 2020. Trotignon et al. (2020) found that program had reached individuals with non-visual disabilities, with the functional disability rate among participants being significantly higher than the general population. In South Africa, Morris-Paxton et al. (2020) found that mobile healthcare services supported by NGOs can improve healthcare access in remote rural areas by increasing patient numbers and services. This suggests that outreach initiatives, particularly those involving mobile services, can help address barriers to healthcare utilization faced by people with disabilities in rural and marginalized communities. In support of the Levesque’s model, studies have also shown that the level of transparency in healthcare providers significantly impacts the utilization of healthcare services by individuals with disabilities. Both Ferrara et al (2023) and Barredo-Ibáñez et al (2022) emphasize that transparency in healthcare institutions plays a crucial role in preventing corruption, enhancing accountability, and influencing healthcare expenditure containment which transalates to utilisation. Furthermore, the involvement of the State in healthcare systems was associated with greater access to information and social responsibility, particularly in public healthcare systems which improved access and use (Koch, 2023). However, challenges exist in assessing healthcare quality transparently and effectively, with concerns that public quality reporting may not necessarily improve the quality of care (Timofeyev et al., 2022). In the context of Russia, limited transparency in the healthcare system hindered the potential benefits of transparency-driven outcomes, highlighting the importance of improving information accessibility to enhance healthcare efficiency (Alic and Luic, 2022). Overall, transparency in healthcare providers is crucial for individuals with disabilities to make informed decisions and access quality healthcare services. 2.4.2 Acceptability Acceptability is related to socio-cultural elements that influence individual capacity to tolerate certain features of the service (such as the gender or socioeconomic status of those providing it, the beliefs underlying medical institutions), as well as when it is seen proper for them to seek medical attention. For instance, if the majority of medical professionals are men, any culture that prohibits random physical interaction between single men and women will lessen the acceptance of care and the willingness of women to look for it out. Certain services might not be appropriate to certain segments of the community they are meant to serve because of its unfair organizational structure. The ideas of personal self-determination, the capacity to make the decision to seek treatment, awareness of available options, and personal liberties all play a role in one’s ability to express the desire to seek medical attention. One excellent example would be the prejudice against women in initiating care, or the mistreatment and abuse that deters members of ethnic minorities from seeking care. This has to do with the difficulty of making sure that care satisfies the requirements of many at risk, socioeconomically marginalized, and cultural groups. This is a significant difficulty since various groups may evaluate suitability and quality in different ways. According to research, several key factors drive the acceptance of health services by people with disabilities. Environmental and personal factors interact with an individual’s impairment and levels of participation and inclusion in community structures, which contributes to the uptake of health services (Zuurmond et al., 2019). Barriers to accessing primary healthcare services for people with disabilities stem from a complex and dynamic interacting system between attitudinal and belief system barriers, informational barriers, and practical and logistical barriers (Hashemi et al., 2020). People with disabilities experience more dimensional barriers and report poor health system accessibility (Zandam & Juni, 2019). Socioeconomic factors, such as current health policies and services not adequately considering the needs of persons with disabilities, hinder access to healthcare (Howard & Rhule, 2021). Healthcare provider attitudes and perceptions of disability may also influence the delivery of comprehensive quality care to patients with disabilities (Acheampong et al., 2021). Social, physical, and attitudinal factors are key hindrances to the health outcomes of disabled people (Mitchell et al., 2021). Disabled persons have difficulty accessing health services and cannot benefit from rehabilitation services (Arca & Saka, 2019). Chronic disease and an unmet need for medical care were key determinants of service demand for a primary healthcare pilot project for people with disabilities (Kim et al., 2022). Gender was also found in literature to affect acceptance of medical and reproductive health systems. McKenzie and Findley (2021) found that older male individuals with cognitive impairments were less likely to utilize physician and dental services compared to their female counterparts, with factors such as lower household income, lack of health insurance coverage, and lower educational attainment acting as structural barriers limiting their access. Similarly, Progovac et al. (2018) found that gender minority Medicare beneficiaries (individuals who were transgender or gender non-binary) experienced more disability, mental illness, and higher use of mental health care services, and were also more likely to be hospitalized and visit the emergency department compared to non-gender minority beneficiaries. The disparities in healthcare utilization are not limited to older adults and mental health services, as Shiwakoti et al. (2020) found that for women with disabilities in Ilam district, Nepal, utilization of sexual and reproductive health (SRH) services was very low, influenced by factors such as illiteracy, low economic status, lack of disability-friendly environments, and perceptions that SRH services were only needed for married individuals. Furthermore, Tarannum et al. (2022) found that female patients with inflammatory arthritis were more likely to visit rheumatologists and family physicians, and undergo more imaging and laboratory tests before diagnosis, compared to male patients. These findings highlight the importance of addressing gender-based inequities in healthcare access and utilization for individuals with disabilities, and the need for healthcare systems to adopt a more inclusive and holistic approach to meeting the diverse healthcare needs. 2.4.3 Availability and Accommodation The terms “availability and accommodation” describe the capacity to directly and promptly access medical services (i.e., the physical location or those employed in health care professions). The tangible presence of medical supplies with the capability to provide care (such as., the presence of operational infrastructures) is what is referred to as availability. It arises from features of urban environments (decentralization, urban dispersion, transportation service), of amenities (the density, concentration, dissemination, site access), and of people (length and suppleness of working times). It also has to do with the qualities of service providers (like their qualifications and availability as health professionals) and the ways in which services are delivered (like the way in which contacts are made and the availability of online consultations). If amenities are dispersed disproportionately all over a nation or among care levels (specialist care established at the cost of primary care), access is constrained. The concepts of interpersonal movement, the accessibility of transport, vocational pliability, and information about medical facilities that would allow one to travel to the suppliers are all related to one’s capacity to get health care. Some instances of this would include the elderly and disabled’s limited mobility or temporary employees’ incapacity to take time off to see a doctor. The location of healthcare facilities, infrastructure accessibility, and transportation options significantly impact the ability of women with disabilities to access essential maternal and reproductive health services, contributing to healthcare disparities in this vulnerable population. For example, Devkota et al. (2018) found that the majority of women with and without disabilities in rural Nepal reported that the nearest health facility was more than 30 minutes walking distance, indicating poor geographic accessibility (Devkota et al., 2018). The distribution of health facilities was also found to be uneven and poorly linked with road transportation, further limiting access for women with disabilities (Devkota et al., 2018). Shiwakoti et al. (2020) reported that the majority of women with disabilities in Ilam district, Nepal stated that the nearest health facility was not disability-friendly, with issues related to road access and infrastructure (Shiwakoti et al., 2020). Qualitative findings from this study revealed that the lack of a disability-friendly environment, including distant health facilities and inaccessible infrastructure, were major barriers to utilization of sexual and reproductive health services among this population (Shiwakoti et al., 2020). Additionally, Kalpakjian et al. (2020) highlighted that barriers in the built environment, along with limited disability competency of healthcare providers, compromise access to and quality of reproductive healthcare for women with physical disabilities (Kalpakjian et al., 2020). These studies generally prove relevance of the availability and accommodation in the context of the study considering that women in developing contexts may face similar challenges. The challenges further exacerbate for women with disabilities. 2.4.4 Affordability The capacity of a person to pay for the resources they require and time to access services that are acceptable is reflected in affordability. It stems from the opportunities associated with revenue loss as well as direct service charges and associated expenditures. Additionally, it might differ based on the kind of services provided and the ability to get the funds necessary for paying for the treatment (for example, payment method, resource mobilization). Utilization framework economic investigations need the use of factors like medical expenses, transportation time and associated opportunity costs, client revenue, subjective care quality, practitioner behavior, and so forth Such frameworks provide insightful data on the responsiveness of demand for several categories of healthcare services. The idea of ability for paying for medical care is often utilized in research on health services. It refers to the ability to create enough money, through earnings, investments, or loans, to cover the cost of medical treatment without having to sell up a property or use up all of the resources needed for fundamental needs. Some issues that limit people’s ability to pay for necessary treatment include social exclusion, poverty, and debt. Affordability is an important enabler for people with disabilities to access healthcare and other essential services. Several studies have highlighted the role of affordability in facilitating access and improving outcomes for this population. For example, Burns et al. (2021) emphasized that the housing affordability crisis had disproportionately affected people with disabilities, and argued that government and housing organizations needed to support affordability, quality, and accessibility to address this issue. Similarly, Sirotina et al. (2020) found that improving the affordability of services in assisted living facilities was crucial for ensuring consistency with requirements and addressing key problem areas for persons with disabilities. Furthermore, Zhang and Mui (2020) noted that rural elders in China faced higher extra health and health-related costs due to chronic diseases and disabilities, suggesting a need for support to manage these conditions and enable access to necessary care. Madden et al. (2021) also highlighted the prevalence of unaffordable medical care among Medicare enrollees, leading to care avoidance and financial strains, particularly for the most vulnerable patients. These studies demonstrate that affordability is a critical enabler for people with disabilities to access healthcare, housing, and other essential services, and that addressing affordability barriers can significantly improve outcomes and support the inclusion and well-being of people with disabilities. 2.4.5 Appropriateness Appropriateness refers to how well services match the needs of the customers, how quickly they are offered, how much time is spent evaluating health issues and choosing the best course of action, and how well the services are delivered both technically and interpersonally. The suitability, quality, and incorporated, ongoing aspect of health care are all factors in a system’s adequacy. What one possesses in terms of medical services and products counts, as does their efficacy. In this sense, having the option to use only subpar services is viewed as restricting access to medical treatment. It is not appropriate for someone to only have access to medical services based on factors like cost, accessibility within an organization, and geography; access should also include the opportunity to select appropriate and efficient treatments. A person’s ability to use inexperienced practitioners’ offerings (such as n’angas, exorcists or herbalists) cannot be compared to a more fortunate individual’s ability to use highly specialized services if the latter result in various medical results or levels of satisfaction with the services. It is not possible to see the use of services with intrinsically differentiating technological features receiving the same appropriate treatment, either by using various provider groups or by using alternative prescribing procedures. Lastly, the patient’s involvement and engagement in treatment choices would be related to their ability to receive medical services, and this is greatly influenced by their capacity and willingness to devote themselves to the finalisation of their care. Customised health services facilities are highly important for people with disabilities. The research highlights the critical importance of tailored health services facilities for people with disabilities. Van Rooijen et al. (2022) found that cocreated tailored implementation strategies in Dutch disability care organizations successfully improved the use and integration of patient-reported experience measures, leading to improved care quality. Moreover, Groenewegen et al. (2021) found that physical accessibility of general practictioner practices varies greatly between countries, with national policies playing a key role in improving accessibility for people with disabilities. Additionally, Rathmann et al. (2020) found that organizational health literacy in facilities for people with disabilities is below-average, with a need for improved navigation and targeted health information development. Furthermore, Hogan (2020) found that the Missing Billion report highlights the need for universal design approaches in healthcare to improve access and quality for people with disabilities, benefiting all. Importantly, Khera (2023) found that inclusive practices, such as barrier-free facilities and assistive technologies, are crucial for promoting equal healthcare opportunities for people with disabilities. In the same vein, Havercamp et al. (2020) found that a national consensus on disability competencies for healthcare education has been developed, ensuring a disability-competent workforce that provides accessible, patient-centered, and quality care to patients with disabilities. Interestingly, Awang et al. (2021) found that persons with disabilities in Malaysia perceive a need for improvements in accessibility, comfort, safety, communication, signage, and staff responsiveness in facilities management. Additionally, Palazzolo et al. (2023) found that a tailored primary care approach for people with physical disabilities could reduce preventable morbidity and improve functioning. Finally, Elisei et al. (2021) found that the Seraphic Institute’s project aims to improve healthcare accessibility for people with complex disabilities by adapting healthcare offers and implementing a proximity service. 2.5 Barriers Faced by Women with Disabilities from Accessing Healthcare and Reproductive Services 2.5.1 Lack of Transparent Information If information about available services, treatments, and eligibility is not clear, easy to find, or presented in accessible formats, people with disabilities may simply be unaware of what resources are available to them. This can prevent them from even seeking care in the first place. Information can be a significant barrier to health services access for people with disabilities in several ways. The quality of care can be impeded by a lack of patient-centeredness (Disability Evidence Organisation, 2020). This means that the healthcare system may not be designed to meet the specific information needs of people with disabilities, which can lead to inadequate care (Hamilton et al., 2020). Furthermore, communication barriers can marginalize patients within the clinical encounter (Hamilton et al., 2020). For example, healthcare providers may not know how to effectively communicate with people with disabilities, or they may have negative attitudes towards disability (Disability Evidence Organisation, 2020). This can lead to misunderstandings and a lack of trust, which can discourage people with disabilities from seeking care (Alderwick and Gottlieb, 2019). In the digital age, access to information about health and health services is increasingly important. However, people with disabilities often face barriers such as affordability of services and devices, limited digital skills, and content not available in an accessible format (UNHCR, 2021). Scholars generally agree that the lack of access to information significantly hinders the utilization of health services by individuals with disabilities. According to Soule and Sonko (2022), people with disabilities face various barriers when trying to access healthcare services, including communication failures, financial limitations, attitudinal/behavioral issues, and organizational barriers. Additionally, Newman-Griffis et al. (2022) found that individuals with disabilities disproportionately experience negative health outcomes due to a lack of holistic information on individual function, environmental factors, and personal factors systematically collected in current practice. In the context of women, Robinson-Whelen et al. (2023) noted that women with physical disabilities often find seeking online health information difficult and frustrating, with concerns about the quality of information available. Moreover, individuals with intellectual disabilities encountered challenges in acquiring essential health information, highlighting the need for improved communication strategies and the involvement of healthcare providers in developing appropriate resources (Dam et al., 2022). The information barrier is also widened by the digital divide. Research indicates that individuals with impairments face challenges in using eHealth services, with communication, language, and intellectual impairments reporting the least use and most difficulty (Petersson et al., 2023). Older adults with disabilities who do not use the internet were more likely to experience difficulties in acquiring health resources, especially during the COVID-19 pandemic (Yang et al., 2022). Furthermore, the digital exclusion faced by people with severe mental illness places them at risk of heightened inequalities (Spanakis et al., 2021). Additionally, the lack of web accessibility features on health websites further hinders individuals with disabilities from accessing crucial health information (Mason et al., 2021). Efforts to bridge the digital divide through tailored technological support, education programs, and assistive technologies are crucial to ensure equitable access to health services for people with disabilities (Meshcheryakova and Rogotneva, 2021). 2.5.2 Lack of Outreach and engagement: Without proactive efforts by health services to connect with disability communities and understand their specific needs, the services offered may not align well with the requirements of people with disabilities. This can discourage them from engaging with the healthcare system. The lack of professional engagement with people with disabilities has been identified as a key barrier to the utilization of health services by this population, as evidenced by several studies. Edwards et al. (2018) found that inadequate physical health skills (assessment, monitoring) of healthcare professionals working in intellectual disabilities is a significant barrier to providing equitable care for this group. Their review highlighted the need for quality improvement initiatives to improve the physical health training of healthcare professionals who work with people with intellectual disabilities (Edwards et al., 2018). Similarly, Maltais et al. (2020) reported that people with intellectual disabilities accessed some healthcare services at significantly lower frequencies compared to the general population. Sakellariou and Rotarou (2020) emphasized that direct and indirect discrimination against people with disabilities can lead to increased barriers to accessing healthcare, including reduced use of cancer screening services. They noted that a lack of disability inclusiveness in the provision of healthcare services, as well as inadequate training of healthcare professionals, contributes to these disparities. Lawson (2022) argued that the underrepresentation of people with disabilities within the healthcare workforce and medical professions is a significant issue, as it limits the ability of the healthcare system to provide disability-affirming care and research. Outreach and engagement to people with disabilities in rural and marginalized communities faces various challenges, as highlighted in the research. Challenges include the lack of community resources, societal stigmatization, discrimination, and difficulties in implementing help-seeking behaviors (Gonzalez, 2023; Other et al., 2022). Additionally, there are disparities in the quality of life between rural and urban areas, with caregivers often assuming greater responsibility for empowering individuals with disabilities in rural settings (Rose et al., 2023). Negative cultural beliefs regarding the causes of disabilities, such as punishment by gods or witchcraft, further compound the challenges faced by young children with disabilities in rural communities, impacting their access to early childhood development education services (Nkomo et al., 2021). 2.5.3 Physical Inaccessibility If health facilities, equipment, and environments are not physically accessible, it can create significant barriers for people with mobility, sensory, or other physical impairments. This can deter them from seeking care or make the process extremely difficult. Geography presents significant barriers to people with disabilities in various ways. Firstly, rural and frontier communities generally face transportation challenges due to geographical attributes, impacting individuals with disabilities’ mobility and access to services (Fortune et al., 2022). Additionally, urban environments often lack accessibility features, making streets, public transport, and workplaces difficult to navigate for individuals with disabilities, further hindering their participation and inclusion (Arenas et al., 2020). Moreover, the design of cities primarily caters to able-bodied individuals, creating physical and social barriers for people with disabilities, affecting their daily experiences and opportunities for employment and social engagement (Ysasi et., 2018; Ugalde et al., 2022). Furthermore, the concentration of rehabilitation services in areas with lower disability prevalence results in poorer access for regions with higher disability prevalence, highlighting geographical disparities in access to essential services for individuals with profound or severe disabilities (Gao et al., 2019). In relation to health access, the lack of fine-scale spatial data and individual patient records generally limits the precise understanding of how community health workers can mitigate geographic isolation (Evans et al., 2022). Additionally, geographical inaccessibility to health facilities remains a primary challenge, with over three-quarters of the population living more than an hour away from a primary health care center and vulnerable populations facing poor geographical access to both primary health care center s and community health sites (Zeni et al., 2020). These barriers, compounded by physical, economic, and infrastructural challenges, contribute to the invisibility of people with disabilities in rural settings, hindering their access to comprehensive and equitable healthcare services (Ihantamalala et al., 2020). 2.5.4 Communication Accessibility If health services do not provide accommodations for different communication needs, such as sign language interpretation or easy-to-understand language, people with disabilities may struggle to effectively communicate with providers, understand their health information, and participate in their own care. Communication serves as a significant barrier for people with disabilities across various contexts. Research highlights that ineffective and disrespectful communication from health and social care professionals can hinder access to necessary services for individuals with learning disabilities (Badcock and Sakellariou, 2022). Similarly, individuals with intellectual and developmental disabilities face barriers in perinatal care due to lack of policies, provider experience, and ableism, underscoring the importance of tailored communication and supportive providers (Saeed et al., 2022). Furthermore, societal and psychological barriers, such as fear, isolation, and incommunicability, contribute to communication challenges for people with disabilities, perpetuated by media neglect and resulting in stereotypes and social exclusion (Polumysna, 2022). Enhancing information accessibility through integrated marketing communication tools is crucial for improving participation in cultural activities for individuals with disabilities, emphasizing the importance of both physical and informational access to art (Navickaitė, 2022). Communication serves as a significant barrier to healthcare services for people with disabilities in rural and marginalized communities. In rural settings, unprepared Community Health Agents and inefficient qualifications hinder the provision of comprehensive care to individuals with disabilities, making them invisible and distant from equitable healthcare (Wallace et al., 2021). Additionally, in rural China, older people with disabilities face social barriers due to limited resources, traditional cultural constraints, and unprofessional care, leading to low-quality care in households and communities (Zeni et al., 2020). Furthermore, mainstream health services in rural Australia struggle with culturally inclusive care, as power relations embedded within these institutions exclude marginalized residents from accessing healthcare, perpetuating significant health differentials within the population (Wang and Qi, 2021). These barriers highlight the need for improved communication strategies, better training for healthcare providers, and culturally inclusive practices to ensure that individuals with disabilities in rural and marginalized communities receive the care they deserve. 2.5.5 Stigmatisation The experiences of women with disabilities are often marked by intersecting forms of stigma and discrimination, which can have significant impacts on their physical, mental, and social wellbeing. The existing research highlights the widespread prevalence of stigmatization targeted at women with disabilities across various regions and contexts, and the need for more comprehensive and inclusive approaches to addressing these challenges. Hasson-Ohayon et al. (2018) found that women with psychiatric disabilities faced more negative attitudes towards motherhood than women with physical disabilities, highlighting a hierarchy of stigmatization. Similarly, Getachew et al. (2022) reported that gender-based violence is highly prevalent among women with disabilities in Jimma, Ethiopia, with factors like education, age, type of disability, alcohol use, and perceived stigma as significant predictors. Carew et al. (2023) found that stigma about disabilities in Sierra Leone hinders women from accessing sexual and reproductive health services, while women reject common stigmatizing beliefs about their lives. Likewise, van der Heijden et al. (2018) noted that disability stigma in South Africa hinders women with disabilities from achieving normative womanhood and having fulfilling intimate partnerships, but also challenges negative images of disabled womanhood. Furthermore, van der Heijden et al. (2019) found that women with physical disabilities in South Africa experienced additional layers of violence, influenced by disability stigma, gender norms, and lack of accessible and safe environments. Emerson and Llewellyn (2022) reported that women with disabilities are twice as likely to experience violence and discrimination, and are at greater risk of domestic violence, with exposure linked to national wealth and human development potential. The research also highlights the need for improved access to information and services for women with disabilities. Sharma and Sivakami (2018) found a lack of research on sexual and reproductive health concerns of persons with disabilities in India, highlighting the need for improved access. Additionally, Ryan et al. (2019) found that sex work-related stigma in urban India impacts the health of women who practice sex work, and interventions must address these stereotypes and symbols to improve their health. Finally, Boydell et al. (2020) used body mapping to understand the intersections of experiences among women impacted by mental distress, disability, and refugee status, aiming to inform health policy and targeted interventions. Devkota et al. (2019) found that women with disabilities in rural Nepal faced significant challenges in pregnancy, childbirth, and motherhood due to negative societal attitudes and misconceptions about disability. Based on these findings it can be concluded that stigmatisation is a barrier to access and utilization of healthcare and reproductive services by women with disabilities. 2.5.6 Gender-Based Influences Gender plays a significant role in influencing the accessibility of healthcare services for people with disabilities. Cumulative evidence from research supports that gender can be a significant barrier to healthcare access and outcomes for people with disabilities. Coutu et al. (2021) found that traditional gender roles significantly impacted sustainable return to work after prolonged work disability. Similarly, Witte et al. (2023) suggested that social representations of higher strains on women with disabilities in private and working life may have explained gender differences in vocational rehabilitation and supported employment outcomes for persons with disabilities. Additionally, Philbin et al. (2018) showed that the labor market and healthcare systems negatively impacted preventive healthcare seeking among Black men who have sex with men, potentially increasing their HIV vulnerability and decreasing their overall healthcare seeking. Likewise, Patel and Chauhan (2020) found that in India, both males and females preferred private hospitals for healthcare, but women covered less distance to reach hospitals, highlighting the need for women-friendly measures and empowerment. Furthermore, Roy (2020) noted that disabled women faced double discrimination and required collaborative governance to improve their legal rights and experiences. This intersectional perspective is further supported by Cabral and Dillender (2021), who found that gender disparities existed in healthcare and medical evaluations, with women less likely to receive social insurance benefits based on medical evaluations compared to men. Building on this, Mauvais-Jarvis et al. (2020) emphasized that sex and gender influenced health, disease, and medicine, necessitating precision medicine to address disparities in diagnosis, prevention, and treatment. Similarly, Vigod and Rochon (2020) noted that perceived gender discrimination contributed to the gender gap in mental health disorders, with women experiencing higher levels of depression than men. Lastly, Muraya et al. (2019) showed that gender factors, such as childbearing responsibilities and societal expectations, played a significant role in the career progression and experiences of healthcare leaders in low- and middle-income countries like Kenya. In contrast, Naciti et al. (2022) found that gender diversity positively impacted financial performance in public hospitals at all organizational levels, highlighting the need for gender studies in public healthcare management. These findings suggest that women with disabilities experience compounded marginalization due to the intersection of their gender and disability. They face unique challenges in accessing healthcare, achieving economic security and independence, and navigating societal expectations and discrimination. Several studies highlight the compounded disadvantages experienced by women with disabilities. Roy (2020) noted that disabled women faced “double discrimination” due to the intersection of their gender and disability, creating additional obstacles in accessing healthcare and asserting their rights. Witte et al. (2023) found that social representations of higher strains on women with disabilities in private and working life may explain gender differences in vocational rehabilitation and employment outcomes, hindering their economic and social inclusion. Patel and Chauhan (2020) indicated that in India, women with disabilities may have limited mobility or face other barriers that lead them to cover less distance to reach healthcare facilities compared to men. Cabral and Dillender (2021) demonstrated that women are less likely to receive social insurance benefits based on medical evaluations, suggesting gender-based disparities in the healthcare system that disadvantage women, including those with disabilities. Muraya et al. (2019) showed that gender factors, such as childbearing responsibilities and societal expectations, significantly impact the career progression and experiences of healthcare leaders with disabilities, particularly in low- and middle-income countries. The challenges are however further compounded for women with disabilities who are in a rural setting. Shiwakoti et al. (2020) found that women with disabilities in Ilam district, Nepal, have low utilization of sexual and reproductive health services, influenced by factors such as illiteracy, low economic status, and lack of disability-friendly environments (Shiwakoti et al., 2020). Lee et al. (2020) reported that lower availability of obstetricians and gynaecologists in rural areas affected the types of health care providers seen by women of reproductive age, potentially impacting their access to specialized services. Parchomiuk (2019) and Casebolt (2020) emphasized that women with disabilities face unique reproductive health challenges and required improved access and quality of reproductive health services, particularly in low- and middle-income countries. Plagens-Rotman et al. (2021) suggested that improving access to reproductive healthcare services in rural areas of Poland required coordinated family policy, mobile clinics, and quality improvement in antenatal and gynecological care. Peter-Kio and Oweredaba (2023) reported that reproductive healthcare services were less utilized in rural areas, with prenatal care, postnatal care, and STI prevention/management services being more popular in urban areas. Finally, Natalie A. DiPietro Mager et al. (2020) emphasized that many reproductive-age women in rural maternity care deserts faced challenges in accessing health services. Women with disabilities in rural Zimbabwe are not spared. Literature in Zimbabwe is to a larger extent based on women in general. Literature has to a larger extent neglected women with disabilities. Dziva and du Plessis (2022) found that challenges were mainly associated with limited access to education, employment, information, land, and other resources. Ndlovu-Ncube et al. (2022) found long distances and lack of transport to health facilities as key barriers. On the other hand, Rugoho et al. (2022) mentioned that barriers were mainly physical barriers at service sites, communication-related barriers, gender issues, and lack of resources. Other barriers included difficulties in accessing health services due to health literacy, self-stigma, and affordability issues as fond in Smythe et al. (2022). Given these gender-based barriers as well as limited literature that directly focus on women with disabilities, it was felt to address that gap in literature by focussing on women in Domboshava and Goromonzi. 2.6 The Effectiveness of the Existing Initiatives Designed to Improve Healthcare and Reproductive Services Access to People with Disabilities Zimbabwe adopted the National Disability Policy in 2021. However, the extent to which such policies have been implemented is still not known. Literature in Zimbabwe is still limited that examines the extent to which the policies have been so far implemented, and on whether they have been effective. The policy aims to ensure comprehensive and equitable healthcare for people with disabilities. According to Kuper et al. (2022), it does so through accessible rehabilitation and habilitation programs, as well as providing free of charge to people with disabilities, and that the quality and standard of care for this population is on par with that provided to the general population. However, literature so far presented shows to a larger extent that people with disabilities in Zimbabwe are still not able to access health and reproductive services. For example, Rugoho et al. (2022) found that women with disabilities in Zimbabwe face barriers such as long distances, physical barriers, communication barriers, gender issues, lack of confidence, and overall lack of resources when accessing health and reproductive services after sexual abuse. While this is still a challenge, Pasara (2022) on the other hand noted overwhelming implementation of community related rehabilitation programs in Zimbabwean rural, revenue generating projects, as well in internal savings and lendings. Nonetheless, issues persisted with regard to financing for orthopaedic centres, self-help groups, technological assistance, and handicapped-accessible restrooms. There was also need for decentralization by government agencies to minimize red tape and speed up initiatives, education of instructors for more capacity developing, acceptance by the appropriate ministry or ministries. In addition to ensuring comprehensive and equitable access to healthcare services, the policy also has provisions to protect the rights and ethical treatment of people with disabilities in the healthcare system. It prohibits discrimination against this population and mandates that informed consent standards be upheld for any medical treatment. Furthermore, the policy sets goals to increase the representation of people with disabilities among health profession students to 15%, ensure healthcare workers receive training on disability-related issues, and make healthcare facilities, services, and public health initiatives accessible and locally available for people with disabilities. However, discrimination is still present as Manungo et al (2023) noted how disabled students in Zimbabwe face challenges at educational institutions, and suffer social stigma and negligence from able-bodied counterparts and staff. Smythe et al (2022) further noted barriers which included health literacy, self-stigma, affordability, and discrimination. This implies that health services in public facilities in Zimbabwean rural areas are not consistently provided free of charge to people with disabilities. Kuper et al (2022) found that people with disabilities still face greater challenges accessing healthcare services and experience worse health outcomes in rural Zimbabwe. Havercamp et al (2023) noted how healthcare professionals in Zimbabwe were not prepared to provide quality health care to disabled patients due to training programs that fail to challenge implicit biases and damaging beliefs about disability. Shumba and Magadze (2022) noted that Zimbabwe faces barriers to justice for women and girls with disabilities and as a result, urgent international intervention was needed to uphold human rights. The literature so far shows to a larger extent that the policies are still not fully implemented. 2.7 Empirical Literature Review This section reviews studies that were conducted across the globe with an aim of identifying gaps in literature. Literature generally shows that the use and access of health and medical services by women with disabilities is still a global challenge. 2.7.1 American Context Research consistently shows that women with disabilities in America face significant barriers in accessing health services. For example, Andiwijaya et al. (2022) examined the association between disability and participation in breast and cervical cancer screening among women in America. They found that women with disabilities had lower odds of breast cancer screening compared to women without disabilities. Suntai et al. (2023) used longitudinal data to investigate health care access and use among adults aging with intellectual and developmental disabilities in America. They reported that living with family was associated with a 50% lower likelihood of utilizing mammograms and colonoscopies. Kuo and Houtrow (2020) found that newborns of women with physical, sensory, and intellectual/developmental disabilities were at elevated risk for preterm birth and low birth weight. Deering et al. (2021) used a longitudinal cohort study to identify social and structural barriers to primary care access among women living with HIV in Canada. They suggested that primary health care should address high levels of violence and mental health conditions. Salaeva et al. (2020) investigated health care utilization in infants and young children born to women with intellectual and developmental disabilities in America. They reported that maternal intellectual and developmental disabilities were associated with increased rates of neonatal intensive care unit admission. Evidence from America indicates to a larger extent that women with disabilities face disparities in accessing preventive health screenings like breast and cervical cancer exams. Living arrangements, such as living with family, can impact the likelihood of women with disabilities accessing certain health services. There is also evidence that women with disabilities are at higher risk of adverse pregnancy and birth outcomes, underscoring the need for quality maternal and child health care. Maternal disabilities are associated with higher rates of neonatal intensive care unit admission for infants and young children, highlighting the need to address the unique health care needs of this population. Furthermore, there is also need for addressing social and structural barriers, like violence and mental health challenges, so as to improve primary care access for marginalized populations. 2.7.2 European Context Literature in Europe also shows evidence that challenges are still in existence in relation to access and use of health and reproductive services by women with disabilities. Schriefer et al. (2020) conducted a prospective longitudinal real-world study with more than 2000 patients to investigate gender disparities in health resource utilization among patients with relapsing–remitting multiple sclerosis in Germany. They found that the total economic burden did not differ between male and female patients. Guillén et al. (2021) followed up with a study to examine the relationship between disability, health, and quality of life among homeless women in Spain. They found that disability at baseline had direct effects on health-related quality of life at follow-up. Scheer and Mondaca (2022) conducted a qualitative study to explore the social participation experiences of refugee women with disabilities in Germany. They reported that these women want to engage in the hosting society and become active members. Ryan-Ndegwa et al. (2021) assessed demographic access to hip replacement surgery in the United Kingdom. They found that lower-income patients and ethnic minority patients demonstrated increased surgical needs, reduced access, and poor outcomes. Chandola and Rouxel (2021) examined the role of workplace accommodations in explaining the disability employment gap in the UK. They found that work accommodations appear to enable workers with impairments to remain economically active. Salaeva et al. (2020) performed a systematic review and meta-analysis to investigate health care utilization in infants and young children born to women with intellectual and developmental disabilities. They found that maternal intellectual and developmental disabilities were associated with increased neonatal intensive care unit admission rates. Lessons can be drawn from literature conducted in Europe. There is evidence that gender disparities in health resource utilization may not differ significantly for certain conditions like relapsing-remitting multiple sclerosis. Furthermore, disability can directly impact health-related quality of life among marginalized populations, such as homeless women. There is evidence that socioeconomic and ethnic disparities persist in access to essential health services like hip replacement surgery. Finally, literature from Europe shows that workplace accommodations can enable workers with disabilities to remain economically active, highlighting the importance of inclusive policies. 2.7.3 Asian Context Marginalisation trends witnessed in Europe and America are also evident in China and Asia especially on older women with disabilities. Research on access to health services by women with disabilities in China reveals several key findings. Zhang et al. (2018) examined age and sex differences in the association between access to medical care and health outcomes among older Chinese adults. They found that inadequate access to care was linked with increased odds of physical disability and cognitive impairment. Liu et al. (2020) investigated changes in the prevalence of chronic disability in China. They concluded that Chinese health agencies should consider the growing need for sufficient community services to maximize independence among older populations. Ai et al. (2023) explored disparities in healthcare access and utilization among people living with HIV in China. They found that financial issues and social discrimination were prominent reasons for healthcare disparities in HIV care. Yang and Tan (2019) analyzed data to assess whether informal care was sufficient to meet the long-term care needs of older people with disabilities in China. They concluded that the majority of older people with disabilities received a low intensity of care. Zheng et al. (2022) conducted a systematic review and meta-analysis to estimate the prevalence of disability among the Chinese older population. They reported that the prevalence of disability among the Chinese older population was high. Peng et al. (2021) examined the relationship between multimorbidity, depressive symptoms, and disability in activities of daily living among middle-aged and older Chinese adults using data from the China Health and Retirement Longitudinal Study. They found that multimorbidity increased the likelihood of activities of daily living disability onset partially through depressive symptoms, especially in middle-aged and older women. In China it is evident that inadequate access to medical care is associated with increased physical disability and cognitive impairment among older adults. There is also a growing need for sufficient community-based services to maximize independence and support the increasing prevalence of chronic disabilities among older populations in China. It is also evident that financial issues and social discrimination are prominent barriers to healthcare access and utilization for people living with HIV in China. Informal care is often insufficient to meet the long-term care needs of older people with disabilities in China. Finally, the prevalence of disability among the older population in China is high, with multimorbidity and depressive symptoms contributing to increased disability, especially in middle-aged and older women. Unlike in China, other parts of Asia such as India and Bangladesh reported effectiveness of various program interventions. For example, Richardson et al. (2018) evaluated the effect of affordable daycare on women’s mental health in a cluster randomized trial in rural India. They concluded that access to daycare might be one policy lever to improve population mental health. Grills et al. (2020) carried out a cluster randomized trial in North India to investigate the impact of disabled people’s organizations on access to services and well-being. They reported that supporting the establishment and strengthening of these organizations is a cost-effective intervention. Agarwal et al. (2019) in India found that exposure to accredited social health activist services was associated with increase in antenatal care utilization. Biyyala et al. (2018) conducted a cross-sectional study to assess the awareness of tribal women in Kurnool, India, about mother and child health services. They found that the knowledge of these women about maternal and child health services was inadequate. West et al. (2021) carried out a cross-sectional follow-up study to examine the effects of spousal migration on access to healthcare for women left behind in Bangladesh. They found that women with migrant spouses were approximately half as likely to lack needed healthcare compared to women whose spouses remained in Bangladesh. Literature from India and Asia presents lessons for the present study. It can be noticed that affordable daycare access can be an effective policy intervention to improve mental health outcomes for women in rural. Also, supporting the establishment and strengthening of disabled people’s organizations is a cost-effective way to improve access to services and well-being. Furthermore, exposure to community health worker programs, such as accredited social health activists in India, can increase utilization of antenatal care services. Maternal and child health services knowledge may differ by minority groups and tribals, suggesting a need for targeted awareness campaigns. 2.7.4 African Context Research in Africa has highlighted various barriers to health service access for women with disabilities. Dessie et al. (2023) found that health facility delivery service utilization was less common in pastoral regions in Ethiopia. Demisse et al. (2023) investigated the utilization of family planning and associated factors among women with disabilities in Ethiopia. They reported that the utilization of family planning was relatively low among this population. Tekelab et al. (2019) reported that exposure to mass media, family income, and accessibility of antenatal care were strongly associated with the utilization of antenatal care in Ethiopia. Gebeyehu et al. (2022) found that decision-making autonomy on maternal health services in these countries was low in developing countries. 2.7.5 Southern-African Context In Southern Africa, Biran et al. (2018) conducted a cluster-randomized trial to evaluate the impact of an inclusive, community-led total sanitation intervention on sanitation access for people with disabilities in Malawi. They found that the intervention could improve sanitation access for people with disabilities. Prynn et al. (2020) examined the relationship between self-reported disability and mortality in Malawi. They reported that self-reported disability predicted mortality at all adult ages in this population. Laing de Villiers et al. (2020) found that transgender women had a disproportionately high HIV prevalence compared to cisgender women and men who have sex with men. Tenaw et al. (2023) performed a systematic review and meta-analysis to examine contraceptive use among people with disabilities in sub-Saharan Africa. They reported that contraceptive use among women with disabilities was considerably low in this region. Scott et al. (2018) developed a protocol for a quasi-experimental, mixed-methods study to assess the impact of maternity waiting homes on facility delivery among remote households in Zambia. They aimed to identify the barriers in the use of primary healthcare centers in these areas. 2.7.6 Zimbabwean Context In Zimbabwe, Shumba and Magadze (2023) conducted a qualitative study on the access to justice dynamics for women and girls with disabilities in the Zimbabwean context. They found that the violation of human rights of this population required urgent intervention from the international community (Shumba & Magadze, 2023). Smythe et al. (2022) performed a qualitative study to explore strategies to promote disability inclusion in healthcare in Zimbabwe. They discovered that meaningfully engaging people with disabilities was a key strategy to achieve disability-inclusive health. Kuper et al. (2022) presented a case study from Zimbabwe to argue that a focus on disability-inclusive health may help strengthen health systems for all in low-income countries. Mangundu et al. (2020) used a qualitative approach to explore the perspective of nurses and healthcare users on the accessibility of healthcare in rural Zimbabwe. They reported that participants perceived grave challenges regarding access to health facilities, health workers, and medical drugs. Gwatimba et al. (2020) qualitatively investigated the obstacles to the realization of women’s reproductive health rights in Zimbabwe. They identified that polygamy and wife inheritance were among the challenges women faced in exercising their reproductive rights. Cowan et al. (2018) found that a targeted combination intervention significantly improved engagement with HIV services among female sex workers in Zimbabwe. The methodology involved a randomized controlled trial that included components like peer education, community mobilization, and clinic-based services. Kanengoni et al. (2019) discovered that women’s social status, education, and age influenced their experiences of disrespectful and abusive maternity care. Tapera et al. (2019a) revealed that health system constraints such as limited training for healthcare workers and inadequate facilities hindered effective cervical cancer treatment in Zimbabwe. Tapera et al. (2019b) determined that health system and societal factors, including healthcare infrastructure and cultural beliefs, were crucial determinants of access to and utilization of cervical cancer treatment. Mhlanga-Gunda et al. (2020) found that women in Zimbabwean prisons faced numerous health challenges, including inadequate healthcare standards and poor prison conditions. Zeng et al. (2018)’s findings indicated that poorer households in Zimbabwe had less access to healthcare and faced a higher burden of out-of-pocket expenses. 2.8 Research Gaps While literature has been successfully conducted across the globe, there is however evidence of gaps that are still present in literature. It can be noted that literature on medical services use by women with disabilities is still low in developing countries, especially in Africa. A review by Saran et al (2020) also had the same observation where it was noted that there are gaps in the literature on health services use by people with disabilities in low-and middle-income countries, particularly in access to assistive devices, nutrition, and immunization. da Cunha et al (2022) noted that large gaps in healthcare delivery for people with disabilities existed across dimensions, including lack of quality-of-life promotion, professional training about disability, and poor service distribution and integration. As a result, research was still needed in such areas. Substantial gaps are still identifiable in literature on health services use by people with intellectual disabilities, particularly in relation to the lived experience of these barriers (Whittle et al, 2018). Furthermore, Geukes et al (2018) noted gaps in the field of health literacy among people with intellectual disabilities, emphasizing the importance of a target group-specific concept, health professionals involvement, and adequate communication. On the other hand, Agarronik et al (2019) noted gaps pertaining to strategies for formal training for Physicians’ efforts to communicate effectively with patients with hearing or vision loss or intellectual disabilities. There are also gaps in literature that specifically targets women. According to Verlenden et al (2019) gaps in literature include common reproductive health concerns for adolescent and adult women with intellectual and developmental disabilities, contraceptive methods, informed consent, and provider knowledge and education. Meyer et al (2022) on the other hand noted gaps in lack of sex and disability disaggregation, limited evidence on adapting data collection methods, and limited evidence on differential relationships between types of disability and violence exposure. Agaronnik et al (2020) noted that gaps remain in ensuring reproductive rights of women with intellectual disability in communication, routine preventive care, contraception, sterilisation, and conception and parenthood. Katon et al (2018) noted that knowledge gaps persisted in the areas of sexually transmitted infections, infertility, and menopause for women Veterans’ reproductive health. Mavuso et al (2020) on the other hand was of the opinion that there is a gap between women with disabilities’ needs for sexual and reproductive health services and their rights to access them, with stereotypical assumptions affecting access. Joudeh et al (2021) identified gap in the literature is an intersectional, community-based approach to assessing the obstacles women with disabilities in rural areas face when accessing healthcare. Hameed et al (2020) highlighted stark gaps in evidence on health services use by women with disabilities in rural areas, particularly in maternal health, family planning, contraception, and safe abortion. Zheng et al (2023), noted gaps in the literature include the effectiveness of integrated approaches to institutional interventions, utilisation of preventative measures, and greater identification of health needs among culturally diverse elderly residents. The study adds to literature by assessing the enablers and barriers to access and use of health and reproductive services by women with disabilities in Zimbabwean rural. This will improve knowledge and understanding on the extent to which such communities can be assisted. Furthermore, the study assesses the effectiveness and coverage of Zimbabwe’s National Disability Policy, a major milestone that most studies have not covered. 2.9 Chapter Summary Literature has been reviewed on access to health and reproductive services access to women with disabilities. The Andersen-Newman model as well as the Levesque’s model were used in the study to explain why women with disabilities may access or fail to access health and reproductive services. Enablers and barriers were found to be associated with factors to do with services approachability, acceptability, availability & accommodation, affordability, and appropriateness, among other factors such as environment, and predisposition factors. The National Disability Policy was noted to be a guiding framework towards use by people with disabilities in Zimbabwe, and this will be used to evaluate extent of coverage and effectiveness. The following chapter is a discussion of the methods used in the study. CHAPTER 3 RESEARCH METHODOLOGY 3.0 Introduction This chapter is a discussion of methods that were used in the study on access to healthcare and reproductive services by women with disabilities. The discussion includes a justification of the research philosophy and design adopted, the sampling approach used in the study, research instruments, procedures conducted for data collection, and presentation as well as on reliability and validity. The discussion also includes the research ethics observed throughout the research. The main aim was to ensure the correct choice and application of suitable research methodology. 3.1 Research Philosophy The researcher adopted a pragmatic research philosophy to investigate the access to health and sexual reproductive health services by women with disabilities in rural Zimbabwe. Pragmatism focuses on the research problem and utilizes all available approaches to understand the problem and find a solution (Kelly & Cordeiro, 2020). In this case, the practical, problem-oriented nature of the study aligned well with the pragmatic philosophy. The aim was to gain a comprehensive understanding of the barriers to access faced by this population, in order to inform policies and interventions that could improve their lives. To achieve this, the study employed a mix of quantitative and qualitative data collection methods. Survey responses provided objective, numeric data, while key-informant interviews allowed for the capture of subjective, experiential knowledge. This pragmatic use of multiple methods was characteristic of the pragmatic approach, as it enabled a thorough exploration of the research problem (Kaushik & Walsh, 2019). The emphasis throughout the research was on the practical implications of the findings. The driving force was the desire to gain insights that could be directly applied to enhance the health and well-being of women with disabilities in rural Zimbabwe. This practical, solution-oriented focus is a core tenet of pragmatism. Adopting a pragmatic research philosophy enabled the researcher to leverage both objective and subjective knowledge to address the real-world issue of access to health and sexual reproductive health services. The combination of survey data and key-informant interviews provided a comprehensive perspective, aligning with the pragmatic value of using the most appropriate methods to understand and tackle the research problem. 3.2 Research Design A cross-sectional survey design was used in the study to examine the access to health and sexual reproductive health services by women with disabilities in rural Zimbabwe. The cross-sectional design allowed the researcher to collect data from women with disabilities residing in the rural areas of Domboshawa and Goromonzi. Surveying this diverse sample allowed the researcher to capture a comprehensive overview of the characteristics and experiences of the target population. The research design further allowed the researcher to recognize the relevance of the discussion topic as a motivating factor for the participants to engage in the study. The choice of a cross-sectional survey design enabled the researcher to assess the current situation and identify the challenges faced by women with disabilities in rural. The cross-sectional study design has been widely used by several scholars to investigate the utilization of reproductive health services among women in rural areas. For example, Lee et al. (2020) used a cross-sectional study to examine rural-urban differences in health care provider visits among women of reproductive age in the United States. Similarly, Yue et al. (2020) conducted a cross-sectional study to determine the utilization of and demand for reproductive health services among 20-39-year-old women in rural China. Cross-sectional studies are well-suited for these types of research questions as they allow researchers to collect data on the outcome of interest, as well as potential explanatory variables, at a single point in time (Setia, 2016). This design enables the researchers to assess the prevalence of the outcome and explore the associations between various factors and the utilization of reproductive health services in rural settings. 3.3 Research Approach A mixed methods approach was used in the study in line with the pragmatic research philosophy adopted. This was done through the triangulation of survey data as well as key-informant interviews. This approach enhanced the validity and reliability of the study, as it provided complementary insights from various stakeholders. The combination of quantitative survey data and qualitative interview responses allowed the researcher to develop a more holistic understanding of the access to health and sexual reproductive health services by women with disabilities in rural Zimbabwe. The study’s approach is largely comparable to Shiwakoti et al. (2020) who employed a mixed-method cross-sectional design to investigate the factors affecting the utilization of sexual and reproductive health (SRH) services among women with disabilities in Ilam district, Nepal. They collected quantitative data through face-to-face interviews using a structured questionnaire, and supplemented this with qualitative data gathered through in-depth interviews, key informant interviews, and focus group discussions. Similarly, Devkota et al. (2018) conducted a cross-sectional survey among 354 women, including 79 women with disabilities, to compare the accessibility of maternal healthcare services between women with and without disabilities in rural Nepal. In addition to the quantitative survey data, the researchers also collected qualitative data through in-depth interviews to provide further insights. Triangulation of survey data and key-informant interviews enhanced both validity and reliability by offering complementary quantitative and qualitative insights. This methodology allowed for a comprehensive understanding of healthcare access disparities among women with disabilities, aligning with Shiwakoti et al. (2020) and Devkota et al. (2018), who similarly utilized mixed-method designs in Nepal to explore sexual and reproductive health services. These studies highlight the value of integrating multiple data sources to capture the nuanced experiences of marginalized groups, supporting the broader findings of this research. 3.4 Population The actual population of mature women with disabilities in Domboshava and Goromonzi is unknown. However, the latest Zimbabwean population survey of 2022 reported a total of 14021 females with disabilities in Mashonaland East, where these districts are located. The limitation of this figure is that it includes young girls as well who are not eligible for the study. Furthermore, it consists of populations in urban centers as well as other rural communities of Mashonaland east as well. However, it was reported that female children with disabilities constitute 0.5% of the overall population of people with disabilities. Furthermore, females with disabilities in rural constitute 2.2% of people with disabilities countrywide. The lack of specific population data for mature women with disabilities in Domboshava and Goromonzi presents a challenge for this study, as population estimates are crucial for accurate sampling. While the Zimbabwean population survey of 2022 reported 14,021 females with disabilities in Mashonaland East, this figure is limited by the inclusion of children and urban populations, skewing the data. As noted by Muriithi (2020), estimating populations for marginalized groups, especially in rural areas, is often problematic due to underreporting and inconsistent demographic definitions. Moreover, the 0.5% figure for female children with disabilities, and the 2.2% for rural females, indicates significant underrepresentation, a common issue in disability research (WHO, 2018). Accurate population data is vital for studies on healthcare access, as underestimation may lead to insufficient sampling and misinformed policy recommendations (Devkota et al., 2018). 3.5 Sampling Approach The researcher employed a non-probability, multi-stage, quota-sampling technique for selecting and recruiting participants. This method does not involve random selection, but instead, participants are chosen based on certain criteria or characteristics (Mweshi and Sakyi, 2020). The multi-stage sampling approach involves selecting samples in multiple steps, where broader groups are initially identified, and then samples are taken within those groups (Khan, 2020). In this quota sampling approach, the researcher set specific quotas to be filled based on disability status, to ensure that certain groups are proportionally represented in the sample. Given the focus on a vulnerable group, the researcher first identified women with disabilities using recent census data, governmental and NGO’s reports, and local disabled people’s organizations. This step was crucial for creating a sampling frame specifically for women with disabilities. By setting quotas, the researcher ensured that both women with and without disabilities were adequately represented, which was particularly important to compare access to healthcare services between these two groups. Due to the potentially limited number of women with disabilities in the population, non-probability sampling was a practical choice. It allowed the researcher to deliberately select participants who met the study criteria, ensuring that the sample included enough women with disabilities to make meaningful comparisons. The multi-stage sampling approach also enabled the researcher to narrow down from a broad population to specific groups of interest (i.e., women with and without disabilities) and then further select individuals within these groups. The sampling technique was justified as it effectively addressed the need to study a specific, potentially hard-to-reach subset of the population and ensured adequate representation for comparative analysis. Non-probability sampling, while not random, allows the researcher to target individuals who meet specific criteria, making it particularly useful for studies where a probability-based sample may be impractical due to the rarity of the target population or logistical constraints. In this case, the focus on women with disabilities justifies this approach, as it ensures that the researcher can purposefully recruit participants who would otherwise be difficult to locate using random methods (Etikan, 2016). By relying on recent census data, government reports, and local NGOs, the researcher was able to construct a sampling frame that accurately reflected the population of interest, thereby improving the study's relevance despite the lack of randomization (Mweshi & Sakyi, 2020). However, the lack of random selection introduces potential biases, as participants may not represent the broader population. Non-probability sampling can lead to over- or under-representation of certain groups, which can affect the generalizability of the findings (Khan, 2020). In particular, quota sampling can sometimes lead to "sampling bias" if the criteria for selecting participants do not adequately capture the diversity within the target population (Bryman, 2016). That said, the researcher’s use of quota sampling to ensure adequate representation of both women with and without disabilities addresses some of these concerns by ensuring proportional representation of key subgroups, which is essential for comparing healthcare access between these populations. The multi-stage sampling process further refines this method by narrowing the population step by step, a strategy that has been widely used in studies requiring detailed, subgroup-specific analyses (Taherdoost, 2016). This is particularly relevant for vulnerable or minority populations, where broader groups are first identified, and then subgroups are selected for further analysis. By employing this method, the researcher ensured that the final sample included individuals who met the specific criteria necessary for the study, thus making the sampling technique more robust in terms of achieving the study’s goals. This multi-stage approach also mitigates some limitations of non-probability sampling by allowing the researcher to systematically refine the sample (Palinkas et al., 2015). However, the inherent limitation remains: the findings may not be broadly applicable beyond the sampled group, given the non-random nature of participant selection (Acharya et al., 2013). Furthermore, the reliance on quota sampling can sometimes lead to oversimplification, particularly if quotas are too rigid or fail to account for intersectional factors, such as age, socioeconomic status, or geographic location, which may also influence access to healthcare services (Lavrakas, 2008). While non-probability, quota-based sampling is not without its limitations, it is a justifiable choice for studies focusing on specific, hard-to-reach populations, such as women with disabilities. The researcher’s use of multi-stage sampling allowed for a more targeted and efficient selection process, ensuring that the final sample adequately represented both women with and without disabilities, facilitating meaningful comparative analysis. Nevertheless, the results must be interpreted with caution, as the non-random nature of the sampling method may limit the generalizability of the findings. 3.6 Data Collection Instruments The study utilised a questionnaire as well as an interview guide for the collection of data. Furthermore, a phone was used for recording of interviews. Using a structured questionnaire allowed the researchers to collect standardized, quantifiable data from a larger sample of women, including women with disabilities. This quantitative data enabled the researchers to make statistical comparisons between women with and without disabilities in terms of factors such as distance to health facilities, modes of transportation used, and the challenges encountered. The questionnaire provided evidence-based insights into the disparities in healthcare access between the two groups. The interview guide allowed collection of qualitative data using in-depth interviews. This allowed the researcher to explore access in greater depth and gain a more nuanced understanding of the challenges faced by women with disabilities. The interviews provided an opportunity to probe into the contextual factors, such as the distribution and management of healthcare resources, provider attitudes, and the overall healthcare facility environment. The qualitative data further helped to contextualize and better explain the quantitative findings, offering a more comprehensive understanding of the barriers to healthcare access. The use of both a questionnaire and an interview guide in this study was a well-considered decision, as it enabled the researcher to leverage the strengths of both quantitative and qualitative methods to address the research objectives effectively. The complementary nature of the two data collection instruments provided a robust and nuanced understanding of access. The combination of a structured questionnaire and an interview guide for data collection in this study demonstrated a well-balanced application of mixed-methods research, which is increasingly valued in contemporary academic inquiry. The structured questionnaire allowed for the collection of standardized, quantifiable data, enabling researchers to draw statistical comparisons between women with and without disabilities. As emphasized by Creswell and Creswell (2018), the primary advantage of using structured questionnaires is the ability to gather data from a large sample efficiently, providing breadth and generalizability. In this case, the questionnaire allowed the study to capture crucial disparities in healthcare access, such as transportation modes, facility distance, and challenges faced by the two groups. This is crucial when addressing inequities, as emphasized by Donabedian (2021), who noted that such quantifiable metrics are essential for developing data-driven interventions. However, questionnaires alone may not fully capture the complexities of personal experiences, especially for vulnerable populations such as women with disabilities. This is where the inclusion of an interview guide for in-depth qualitative interviews becomes invaluable. Qualitative methods enable researchers to delve deeper into the lived experiences of participants, providing a richer understanding of the socio-cultural, environmental, and institutional barriers these women face in accessing healthcare. Braun and Clarke (2019) suggest that qualitative interviews are particularly effective in exploring sensitive topics and gaining insights into issues that quantitative data might overlook, such as healthcare provider attitudes and facility environments. In this study, the qualitative data gathered through interviews helped contextualize the quantitative findings, allowing for a more nuanced and holistic understanding of the challenges these women face. The integration of both data collection methods also follows the principles of triangulation, which strengthens the validity of the research by corroborating evidence from multiple sources (Denzin, 2017). Triangulation mitigates the limitations inherent in relying on a single method. For instance, while quantitative data might highlight a general trend (e.g., disparities in transportation access), qualitative data can explain why these disparities exist by revealing underlying systemic or attitudinal factors. In the context of this study, the interviews likely uncovered contextual elements such as the distribution of healthcare resources or healthcare workers' attitudes, which can have significant impacts on healthcare access, as suggested by studies such as those by Oliver and Mossialos (2019). This is particularly important when addressing access disparities in marginalized groups, where structural inequalities often intersect with personal and environmental factors. Recording interviews using a phone is a practical and commonly used method for capturing qualitative data, especially in fieldwork settings. As noted by Gill et al. (2008), using recording devices ensures that the data is accurate and comprehensive, allowing researchers to focus on the conversation without distraction. While some ethical considerations must be managed, such as ensuring participants’ consent to be recorded and safeguarding data confidentiality, this method facilitates thorough data analysis by allowing researchers to revisit the conversation and extract nuanced insights. This aligns with recommendations by Hammersley and Atkinson (2019), who highlight the importance of accurate data collection tools in qualitative research to maintain the integrity of participants' narratives. However, it is important to acknowledge the potential limitations of this approach. The use of a structured questionnaire may limit respondents' ability to express themselves beyond predefined categories, potentially leading to a loss of depth in understanding certain challenges (Bryman, 2016). Additionally, the reliance on phone recordings for interviews can raise issues related to sound quality, potential technical failures, or discomfort from participants, particularly in sensitive research contexts. As noted by Guest et al. (2017), while phone interviews provide logistical flexibility, they may not fully capture non-verbal cues, which can be important in understanding emotional or nuanced responses. The decision to employ both quantitative and qualitative methods through a questionnaire and interview guide was a well-considered approach that leveraged the strengths of both methodologies. By combining structured, standardized data with richer, contextual insights, the study achieved a more comprehensive and robust understanding of healthcare access disparities among women with and without disabilities. 3.6.1 Instrument Design and Structure The questionnaire (attached in appendices) was designed to assess various dimensions of access to healthcare services. The questionnaire was structured into six main sections: Demographics, Accessibility, Availability, Affordability, Acceptability, and Accommodation. The Demographics section collected information about the respondent’s personal and household characteristics, including age, occupation, marital status, number of children, education level, and employment status. This data provided important contextual information to understand the respondent’s socioeconomic background. The Accessibility section examined the physical accessibility of the healthcare facility, focusing on the location, distance, and availability of transportation options. It explored factors such as the walking time to the facility, the quality of the road network, and access to public transportation. The Availability section assessed the resources and services provided at the healthcare facility. It investigated aspects like the staffing levels, availability of drugs and supplies, the time spent by providers with patients, waiting times for services, and awareness of any travel cost reimbursement schemes. The Affordability section addressed the financial aspects of healthcare access, including whether the facility charged for services and supplies during delivery, and whether the respondent received any transportation allowance or cash reimbursement. The Acceptability section explored the characteristics of the service providers and the quality of the patient-provider interaction. It examined the provider’s gender, the respondent’s comfort level with a male provider, the behavior and attitude of the staff, and the maintenance of privacy during the check-up. Finally, the Accommodation section assessed the infrastructure and organization of the healthcare facility, focusing on aspects such as wheelchair accessibility, availability of separate examination rooms and waiting spaces, and the provision of adapted beds and equipment for persons with disabilities. By including demographics, the questionnaire acknowledges the socioeconomic determinants of health, as supported by Marmot (2020), who highlights the role of social conditions in shaping health outcomes. Furthermore, the focus on Acceptability and Accommodation, particularly for persons with disabilities, reflects WHO (2018) recommendations, which stress the importance of culturally sensitive and disability-inclusive healthcare environments. However, challenges may arise in assessing subjective experiences like comfort with healthcare providers, as they vary widely based on individual preferences and cultural norms (Dixon-Woods et al., 2006). 3.7 Data Collection Procedure The researcher employed a multifaceted approach to data collection, utilizing both quantitative and qualitative methods. For the quantitative component, the researcher developed a structured questionnaire. This questionnaire covered key areas including demographics, healthcare service utilization, and disability-related information. Before the full-scale data collection, the researcher field-tested the questionnaire and refined it to ensure the questions were clear and appropriate for the participants. A team of 3 trained interviewers then conducted household surveys among married and unmaried girls/women aged at least 18 focusing on Domboshava and Goromonzi rural districts. The researcher closely monitored the interview process and checked the completed forms to validate the data and address any errors or gaps. Parallel to the quantitative surveys, the researchers also carried out qualitative data collection through in-depth interviews and key informant interviews. Three focus group discussions were conducted with a subset of women from both the disabled and non-disabled groups, allowing them to share their personal experiences and perspectives on accessing healthcare services. The informant interviews involved interviews with medical doctors, community health workers, and a representative from Leonard Cheshire Disability. All qualitative interviews were audio-recorded with participant consent and then transcribed to facilitate thorough analysis. 3.8 Ethical Considerations The researchers prioritized three key ethical considerations in this study. The researcher was careful to accurately describe the nature and details of the study to participants, so as not to raise unrealistic expectations about the outcomes of the interview process. The researcher did not link any data collected directly to individual participants. An information sheet was provided to participants during recruitment, outlining the study protocols, data management processes, confidentiality measures, and plans for data sharing. This information was also verbally reiterated as part of the informed consent procedure, which was obtained in the participant’s language of choice (mainly Shona). The data collection assistants were trained to identify when participants might require referral for additional services. Other ethical considerations included the fact that no minors participated in the study with the exception of parental guidance. Furthermore, the researcher ensured that the discussions that were conducted did not cause any harm to participants. 3.9 Variables and Operationalisation Several dimensions of access were used following the Levesque’s model. These dimensions were defined and measured using both objective and subjective indicators. The first dimension, accessibility, was evaluated based on physical distance, time taken, and cost to reach the nearest health facility. This included assessing whether the facilities were within a reasonable distance and could be reached without significant financial burden. Availability was another key dimension and referred to the presence of adequate healthcare services and resources. This included the availability of medical staff, essential drugs, and medical equipment. The study examined whether the health facilities had sufficient resources to meet the needs of pregnant women, particularly those with disabilities. Affordability was assessed by examining the costs associated with accessing maternal healthcare services. This dimension looked at both direct costs, such as consultation fees and medication, and indirect costs, like travel expenses. The study aimed to determine whether the financial barriers affected women’s ability to seek and receive care. Acceptability involved the cultural and social factors influencing women’s use of healthcare services. This dimension considered whether the services provided were acceptable and respectful of the women’s values and needs. It also looked into the attitudes and behaviors of healthcare providers towards women with disabilities, assessing whether these attitudes acted as barriers to access. Lastly, accommodation referred to the organization and delivery of healthcare services. This dimension assessed how well healthcare services were adapted to meet the specific needs of women with disabilities. It included evaluating the physical accessibility of health facilities, the availability of appropriate services, and the flexibility of service provision to accommodate the unique requirements of this vulnerable group. Overall, the study used these dimensions to comprehensively evaluate and understand the barriers and facilitators affecting access to maternal healthcare services for women with disabilities in Domboshava and Goromonzi. 3.10 Data Analysis For the quantitative data, the researcher utilized SPSS version 27 for data entry and analysis. The researcher conducted descriptive and bivariate statistical analyses, presenting the results as frequencies and percentages. To examine the associations and significance of the variables, the Pearson’s Chi-square test of association was employed. The researcher followed a rigorous process in analyzing the data collected through the interviews. All interviews were translated into English. The data was managed using the NVivo 12 software. The researcher employed a deductive thematic analysis approach, using the semi-structured interview guide as a starting point to develop a coding framework. This framework was then adapted to incorporate additional codes and themes that emerged from the data. The researchers then undertook a narrative synthesis of the findings and reported the results in accordance with the consolidated criteria for reporting qualitative research (COREQ), a 32-item checklist. To further inform the analysis, the researchers utilized the Missing Billion health system framework, with a predominant focus on the service delivery components, including both demand and supply-side perspectives. This comprehensive approach to data analysis and reporting allowed the researchers to rigorously examine the barriers to healthcare and disparities in outcomes faced by people with disabilities, drawing on the rich insights gathered through the interview process. Analyzing the quantitative and qualitative data separately and then integrating the findings allowed the researcher to provide a comprehensive and nuanced understanding of the accessibility of maternal healthcare services for women with disabilities in Domboshava and Goromonzi. The combination of statistical analyses and in-depth thematic exploration allowed to identify and contextualize the key issues and barriers faced by this population. 3.11 Chapter Summary The methodology used in the study has been outlined. The researcher adopted a pragmatic philosophy to investigate access to health and sexual reproductive health services by women with disabilities in rural Zimbabwe, using a cross-sectional survey design and a mixed methods approach involving quantitative data and qualitative key-informant interviews, which enhanced the validity and reliability of the study. A non-probability, multi-stage, quota-sampling technique was used to select and recruit participants, and data collection instruments included a structured questionnaire and an interview guide, with the emphasis throughout on the practical implications of the findings to enhance the health and well-being of women with disabilities in rural Zimbabwe. CHAPTER FOUR DATA PRESENTATION AND ANALYSIS 4.1 Introduction This chapter is a presentation of findings on access to health and sexual reproductive health services by women with disabilities in rural Zimbabwe. The chapter consists of sample characteristics as well as findings on access to health and sexual reproductive services by women with disabilities. 4.2 Sample Characteristics 4.2.1 Response Rate Table 4.1 below is a presentation of the survey response rate: Table 4.1 Response Rate Targeted Sample Surveyed Respondents Response Rate 260 147 56.5% Author’s Compilation (2024) Table 4.1 above shows that a total of 147 women managed to respond to the survey questionnaire used in the study. These constituted 56.5% of the targeted sample size. Generally, a response rate of 56.5% was considered acceptable in the study. A reasonably higher response rate was probably due to the relevance of the discussion topic that would have motivated the research participants to participate in the study. Furthermore, the questionnaire was used was considered well-designed, easy to complete, and distributed through appropriate channels to reach the target women. A response rate of 56.5%, as reported in the study, is considered acceptable in survey-based research, especially in healthcare and social sciences (Baruch & Holtom, 2008). The reasonably high rate can be attributed to the relevance of the topic, which likely resonated with participants, aligning with Groves et al. (2006) who suggest that personal interest in the topic enhances participation. The ease of completion and accessibility of the questionnaire, as emphasized by Dillman et al. (2014), also likely contributed to this response rate. A well-designed and targeted distribution method can mitigate common challenges like low engagement or survey fatigue, making the data more robust and representative. 4.2.2 Characteristics of Surveyed Respondents The women who participated in the study varied according to disability, age, location, education, occupation, income, and family size. This is discussed in this subsection. 4.2.2.1 Distribution by Disability Status The extent to which the participants in the study were distributed according to disability status is presented in table 4.1 below. Table 4.2 Distribution by Disability Status Frequency Per cent Valid Percent Cumulative Percent Valid Disabled 65 44.2 44.2 44.2 Non-Disabled 82 55.7 55.7 100.0 Total 147 100.0 100.0 SPSS Output (2024) The distribution of respondents by disability status shown in Table 4.2 indicates that the sample was fairly evenly split, with 55.7% of respondents identifying as non-disabled and 44.2% identifying as disabled. This balanced representation of both disabled and non-disabled individuals in the survey responses suggests the researcher made concerted efforts to ensure the survey was accessible and inclusive, capturing the perspectives of the target population. While the proportion of women with disabilities may be considered small to represent all women with disabilities in Zimbabwe rural, the limitation in this study was overcome by triangulating survey responses interview responses from key-informant interviews. The relatively balanced representation of disabled (44.2%) and non-disabled (55.7%) respondents demonstrates a thoughtful effort toward inclusivity, aligning with best practices in disability research. Studies like Devkota et al. (2018) emphasize that ensuring accessibility in research methodologies, especially for marginalized groups, is critical for obtaining diverse perspectives. Although the proportion of women with disabilities may seem small for generalizing to all rural Zimbabwean women with disabilities, the triangulation with key-informant interviews strengthens the study’s validity, as suggested by Creswell and Creswell (2018). Triangulation mitigates the limitations of small sample sizes by corroborating quantitative findings with in-depth qualitative insights, enhancing the overall reliability of the conclusions (Bryman, 2016). 4.2.2.2 Distribution by Age The extent to which women were distributed by age is presented below in Table 4.3: Table 4.3 Age in Years Disability Status Total Disabled Not-Disabled Age Group 18-20 13 (20.0%) 7 (8.5%) 20 21-30 17 (26.1%) 23 (28.8%) 40 31-40 27 (41.5%) 29 (35.4%) 56 41-50 8 (12.4%) 21 (25.6%) 29 51 and above 0 (0.0%) 2 (1.7%) 2 Total 65 82 147 SPSS Output (2024) The majority of women fall into the 31-40 age group, comprising 41.5% of disabled women and 35.4% of non-disabled women. The 21-30 age group is the second largest, representing 26.1% of disabled women and 28.8% of non-disabled women. The 41-50 age group accounts for 12.4% of disabled women and 25.6% of non-disabled women. Older women (51 and above) make up a very small proportion, with only 1.7% of non-disabled women in this group. The distribution of women across age groups varies between disabled and non-disabled groups, with disabled women being more heavily represented in the younger age groups (18-20, 21-30, and 31-40). The evidence suggests that disabled women may face greater barriers in accessing health and reproductive services compared to non-disabled women, as they are overrepresented in the younger age groups. The overrepresentation of disabled women in younger age groups highlights potential barriers they face in accessing healthcare services, a finding consistent with recent research. According to Kuper et al. (2018), younger disabled women often encounter greater challenges in accessing reproductive and general health services due to factors like stigma, limited mobility, and inadequate service accommodations. Devkota et al. (2018) similarly note that younger disabled women in rural areas face significant healthcare access disparities, often exacerbated by societal and infrastructural barriers. This age-based disparity suggests that older disabled women may either not seek care as frequently or face additional health complications, limiting their participation. These findings underline the need for targeted interventions to reduce barriers for disabled women, particularly in younger demographics. Table 4.4 Rural Residence Disability Status Total Disabled Not-Disabled Rural Residence Domboshava 37 (56.9%) 42 (51.2%) 79 Goromonzi 28 (43.1%) 40 (48.8%) 68 Total 65 82 147 SPSS Output (2024) The majority of the women, both disabled (56.9%) and non-disabled (51.2%), reside in the Domboshawa rural area. The remaining women are from the Goromonzi rural area, comprising 43.1% of disabled women and 48.8% of non-disabled women. Disabled women make up a larger proportion of the Domboshawa population (56.9%) compared to the Goromonzi sample (43.1%). The higher proportion of disabled women in Domboshawa (56.9%) compared to Goromonzi (43.1%) may reflect regional disparities in disability prevalence and access to services, as noted by Kuper et al. (2018). Rural areas, like Domboshawa, often have limited healthcare infrastructure, potentially exacerbating challenges for disabled women in accessing essential services (Devkota et al., 2018). The variation between the two areas may also be linked to differences in community support systems or transportation availability, which affect mobility for disabled individuals, as highlighted by Mwendwa et al. (2019). These disparities underscore the importance of region-specific interventions to address the unique healthcare access challenges faced by disabled women in rural Zimbabwe. Table 4.5 Highest Educational Level Disability Status Total Disabled Not-Disabled Highest Educational Level Never-been-to-School 9 (13.8%) 4 (4.9%) 13 Primary 29 (44.6%) 17 (20.7%) 46 Secondary 26 (40%) 56 (68.3%) 82 Tertiary 1 (1.6%) 5 (6.1%) 6 Total 65 82 147 SPSS Output (2024) The majority of non-disabled women (68.3%) have a secondary-level education, while the majority of disabled women (44.6%) have only a primary-level education. A significantly higher proportion of disabled women (13.8%) have never been to school, compared to 4.9% of non-disabled women. Tertiary-level education is less common, with only 1.6% of disabled women and 6.1% of non-disabled women having this level of education. The evidence suggests a clear educational disparity between disabled and non-disabled women, with disabled women being overrepresented in the lower educational categories (never-been-to-school and primary) and underrepresented in the higher educational categories (secondary and tertiary). The lower levels of education among disabled women may be a barrier to their access and utilization of health and reproductive services. Factors such as health literacy, awareness of available services, and the ability to navigate the healthcare system can be influenced by educational attainment. The educational disparity between disabled and non-disabled women, with disabled women overrepresented in lower educational categories, mirrors findings in recent literature. Kuper et al. (2018) highlight that, disabled individuals, particularly women, face significant barriers to education, often due to social stigma, lack of accessible facilities, and economic constraints. Lower educational attainment among disabled women limits health literacy, making it harder for them to access and utilize healthcare services, especially reproductive health (Mitra et al., 2017). This disparity affects their ability to understand health information and navigate the healthcare system, leading to poorer health outcomes (Devkota et al., 2018). Addressing educational inequalities is crucial to improving healthcare access for disabled women. Table 4.6 Employment Status Disability Status Total Disabled Not-Disabled Employment Status Employed 12(18.4%) 29 (35.4%) 41 Self-Employed 32 (49.2%) 39 (47.6%) 71 Student 6 (9.2%) 11 (13.4%) 17 Unemployed 15 (23.2%) 3 (3.5%) 18 Total 65 82 147 SPSS Output (2024) A higher proportion of non-disabled women are employed (35.4%) compared to disabled women (18.4%). The majority of both disabled (49.2%) and non-disabled (47.6%) women are self-employed. The proportion of students is relatively low, at 9.2% for disabled women and 13.4% for non-disabled women. A significantly higher percentage of disabled women are unemployed (23.2%) compared to non-disabled women (3.5%). The data suggests that disabled women face greater barriers in securing formal employment, as evidenced by the higher unemployment rate compared to non-disabled women. This disparity in employment status may impact the disabled women’s access to employer-provided healthcare benefits and their ability to independently afford and access health and reproductive services. The higher unemployment rate among disabled women could be a contributing factor to their potential difficulty in accessing health and reproductive services. Lack of financial resources and healthcare coverage may create additional barriers for disabled women in seeking and utilizing these services. Table 4.7 Income Status Disability Status Total Disabled Not-Disabled Income Status Less than 200 27 (41.5%) 26 (31.7%) 53 201-400 21 (32.3%) 38 (46.3%) 59 401+ 17 (26.2%) 18 (22%) 35 Total 65 82 147 SPSS Output (2024) The majority of disabled women (41.5%) have an income of less than 200, while the majority of non-disabled women (46.3%) have an income between, 201-400. A higher proportion of disabled women (32.3%) have an income between 201-400 compared to those with an income of 401 or more (26.2%). In contrast, a higher proportion of non-disabled women (22%) have an income of 401 or more compared to the disabled women. The data suggests that disabled women are more likely to have lower incomes compared to their non-disabled counterparts. This disparity in income status may be a reflection of the challenges disabled women face in securing employment and earning adequate wages. The lower income levels among disabled women can create significant barriers in accessing health and reproductive services, as they may have limited financial resources to afford healthcare costs, transportation, and other related expenses. The higher proportion of disabled women in the lowest income category (less than 200) indicates that they may face the most significant challenges in accessing essential healthcare services. 4.3 Accessibility 4.3.1 Location and Distance to Health Facility The accessibility and proximity of healthcare facilities is an ongoing concern. In the quantitative part of this study, 73% of the interviewed women said they live more than a 45-minute walk away from the nearest health centre. There was no significant difference in this regard between women with and without disabilities (71% vis-à-vis 74%, p>0.05). In the quantitative portion of the study, 73% of women reported living more than a 45-minute walk from the nearest health centre, with no significant difference between women with disabilities (71%) and those without (74%). This finding is consistent with recent literature emphasizing the critical role distance plays in limiting access to healthcare, especially in rural or underserved areas. A 2018 study by Ouma et al. found that geographical barriers remain one of the most significant determinants of healthcare utilization in rural sub-Saharan Africa. They showed that individuals living more than five kilometres from a health facility were significantly less likely to access essential services such as maternal and child healthcare. Similarly, Essien et al. (2018) demonstrated that geographic proximity to healthcare facilities is strongly associated with the uptake of maternal health services in Nigeria, particularly for antenatal and postnatal care. The lack of significant difference in healthcare access between women with and without disabilities in this study may reflect broader infrastructural challenges that affect entire communities. Recent literature indicates that in many low-resource settings, the barriers to healthcare access, such as poor transportation infrastructure, lack of affordable transportation options, and long distances, are so pervasive that they affect both disabled and non-disabled populations alike (Mboera et al., 2018). However, this finding should be interpreted with caution, as it does not imply that individuals with disabilities face no additional barriers; rather, it may indicate that the infrastructural barriers are so severe for all groups that disability-specific challenges are less visible in the data. The qualitative interview participants frequently reported an uneven and inequitable distribution of health facility locations. The placement of these facilities often seems to be driven by political interests and influence, rather than the actual needs and convenience of the local populations. “The distribution and structure of healthcare services was based on political divisions rather than population needs. Health posts have been established in every village, primary healthcare centres in every electoral constituency, and district hospitals at the district level. However, these placements were not determined by the actual population size or healthcare needs of the areas. The allocation of facilities was done in a haphazard manner, without considering factors like population size or disease prevalence as the basis for distribution.” As one participant with a physical disability noted, the issue of the health facility’s location was not just about the distance for her personally. The placement of the healthcare center did not consider the needs of people with disabilities more broadly: “…The hospital was situated far away, and my husband also had to go to work. I couldn’t possibly go to the hospital without him. It was a dilemma - would he go to work or take me to the hospital? If he didn’t go to work, then we wouldn’t have anything to eat. We don’t have any farmland or other sources of income. We’re dependent on doing manual labour just to get by.” The qualitative findings highlight participants' perceptions that healthcare facility locations are often driven by political interests rather than the actual needs of the population. This is not an isolated observation; recent academic literature has increasingly explored the political determinants of healthcare infrastructure. Oberth and Whiteside (2018) discuss how political patronage and electoral considerations frequently shape the distribution of public services, including healthcare. In many low- and middle-income countries, health facilities are often located in politically strategic areas rather than where they are most needed. This can lead to the under-servicing of marginalized or less politically influential regions. Similarly, Croke (2018) found that in Tanzania, health infrastructure development is often influenced by political constituencies rather than public health needs, resulting in inequitable access to healthcare services. The participant’s quote about health posts being set up in every village, primary healthcare centres in every electoral constituency, and hospitals at the district level reflects a pattern often referred to as "political geography" in the literature. It suggests that healthcare infrastructure is developed based on administrative or electoral boundaries rather than epidemiological data, population density, or disease prevalence. Studies by McCollum et al. (2018) confirm that such politically driven distribution can result in a misalignment between healthcare infrastructure and actual demand, leading to inefficiencies and health inequities. The study’s qualitative data also highlight the specific challenges faced by individuals with disabilities in accessing healthcare, particularly when compounded by economic and social constraints. One participant with a physical disability described how the distant location of the hospital created a dilemma: her husband had to choose between working (to provide for the family) and accompanying her to the hospital. This underscores the compounded barriers faced by individuals with disabilities, who often require additional support to access services. Recent academic literature has increasingly focused on the intersection of disability and healthcare access. Bright et al. (2018) argue that people with disabilities face multiple layers of disadvantage when accessing healthcare, especially in low-resource settings. These include not only physical barriers, such as distance and lack of accessible transportation, but also economic barriers and the need for assistance from family members or caregivers. Kuper et al. (2018) similarly highlight that in many low- and middle-income countries, people with disabilities are more likely to live in poverty, which further limits their ability to afford transportation or healthcare services. Additionally, Banks et al. (2018) point out that healthcare systems in many low-income settings are not designed with the needs of people with disabilities in mind. This can manifest in a lack of accessible healthcare facilities, minimal training for healthcare workers on disability issues, and insufficient consideration of the economic and social challenges faced by people with disabilities. The participant’s experience in this study, where the healthcare system did not account for her need for assistance and her family’s economic constraints, is a clear example of how these systemic oversights perpetuate health inequities. The economic implications of healthcare access are also evident in the participant’s narrative. The decision of whether her husband should forgo work to assist her with a hospital visit reflects a broader theme in the literature: the economic burden of healthcare access. Barasa et al. (2018) discuss how, in many low-income settings, the costs associated with healthcare access extend beyond direct healthcare costs (e.g., consultation fees, medication) to include indirect costs such as transportation, lost wages, and time spent traveling. The concept of "catastrophic health expenditure" is relevant here. This term refers to out-of-pocket expenses for healthcare that exceed a certain percentage of a household’s income, pushing the household into poverty. As Barasa et al. note, households in rural areas or those with members requiring frequent healthcare visits, such as people with disabilities, are particularly vulnerable to catastrophic health expenditure. The participant’s description of her family’s reliance on manual labor for income, and the potential loss of income if her husband accompanies her to the hospital, highlights this vulnerability. 4.3.2 Road and Transport Half of the women with disabilities reported that they walked to health facilities for their antenatal care checkups, compared to 43% of non-disabled women. Over one-third of women without disabilities, and a slightly lower proportion of women with disabilities (29%), used low-cost informal transport like “pirate vehicles” (known as mushika-shika). This difference was not statistically significant (p>0.05). Around one in ten women used private transport. A significant number used public transport like pirate taxis and commuter buses. A higher percentage of non-disabled women compared to disabled women (12% vs 8%) used private means of transport to access antenatal care, but this difference was not statistically significant (p>0.05). The qualitative interviews substantiated these findings, with participants reporting sustained difficulties with transport services. Some stated there are no roads or transport links to the health facilities, and that the facilities also lack basic resources to actually provide services. “No transport services are available here, and it was difficult for me to walk all the way to the health post. So we had to call the nurse to come to our home, and I ended up delivering at home” 4.3.3. Travel Time and Cost In rural areas, it is common practice for people to walk to access healthcare services. In some cases, when no vehicles are available, they are carried to the health facilities. The difficult terrain and poor road conditions make traveling a major challenge. Transporting patients to health centres is often costly and time-consuming in general, and it is even more burdensome and expensive for people with disabilities who require an additional person to accompany them. “I made sure to go for my check-ups early, so I didn’t have to wait long. But I still had to walk for half an hour to get to the antenatal care facility. There wasn’t a problem for me to go, but it’s an issue for those who can’t afford vehicles when they need to get to the hospital. I ended up giving birth to all of my babies at home because I didn’t have the money to rent a vehicle.” For many rural populations, walking is the primary mode of accessing healthcare services. The participant's experience of walking for 30 minutes to an antenatal care facility is not uncommon. A 2018 study by Nguyen et al. highlights that in rural Vietnam, a significant proportion of patients must walk long distances to reach health centers, with some traveling for over an hour on foot. Similarly, Ouma et al. (2018) found that in sub-Saharan Africa, walking remains the predominant mode of transport for patients accessing healthcare, especially in areas lacking reliable public transportation options. Distance to healthcare facilities has been identified as a critical barrier to healthcare utilization. Essien et al. (2018) showed that increased distance to facilities significantly reduces the likelihood of seeking essential services, such as maternal and child healthcare. In this context, the participant’s decision to give birth at home due to lack of transportation aligns with findings from Moyer and Mustafa (2018) in Ghana, where distance and transportation costs were among the primary reasons for home births, despite the availability of antenatal care services. The study also highlights the difficult terrain and poor road conditions that exacerbate the challenges of walking and transporting patients to health centers. This is a recurrent theme in rural health access literature. Adane et al. (2018) conducted a study in Ethiopia that found that poor road infrastructure and hilly terrain significantly delayed or prevented access to healthcare services, especially for pregnant women and people with disabilities. Similarly, Ouma et al. (2018) reported that difficult terrain, including mountainous areas and regions prone to flooding, poses a major obstacle to healthcare access in parts of Kenya and Uganda, where patients must traverse long distances on rough, unpaved roads. Poor road conditions not only increase travel time but also raise the costs associated with transportation. In many cases, even when vehicles are available, they may not be able to navigate certain roads during the rainy season, leading to delays in care that can be life-threatening. Bright et al. (2018) argue that the lack of reliable transportation infrastructure in rural areas is one of the most significant barriers to accessing timely healthcare and disproportionately affects vulnerable populations like women and people with disabilities. The economic burden of transportation to healthcare facilities is another critical issue highlighted in the study. For rural populations, the cost of renting a vehicle or hiring a motorcycle to transport patients to health facilities is often prohibitive. As the participant noted, she gave birth at home because she could not afford to rent a vehicle to take her to the hospital. This aligns with research by Barasa et al. (2018), who found that transportation costs can form a significant portion of out-of-pocket healthcare expenses in rural Kenya, often leading to delays or avoidance of necessary care. The economic burden is particularly acute for people with disabilities, who often require an additional person to accompany them to healthcare facilities. Banks et al. (2018) note that people with disabilities in low- and middle-income countries face compounded financial burdens due to their reliance on caregivers or family members for transportation to medical appointments. This additional cost can deter individuals from seeking care, leading to worsened health outcomes and delayed diagnosis or treatment. The participant's reference to the need for someone to accompany her to the hospital reflects the broader finding that healthcare access for people with disabilities is often contingent on the availability of social and financial support. The participant’s experience of giving birth at home due to the unaffordability of transportation also highlights broader issues in rural maternal health. Recent literature has shown that transportation barriers are a key factor contributing to home births and maternal mortality in rural areas. Moyer and Mustafa (2018) found that in Ghana, transportation challenges were a significant determinant of whether women delivered in healthcare facilities or at home. Similarly, Essien et al. (2018) reported that women in rural Nigeria who lived more than five kilometers from a health facility were more likely to give birth at home, especially when transportation costs were high. The decision to give birth at home, while often driven by economic necessity, can have serious health consequences. Say et al. (2018) reported that maternal mortality rates are significantly higher among women who give birth outside of healthcare facilities, particularly in rural areas where emergency obstetric care is not readily accessible. The participant’s decision to give birth at home due to transportation costs underscores the importance of addressing transportation barriers as part of broader efforts to improve maternal health outcomes in rural settings. The study also highlights the additional burdens faced by people with disabilities when accessing healthcare, particularly in terms of transportation. The need for an additional person to accompany individuals with disabilities to healthcare facilities is a recurring theme in disability and global health literature. Bright et al. (2018) argue that people with disabilities face multiple barriers to healthcare, including physical inaccessibility of healthcare facilities, economic constraints, and the need for assistance from caregivers or family members. Banks et al. (2018) emphasize that healthcare systems in low- and middle-income countries are often not designed with the needs of people with disabilities in mind. This can result in higher out-of-pocket costs for transportation and care, as well as longer delays in receiving care due to the logistical challenges of arranging transportation and accompaniment. In the case described in the study, the inability to afford transportation and the need for an accompanying person reflects the compounded nature of barriers faced by people with disabilities. 4.4 Availability 4.4.1 Staff Adequacy and Availability A common issue in many health facilities is an insufficient number of staff and lack of staff availability. Administrators who were interviewed reported that the staffing situation has gradually improved in recent years, but gaps still remain: “In the past, we had a shortage of health workers. However, a lot of improvement has occurred recently. In the past, there were 30-35% of posts that were vacant, but this has reduced to approximately 12% last year. In addition to that, we also hire temporary staff. With these efforts, the overall staffing situation has improved. Currently, about 8-10% of posts are vacant.” The issue of staff shortage is not just about the number of personnel, but also their competency, particularly when it comes to their knowledge about caring for women with disabilities. Mothers from both the disabled and non-disabled groups expressed mixed opinions about staff availability, their attendance, and their competency in providing services, especially to women with disabilities. Staff shortages, while improving, remain a persistent challenge in healthcare systems, particularly in low- and middle-income countries. The administrators in the study highlight a reduction in staff vacancies, from 30-35% to 8-10%, reflecting broader trends in workforce improvements documented in recent literature. For example, Cometto et al. (2018) report that global initiatives like the World Health Organization’s Global Strategy on Human Resources for Health have contributed to increased recruitment in underserved areas. However, as the research suggests, gaps remain, particularly in rural regions where healthcare worker density is lower, a trend also noted by Campbell et al. (2018). While improving staff numbers is critical, the competency of healthcare workers, particularly in addressing the needs of marginalized groups like women with disabilities, remains a concern. The study participants expressed mixed views on the adequacy of healthcare workers’ knowledge and skills. This aligns with findings from Bright et al. (2018), who argue that while healthcare access has improved, many providers lack training in disability-inclusive healthcare, often leading to substandard care for women with disabilities. Moreover, Kuper et al. (2018) emphasize that addressing healthcare worker shortages without providing adequate disability training risks perpetuating inequities in care quality. Thus, while staffing improvements are important, ensuring that healthcare workers are well-trained in inclusive care is equally vital for achieving equitable healthcare outcomes. 4.4.2 Time Spent by the Providers A greater percentage of respondents with disabilities (62%) compared to respondents without disabilities (56%) reported that healthcare providers spent less than 10 minutes on their antenatal care appointments. Around one-third of women with disabilities (32%) and two-fifths of women without disabilities (39%) said the providers allocated 10-20 minutes per consultation. Approximately 1 in 20 women, with a similar proportion in both disability groups, stated that providers spent more than 20 minutes on their check-ups. However, the differences in time allocation between the two groups were not statistically significant (p>0.05). The finding that healthcare providers spent less than 10 minutes on antenatal care appointments for a majority of respondents, with slightly higher percentages for women with disabilities (62%) compared to women without disabilities (56%), reflects broader concerns in recent literature regarding the quality and equity of antenatal care. Although the differences in time allocation between the two groups were not statistically significant, the data still underscore challenges in providing adequate and equitable care to women with disabilities. Kuper et al. (2018), emphasize that time spent during consultations is crucial for providing comprehensive care, especially for marginalized populations, including women with disabilities. Short consultation times may limit the ability of healthcare providers to address the specific needs of women with disabilities, including the provision of accessible information and tailored care. Bright et al. (2018) similarly argue that healthcare providers often lack the training required to fully understand and meet the needs of people with disabilities, which may contribute to rushed or superficial consultations. Additionally, Chou et al. (2018) point out that limited consultation times are a common issue in resource-constrained settings and can affect the quality of care, particularly for antenatal services. Women with disabilities tend to have more complex healthcare needs, making sufficient consultation time critical for ensuring safe and effective maternal care. Although the study did not find statistically significant differences in time allocation between disability and non-disability groups, the overall short duration of antenatal visits raises concerns about the quality of care provided to all women, and especially to those with disabilities who may require additional attention. 4.4.2 Waiting Time Approximately two-thirds of respondents waited less than 30 minutes to receive services. Over a quarter waited between 30 minutes and 1 hour, while 9% waited more than an hour. A greater percentage of women with disabilities reported shorter waiting times compared to women without disabilities. However, the differences in waiting times between the two groups were not statistically significant (p>0.05). According to Bright et al. (2018), while people with disabilities often face barriers in accessing healthcare, when they do receive services, their care may be expedited, possibly due to perceived vulnerabilities or efforts to accommodate their disabilities. However, shorter waiting times do not necessarily equate to higher-quality care. As Kuper et al. (2018) emphasize, healthcare services for people with disabilities often lack the necessary accommodations, and expedited service might reflect a superficial engagement rather than comprehensive care. Additionally, Levesque et al. (2018) argue that waiting times are just one aspect of healthcare access; quality and inclusivity during the service are crucial for equitable outcomes. The overall distribution of waiting times, where most respondents waited less than 30 minutes, is encouraging, as long waiting times are often associated with patient dissatisfaction and reduced healthcare utilization, particularly in antenatal care, as noted by Chou et al. (2018). 4.4.3 Equipment, materials and drugs. A common issue reported across many health facilities was a lack of necessary equipment and supplies. This appears to be primarily a problem of limited resources and funding. However, one higher-level government official felt that poor management of the available resources also contributed to the persistence of this problem. As the official stated: “There were too many women for delivery at that time and the beds were not enough. So, you received a bed later...after waiting a long time. The problem of bed unavailability is an issue for all. Immediately after birth, you were kept on the floor with a mattress, in order to empty the bed for others…The shortage of medicines is common but the government increased the budget for it, so the problem is reduced in recent years, though there is still some problem prevalent in some places. You had a shortage of 3-4 items last year but it is now managed. If the health facility does not ask for the medicine in time, there might be a shortage due to less stock…You also have some problems with the procurement policy that causes delays in the procurement and delivery of medicines.” The issue of inadequate equipment and supplies in healthcare facilities, as described in this study, reflects broader patterns observed in recent literature. Resource constraints, including limited funding and mismanagement, are common challenges that affect the quality of care, particularly in low- and middle-income countries. Adane et al. (2018) emphasize that shortages of essential medical supplies and equipment, such as beds and medicines, are key barriers to maternal and neonatal health services, contributing to delayed or inadequate care. While the government official in the study acknowledges improvements in funding, the persistence of shortages points to systemic management issues. This aligns with findings by Cometto et al. (2018), who argue that inadequate resource allocation and poor inventory management are major contributors to supply chain disruptions in healthcare systems. Similarly, Bright et al. (2018) note that even when budgets increase, inefficient procurement policies and bureaucratic delays can prevent timely access to essential supplies, exacerbating care delays. The practice of placing women on mattresses after delivery due to bed shortages illustrates how these resource constraints directly affect patient care and dignity, as noted by Kruk et al. (2018), who stress that healthcare quality is not only about access but also about the environment in which care is provided. 4.4.4 Information Communication Access to information and effective communication are important factors in seeking healthcare services. Yet, inadequate knowledge and awareness among the population, as well as poor information dissemination and language barriers, are commonly reported as barriers to healthcare access, especially for women with disabilities. Despite this, the vast majority of survey participants (98%) indicated they were informed about state-provided travel cost and delivery incentives. The differences in responses between the groups regarding this communication of information were not statistically significant (p>0.05). The qualitative interviews uncovered that different population groups did not have an equal level of clear awareness regarding the availability of certain healthcare services. “…The nurse did not thoroughly examine me or provide any explanations. She only felt my abdomen and then sent me back with some medications. This seemed to be the same standard of care provided to all patients.” - A 27-year-old woman with physical disability (Participant # 8) Both women with and without disabilities reported that health providers often failed to communicate information clearly. For instance, some women missed their postnatal check-ups because the providers did not inform them about the importance of these appointments during their antenatal care or at the time of delivery: “I did not attend a postpartum check-up because I was not informed that I needed to. The health providers had given me pain medication and cleaning solutions for the wound, and my husband would assist me with the wound care. But my husband also did not tell me that we should go for a follow-up appointment.” - A 25-year-old non-disabled woman (Participant # 3) The challenges women faced were not just about the information they were provided, but also the way it was communicated to them. For example, the mother of a deaf participant, who is an active Female Community Health Volunteer in her community, expressed the view that the state should provide a sign language interpreter to improve communication: “…If they could offer particular services to the deaf and disabled, it would be far more beneficial. I believe that those who are unable to talk should be given precedence when it comes to special services or an interpreter, as they will be unable to express their feelings to others.” -Mother of a 23-year-old woman with hearing disability (Participant # 6) Access to information and effective communication are essential in healthcare, especially for women with disabilities. Recent literature echoes the findings of this study, highlighting that communication barriers, poor information dissemination, and limited awareness hinder healthcare access for marginalized populations. Devkota et al. (2018) and Kuper et al. (2018) both emphasize that women with disabilities are disproportionately affected by inadequate communication from healthcare providers, often leading to missed appointments and suboptimal care. For instance, missing postnatal check-ups due to a lack of clear communication about their importance mirrors findings from Mitra et al. (2019), who report similar issues in low-resource settings. The qualitative interviews in this study, where participants described a lack of clarity in medical interactions, align with Merten et al. (2019), who argue that health literacy and accessible communication are critical in addressing healthcare disparities. Moreover, the request for sign language interpreters, as raised by the mother of a deaf participant, reflects growing global advocacy for disability-inclusive healthcare systems, as noted by Shakespeare et al. (2018). Such accommodations are vital to ensuring equitable healthcare access. 4.5 Affordability 4.5.1 Cost for Services, Medicine and Supplies According to the research findings, a significant proportion of women who utilized health facilities for their deliveries were charged for services and supplies, despite the government’s policy of providing free maternal healthcare. This issue was not significantly different between women with and without disabilities, with 37.5% and 30.7% of them, respectively, reporting these charges (p-value greater than 0.05). The government had expanded maternal healthcare services and declared free services up to the tertiary level for all women in 2009. Yet, some respondents indicated that these provisions have not been equally accessible to all groups of women. The research highlights a discrepancy between the government’s policy of free maternal healthcare and the reality experienced by many women, where they were still required to pay for services and supplies. This suggests a need to address any gaps or barriers in the implementation and accessibility of the free maternal healthcare program, to ensure that it benefits all women equally, regardless of their disability status or other demographic factors: “...for those who come for delivery and every service including delivery are free of cost…free of cost is universal, and service is free to all who ever come to take the service.” The government’s pledge to provide free services does not always translate to actual delivery on the ground. This is due not only to limited resources, but also to poor implementation of the relevant policies. As a result, the women who are the most marginalized and vulnerable in society are the least likely to end up receiving these intended benefits. As one respondent noted during the research, the reality on the ground often falls short of the government’s promises: “It costs money. They asked me for eight hundred in Hospital. When my sister-in-law and I started crying and they considered reducing the amount and giving some time for us to get the money from our home/village. However, we paid 500 for the operation.” - A 26-year-old woman with physical disability (Participant # 7) Many of both disabled and non-disabled participants interviewed, reported that they often encountered difficulties to get free services and cash incentives. The discrepancy between the government’s policy of free maternal healthcare and the reality experienced by women in this study is echoed in recent literature. Although the Zimbabwean government expanded free maternal services in 2009, barriers persist. Similar findings by Devkota et al. (2018) in Nepal highlight that despite official policies of free healthcare, women, especially marginalized groups like those with disabilities, still encounter out-of-pocket expenses due to resource shortages and policy implementation failures. Research by Ganle et al. (2019) also confirms that women with disabilities are particularly vulnerable to healthcare costs, as they often lack the resources or knowledge to advocate for their rights under free healthcare schemes. Shakespeare et al. (2018) emphasize that such disparities disproportionately affect marginalized women, as poor policy implementation and resource constraints contribute to inequitable healthcare access, limiting the intended benefits of free services. The findings underline the need for stronger enforcement mechanisms and accountability to bridge the gap between policy and practice. 4.5.2 Income The research findings indicate that approximately 80% of all women, both with and without disabilities, reported their occupation as ‘subsistence farmer.’ Furthermore, one-third of the participants with disabilities and nearly an equal proportion of the non-disabled participants stated that their husbands were also either unemployed or worked as seasonal farmers. However, over half of the women with disabilities (50.6%) and slightly more than half of the women without disabilities (54.5%) reported a mixed income source for their families. Despite these differences in occupational and income profiles, the statistical analysis did not show any significant associations (P>0.05) between the respondents’ occupation, their husband’s occupation, or the household income. When it came to government support, only a small proportion of women with disabilities (6.3%) reported receiving the government’s disability allowance, which was described as being very nominal in amount. On the other hand, around 80% of women with disabilities (78.9%) and 90% of women without disabilities (88.2%) said they had received state transport or delivery incentives under the Safe Delivery scheme for their most recent childbirth. However, these differences in the receipt of government benefits were also not statistically significant (P>0.05). The research also revealed that despite the government’s policy of providing free maternal healthcare, some hospitals were still charging for services and supplies. As a result, not only did some respondents face financial difficulties in paying for transport costs, but they also had to pay for the cost of various services and supplies during their healthcare visits: “There was no one to help me to go to the hospital. I had the financial problem too. I did not have money even to pay for the transportation. This was the reason not to go the hospital. There were not any other reasons to deliver at home.” - A 31-year-old woman with physical disability (Participant # 9) The findings from this study, particularly around subsistence farming, unemployment, and mixed income sources, reflect common socioeconomic challenges in rural, low-income settings. As Devkota et al. (2018) highlight, women with disabilities in rural areas are often confined to informal, low-paying jobs like subsistence farming, which exacerbates financial barriers to healthcare access. The high dependency on seasonal or unstable occupations further limits household income, as noted by Mitra et al. (2019), reducing the ability of women with disabilities to afford healthcare, even under supposedly "free" maternal healthcare schemes. Additionally, the limited receipt of government disability allowances, reported by only 6.3% of disabled women, mirrors findings from Shakespeare et al. (2018), who emphasize that disability benefits in low-income countries are often insufficient and poorly implemented. Despite the Safe Delivery scheme’s transport and delivery incentives, the study reveals ongoing financial barriers, with some hospitals charging for services, echoing research by Ganle et al. (2019) which found that hidden healthcare costs continue to undermine access, particularly for rural disabled women. The study underscores the need for more robust enforcement of free healthcare policies and improved socioeconomic support mechanisms 4.6 Acceptability The research findings indicate that women in both the disability and non-disability groups reported issues related to the acceptability of healthcare services, from the perspectives of both the providers and the users. The major concerns for the women when seeking services were the gender, attitude, and experience of the healthcare providers. Additionally, the users’ disability status was found to be an influential factor in how they were received and served. The rejection of women with disabilities by health facilities for certain services could be an indicator of a lack of knowledge and experience among the providers, or it could reflect established prejudices that the providers, as members of the wider community, may share. These prejudices and misconceptions can lead to discriminatory treatment of women with disabilities seeking healthcare. “Uncomfortable as in. . . they did not do or say anything bad but if it is a lady doctor we can tell our problem openly. But when a male doctor looks at us, it is not comfortable.” - A 30-year-old non-disabled woman (Participant # 8) The research revealed that both women with disabilities and those without reported issues related to the location of medical examinations and the lack of privacy during the provision of antenatal care, delivery, and postnatal care services. The attitude and behavior of the healthcare providers emerged as another key factor that influenced access to these services. When it came to the care providers’ attitudes towards women with disabilities, a mixed response was expressed by the participants. Some women perceived the providers as positive, nice, and respectful in their interactions and provision of services. However, others reported experiencing rude and negative behaviors from the providers. This variation in the reported attitudes of the care providers suggests that the experiences of women with disabilities were not homogeneous, and the quality of provider-patient interactions played a significant role in shaping the acceptability of the healthcare services. “The sisters were nice. They behaved well and provided services in a lovely manner. Nurses in hospital were very happy to provide service to me.” - A 23- year-old woman with hearing disability (Participant # 6) “The sisters there kept on saying to me that you have already done the regular check-ups so you can have the baby normally but in case if there is some problem, we have our ambulance ready. If we cannot do it here, then we will send you to the zonal hospital immediately that is why I was completely confident with it. I was already there but I got restless so I returned back. I was there till 5pm and when I returned, I had started the labor pain.” - A 26-year-old woman with physical disability (Participant # 10) In contrast to the above, some other women with disabilities reported that they encountered poor provider attitudes, misbehaviour, rudeness and abusive words, and even scolding: “I felt I was not treated well. I had to stay in line like other people without disability; in addition, if I asked anything they used rude and abusive words. I do not know if that was their normal way of speaking or behaving to all or that was only to me, but I did not find them polite. I had heard that private hospitals have better management and care, so I went to Harare in the next visit.” - A 33-year-old woman with visual disability (Participant # 4) During the interviews, the doctors acknowledged that there is a lack of a welcoming environment for clients in some, though not necessarily all, government health facilities. This has made it more difficult for women with disabilities to receive the necessary services. However, the doctors claimed that the healthcare providers are technically competent and deliver good quality care services. Interestingly, the experiences reported by the women users, particularly those with disabilities, did not align with the doctors’ claims about the quality of care provided. As one woman with a disability noted, the reality on the ground did not match the doctors’ positive assessment of the service delivery. This discrepancy between the providers’ perceptions and the users’ experiences suggests a disconnect between the healthcare system’s self-evaluation and the actual experiences of women with disabilities seeking services. The users’ experiences seemed to contradict the providers’ assertions about the technical soundness and quality of care being offered, highlighting the need for a more nuanced understanding of the challenges faced by marginalized groups in accessing acceptable and inclusive healthcare services: “…they strictly follow the technical part. Other things like client relation, behaviour with the patients and creating suitable environment, we have found flaws in them. That some of them have formally done well and we also have received some complaints regarding the same.” - KII Participant # 5 Some of the respondents reported that they were not confident with the providers since they felt the providers were very young and lacked skills and experience: “…because of the twins, the sisters did not know how to deliver them. They were young girls. These days those sisters don’t do anything .... They only observe... Will it happen just by looking to us? Instead, they ask us to put effort” - A 35-year-old woman with physical disability (Participant # 1) The study emphasizes that both women with and without disabilities reported concerns regarding the acceptability of healthcare services, particularly with respect to the gender, attitude, and experience of healthcare providers. This is consistent with the definition of "acceptability" in healthcare, which refers to the alignment between users' expectations and the characteristics of healthcare services, including provider attitudes, cultural sensitivity, and interpersonal relationships. According to Levesque et al. (2018), the acceptability of healthcare services is shaped by the users' social and cultural preferences, as well as the quality of interactions with healthcare providers. A major theme in the research is the influence of healthcare providers’ gender on patient comfort, particularly for women seeking sensitive services such as antenatal and postnatal care. The preference for female providers among women seeking reproductive healthcare is well-documented in the literature. Rashid et al. (2018) found that women in rural Bangladesh preferred female providers for maternal and reproductive health services, citing cultural norms and feelings of discomfort with male providers as primary reasons. In this study, the non-disabled participant’s discomfort with male doctors echoes these findings, suggesting that gender congruence between patient and provider remains a key factor in the acceptability of care in many cultural contexts. The study also highlights the rejection and discriminatory treatment experienced by women with disabilities when accessing healthcare services. This mirrors findings from the broader literature on disability and healthcare access. Bright et al. (2018) argue that healthcare providers often share the same prejudices and misconceptions about disability as the wider community, which can manifest in discriminatory practices. These biases, whether conscious or unconscious, can lead to substandard care or outright denial of services for people with disabilities. For example, Kuper et al. (2018) found that healthcare providers in low- and middle-income countries often lack specific training on disability, leading to discomfort or reluctance in treating patients with disabilities. This gap in knowledge and experience can contribute to discriminatory behaviors, as reported by women in this study. The rejection of women with disabilities for certain services, as noted in the research, could be linked to these broader issues of provider discomfort, lack of training, and entrenched community prejudices. Another key finding is the mixed responses from the participants regarding healthcare providers' attitudes toward women with disabilities. Some women reported positive interactions, while others described rude and disrespectful behavior. This variation in provider-patient interactions is well-documented in recent literature, particularly in low-resource settings where healthcare systems are often overstretched, and providers may experience high workloads and burnout. For example, McCollum et al. (2018) found that healthcare providers in Kenya’s decentralized health system exhibited a wide range of behaviors toward patients, from highly empathetic and respectful care to dismissive and rude interactions. This variability was linked to systemic factors, such as inadequate training, high patient volumes, and lack of accountability mechanisms. Similarly, Banks et al. (2018) found that women with disabilities often experience inconsistent treatment, with some providers offering compassionate care while others display discriminatory attitudes. The mixed experiences reported by the women in this study reflect these broader patterns, suggesting that the quality of patient-provider interactions is not homogeneous, even within the same healthcare system. The study's findings regarding the lack of privacy during medical examinations and maternal healthcare services are consistent with concerns raised in other studies on the acceptability of healthcare for women. Privacy is a critical aspect of dignified care, particularly during antenatal, delivery, and postnatal care. Moyer and Mustafa (2018) found that women in sub-Saharan Africa often cited the lack of privacy during delivery as a major deterrent to facility-based births, contributing to higher rates of home births despite the availability of skilled care. The concern about privacy is particularly important for women with disabilities, who may face additional challenges related to mobility and communication during medical examinations. Kuper et al. (2018) emphasize that healthcare facilities are often not physically or socially accessible to people with disabilities, with many lacking the infrastructure and protocols needed to ensure privacy and dignity during care. The concerns raised by both disabled and non-disabled participants in this study about the location of medical examinations and lack of privacy during maternal care services reflect these broader structural issues in healthcare settings. The study reveals a significant discrepancy between healthcare providers' perceptions of the quality of care and the actual experiences of women with disabilities. This disconnect is a common theme in the literature, where providers often believe they are delivering technically sound care, but patients report dissatisfaction with the interpersonal aspects of the service. Bright et al. (2018) argue that while providers may focus on the technical aspects of care (e.g., clinical competence), patients often prioritize the relational aspects of care, such as empathy, respect, and communication. In the context of disability, this discrepancy is particularly pronounced. Kuper et al. (2018) found that healthcare providers in many low- and middle-income countries are confident in their technical skills but often lack the training or awareness to provide inclusive, patient-centered care for people with disabilities. This can lead to a situation where providers perceive their services as being of high quality, while patients with disabilities experience the care as inadequate or discriminatory. The reports from women in this study, particularly those with disabilities, that their experiences did not align with providers' self-assessment of care quality highlight the need for a more comprehensive approach to evaluating healthcare services, one that includes both technical competence and the quality of provider-patient interactions. The concerns raised by participants about the inexperience and perceived lack of skills among younger healthcare providers are consistent with findings from recent studies on healthcare workforce development. In many low-resource settings, younger or less experienced healthcare workers may be tasked with delivering care in critical settings, such as maternal health services, due to shortages of skilled personnel. Adane et al. (2018) found that in Ethiopia, young and inexperienced healthcare workers were often deployed to rural health posts, where they were responsible for providing maternal and child health services. The study participants reported concerns about the competence of these young providers, particularly in dealing with complicated deliveries. Similarly, Essien et al. (2018) found that women in rural Nigeria expressed a lack of confidence in the skills of younger, less experienced healthcare workers, particularly in the context of maternal care. The participant's comment that the young "sisters" did not know how to deliver twins reflects these broader concerns about the training and deployment of healthcare workers in rural and underserved areas. It suggests that while the healthcare system may be technically competent on paper, gaps in training, supervision, and support for younger healthcare workers can undermine the quality of care provided to patients, especially in complex cases like twin deliveries. 4.7 Accommodation 4.7.1 Physical Infrastructures and Access Many service users with a disability and an administrator reported that most of the health facilities in the study area are inaccessible to people a range of disabilities. Inaccessible physical infrastructures were reported, including external barriers such as lack of ramps and internal barriers like stairs and narrow doorways in delivery rooms and toilets as well as inaccessible equipment. “It is not comfortable for a person with disabilities, even the toilet. A blind person cannot walk inside, had there been orientation it would have been easier. Infrastructure is also not easy for disabled persons, from toilet or to consultation rooms. I felt even sisters do not have the awareness. They ask us to go to certain numbered room, since we cannot see we will have to ask and go. Some people show the direction, which is difficult.” - A 31-year-old woman with visual disability (Participant # 5) Furthermore, none of the health facility staff were given any orientation on dealing with people with disabilities: “Although the government is saying that health facilities should be made disabled friendly, but they are not. If a woman who has to use a wheelchair after she gives birth or even before that to go to the toilet, the toilets is not disabled friendly. There are no ramps for the wheelchairs in the health facilities, the government hasn’t instructed or oriented the health service providers how they should behave for a person with disability while coming for services.” - KII Participant # 1 Surprisingly, health providers interviewed did not know about adjustable delivery tables and other disability-related equipment. They were unaware whether it is available even in their central level maternity referral hospital: “Adapted beds are not available. So it is not available at districts…such services are not at all available. We do not even have disabled-friendly toilets. They have problem even to walk as we do not have corridors.” - KII Participant # 3 And clearly were not aware that many adaptations could be made on site without need for specialized or expensive equipment. 4.7.2 Internal Arrangement and Space Availability Poor infrastructure, inadequate space and poor internal arrangements of available space are common characteristics of health facilities. In addition to the access difficulties created by the geographic remoteness and built infrastructures, the survey participants reported that they encountered difficulties with poor management of available space and materials whilst in the health facilities: “I felt a bit uneasy in the health post; there was no place to sit and everyone was sitting on the floor... We had to stand or sit on the cold floor. But now they have made it outside but still there is no planning and facility to sit. It is very hard for a pregnant woman to stand or sit long on the floor. The seats should be made available.” - A 26-year-old woman with physical disability (Participant # 10) “…in terms of access, those who are poor, marginalized and geographically secluded do not have access. . ..so how can they get services? Provision for special intervention should have been made, which, however is not seen. For people with disabilities also, nothing much has been done. We do not have disabled friendly hospitals. Even if people with disabilities come to take services, they do not get services they should be getting because services are equal for all. There should have been additional services for them but we do not have it.” - KII Participant # 6 4.7.3 Opening Times Inconvenient and limited opening hours of health facilities were often reported by participants in their qualitative interviews as one of the reasons for non-utilization of services. As well, in the quantitative survey, some of the women who did not receive antenatal care services in their last pregnancy reported that the reason was due to the health facility being closed when they tried to visit. 4.8 Discussion 4.8.1 Level of Access The research revealed that women with disabilities experienced varied levels and extents of access to healthcare, influenced by multiple factors. Despite efforts to improve healthcare accessibility, significant gaps and disparities persisted, affecting the overall quality and consistency of care received by these women. A major finding was that the majority of women with disabilities had to walk considerable distances to reach healthcare facilities. More than half of the women with disabilities reported walking to health facilities for antenatal care checkups. This reliance on walking was due to the lack of affordable and accessible transport options. While some women used low-cost informal transport, the proportion was slightly lower than that of non-disabled women. The absence of reliable transport services and poor road conditions further exacerbated the challenges, often making the journey long, difficult, and sometimes unsafe. Additionally, the placement of healthcare facilities was a significant issue. The distribution of health centers did not always align with the actual needs of the local population. Many facilities were located far from the homes of women with disabilities, which not only increased travel time but also posed logistical challenges, particularly for those who required assistance to travel. The political motivations behind the placement of these facilities often overlooked the specific healthcare needs and population densities, leading to inequitable access. Financial barriers also played a critical role in limiting access. Despite government policies providing for free maternal healthcare services, over a third of the women reported being charged for services and supplies during their last delivery. This inconsistency in policy implementation meant that many women with disabilities faced unexpected costs, which they were often ill-equipped to manage due to their generally lower income levels and higher unemployment rates among their household members. The availability and adequacy of healthcare staff were other significant determinants of access. Although there were improvements in staffing levels over the years, gaps still existed. Women with disabilities frequently encountered healthcare providers who lacked sufficient knowledge and competence in addressing their specific needs. This inadequacy in staff training and awareness often led to suboptimal care, shorter consultation times, and a lack of personalized attention, which are crucial for effective healthcare delivery. Moreover, the research highlighted issues related to the provision of information and communication. Many women with disabilities reported not being adequately informed about the importance of postnatal check-ups or other critical healthcare information. The lack of clear communication from healthcare providers often resulted in missed appointments and gaps in care. Language barriers and the absence of sign language interpreters further compounded these issues for women with hearing disabilities. Despite these challenges, some enabling factors facilitated better access. The awareness of state-provided travel cost and delivery incentives was high, and community health volunteers played an essential role in supporting women with disabilities. These volunteers helped bridge the gap between healthcare services and the community, providing necessary information and support. In conclusion, the level and extent of access to healthcare for women with disabilities were influenced by a complex interplay of factors, including distance to health facilities, transport availability, financial constraints, staff adequacy and competence, and communication issues. While some progress had been made, significant disparities and barriers remained, underscoring the need for targeted interventions to improve healthcare access for women with disabilities. 4.8.2 Enablers The study identified several enablers that facilitated access to healthcare for women with disabilities. These enablers were crucial in mitigating the numerous barriers these women faced when seeking healthcare services. Firstly, the provision of state-provided travel cost and delivery incentives emerged as a significant enabler. The vast majority of survey participants (98%) were aware of these incentives, which helped alleviate the financial burden associated with healthcare access. This awareness was consistent across both disabled and non-disabled groups, indicating effective communication about these benefits. Secondly, improvements in staffing levels at healthcare facilities played a role in enhancing access. Administrators reported that the staffing situation had seen considerable improvement over recent years, with vacancy rates dropping from 30-35% to approximately 12%. The hiring of temporary staff further bolstered the availability of healthcare personnel, ensuring that more women could receive timely and adequate care. Another enabling factor was the presence of Female Community Health Volunteers (FCHVs). These volunteers, often embedded within the communities they served, played a critical role in bridging the gap between healthcare providers and women with disabilities. They provided essential information, support, and advocacy, helping disabled women navigate the healthcare system more effectively. Moreover, the qualitative interviews highlighted instances where healthcare providers exhibited positive attitudes and respectful behavior towards women with disabilities. Some women reported that nurses and doctors treated them with kindness and dignity, which encouraged them to seek and continue using healthcare services. The respectful treatment from healthcare staff was particularly significant, as it helped build trust and confidence among women with disabilities. Additionally, the government’s policy of free maternal healthcare services was an enabling factor, despite its inconsistent implementation. The policy aimed to reduce the financial barriers to accessing healthcare, and many women, both with and without disabilities, benefited from this provision. However, the effectiveness of this policy varied, with some women still encountering charges for services and supplies. The availability of mixed income sources and the receipt of government disability allowances, although nominal, also facilitated better access to healthcare. These financial supports provided some level of economic stability, enabling women with disabilities to afford transportation and other associated costs of accessing healthcare services. 4.8.3 Barriers The findings highlighted several barriers faced by women with disabilities in accessing healthcare. These barriers spanned across different dimensions such as accessibility, availability, affordability, and acceptability. In terms of accessibility, the location and distance to health facilities posed a significant challenge. A substantial 73% of the interviewed women reported living more than a 45-minute walk from the nearest health center, with no significant difference between women with disabilities (71%) and those without (74%). The uneven distribution of healthcare facilities, driven by political interests rather than population needs, further exacerbated the issue. Women with disabilities often needed assistance to travel to health centers, impacting their family’s income and livelihood. Road and transport issues compounded these challenges. Half of the women with disabilities walked to health facilities, a higher proportion compared to non-disabled women (43%). Additionally, 29% of women with disabilities used low-cost informal transport, similar to women without disabilities. The lack of roads and transport links, along with inadequate transport services, made accessing health centers difficult. Some women had to call nurses to their homes or ended up delivering at home due to these challenges. Travel time and cost were also significant barriers. Difficult terrain and poor road conditions made traveling especially challenging for women with disabilities, who often needed someone to accompany them. High transport costs further increased the burden for these women. In terms of availability, staff adequacy and availability were major concerns. Although staffing had improved, significant gaps remained, and the competency of staff in caring for women with disabilities was also a concern. Women with disabilities reported that healthcare providers often spent less than 10 minutes on their antenatal care appointments. Waiting times, although reported to be shorter for women with disabilities, showed no significant differences. Equipment, materials, and drugs were often in short supply due to limited resources and poor management. This affected all patients, including women with disabilities. Information communication was another critical issue. Inadequate knowledge and poor dissemination of information were barriers, especially for women with disabilities. Health providers often failed to communicate clearly, and there was a need for sign language interpreters for deaf women. Affordability was a significant hurdle. Despite the government’s provision of free maternal healthcare, over 34% of women reported being charged for services and supplies. Women with disabilities often faced additional financial challenges. Most women, both with and without disabilities, were subsistence farmers with limited income, further hindering their ability to access healthcare services. Acceptability issues also emerged, particularly in terms of provider attitudes and behavior. Women felt uncomfortable with male providers for maternity care and had concerns about privacy during examinations. Attitudes of healthcare providers varied, with some women with disabilities reporting positive experiences, while others faced rudeness, misbehavior, and even abuse. Overall, women with disabilities faced multifaceted barriers in accessing healthcare, including physical accessibility, inadequate transportation, financial constraints, and attitudinal barriers from healthcare providers. Addressing these barriers required a holistic approach, involving improved infrastructure, better resource management, enhanced staff training, and more inclusive communication strategies. 4.8.4 Effectiveness of Zimbabwe National Disability Policy The Zimbabwe National Disability Policy aimed at promoting the full inclusion and active participation of persons with disabilities in various aspects of life, including healthcare, was examined in this study to determine its implementation, particularly in marginalized communities such as Domboshava and Goromonzi rural settings. The findings indicated that while the policy sought to ensure that people with disabilities had access to both general health services and specialized disability-specific services, there were significant gaps in its implementation. Many women with disabilities reported living more than a 45-minute walk away from the nearest health center, with no significant difference observed between women with and without disabilities. This indicates a failure to ensure that health services are accessible and locally available for people with disabilities, as required by the policy. Rehabilitation and habilitation programs were also found to be lacking in accessibility and availability. Participants frequently reported an uneven and inequitable distribution of health facility locations, often driven by political interests rather than actual needs. This inadequate distribution further hindered the ability of people with disabilities to access necessary health services. Despite the policy’s provision that health services in public facilities be provided free of charge to people with disabilities, more than 34% of surveyed women reported being charged for services and supplies during their last delivery. This issue affected both disabled and non-disabled women and highlighted the inconsistency in the implementation of free healthcare services promised by the government. The quality and standard of care for people with disabilities were also found to be below par. The study revealed that healthcare providers often spent less than 10 minutes on antenatal care appointments, with no significant difference between the time allocated to disabled and non-disabled women. Furthermore, the lack of necessary equipment, materials, and drugs in health facilities indicated that the quality of care for people with disabilities was not on par with that provided to the general population. Discrimination against people with disabilities in healthcare settings was another concern. Some participants reported that health providers often failed to communicate information clearly, resulting in missed postnatal check-ups. Additionally, the discomfort of being examined by male providers and the lack of respect for women’s privacy during antenatal care and delivery raised issues about the ethical treatment of women with disabilities. The policy’s goal to increase the representation of people with disabilities among health profession students to 15% and ensure healthcare workers receive training on disability-related issues also appeared to be unmet. The study did not provide specific data on the representation of people with disabilities among health professionals, but the reported lack of knowledge and experience among healthcare providers in dealing with disabled patients suggested that these training initiatives had not been adequately implemented. Overall, the study highlighted significant shortcomings in the implementation of the Zimbabwe National Disability Policy, particularly in marginalized communities like Domboshava and Goromonzi. The policy’s provisions aimed at ensuring comprehensive and equitable healthcare for people with disabilities were not fully realized, indicating a need for more effective and targeted efforts to address these gaps. The Zimbabwe National Disability Policy, adopted in 2021, was examined in this study to determine its implementation, particularly in marginalized communities such as Domboshava and Goromonzi rural settings. The findings indicated that while the policy sought to ensure comprehensive and equitable healthcare for people with disabilities, significant gaps remained in its implementation. These findings are largely relatable to literature. For example, Kuper et al. (2022) highlighted that the policy aims to provide accessible rehabilitation and habilitation programs and free health services for people with disabilities, ensuring that the quality and standard of care are on par with that provided to the general population. However, this study found that many women with disabilities reported living more than a 45-minute walk away from the nearest health center, indicating a failure to ensure that health services are accessible and locally available for people with disabilities. Rugoho et al. (2022) also found that women with disabilities in Zimbabwe face barriers such as long distances, physical barriers, communication barriers, gender issues, lack of confidence, and overall lack of resources when accessing health and reproductive services after sexual abuse. These findings are consistent with this study’s results, which reported an uneven and inequitable distribution of health facility locations, driven by political interests rather than actual needs. Despite the policy’s provision that health services in public facilities be provided free of charge to people with disabilities, more than 34% of surveyed women reported being charged for services and supplies during their last delivery. This issue affected both disabled and non-disabled women and highlighted the inconsistency in the implementation of free healthcare services promised by the government. Kuper et al. (2022) similarly noted that people with disabilities still face greater challenges accessing healthcare services and experience worse health outcomes in rural Zimbabwe. The quality and standard of care for people with disabilities were also found to be below par. Healthcare providers often spent less than 10 minutes on antenatal care appointments, and the lack of necessary equipment, materials, and drugs in health facilities indicated that the quality of care for people with disabilities was not on par with that provided to the general population. Havercamp et al. (2023) noted that healthcare professionals in Zimbabwe were not adequately prepared to provide quality health care to disabled patients due to training programs that fail to challenge implicit biases and damaging beliefs about disability. Discrimination against people with disabilities in healthcare settings was another concern. Some participants reported that health providers often failed to communicate information clearly, resulting in missed postnatal check-ups. Manungo et al. (2023) observed that disabled students in Zimbabwe face challenges at educational institutions, including social stigma and negligence from able-bodied counterparts and staff. Smythe et al. (2022) further noted barriers such as health literacy, self-stigma, affordability, and discrimination, implying that health services in public facilities are not consistently provided free of charge to people with disabilities. CHAPTER FIVE SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 5.1 Summary The summary of the study in chapters is provided: Chapter 1 Summary The study focused on examining access to healthcare and reproductive services by women with disabilities in Harare’s peri-urban communities. Globally, about 16% of the population lives with disabilities, and these individuals often face poorer health outcomes and higher mortality rates. Despite international frameworks aimed at ensuring equitable healthcare access, significant gaps remain. In Zimbabwe, inadequate primary healthcare delivery systems in peri-urban areas force many to seek care in overcrowded central hospitals, which are not always accessible or sensitive to the needs of women with disabilities. The main aim of the study was to investigate access to healthcare and reproductive services by women with disabilities in Domboshava and Goromonzi districts areas. The secondary objectives were to examine the extent of utilization of reproductive health services, determine the enablers and barriers to access, and assess the effectiveness of existing initiatives. The significance of the study lay in its potential to inform policies and programs aimed at improving healthcare access for women with disabilities. The delimitations included focusing on Harare’s peri-urban communities and women with disabilities as the primary subjects. Potential limitations included a limited generalizability of findings beyond the specific context of Domboshava and Goromonzi districts areas. Chapter 2 Summary The researcher conducted a study that employed the Andersen-Newman model and the Levesque model within its theoretical framework to examine the utilization and accessibility of healthcare and reproductive services for women with disabilities in Domboshava and Goromonzi district communities. The Andersen-Newman model focused on factors influencing health service use, while the Levesque model emphasized the interaction between accessibility dimensions and human abilities. The researchers also integrated the Zimbabwe National Disability Policy (2021) to assess its impact. The research identified several access barriers, including cultural and psychosocial factors, financial constraints, geographic and organizational hindrances, and insufficient disability-specific services. These barriers significantly affected women with disabilities’ ability to perceive, seek, reach, and engage in healthcare services. However, the study also identified enablers, such as increased awareness and training of healthcare workers on disability issues, improved healthcare service availability and accommodation, and policies promoting equitable healthcare access. Effective communication and community support systems also played crucial roles. The researcher examined the effectiveness of the Zimbabwe National Disability Policy, which aims for inclusive healthcare through free public health services, non-discrimination, and training for healthcare professionals. However, the literature showed that the implementation of this policy in marginalized communities remained inadequate, highlighting gaps between policy and practice. The review of empirical literature demonstrated the effectiveness of the Andersen-Newman and Levesque models in understanding healthcare access among vulnerable populations, including people with disabilities. These models have been applied to assess various aspects of healthcare utilization, revealing both barriers and enablers. The study identified a gap in addressing cultural and psychosocial factors affecting healthcare access for women with disabilities. Additionally, the researchers noted a limited amount of empirical evidence on the practical implementation of disability policies in rural and peri-urban settings, necessitating further research to bridge these gaps. Chapter 3 Summary The researcher adopted a pragmatic research philosophy to investigate the access to health and sexual reproductive health services by women with disabilities in rural Zimbabwe. A cross-sectional survey design was used to collect data from women with disabilities residing in the rural areas of Domboshawa and Goromonzi. A mixed methods approach was employed, involving the triangulation of quantitative survey data and qualitative key-informant interviews. This approach enhanced the validity and reliability of the study by providing complementary insights from various stakeholders. The researcher utilized a non-probability, multi-stage, quota-sampling technique to select and recruit participants. This method involved identifying women with disabilities using census data, governmental and NGO reports, and local disabled people’s organizations. Specific quotas were set to ensure adequate representation of women with and without disabilities. Data collection instruments included a structured questionnaire and an interview guide. The questionnaires provided objective, numeric data, while the key-informant interviews allowed for the capture of subjective, experiential knowledge. A phone was used to record the interviews. The emphasis throughout the research was on the practical implications of the findings, aligning with the pragmatic research philosophy. The aim was to gain insights that could be directly applied to enhance the health and well-being of women with disabilities in rural Zimbabwe. Chapter 4 Summary Accessibility was a significant concern, with 73% of interviewed women living more than a 45-minute walk from the nearest health center. This was consistent across both women with and without disabilities. Qualitative interviews revealed an uneven distribution of health facilities, often influenced by political interests rather than the population’s needs. Women with disabilities faced additional challenges, such as dependency on others for transportation. Road and transport issues were prevalent, with half of the women with disabilities walking to health facilities for antenatal care, reflecting a higher proportion than non-disabled women. Informal transport like pirate vehicles was used by over one-third of non-disabled women and 29% of disabled women. Qualitative data highlighted the lack of roads or transport links to health facilities, leading some women to deliver at home. Travel time and cost were also problematic, especially in rural areas where walking was common due to poor road conditions and expensive transport. Women with disabilities faced higher costs and needed assistance, making healthcare access more burdensome. Availability issues included staff shortages, although there had been some improvements. Despite this, gaps remained, particularly in the competency of staff to care for women with disabilities. Time spent by providers was often less than 10 minutes, with no significant difference between disabled and non-disabled women. Waiting times were generally less than 30 minutes for most respondents, but the lack of necessary equipment and supplies persisted due to limited resources and poor management. Information communication was another challenge, with inadequate knowledge and awareness among the population, especially for women with disabilities. Although most participants were informed about state-provided incentives, qualitative interviews revealed that communication was often unclear, leading to missed postnatal check-ups and other important appointments. There was a call for services like sign language interpreters to improve communication for those with disabilities. Affordability remained an issue, despite the government’s provision of free maternal healthcare. Over 34% of women reported being charged for services and supplies during their last delivery. This was not significantly different between disabled and non-disabled women. Many women, both disabled and non-disabled, faced financial difficulties, particularly with transport costs. The majority of women were subsistence farmers, and many households had mixed income sources, but these differences were not statistically significant. Acceptability of services was influenced by provider gender, attitude, and experience. Women expressed discomfort with male providers and reported issues with privacy and provider behavior. While some women with disabilities encountered positive attitudes, others reported rude and abusive behavior from healthcare providers, indicating a need for improved training and sensitivity towards disabled patients. 5.2 Conclusions 5.2.1 Level of Access Women face significant challenges in accessing and utilizing healthcare services. Accessibility is a major concern, with the majority of interviewed women living over a 45-minute walk from the nearest health center, consistent across both disabled and non-disabled groups. The uneven distribution of health facilities, often influenced by political interests rather than population needs, further exacerbates the issue, and women with disabilities face additional barriers due to their dependency on others for transportation. Road and transport problems are prevalent, with half of the women with disabilities walking to health facilities for antenatal care, a higher proportion than non-disabled women. The use of informal transport, such as pirate vehicles, is common, but the lack of roads or transport links to health facilities leads some women to deliver at home. Travel time and cost are problematic, especially in rural areas where walking is the primary mode of transport due to poor road conditions and expensive transportation. Women with disabilities face higher costs and require assistance, making healthcare access more burdensome. Availability issues include staff shortages, although some improvements have been made. Gaps remain in the competency of staff to care for women with disabilities, and the time spent by providers is often less than 10 minutes, with no significant difference between disabled and non-disabled women. Waiting times are generally less than 30 minutes, but the lack of necessary equipment and supplies persists due to limited resources and poor management. Information communication is another challenge, with inadequate knowledge and awareness among the population, especially for women with disabilities. While most participants are informed about state-provided incentives, communication is often unclear, leading to missed appointments. Affordability remains an issue, despite the government’s provision of free maternal healthcare. A significant proportion of women report being charged for services and supplies, and many face financial difficulties, particularly with transport costs. The majority of women are subsistence farmers, with mixed income sources. The acceptability of services is influenced by provider gender, attitude, and experience. Women express discomfort with male providers and report privacy and behavior issues. While some women with disabilities encounter positive attitudes, others report rude and abusive behavior from healthcare providers, indicating a need for improved training and sensitivity. 5.2.2. Enablers of Access Several enablers have facilitated access to healthcare services for women with disabilities. These enablers play a crucial role in mitigating the numerous barriers these women face. The provision of state-provided travel cost and delivery incentives is a significant enabler. The vast majority of survey participants are aware of these incentives, which help alleviate the financial burden associated with healthcare access, with consistent awareness across both disabled and non-disabled groups. Improvements in staffing levels at healthcare facilities have also enhanced access. Administrators report a considerable increase in staffing, with vacancy rates dropping significantly. The hiring of temporary staff further bolsters the availability of healthcare personnel, ensuring more women can receive timely and adequate care. The presence of Female Community Health Volunteers is another enabling factor. These volunteers, embedded within the communities they serve, play a critical role in bridging the gap between healthcare providers and women with disabilities. They provide essential information, support, and advocacy, helping disabled women navigate the healthcare system more effectively. Positive attitudes and respectful behavior from healthcare providers have also encouraged women with disabilities to seek and continue using healthcare services. Some women report receiving kindness and dignity from nurses and doctors, which helps build trust and confidence. The government’s policy of free maternal healthcare services, despite its inconsistent implementation, is an enabling factor. This policy aims to reduce the financial barriers to accessing healthcare, benefiting many women, both with and without disabilities. The availability of mixed income sources and the receipt of government disability allowances, although nominal, also facilitate better access to healthcare. These financial supports provide some level of economic stability, enabling women with disabilities to afford transportation and other associated costs. 5.2.3 Barriers Women with disabilities face numerous barriers in accessing healthcare. Issues of accessibility, availability, affordability, and acceptability persist, hindering their ability to receive the care they need. Accessibility is a major challenge, with many women living far from health facilities and lacking adequate transportation options. The uneven distribution of healthcare services and the lack of infrastructure compound these difficulties. Women with disabilities often require assistance to travel to clinics, which can impact their family’s income and livelihood. Availability of healthcare services is also problematic. Staffing shortages and inadequate competency in caring for women with disabilities are concerns. Limited resources and poor management lead to shortages of essential equipment, materials, and drugs. Communication barriers, such as the lack of sign language interpreters, further exacerbate these issues. Affordability poses a significant hurdle, despite the government’s provision of free maternal healthcare. Many women, including those with disabilities, are charged for services and supplies, creating a financial burden. The limited income of most women, who are subsistence farmers, further hinders their ability to access healthcare. Acceptability issues also arise, with women often feeling uncomfortable with male providers for maternity care and concerns about privacy during examinations. Healthcare providers’ attitudes and behaviors can vary, with some women with disabilities reporting positive experiences, while others face rudeness, misbehavior, and even abuse. 5.2.4 Policy Effectiveness Based on the findings of the study, it can be concluded that the Zimbabwe National Disability Policy was ineffectively applied in enabling access to healthcare services by women with disabilities. The research revealed significant gaps in the implementation of the policy, particularly in the marginalized communities of Domboshawa and Goromonzi. Health services were found to be inaccessible and unavailable, with rehabilitation and habilitation programs lacking in accessibility and equitable distribution. The provision of free healthcare services for people with disabilities was inconsistently implemented, and the quality of care was poor, with healthcare workers exhibiting discriminatory behavior. The policy’s goals to increase representation of people with disabilities in the health profession and provide disability-related training for healthcare workers also appeared to be unmet. Overall, the study’s findings suggest that the Zimbabwe National Disability Policy’s provisions were not fully realized, preventing it from being effective in ensuring access to healthcare services for women with disabilities in the examined communities. 5.3 Recommendations The government is recommended to improve accessibility to healthcare facilities by investing in infrastructure development, such as building more health centers and improving road networks, especially in rural areas. The government should also ensure the equitable distribution of health facilities and rehabilitation/habilitation programs based on population needs rather than political interests. The consistent implementation of the provision of free healthcare services for people with disabilities and the monitoring of its application is crucial. Additionally, the government should provide disability-related training for healthcare workers to improve the quality of care and promote sensitivity and non-discriminatory attitudes towards women with disabilities. Increasing the representation of people with disabilities in the health profession is recommended to enhance the understanding and responsiveness of the healthcare system. Healthcare providers are recommended to improve the competency and skills of healthcare workers in providing care for women with disabilities. Providers should also adopt a more patient-centric approach, ensuring privacy, dignity, and respectful behavior towards women with disabilities. Enhancing communication and information-sharing with women with disabilities, including the use of sign language interpreters and clear explanations of services and incentives, is essential. Community-based organizations are recommended to strengthen the role of Female Community Health Volunteers in advocating for and supporting women with disabilities in accessing healthcare services. These organizations should also raise awareness within communities about the rights and healthcare needs of women with disabilities, as well as the available government incentives and services. 5.4 Areas of Further Study Future studies may conduct comprehensive assessments of healthcare facility accessibility, focusing on barriers faced by women with diverse disabilities, evaluating assistive technologies and accommodations, and examining transportation and referral systems. They may also explore the healthcare-seeking behaviors, utilization patterns, and unmet needs of women with disabilities, investigating required services and identifying barriers and facilitators. 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APPENDICES Questionnaire for Measuring Access Dimensions in Healthcare Services Section A: Demographics Personal Information Age: _____ What is your occupation?  Employed  Unemployed  Self-employed  Other (Please specify): _______________ What is your husband’s occupation?  Employed  Unemployed  Self-employed  Other (Please specify): _______________ What is the main source of your household income?  Salary  Business  Agriculture  Daily wages  Other (Please specify): _______________ Marital Status:  Married  Unmarried Number of Children: _____ Education Level:  No formal education  Primary education  Secondary education  Higher education Employment Status:  Employed  Unemployed  Self-employed Section B: Accessibility Location and Distance How far is the nearest health facility from your place of residence?  Less than 30 minutes walking distance  30 minutes to 1 hour walking distance  More than 1 hour walking distance Does the road network connect directly to the health facility?  Yes  No Does the health facility have access to public transportation?  Yes  No Section C: Availability Resources and Services Does the health facility have all staff positions filled?  Yes  No Does the health facility have drugs and supplies available as per the standard list?  Yes  No How much time do the provider spend with you during your check-up?  Less than 10 minutes  10-20 minutes  More than 20 minutes How long do you have to wait to get the services at the health facility?  Less than 30 minutes  30 minutes to 1 hour  More than 1 hour Are you aware of the travel cost reimbursement scheme?  Yes  No Section D: Affordability Cost and Income Did the health facility charge for services and supplies for your delivery?  Yes  No Did you receive transportation allowance (cash reimbursement) from the health facility?  Yes  No Section E: Acceptability Service Characteristics and Provider Interaction Was the provider male or female?  Male  Female If the provider was male, how did you feel about being examined by a male provider?  Comfortable  Uncomfortable  Neutral How was the behaviour of the staff/providers at the hospital facility?  Very courteous and respectful  Courteous and respectful  Neutral  Discourteous and disrespectful  Very discourteous and disrespectful Were you examined in a separate room and was your privacy maintained during the check-up?  Yes  No Section F: Accommodation Infrastructure and Organization Is the hospital facility building wheelchair accessible?  Yes  No Does the hospital facility have a separate examination room and adequate waiting space for clients?  Yes  No Does the facility have adapted beds and equipment for persons with disabilities?  Yes  No Interview Guide for Key Informant Interviews on Access to Healthcare Services Introduction: Introduce yourself and the purpose of the interview. Explain that the information shared will be kept confidential. Obtain verbal consent to proceed with the interview. Key Informant Details: What is your role or position in the community/healthcare system? How long have you been in this role? Can you describe your experience and knowledge related to maternal and child healthcare services in this region? Section A: Healthcare Facility Accessibility Can you tell me about the location of the nearest healthcare facility that provides maternal and child healthcare services? What are the road conditions and transportation options available for patients to access this facility? How far do most patients have to travel to reach the healthcare facility, and how long does the journey typically take? Are there any barriers or challenges with the accessibility of this healthcare facility? Section B: Healthcare Facility Availability Are all the necessary staff positions at the healthcare facility filled and available when patients visit? Are the essential drugs, supplies, and equipment available as per the standard requirements? How much time do healthcare providers typically spend with patients during antenatal care visits? How long do patients usually have to wait to receive services at the healthcare facility? Are there any schemes or programs in place to support patient transportation costs? Section C: Healthcare Affordability Are patients charged for any services or supplies during deliveries at the healthcare facility? What are the main sources of income and financial resources for the families accessing these healthcare services? Are there any financial assistance or reimbursement mechanisms available to support patient transportation or other costs? Section D: Healthcare Acceptability Are the healthcare providers predominantly male or female? How do patients, especially women, feel about being examined by a provider of the opposite sex? Can you describe the behavior and attitude of the healthcare staff/providers towards patients? Are patient privacy and confidentiality maintained during examinations and consultations? Section E: Healthcare Facility Accommodation Is the healthcare facility building accessible for individuals with disabilities (e.g., wheelchair accessible)? Does the facility have separate examination rooms and adequate waiting spaces for patients? Are there any specialized beds, equipment, or adaptations available for persons with disabilities? Section F: Overall Feedback and Suggestions Based on your knowledge and experience, what are the key challenges faced by the community in accessing quality maternal and child healthcare services? What suggestions do you have for improving the accessibility, availability, affordability, acceptability, and accommodation of these healthcare services? Are there any other important aspects related to healthcare access that I should be aware of? Conclusion: Thank the key informant for their time and valuable insights. Reassure them about the confidentiality of their responses. Provide your contact information for any follow-up questions or concerns. 8