Disaster 3 Ijerph 15 01879 v2

International Journal of
Environmental Research
and Public Health
Review
A Systematic Review of Access to General Healthcare
Services for People with Disabilities in Low and
Middle Income Countries
Tess Bright * ID
and Hannah Kuper
International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine,
London WC1E 7HT, UK; hannah.kuper@lshtm.ac.uk
* Correspondence: tess.bright@lshtm.ac.uk; Tel.: +44-207-958-8343

Received: 16 July 2018; Accepted: 29 August 2018; Published: 30 August 2018
Abstract: Background: A systematic review was undertaken to explore access to general healthcare
services for people with disabilities in low and middle-income countries (LMICs). Methods: Six electronic
databases were searched in February 2017. Studies comparing access to general healthcare services
by people with disabilities to those without disabilities from LMICs were included. Eligible measures
of healthcare access included: utilisation, coverage, adherence, expenditure, and quality. Studies
measuring disability using self-reported or clinical assessments were eligible. Title, abstract and
full-text screening and data extraction was undertaken by the two authors. Results: Searches
returned 13,048 studies, of which 50 studies were eligible. Studies were predominantly conducted
in sub-Saharan Africa (30%), Latin America (24%), and East Asia/Pacific (12%). 74% of studies
used cross-sectional designs and the remaining used case-control designs. There was evidence that
utilisation of healthcare services was higher for people with disabilities, and healthcare expenditure
was higher. There were less consistent differences between people with and without disabilities in
other access measures. However, the wide variation in type and measurement of disability, and access
outcomes, made comparisons across studies difficult. Conclusions: Developing common metrics for
measuring disability and healthcare access will improve the availability of high quality, comparable
data, so that healthcare access for people with disabilities can be monitored and improved.
Keywords: access; health care; low and middle income country; LMIC; universal health coverage;
people with disabilities
1. Introduction
The WHO estimates that one billion people globally have disabilities, equating to 15% of the
worldwide population [1]. There is extensive evidence that people with disabilities are on average
poorer, face widespread stigma, and often face a range of exclusions, including from employment,
education, and access to services [2]. It is widely believed that people with disabilities also face
exclusion from healthcare services, although to date this issue has received little research attention.
The relationship between disability and health is complex, as they are interlinked and
over-lapping. A range of definitions of disability are used, but the most prevailing is that of the United
Conventions on the Rights of Persons with Disabilities (UNCRPD) which states that “Persons with
disabilities include those who have long-term physical, mental, intellectual or sensory impairments
which in interaction with various barriers may hinder their full and effective participation in society
on an equal basis with others” [3]. By definition, therefore, people with disabilities experience an
impairment related to a health condition, for instance they may have visual impairment because
of diabetes.
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Int. J. Environ. Res. Public Health 2018, 15, 1879 2 of 29
The link between disability and poor health can also arise through other pathways. For instance,
an impairment (e.g., physical impairment) may lead to further health issues (e.g., bed sores due to
low mobility). People with disabilities often occupy a marginalised position in society, and so may
be more vulnerable to poor health due to poverty and adverse living conditions (e.g., vulnerability
to injuries) [2]. This means that on average people with disabilities will have poorer health than
people without disabilities [1]. As an example, a study across 30 countries found that children with
disabilities were more likely to report having a serious health problem in the last 12 months compared
to their peers without disabilities [4]. Overall, therefore, people with disabilities may on average have
a greater need for healthcare services, both because of their impairment and their vulnerability to poor
general health.
People with disabilities may also face challenges in accessing healthcare services, despite their
greater need, which can contribute to poorer health. Services and/or transport may be physically
inaccessible to people with certain impairments. People with disabilities may experience stigma
and discrimination at the point of care, which can discourage them from attending. The skills and
experience of healthcare professionals may be inadequate to provide a quality service (e.g., difficulties
communicating with people with hearing or intellectual impairment). The cost of seeking services
may be prohibitive to people with disabilities, both on account of on average higher levels of poverty
as well as the additional costs incurred when seeking care (e.g., need for accessible transport or for a
carer to attend). As a result of these different barriers, people with disabilities may have poorer access
to healthcare services, despite their higher need.
Failure to address access of people with disabilities to healthcare services may have profound
implications. The UNCRPD specifically states that people with disabilities must have access to
general and specialist healthcare (articles 25 and 26), and so exclusion from services will be an
infringement on human rights since this convention has been ratified by more than 170 countries [3].
Furthermore, the achievement of Universal Health Coverage (UHC) is a key target within the
Sustainable Development Goals. UHC means ensuring access to health services for all by expanding
the breadth of the population covered, with the depth of services that they need, without suffering
financial hardship. This target would not be met without a specific focus on people with disabilities,
since they make up a large group and may be excluded from both general and specialist services.
Despite the importance of this topic, access to healthcare among people with disabilities has
received little attention in research. One challenge is the lack of consensus in how access is measured.
Monitoring frameworks for UHC often recommend measuring utilization of services, yet this may be
an inadequate measure of coverage or met needs for healthcare, since people with disabilities may
have higher healthcare needs [5,6]. Furthermore, assessing uptake alone is insufficient; attention is also
needed on the quality and affordability of services, as acknowledged within the UHC framework [7].
Access to healthcare among people with disabilities is an important issue that has not been
reviewed systematically to date. Assessing access to health is complex, and needs a considered
and nuanced assessment, particularly with respect to people with disabilities. The objective of this
study is to systematically review the evidence on access to general healthcare services among people
with disabilities in low and middle-income countries (LMIC). Access to specialist services, including
rehabilitation, will be the focus of a separate review.
2. Materials and Methods

The systematic review was performed and reported according to the Preferred Reporting Items
for Systematic Reviews and Meta-Analysis (PRISMA) statement [8]. The search was conducted in
February 2017 to identify peer-reviewed articles that presented research findings on access to general
healthcare services for people with disabilities in LMIC settings.
2.1. Eligibility Criteria

Studies were eligible if they met the following criteria: (1) quantitative research that included
people with disabilities and a comparison group of people without disabilities; (2) results reported
access to general healthcare services for people with disabilities, in comparison to people without
disabilities; and (3) research was undertaken in a LMIC as defined by the World Bank country
classification 2017 [9]. Studies were excluded if the full text was not available. If multiple reports from
the same study were identified, the results were either combined if they reported different results or
secondary papers were excluded if the results were the same as the primary report.
2.1.1. Types of Access Measures

We defined access to health according to the definition of UHC: “all people and communities
can use the promotive, preventive, curative, rehabilitative and palliative health services they need,
of sufficient quality to be effective, while also ensuring that the use of these services does not
expose the user to financial hardship” [7]. Thus possible outcome measures were broad and included
utilisation of general health services (e.g., hospitalisation, health centre visits), coverage of preventive
(e.g., vaccination), and curative services (e.g., use of tuberculosis treatment services), and adherence
to medications. Access to rehabilitative services is the subject of a separate review. We also included
studies that measured expenditure on health services and insurance coverage to address the issue
of access without exposure to financial hardship. Further, in addition to these primary outcomes,
we included data about the quality of care received and reported barriers to access as secondary
outcomes (if these were measured quantitatively). We did not consider health outcomes or risk
behaviours such as anthropometric measures or smoking status as measures of access to health.
2.1.2. Types of Disability Measures

Defining disability is complex and approaches have evolved over time. Early models described
disability as a purely medical issue, whereby an individual has an impairment in body function
or structure (e.g., hearing impairment). More recent models take a broader approach and include
societal barriers that prevent people with disabilities from full participation [10]. Currently, the most
widely used framework is the International Classification of Functioning, Disability, and Health (ICF)
developed by the World Health Organisation [11]. This model takes in to account the impairment,
activity limitations, and participation restrictions as well as considering environmental factors creating
the disability. This framework is considered as a bio-psycho-social model of disability. This framework
also aligns with the UNCRPD definition of disability. Studies were eligible for inclusion if they defined
disability based within the ICF framework (e.g., functioning, activity limitations, or participation
restrictions) or medical model definitions (i.e., specific impairments or disorders).
2.2. Information Sources

Six databases (EMBASE, Global Health, CINAHL, Web of Science, MEDLINE, and PSYCINFO)
were searched. No limits were placed on language or date of publication. The search strategy included
key words for the following three concepts: LMICs, people with disabilities, and access to health
services. Terms were developed using MeSH (Medical Subject Headings used by the National Library
of Medicine to index articles) or equivalent as well as from other reviews on similar topics. Boolean,
truncation, and proximity operators were used to construct and combine searches for the key concepts
as required for individual databases. An example of the search strategy is provided as Supplementary
File S1. We also included eligible studies known to the authors.
2.3. Study Selection

All studies identified through the search process were exported to a bibliographic database
(EndNote version X7, Clarivate Analytics, Philadelphia, PA, USA) for removal of duplications and
screening. Two review authors (Tess Bright and Hannah Kuper) independently examined the titles,
and abstracts of electronic records according to the eligibility criteria. Results of the initial screening
were compared and full-text records obtained for all potentially eligible studies. Two review authors
(Tess Bright and Hannah Kuper) screened the full texts using eligibility criteria for final inclusion in
the systematic review. Systematic reviews identified through the search were reviewed for eligible
studies. If study protocols were identified, a search was made to determine whether the results of
the study had been published. Any disagreements in the selection of the full text for inclusion were
resolved through discussion.
2.4. Data Extraction and Analysis

Data were extracted into a Microsoft Excel database developed for the purposes of this review.
The first author (Tess Bright) extracted all data and this was independently checked by the second
reviewer (Hannah Kuper) to ensure accuracy. Any differences between the reviewers were discussed
and resolved. Data were extracted on the following study components:
• General study information, including author, year of publication
• Study design, sampling, and recruitment methods
• Study setting and dates conducted
• Population characteristics including age, sex, sample size, proportion of participants with
a disability
• Study measures: Means of assessing disability, means of assessing access
• Research outcomes (main findings related to access to health): where possible odds or prevalence
ratios were extracted as a measure of association. In the absence of these effect estimates, p-values
comparing the measures in people with and without disabilities were extracted
We did not conduct a meta-analysis due to the wide variation in included study designs,
intervention types and outcomes measured. Instead, a narrative synthesis was undertaken. Results
were summarised by outcome type (i.e., measure of healthcare access). Each outcome type was
classified in terms of whether access to healthcare of people with disabilities in comparison to people
without disabilities was “higher”, “lower” or not different “null”. If studies measured multiple
outcomes within the same type (e.g., utilisation of hospital and health centre), studies were classified
as “higher” or “lower” if at least one outcome was statistically significant and the others were null.
Studies were classified as “mixed” if results for a study were higher in one variable of interest or
disability domain and lower in another.
2.5. Risk of Bias in Individual Studies

Quality assessments of all eligible studies were carried out independently by two reviewers
(Tess Bright and Hannah Kuper). We evaluated studies based on a set of criteria according to the
SIGN50 (Scottish Intercollegiate Guidelines Network) checklists [12]. The criteria are outline in Table 1.
Table 1. Quality assessment criteria and ratings.
Assessment Criteria by Study Design

All study designs
• Study design, sampling method is appropriate to the study question

• Adequate sample size (>100 participants), or sample size calculations undertaken
• Response rate reported and acceptable (>70%)
• Disability/impairment measure is clearly defined and reliable
• Measure of access clearly defined and reliable
• Potential confounders taken into account in analysis
• Confidence intervals are presented
Table 1. Cont.
Assessment Criteria by Study Design

All study designs
Case control (additional criteria)
• Cases and controls are comparable

• Cases and controls are clearly defined
Cohort (additional criteria)
• Groups being studied are comparable at baseline

• Losses to follow up are presented and acceptable
Overall Ratings
Low risk of bias: All or almost all of the above criteria were fulfilled, and those that were not fulfilled were
++
thought unlikely to alter the conclusions of the study
Medium risk of bias: Some of the above criteria were fulfilled, and those not fulfilled were thought unlikely to
+
alter the conclusions of the study
High risk of bias: Few or no criteria were fulfilled, and the conclusions of the study were thought likely or very
−
likely to alter with their inclusion.
Int. J. Environ. Res. Public Health 2018, 15, x 5 of 30
3. Results
3. Results
A total of 13,045 studies were initially identified by the electronic searches, of which 50 studies
A total of 13,045 studies were initially identified by the electronic searches, of which 50 studies
were were
selected for inclusion
selected in the
for inclusion review.
in the review.The
Thescreening
screening process
process isisdetailed
detailedinin Figure
Figure 1. 1.
Records identified through database Additional records identified

searching through other sources
(n =13,045) (n = 3)
Records screened after duplicates removed

(titles, abstracts) (n = 8882)
Records excluded
(n = 8604)
Full-text articles assessed for Full-text articles excluded, with

eligibility (n = 278) reasons
n = 228
Measured outcomes related to
specialist health services n = 74
Did not measure disability n = 54
Did not measure access outcomes = 51
Did not report relationship between
disability and access n = 8
Studies included in
Results for LMIC not reported n = 1
qualitative synthesis
Full text unavailable n = 14
(n = 50)
High income country n = 11
Qualitative study n = 3
Not original research n = 1
Service level data n = 6
Systematic review n = 3
Not peer reviewed n = 2
Figure 1. Flow chart of search results.

Figure 1. Flow chart of search results.
3.1. Study Characteristics
Table 2 summarises the characteristics of the included studies. The vast majority of included
studies were conducted in 2010 or later (82%). Nearly one third (30%) of studies were conducted in
sub-Saharan Africa, 24% in Latin America, 12% in East Asia/Pacific, 4% in the Middle East, 12% in
South Asia, 2% in Europe and the remaining 16% were conducted across multiple regions. By country
3.1. Study Characteristics

Table 2 summarises the characteristics of the included studies. The vast majority of included
studies were conducted in 2010 or later (82%). Nearly one third (30%) of studies were conducted
in sub-Saharan Africa, 24% in Latin America, 12% in East Asia/Pacific, 4% in the Middle East,
12% in South Asia, 2% in Europe and the remaining 16% were conducted across multiple regions.
By country income group (World Bank Classifications), 16% were conducted in low-income countries,
34% in lower-middle, 34% in upper-middle, and 16% in countries across multiple income groups.
Approximately half of studies were conducted in both urban and rural areas (48%), with a further
30% conducted in urban areas alone, and 8% in rural areas alone. For 14% of studies the location
was unclear. The majority of studies were cross-sectional surveys (74%) with the remaining studies
using case-control designs (26%). Of the cross-sectional studies, 80% were population-based whilst the
remaining recruited participants from clinics (three studies), registries (three studies), or schools (two
studies). Supplementary File S2 provides a detailed summary of included studies.
Table 2. Characteristics of included studies.
Variable Category No. %

Latin America/Caribbean 12 24
East Asia/Pacific 6 12
Sub-Saharan Africa 15 30
Region Middle east 2 4
South Asia 6 12
Europe/Central Asia 1 2
Various 8 16
Low 8 16
Lower middle 17 34
Income level
Upper middle 17 34
Mixed 8 16
Urban 15 30
Rural 4 8
Location
Both 24 48
Unclear 7 14
1990 1 2
Decade of publication 2000 8 16
2010 41 82
Cross-sectional 37 74
Study design
Case-control study 13 26
Utilisation 20 40
Coverage 22 44
Expenditure 8 16
Outcome measured Insurance 5 10
Adherence 3 6
Barriers 8 16
Quality 3 6
All ages (includes >5 years; >4 years) 9 18
Adults only (>18 years) 17 34
Age group Older adults (>40 years; >50 years; >60
11 22
years)
Children only (0–18 years) 10 20
Unclear age/not presented 3 6
Visual impairment 11 22
Hearing impairment 15 30
Physical impairment 15 30
Mental impairment 24 48
Disability domain
Functional difficulties * 24 48
Assistance with activities of daily living 3 6
Other (communication, sensory, albinism) 3 6
Multiple domains 19 38
* Typically includes difficulties with hearing, vision, walking, self-care, communicating, and remembering
or concentrating.
3.2. Participants
The studies selected for inclusion provided data for 1,510,959 people across 75 countries
(not including the data from the World Health Surveys, included in the World Report on Disability).
On average, people with disabilities made up 51% of the study participants in included studies.
The studies included a broad distribution of people of different ages: 20% of studies included people
of all ages, 32% included adults only (typically >18 years), 22% included older adults (>40 years),
and 20% included children (<18 years). Two studies did not present the age of the participants.
In terms of domains of disability, seven categories were identified: hearing impairment, visual
impairment, physical impairment, mental impairment, functional difficulties, participation, and others.
48% of studies measured functional difficulties across domains of hearing, vision, walking, self-care,
communicating and remembering or concentrating. Among studies that focused on impairment
types, the most common category was mental impairment (includes poor mental health, intellectual,
and cognitive impairment-measured in 48% of studies), followed by physical impairment (30%),
hearing impairment (30%) and visual impairment (22%). Disability was measured in terms of whether
people needed assistance with activities of daily living (basic or instrumental) in 6% of studies.
Supplementary File S2 provides details of the disability domains and how they were measured in
each study. A wide range of tools were utilized to measure disability–both self-report and clinical
tools. Access outcomes were disaggregated by disability type or functional domain in 22 studies.
Overall, 8 studies provided access outcome results for people with hearing impairment, 14 for mental
impairment or cognitive difficulties, eight for physical impairment, and four for visual impairment.
3.3. Outcome Types

The following seven outcome types were identified with respect to access to healthcare services:
utilisation of services (20 studies), coverage of services (22 studies), insurance coverage (5 studies),
cost/expenditure on services (8 studies), adherence to treatment (3 studies), quality of service delivery
(3 studies) and barriers to access (8 studies).
3.4. Risk of Bias within Studies

Of the included studies, 54% were judged to have low risk of bias, 34% medium, and 12%
high risk of bias. Low response rate (<70%) or insufficient information to make judgement was a
concern in 26 studies. Some important aspects of a robust analysis were lacking from several studies,
such as lack of reporting of confidence intervals (13 studies), or lack of adjustment for confounders
(20 studies). In three studies, the methods for assessing disability were unclear. One study used a
single binary question to determine whether an individual had a disability or not and one study used
binary responses across several domains (e.g., seeing, hearing). These types of questions are likely to
underestimate the prevalence of disability by missing milder forms of disability. Supplementary File
S3 provides details of the risk of bias by domain.
3.5. Description of Findings Related to Healthcare Access

Figure 2 provides a summary of the results from the 50 included studies, grouped by outcome
type. Of the 20 studies measuring utilisation of healthcare, 17 (85%) found that utilisation of healthcare
services was higher for people with disabilities compared to those without, and the remaining
three studies (15%) showed lower utilisation. Twenty two studies measured healthcare coverage.
The majority of studies found no difference in coverage between people with disabilities in comparison
to people without (n = 13; 59%). Two studies found higher coverage (9%), and seven found lower
coverage (32%). Three studies measured adherence, all finding lower adherence amongst people
with disabilities. Eight studies measured outcomes related to health expenditure; Five studies (63%)
found higher expenditure, and three studies (37%) found no difference. Of the five studies measuring
remaining three studies (15%) showed lower utilisation. Twenty two studies measured healthcare
coverage. The majority of studies found no difference in coverage between people with disabilities
in comparison to people without (n = 13; 59%). Two studies found higher coverage (9%), and seven
found lower coverage (32%). Three studies measured adherence, all finding lower adherence
amongst
Int. people
J. Environ. with
Res. Public disabilities.
Health Eight studies measured outcomes related to health expenditure;
2018, 15, 1879 8 of 29
Five studies (63%) found higher expenditure, and three studies (37%) found no difference. Of the five
studies measuring insurance coverage, four (80%) found no difference, and one (20%) found lower
insurance
coverage among coverage, fourwith
people (80%) found no The
disabilities. difference,
results and one (20%)infound
are discussed morelower
detailcoverage among
in the following
people
sections. with disabilities. The results are discussed in more detail in the following sections.
18 17
16
14 13
12
10
8 7
6 5
4
4 3 3 3
2
2 1
0 0 0 0 0 0 0 0 0 0
0
Utilisation Coverage Adherance Expenditure Insurance
Higher Lower Mixed Null difference
Figure 2. Results by outcome type.

Figure 2. Results by outcome type.
3.5.1. Utilisation
Utilisation of healthcare services was measured using a range of outcomes in two main groups
(use of primary or secondary health services, and use of tertiary (hospital) services), and by different
time-periods of assessment. The outcomes included the following:
• Primary or secondary health services (13 studies)
# Number of visits to health centre or public health facility in past 12 months (4 studies);
6 months (1 study); and 1–3 months (4 studies)
# Access to services in past 6 months (1 study)
# Home visits by a doctor in past 12 months (1 study)
# Length of time since last consultation (1 study)
# Clinic attendance (unspecified time frame; 1 study)
• Tertiary services (hospital) (12 studies)
# Hospitalisations (inpatient admission) in the past 5 years (1 study); 12 months (7 studies),

6 months (1 study); 3 months (1 study); or over an unspecified time frame (1 study)
# Hospital outpatient visit in the previous 12 months (1 study), 6 months (1 study) or one
month (2 studies)
Utilisation: Primary or Secondary Service Use

Thirteen studies assessed utilisation of primary or secondary healthcare services, comparing
people with and without disabilities (summarised in Table 3). Three different periods of recall were
assessed across studies: past 12 months, 2–3 months, and one month. Five of the 13 studies measuring
this outcome were conducted in Brazil.
For utilization of services in the past 12 months, one of four studies found no significant difference
between people with and without disabilities, and for the remaining study the results showed higher
utilisation for people with disabilities. For utilisation in the past six months, two studies found higher
utilisation and one found lower utilisation for people with disabilities. All studies found higher
utilisation in the past 1–3 months amongst people with disabilities compared to those without. Regular
clinic attendance over an unspecified period was lower for people with disabilities in one study.
Table 3. Comparison of utilisation of primary health or secondary services between people with and without disabilities.
Age Group of Time Period (Months)

Study Country Disability Domain Outcome Result Summary
Participants 12 6 1–3 NS
Multiple: Physical
impairment, sensory, mental
Trani et al. (2010), Trani People with disabilities 82%; No
Afghanistan >4 years impairment (mental X • • • Health centre utilisation NS
et al. (2012) [13,14] disability 84% (p > 0.05)
illness/intellectual
impairment)
Number of appointments in ADL Number of appointments:
past 12 months (0–1; 2–4; 5 PR (5 or more vs. 0–1) = 1.1 (1.0, 1.3)
Fialho et al. (2014) [15] Brazil ≥60 years Activities of Daily Living X • • • or more); PR (2–4 vs. 0–1) = 1.1 (0.9, 1.1) +
Home visits by doctor in past Home visits: ADL PR = 8.5
12 months (4.2, 17.3)
Number of visits to health
Adults: OR = 2.1 (1.0, 4.3) Children:
Danquah et al. (2015) [16] Haiti ≥5 years Functional difficulties X • • • centre (No visits (base); versus +
OR = 1.3 (0.5, 2.9)
≥3 visits)
Mexico, Peru, Cuba, Pooled prevalence ratio (all
Multiple: Mental impairment
Dominican Republic, countries): Depression 1.2 (1.1, 1.4);
(Dementia, depression),
Albanese et al. (2011) [17] Puerto Rico, >65 years X • • • Community health service use Dementia 0.9 (0.9, 0.9); +
physical impairments,
Venezuela, China, Physical impairment 1.4 (1.3, 1.5);
mobility restriction
India, Nigeria Mobility restriction 1.0 (0.9, 1.1)
Bangladesh: People with
disabilities 69%; No disability 66%
Marella et al. (2014) [18] Bangladesh, Fiji ≥18 years Functional difficulties • X • • Access to health services (p < 0.001); −
Fiji: People with disabilities 82%;
No disability 82% (p < 0.001)
Medical visit at
Rodrigues et al. (2009) [19] Brazil >65 years Functional difficulties • X • • the primary PR = 1.3 (1.2; 1.5) +
health care unit
Mean visits:
Number of visits
People with disabilities Treated for depression
Mental impairment to traditional
Fujii et al. (2012) [20] Brazil >18 years • X • • 14.4 ± 20.6, +
(depression) health care
People with disabilities not treated for depression
provider
8.4 ± 10.5; No disability 3.3 ± 5.6 (p < 0.05)
Medical
Freire et al. (2009) [21] Brazil >15 years Hearing impairment • • X • PR = 1.3 (1.1, 1.5); p = 0.007 +
consultation
Dementia:urban OR = 0.9 (0.7, 1.2); rural OR = 1.5
(0.8, 3.1);
(Dementia), limiting physical
Use of Number of limiting physical illness:
illness (hearing impairment,
Liu et al. (2009) [22] China ≥65 years • • X • community 1–2 vs. none: urban OR = 2.3 (1.8, 2.9), rural OR = +
physical impairment (limb or
services 3.8 (2.1, 6.9)
arthritis), and/or visual
2 or more vs none: urban OR = 3.7 (2.9, 4.8); rural
impairment (eye problem))
OR = 8.3 (4.1, 17.0)
Table 3. Cont.

Study Country Disability Domain Outcome Result Summary
Participants 12 6 1–3 NS
China, Cuba, (Dementia, depression),
Dominican Republic, functioning difficulties Previous health
Depression severity PR=1.0 (1.01, 1.03);
Twomey et al. (2015) [23] India, Mexico, Nigeria, ≥65 years (concentrating/remembering, • • X • service +
Functioning difficulties: PR = 1.01 (1.00, 1.03)
Peru, Puerto Rico, self-care, physical, utilisation
Venezuela communication,
participation)
General health
Mental impairment (mental service Any psychiatric disorder 38% (SE = 2.8);
Andrade et al. (2002) [24] Brazil >18 years • • X • +
disorders) utilisation in the No psychiatric disorder 24% (SE = 1.6)
past month
People with disabilities 69%;
Groce et al. (2006) [25] Swaziland ≥18 years Hearing impairment • • • X Clinic attendance -
No disability 87% (p < 0.05)
Length of time since last People with disabilities 44%; 15%;
consultation: last 30 days; 1–5 8%; 16%; 5%; 2%; 2%; 10%No
months ago; 6–12 months ago; disability 20%; 14%; 8%; 29%; 10%;
Moodley et al. (2015) [26] South Africa Adults Functional difficulties • • • X +
>1 and <2 years ago; 2–4 years 4%; 2%; 13%p < 0.001; p = 0.17; p =
ago; 5–10 years ago; >10 years 1.00; p < 0.001; p < 0.001; p < 0.001; p
ago; never = 1.00; p < 0.001
+ higher utilization among people with disabilities; − lower; NS: no difference; ADL: activities of daily living; PR: prevalence ratio; OR: odds ratio; Xyes; • no.
Finally, one study measured the length of time since last consultation and found a higher
proportion of people with disabilities had sought care in the past 30 days, and a lower proportion
reported they had sought care between 1–2 years ago in comparison to people without disabilities.
Seven studies measuring utilisation of primary health services disaggregated results by domain of
disability or only measured one disability domain; five by mental impairment, one hearing impairment
and two physical impairment. Considering studies measuring mental impairment, in Brazil, Fujii et al.
found a greater number of health care visits for adults with mental health conditions [20]. Albanese et al.
reported higher community health service use for older adults (>65 years) with depression across nine
LMIC [17]. Similarly, Andrade et al. found higher utilisation of general health services for adults with
mental disorders in Brazil [24]. In contrast, Blay et al. found no difference in health care utilisation
Brazil for people with or without mental health conditions [27]. Further, in China, Liu et al. found no
difference in health service utilisation for older adults with dementia compared to those without [22].
Considering utilisation results by other disability types, Groce et al. found adults with
hearing impairment had lower regular clinic attendance compared to adults without impairment in
Swaziland [25]. Albanese et al. reported that community health service use was higher for older people
(>65 years) with physical impairments and mobility restrictions (pooled-estimate across multiple
LMICs) compared to those without [17]
Utilisation: Hospitalisation
Twelve studies measured hospitalisation (inpatient or outpatient) over varying periods of time
(Table 4). Nearly half of these studies were conducted in Brazil (five studies). In general, occurrence
of inpatient hospital admission was significantly higher amongst people with disabilities compared
to people without disabilities. Outpatient visits were measured in four studies, and the majority
(n = 3; 75%) found no significant difference between frequency of visits for people with and without
disabilities, and one found a higher number of visits among those with disabilities.
The World Report on Disability summarises results from 50 World Health Surveys and reports
individuals’ care seeking behaviour by country income level [1]. The analysis found that in low-income
countries, a significantly higher proportion of both males and females with disabilities (>18 years)
sought inpatient and outpatient care. Higher levels of care seeking for people with disabilities was
seen for people in all age groups except for those aged 60 years and older.
Several studies disaggregated results by disability domain, but the numbers of studies in each
group were too small to detect consistent patterns. Castro et al. found no significant difference in
hospitalisation for people of all ages with and without hearing impairment (Brazil) [28], while Freire et al.
found a higher proportion of adults with hearing impairment had been hospitalised in the past year
(Brazil) [21]. Blay et al. found no difference in outpatient visits, but higher hospitalisations in the past
12 months for older adults with physical impairments (>60 years) in Brazil [27]. Similarly, both Liu et al.
and Castro et al. found higher hospitalisation for adults with physical impairments in both China
and Brazil respectively [22,28]. Twomey et al. reported that hospital admission did not differ between
those with and without depression [23]. However, for those with functional difficulties an increase in
hospitalisation in the past 3 months was found.
3.5.2. Coverage
Table 5 summarises the results of the 22 studies measuring coverage. Coverage outcomes included:
• Care seeking when ill (over varying time periods) (9 studies)

• Coverage of specific services: HIV related (four studies); vaccination coverage (9 studies); dental
visits (4 studies); maternal health outcomes (4 studies); receipt of vitamin A (1 study); and others
(1 study).
Table 4. Comparison of utilisation of hospital services between people with and without disabilities.

Study Country Disability Domain Summary of Results Hospitalisation Outpatient
Participants 12 6 3 1 NS Visit
Multiple: Physical impairment,
Hospital admission (12 months):
Trani et al. (2010, sensory, mental impairment
Afghanistan >4 years X • • • • People with disabilities 80%; −
2012) [14,29] (mental illness/intellectual
No disability 90%; p < 0.001
impairment)
hearing impairment, speaking, Inpatient (past 12 months) OR = 1.7
Palmer et al. (2011,
Vietnam >5 years visual impairment, mental X • • X • (p ≤ 0.01) + NS
2012) [30,31]
impairment (intellectual Outpatient (past month) OR = 1.1 (p = NS)
impairment, mental illness)
Inpatient visit in last 12 months mean 0.19
(SE = 0.12) Significantly higher than other
groups studied (formal employee, person
Palmer et al. (2014) [32] Vietnam >5 years Functional difficulties X • • X • living in poverty, self-employed) + NS
Outpatient visit in the past month: mean
0.32 (SE = 0.015). Higher than other
groups, but statistical test not reported.
Multiple: Physical impairments,
visual impairment, hearing Need to visit hospital (past year) OR 1.6
Murthy et al. (2014) [33] India >18 years X • • • • +
impairment, mental impairment (0.9, 2.5), p = 0.05
(intellectual impairment)
PR for hospitalisation
No disability PR: 1.00 (base)
Multiple: Visual impairment,
Visual: PR: 0.9 (0.45, 1.6); NS
Castro et al. (2013) [28] Brazil >11 years hearing impairment, physical X • • • • +
Hearing: PR: 1.6 (0.9, 2.9); NS
impairment
Physical: PR:3.8 (2.0, 7.1)
Multiple: PR:3.3 (1.6, 6.6)
Fialho et al. (2014) [15] Brazil ≥60 years Participation X • • • • PR for hospitalization = 1.6 (1.2, 2.3) +
Freire et al. (2009) [21] Brazil >15 years Hearing impairment X • • • • PR for hospitalization = 2.1 (1.4, 3.1) +
Hospitalisations (12 months)
Rheumatism OR = 0.9 (0.8, 1.1)
Psychiatric morbidity OR = 1.4 (1.1, 1.9)
Blay et al. (2008) [27] Brazil >60 years mental impairment (mental X X • • • + NS
Outpatient visit (6 months)
health condition)
Rheumatism OR = 1.1 (0.9, 1.3)
Psychiatric morbidity OR = 1.1 (0.9, 1.2)
Hospitalisations (6 months):
People with disabilities treated for
Mental impairment depression 24%;
Fujii et al. (2012) [20] Brazil >18 years • X • • • +
(mental health) People with disabilities not treated for
depression: 17%;
Control 8%; p < 0.05
Table 4. Cont.

Study Country Disability Domain Summary of Results Hospitalisation Outpatient
Participants 12 6 3 1 NS Visit
Devendra et al. Overnight hospital admission OR = 2.7
Malawi 2–9 years Functional difficulties • • • • X +
(2013) [34] (1.2, 6.2)
Hospital admission (past 3 months)
Twomey et al.
Various >65 years Functional difficulties • • X • • Depression severity PR = 1.1 (0.9, 1.3) +
(2015) [23]
Functioning: PR = 1.1 (1.02, 1.3)
Overall, people with disabilities sought
more inpatient and outpatient care in the
World report on Various (50 last 5 years compared to people without
18+ years Functional difficulties X • • • • + +
disability (2011) [1] LMIC) disabilities, and this difference was
evidence across both genders and all age
groups, except in people aged 60+
+ higher utilization among people with disabilities; − lower; NS: no difference; LMIC: low and middle-income countries; PR: prevalence ratio; OR: odds ratio; Xyes; • no.
Care Seeking When Ill

Of the nine studies measuring care seeking when ill, four found lower coverage for people with
disabilities and five studies found no difference (Table 5). By disability domain, care seeking when
ill was found to be lower in one study by Wanera et al. amongst adults (>50 years) in Uganda for
either physical impairments, visual impairments or mental impairment, however no difference was
seen for people with hearing impairment [35]. Emerson et al. found across 25 LMIC that children with
intellectual disability had reduced odds of seeking care for acute respiratory infection, reduced odds of
pre-packaged oral rehydration treatment for diarrhoea, and no significant difference for help seeking
for fever [36].
Coverage of Specific Services

Four studies measured coverage of dental services, all of which focussed on children with
intellectual disabilities Khatib et al. and Al Habeshneh et al. found lower previous dental attendance
for children with intellectual disability in Egypt, and Jordan respectively [37–39]. Oredugba et al. and
Rahim et al. found no difference in any dental treatment received amongst children with intellectual
disability in Nigeria and Malaysia respectively [40].
Four studies measured indicators of maternal health coverage. None of these studies found a
difference between women with and without disabilities. Results were not disaggregated by disability
domain for any of the studies.
Five studies measuring vaccination coverage for people with and without disabilities were
conducted in Brazil (>60 years), India (children), Kenya (children), Peru (all ages), and Sierra Leone
(adults only). In Sierra Leone, level of immunisation was lower for people with severe functional
difficulties than people without. No differences were observed in other studies. Sato et al. (2015) found
no significant difference in influenza vaccination coverage for people with either depression or “being
bedridden”. No other studies disaggregated results by disability domain [41].
Higher coverage of HIV services (e.g., HIV testing) was found in two of four studies, with the
remaining finding no difference. By disability domain, Abimanyi-Ochom et al. found people (aged
15–54 years) with hearing impairment had fewer months since their last HIV test (Uganda) [42].
In contrast, Bisol et al. found a no difference between people with and without hearing impairment
aged 15–21 years in testing for HIV (Brazil) [43].
Two studies measured other indicators of coverage of health services. Freire et al. (2009) found
no significant difference in time since last prostate examination in Brazilian men with and without
hearing impairment, however women with hearing impairment had a significantly longer time since
last Pap smears [21]. Gottleib et al. assessed vitamin A supplementation in children aged 2–4 years by
disability status across 18 countries, and found lower coverage among children with disabilities in
Bangladesh, Belize, Ghana, Iraq and Mauritiana [44]. No difference was found in the remaining 13
countries included in the study.
3.5.3. Adherence
Three studies measured adherence to treatment by disability status—either to HIV treatment,
fluid or diet restrictions for end stage renal disease, or medication (Table 6). Of these studies, two found
mixed results by impairment type, and one found adherence was lower among people without
disabilities than in people without disabilities. Hannass-Hancock et al. (2015) found no difference
in HIV treatment adherence in South Africa for people with cognitive difficulties compared to those
without, however adherence was found to be lower for adults with mobility impairments [45]. Tavares
et al. (2013) found lower adherence for people reporting difficulties in participation (Instrumental
Activities of Daily Living incapacity) in Brazil (>60 years), however no difference was seen for people
with cognitive impairment or depression [46].
Table 5. Summary of studies measuring coverage.
Age Group of People with People without

Study Author, Year Country Disability Group Outcome Comparison Summary
Participants Disabilities Disabilities
Care seeking when ill
Serious illness in the
Physical, mental, vision,
Kuper et al. (2014) [4] 30 LMIC Children last 12 months and if >97% >97% Not reported NS
communication, hearing
sought treatment
Physical, epilepsy, visual,
Kuper et al. (2015) [47] Kenya Children hearing, intellectual, Took action when sick 83% 84% OR = 1.2 (0.6, 2.2) NS
functional difficulties
Proportion seeking
Kuper et al. (2016) [48] Tanzania All ages Functioning (WG) 94% 96% Not reported NS
care when ill
India a OR = 0.9
Mactaggart et al. India and Sought care if serious
All ages Functioning (WG) (0.3, 3.1); Cameroon a NS
(2015) [49] Cameroon health problem
OR = 1.8 (0.7, 4.3)
Overall: 70%
Overall: 80%
Within domains: p < 0.001
Communicating 76%
Communicating: 49% p = 0.01
Seeing 78%
Access to healthcare Seeing: 67% p = 0.03
Wandera et al. Hearing 77%
Uganda Older adults Functioning (WG) in the last 30 days Hearing: 67% p = 0.14 −
(2015) [35] Walking 80%
when ill Walking: 63% p < 0.001
Remembering or
Remembering or p < 0.001
concentrating 77%
concentrating: 55% p = 0.001
Self-care 77%
Self-care: 55%
Could you receive
Trani et al. (2015) [50] India Not specified Mental health 4% 3% p = 0.28 NS
healthcare when sick?
Help sought for
Emerson et al. 53% 65% OR = 0.69 (0.59, 0.80)
25 LMICs Children Intellectual disability respiratory infection −
(2017) [36] 48% 50% OR = 0.95 (0.86, 1.05)
Help sought for fever
Sudan; Statistical test not
Probability of not
Namibia; shown—trend for
Eide et al. (2015) [51] Not specified Functioning (WG) receiving necessary 0.19 0.07 −
South Africa; higher probability of
health care
Malawi not receiving care
Multiple: Visual impairment,
hearing impairment,
communication, physical
Met need for general
Marella et al. (2016) [52] Philippines ≥18 years impairment, mental OR = 0.5 (0.3, 0.7) −
health services
impairment (cognitive,
appearance, psychological
distress)
Table 5. Cont.

Dental
Dental visits
Al Habashneh et al. Children Intellectual disability (parent report)
Jordan 32%, 58%, 10% 16%, 51%, 34% p < 0.01 −
(2012) [37] 12–16 years (Down’s syndrome) Visit dentist: Never,
irregular, regular
El Khatib et al. Behavioural impairment
Egypt Children Dental visits in the 44%; 64% 67%; 25% p = 0.002 −
(2014) [38] (Autism)
past year; difficulty
finding a dentist
(parent report)
Intellectual disability
Rahim et al. (2014) [40] Malaysia Children Received any dental 49% 53% p > 0.01 NS
(Down’s syndrome)
treatment
Multiple: mental disabilities
Oredugba et al. Children 5–19 (e.g., Down’s syndrome,
Nigeria Previous dental 4% 4% p > 0.05 NS
(2006) [39] years autism); physical
attendance
(cerebral palsy)
Maternal
Bernabe-Ortiz et al.
Peru All ages Functioning (WG) Accessing prenatal 100% 100% p > 0.05 NS
(2016) [53]
care for pregnancies
in the past 5 years
Mactaggart et al. Cameroon All ages Functioning (WG) Antenatal OR = 0.6 (0.2, 2.1) NS
(2015) [49] care/vaccines for
women (yes; no)
Physical, visual, hearing,
Murthy et al. (2014) [54] India Adults Baby delivered at 63% 72% p = 0.15 NS
intellectual
hospital in the last
2 years
94% 84% p = 0.35
94% 84% p = 0.07
Trani et al. (2011) [29] Sierra Leone Adults Functioning (bespoke tool) Antenatal visit; NS
87% 76% p = 0.18
Birth attended by
80% 76% p = 0.82
professional;
Delivery in hospital;
Access to
emergency care
Table 5. Cont.

Vaccination
Physical, epilepsy, visual,
Child received
Kuper et al. (2015) [47] Kenya Children hearing, intellectual, 97% 98% OR = 1.3 (0.5, 3.5) NS
vaccinations
functioning
Vaccination of
Bernabe-Ortiz et al.
Peru All ages Functioning (WG) children born in the 100% 100% p > 0.05 NS
(2016) [53]
past 5 years
Influenza vaccination
Mental impairment
coverage (self-report): PR = 0.9 (0.9, 1.0)
Sato et al. (2015) [41] Brazil Older adults (depression); physical NS
Depression; PR = 1.0 (0.8, 1.3)
impairment (“bedridden”)
“bedridden”
Mactaggart et al. Child vaccinated
India All ages Functioning (WG) OR = 1.8 (0.3, 11.9) NS
(2015) [49] (yes; no)
Trani et al. (2011) [29] Sierra Leone Adults Functioning (bespoke tool) Not immunised 25% 11% p = 0.003 −
HIV
Abimanyi-Ochom et al.
Uganda Adults Functioning (WG) Month since last test p < 0.05 for all comparisons +
(2017) [42]
Bisol et al. (2008) [43] Brazil Children Hearing impairment Ever been tested 21% 8% p = 0.08 NS
De Beaudrap et al.
Cameroon Adults Functioning (WG) Ever been tested 71% 77% OR = 0.8 (0.6, 1.0) NS
(2017) [55]
Trani et al. (2011) [29] Sierra Leone Adults Functioning (bespoke tool) Ever been tested 16% 20% p < 0.001 −
Other outcomes
(1) Average time
(1) 7.2
elapsed since the last
(1) 24.3 (SD = 32.9) (SD 13.8) (1) p < 0.001
Freire et al. (2009) [21] Brazil Adults Hearing impairment Pap smear −
(2) 30.6 (SD = 28.6) (2) 30.5 (2) p = 0.98 (NS)
(2) Time since last
(SD = 24.1)
prostate exam
Receipt of vitamin A
Gottlieb et al. supplements (ever
18 LMIC Children Functioning (Ten Questions) 28% 77% No significance test reported −
(2009) [44] received yes or no)
(parent report)
+ higher utilization among people with disabilities; − lower; NS no difference; PR prevalence ratio; OR odds ratio; LMIC: low and middle income countries; WG: Washington
group questions
Table 6. Results of studies measuring adherence.
Measure Among
Study Author, Relevant Measures Measure Among
Country Age Range Disability Domain People with Measure of association Summary
Year of Access Controls
Disabilities
Relative risk ratios (RR)
Global limitation 1.1 (1.05–1.14)
Mobility 1.3 (1.2, 1.5)
Hannass-Hancock Non-adherence to Life activity 0.7 (0.4, 1.2); NS
South Africa 18–88 years Functional difficulties - - −
et al. (2015) [45] HIV treatment Cognition 1.1 (0.8, 1.5); NS
Participation 1.2 (0.9, 1.5); NS
Self-care 0.7 (0.3, 1.4); NS
Activity limitations OR = 1.1 (1.1, 1.2)
p < 0.001 (comparing scores between
no, mild, moderate, severe disability)
Diet non adherence
Severe level OR = 3.6 (2.1, 6.1) (comparing high to
(mean (SD))
Mollaoglu et al. 3.22 (0.66) 2.46 (0.75) low level of disability)
Turkey >18 years Functional difficulties Fluid non −
(2015) [56] Severe level 3.28 (0.45) p < 0.001 (comparing scores between
adherence
3.88 (1.05) no, mild, moderate, severe disability)
(mean (SD))
OR = 2.9 (1.0, 1.2) (comparing high to
low level of disability)
Multiple:
No IADL 26%;
Participation IADL: 33%; PR = 1.3 (1.1, 1.5) p = 0.009
Tavares et al. No depression 28%;
Brazil >60 years Mental impairment % low adherence Depression: 31%; PR = 1.1 (0.9, 1.4) p = 0.49 −
(2013) [46] No cognitive
(cognitive deficit, Cognitive: 27% PR = 0.9 (0.7, 1.2) p = 0.67
deficit 29%
depression)
+ higher utilization among people with disabilities; − lower; NS no difference; PR prevalence ratio; OR odds ratio.
3.5.4. Health Expenditure

Table 7 shows the results of the eight studies measuring health expenditure. Expenditure outcomes
included catastrophic health expenditure (three studies); total out of pocket expenditure (four studies);
total medical expenses (one study) and health expenditure to income ratio (one study). Five studies
(63%) found higher expenditure incurred by people with disabilities, three studies (37%) found
no difference.
Two studies reported results of expenditure amongst those with and without hearing impairment.
Brinda et al. found out of pocket expenditure was higher for adults with either hearing or vision
impairment in India when seeking healthcare [57]. In contrast, Brinda et al. found no difference in
expenditure for adults with hearing impairment compared to those without hearing impairment in
Tanzania [58].
Three studies reported expenditure for those with varying mental impairments. Brinda et al.
found higher out of pocket expenditure for older adults with dementia in India [57]. Also in India,
Brinda et al. found higher catastrophic expenditure for older adults with depression [59]. In contrast,
Brinda et al. found no significant difference in out of pocket expenditure for adults with psychiatric
morbidity in Tanzania [58].
Brinda et al. also found no difference in out of pocket expenditure for adults with physical
impairment (“limb defects”) in Tanzania [58]. Finally, both Brinda et al. and Brinda et al. found no
significant difference in out of pocket expenditure for adults with visual impairment compared to
those without in India and Tanzania respectively [57,59].
3.5.5. Health Insurance Coverage

Table 7 shows the results of the five studies measuring insurance coverage. Access to health
insurance was measured in two main ways—medical payment method (out of pocket, or by insurance
plan) or coverage (four studies). One study found lower coverage amongst people with disabilities,
and four studies found no difference in coverage.
Table 7. Results of studies measuring insurance and expenditure.
Measure among
Relevant Measures Measure among
Study Author, Year Country Age Range Disability Domain People with Measure of Association Summary
of Access Controls
Disabilities
Insurance
Multiple: Hearing Medical payment
impairment, visual method: 80% 82%
Alhajj et al. (2010) [60] China 15–84 years impairment, physical Out of pocket 20% 20% p > 0.05 NS
impairment, mental Government insurance 0.7% 0.6%
impairment Commercial insurance
Bernabe-Ortiz et al. Enrolled in insurance
Peru ≥5 years Functional difficulties 83%; 81% OR = 0.9 (0.5, 1.6) NS
(2016) [53] scheme
Freire et al. (2009) [21] Brazil >15 years Hearing impairment Enrolled in health plan PR = 1.1, 95%CI 1.0–1.3; p = 0.11 NS
Moodley et al. (2015) [26] South Africa “adults” Functional difficulties Medical aid receipt 10% 18% p < 0.001 −
Multiple: Physical
impairment, hearing
Palmer et al. (2011) and Insurance card holder
Vietnam >5 years impairment, speaking, 0.19 (SE = 0.007) 0.18 (SE = 0.003) p > 0.05 NS
Palmer (2012) [30,31] (mean)
visual impairment,
mental impairment
Expenditure
Correlates of out of pocket health expenditure
Visual impairment p = 0.82
Multiple: Functional
Hearing impairment p = 0.14
difficulties; mental
Total out of pocket Dementia p < 0.001
impairment (Alzheimers,
health expenditure; Major depression p < 0.001
Brinda et al. (2012) [57] India >60 years Dementia, Mental +
catastrophic health WHODAS II p < 0.001
Health), hearing
expenditure Correlates of catastrophic health expenditure
impairment, visual
Visual impairment; p = 0.78
impairment
Hearing impairment; p = 0.66
Dementia; p = 0.01
Out of pocket health expenditure (18–59 years)
Blindness/visual defect NS
Hearing defect: p = 0.02
Limb defect: NS
Psychiatric morbidity NS
Multiple: Visual Functional disability: p < 0.001
Total out of pocket
impairment, hearing Out of pocket health expenditure (>60 years)
health expenditure;
Brinda et al. (2014) [58] Tanzania ≥18 years impairment, functional Blindness/visual defect: p = 0.01 +
catastrophic health
difficulties, mental Hearing defect: NS
expenditure
impairment Limb defect: NS
Psychiatric morbidity: NS
Functional disability: p = 0.01
Catastrophic expenses
functional disability:
1.19 (0.93, 1.51); NS
Table 7. Cont.
Measure among
Relevant Measures Measure among
Study Author, Year Country Age Range Disability Domain People with Measure of Association Summary
of Access Controls
Disabilities
Insurance
Disability was positively correlated with
Out of pocket health
out-of-pocket health expenditure (p < 0.001)
expenditure and
Brinda et al. (2015) [59] India ≥65 years Functional difficulties Catastrophic health expenditure was associated +
catastrophic health
with depression:
expenditure
OR = 3.5 (1.5, 7.5); p = 0.004
Inpatient expenditure
(past month)
Outpatient expenditure Inpatient: 401 (57) Inpatient: 35–235
Inpatient and outpatient expenditures: NS
(past month) Outpatient: 51 (8) Outpatient: 6–39
Outpatient visit in the past month: NS
Palmer et al. (2014) [32] Vietnam >5 years Functional difficulties Catastrophic health 10%: 50% 10%: 20–40% NS
Effect of insurance on catastrophic health
expenditure: 20%: 30% 20%: 10–20%
expenditure: NS
10% threshold; 20% 40%: 12% 40%: 3–10%
threshold; 40%
threshold
Multiple: Physical, Expenditure ratio:
Palmer et al. (2011) and Expenditure ratio:
Vietnam >5 years hearing, speaking, visual, Inpatient 1.7 (0.15) p ≤ 0.01 +
Palmer (2012) [30,31] Inpatient; outpatient
mental impairment Outpatient 0.9 (0.07) p = NS
Multiple: Physical
Health expenditure: %
impairment, sensory
Trani et al. (2011) [29] Sierra Leone ≥18 years total average yearly HH severe 4% 3% Not measured NS
disabilities, mental
income spent on health
impairment
M 31.2%; F 33%; M 20%; F 20%;
For all comparisons, catastrophic health
World report on disability Various (50 Catastrophic health 18–49 years: 33%; 18–49 years: 20%;
≥18 years Functioning expenditure was higher among people with +
(2011) [1] LMIC) expenditure 50–59 years: 33%; 50–59 years: 18%;
disabilities p < 0.05
60+ years: 30% 60+ years: 21%
Medical expenses None: 75% None: 76%
Trani et al. (2010) and (Afghanis) amongst 1–499: 15% 1–499: 15%
Afghanistan >4 years Functioning p > 0.05 NS
Trani et al. (2012) [13,14] those with severe 500–1999: 7% 500–1999: 7%
difficulties 2000–105,000: 3% 2000–105,000: 8%
+ higher utilization among people with disabilities; − lower; NS no difference; PR prevalence ratio; OR odds ratio; SE standard error.
3.5.6. Barriers to Access

In addition to other access outcomes, eight studies measured barriers to accessing general
healthcare services as a secondary outcome. The most commonly reported barriers across studies
were transport difficulties, financial difficulties and attitudes of staff. People with disabilities reported
experiencing greater barriers to accessing health services than people without disabilities in all five
studies that made this comparison (three studies only reported barriers for people with disabilities).
These results are shown in Table 8.
Table 8. Barriers to accessing health services reported in included studies.
World report on Disability (2011) [1]

Al Habashneh et al. (2011) [37]
Danquah et al. (2015) [16]
Marella et al. (2016) [52]
Murthy et al. (2014) [33]
Rahim et al. (2014) [40]

Badu et al. (2016) [61]
Eide et al. (2015) [51]

Barrier
Geographic accessibility
Transport difficulties X X X X X
Location of services X
Affordability
Financial X X X X X
No accommodation at health facility X
Acceptability
Lack of perceived need X X
Other commitments X X
Lack of awareness or information X X X
Did not know where to go X X
Fear of service X
Fear of journey X X
Faith/belief X
Discrimination or lack of awareness amongst health workers X X X X
Previous bad experience X
Communication with health providers X
Standard of facility X
Physical access to facility X X
Availability
Services not available X
Lack of equipment X X X
Tried but denied X X
Health care providers skills inadequate X
Difficulty finding doctor X
X yes.
3.5.7. Quality of Services

Three studies measured quality-related outcomes with respect to health access including: ease of
access, satisfaction, and overall accessibility. Trani et al. found no difference in satisfaction with public
health facilities in Afghanistan for people aged >5 years with and without disabilities [14]. In Thailand,
a study by Wongkongdech et al. found that 66% of people with physical impairment of all ages ranked
their accessibility to health services at a moderate level (i.e., neither high nor low), taking in to account
adequacy of health personnel, respect for rights and dignity, transport, service related aspects, personal
factors and costs [62]. Finally, Badu et al. found that 71% of people faced discrimination from health
care providers [61].
4. Discussion
4.1. Overview of Results

This review provides a comprehensive overview of published studies that have assessed the
relationship between disability and access to general healthcare services in LMIC. Seven main groups
of healthcare access outcomes were identified: health care utilisation, coverage, adherence, health
insurance coverage, health expenditure, barriers and quality related outcomes.
Utilisation is expected to be higher for some people with disabilities because by definition, people
with disabilities have an underlying health condition that causes an impairment [11]. Our found some
evidence to support this expectation. This review found evidence that in general both hospitalisation
and utilisation of primary health services was higher for people with disabilities compared to people
without disabilities. However, half of these studies were judged to have a high or moderate risk of
bias, which may influence the findings.
It is commonly believed that coverage of health services is lower for people with disabilities
than people without, our review found limited evidence to support this assumption [63]. Overall,
coverage outcomes were varied in this review, even within sub-groups. We found some evidence
that coverage of dental services for children with intellectual impairments was lower than children
without disabilities. No difference in coverage of maternal health services was seen between people
with and without disabilities. Results of studies measuring coverage of HIV services, care seeking
when ill, and vaccinations were varied with both higher and lower coverage reported for people
with disabilities. Again these results should be interpreted in light of the poor quality of some of the
included studies.
Few studies measured outcomes related to adherence. However, results suggested a trend
towards lower adherence among people with disabilities. The majority of studies that measured health
insurance found no significant difference between people with and without disabilities. Results from
studies measuring health expenditure showed a trend toward higher expenditure for people with
disabilities. Of eight studies, five found higher expenditure for people with disabilities compared to
people without. A further three studies found null difference.
Commonly reported barriers included those related to geographic accessibility, financial
accessibility and acceptability of health services. Quality of services received by people with disabilities
was measured in very few studies.
The review highlighted that a diverse range of indicators are used to measure access to health
services, making it difficult to compare studies and draw strong conclusions. This highlights the need
for defined, consistent metrics for measuring access to allow comparability and monitoring of progress
towards UHC. Nearly half of the studies in this review were judged to have a high or moderate risk of
bias, which highlights the urgent need for high quality studies to be carried out. No consistent patterns
were seen by age, locality or disability domain, although the number of studies disaggregating data by
these variables was small. These indicators, alongside other measures of equity such as socioeconomic
status or gender are crucial for understanding progress towards UHC.
4.2. Consistency with Previous Literature

Few systematic reviews have been conducted on this topic to allow for comparisons to be made,
but findings from high-income countries more clearly show poor healthcare access among people
with disabilities. A review by Gibson et al. found that people with disabilities had restricted access
to and report less satisfaction in their medical care [64]. This paper had a bias towards high-income
contexts, and was based mostly on qualitative studies. In another review by Alborz et al., evidence
suggested that people with learning disabilities may access general practices and dental surgeries
less frequently than the general population [65]. This concurs with our findings. Alborz et al. also
identified that people with learning disabilities were less likely to receive preventive healthcare. Again,
this review had a focus on high-income contexts which means the results are not directly comparable
to our review. Other studies from high income settings also show poorer access to healthcare among
people with disabilities, including in Chile [66], and the United Kingdom, with long waiting lists and
transportation being the main reported barriers in the UK [67]. The results for our review were more
mixed. Often, overall coverage was very high for some indicators (e.g., for vaccination), making it
difficult to find differences between groups.
Our review found that health expenditure was typically higher for people with disabilities.
There is a growing body of evidence to support the link between disability and poverty [2]. Recent
research in Vietnam and Nepal on social protection for people with disabilities found that spending
on health care was one of the main courses of additional costs for people with disabilities that could
contribute to poverty [68,69]. This aligns with the findings of our review, however further evidence
is needed.
Results from high-income contexts including the United States and Korea suggest that adherence
to treatment tends to be lower for people with disabilities. A study by Park et al. found people with
disabilities had lower adherence to antihypertensive medications than people without disabilities [70].
In the USA, lower adherence to prescription medication was found for post-myocardial infarction
patients with disabilities [71]. Although our review identified few studies measuring adherence,
the findings concur with this research from high income contexts.
This review has highlighted that further research is needed to understand how people with
disabilities are accessing health services, not just in terms of utilisation, but also coverage of preventive
services, affordability of health services, and the quality of care received. In particular, there is a need
to define a broader range of metrics to measure access more holistically (beyond utilization alone) and
allow greater comparability of outcomes across countries. There is also a need for consistent definitions
of disability to be used, in order to allow comparability across studies.
UHC strives to achieve health for all, leaving nobody behind, and without more inclusive
indicators, we will not be able to monitor progress towards this target. Although the results were
varied, this review found supporting evidence that people with disabilities are being left behind on the
path towards UHC. Consequently, efforts are needed to remove barriers so that access to healthcare
services is made equitable for people with disabilities. The right to healthcare and rehabilitation
for people with disabilities is enshrined within the UNCRPD, and within the laws and policies of
most countries [3]. More efforts are therefore needed to make changes at the levels of services and
programmes, rather than at the policy level. Yet currently evidence on the effectiveness of interventions
that work towards achieving these changes is limited [72,73].
Some examples of good practice for achieving improvements in the dimensions of UHC exist
from LMIC. Considering financial coverage, in Vietnam, some people with disabilities who are
recipients of a Disability Allowance also receive free health insurance, which may help achieve
financial protection [68]. As another example, in India a 3-year programme between 2009–2011
“Inclusion for All” was initiated by World Vision to increase awareness of HIV/AIDS amongst people
with disabilities and resulted in a positive change in attitude towards people with disability in the
community [74].
4.3. Strengths and Limitations of the Review

This review has several limitations that need to be taken in to account when considering the results.
The definition of access we adopted may not have captured all of the commonly cited dimensions of
access–affordability, acceptability, availability, and accessibility [75]. The indicators in this review may
not sufficiently capture the additional complexities that people with disabilities may face in seeking
and receiving health care of high quality. Our primary interest was receipt of health care, and using this
approach we may have missed details about the quality and effectiveness of care received. Although
we extracted data on barriers and quality as secondary outcomes, qualitative evidence may be able to
provide a more in-depth analysis of these aspects of access. Barriers to access such as lack or cost of
transport may play a more crucial role in access to health for people with disabilities than insurance
coverage. Particularly as insurance may not cover all required services. The review was unable to
examine in depth the influence that health financing, or health system performance has on access to
health for people with disabilities. The outcomes were too varied to allow meaningful comparisons to
be made. Further, the review found a trend for higher utilisation for people with disabilities, which
is not unexpected given that people with disabilities tend to have greater health needs than people
without disabilities. However, we have not captured information in this review about the availability
of health services, from the health systems perspective—i.e., the types of services offered to people with
disabilities and ability of the health workforce to meet population need. These factors are important to
ensuring equitable access to health services for people with disabilities. The mixed results found in
this study may underestimate the differences in access to health from an equity perspective.
The searches were conducted in the English language and thus publications not in the English
language may have been missed. Further, as 30% of publications were conducted in sub-Saharan
Africa, our results may have a bias towards the conditions in these countries. 54% of studies in
this review were judged to have a low risk of bias, with the remaining having high or moderate
risk of bias. When interpreting the findings of this review, this must be taken in to consideration.
Finally, as we focused on peer-reviewed empirical evidence, our review may have missed relevant
information on access from grey literature sources. This review also has several strengths. The review
followed PRISMA guidance, adopting a thorough approach to screening, data extraction and analysis
of the results.
5. Conclusions
This review summarises the available literature on access to general healthcare services for people
with disabilities in LMIC. Although 50 studies were included in the review, the wide range of outcomes
and methods for measuring disability made it difficult to draw strong conclusions. Developing
common metrics for measuring disability and healthcare access, will improve the availability of high
quality, comparable data. Providing good access to health for people with disabilities will ensure
that their rights are met and help in achieving good health. This will also help in efforts towards
achievement of UHC—by ensuring that healthcare services reach the whole population, so that they
can experience better health, better productivity, and less poverty.
Supplementary Materials: The following are available online at http://www.mdpi.com/1660-4601/15/9/1879/

s1, File S1: EMBASE search strategy, File S2: Data Extraction, File S3: Quality review results
Author Contributions: Conceptualization, T.B. and H.K.; Methodology, T.B. and H.K.; Formal Analysis, T.B.;
Data Curation, T.B.; Writing-Original Draft Preparation, T.B.; Writing-Review & Editing, T.B. and H.K.; Funding
Acquisition, H.K.
Funding: This research was funded by CBM International grant number ITCRZK1810. The funders had no role in
the design of the study, data extraction, analysis, interpretation or writing of the report.
Acknowledgments: The authors are grateful to Letitia Pancieri for her assistance with data extraction for
Portuguese articles.
Conflicts of Interest: The authors declare no conflict of interest
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2. Materials and Methods

2.1. Eligibility Criteria

2.1.1. Types of Access Measures

2.1.2. Types of Disability Measures

2.2. Information Sources

2.3. Study Selection

2.4. Data Extraction and Analysis

2.5. Risk of Bias in Individual Studies

Table 1. Quality assessment criteria and ratings.

Assessment Criteria by Study Design

• Study design, sampling method is appropriate to the study question

Assessment Criteria by Study Design

• Cases and controls are comparable

Cohort (additional criteria)

• Groups being studied are comparable at baseline

Records identified through database Additional records identified

Records screened after duplicates removed

Full-text articles assessed for Full-text articles excluded, with

Figure 1. Flow chart of search results.

3.1. Study Characteristics

Table 2. Characteristics of included studies.

Variable Category No. %

3.3. Outcome Types

3.4. Risk of Bias within Studies

3.5. Description of Findings Related to Healthcare Access

Higher Lower Mixed Null difference

Figure 2. Results by outcome type.

• Primary or secondary health services (13 studies)

# Hospitalisations (inpatient admission) in the past 5 years (1 study); 12 months (7 studies),

Utilisation: Primary or Secondary Service Use

Age Group of Time Period (Months)

Age Group of Time Period (Months)

• Care seeking when ill (over varying time periods) (9 studies)

Age Group of Time Period (Months)

Age Group of Time Period (Months)

Care Seeking When Ill

Coverage of Specific Services

Table 5. Summary of studies measuring coverage.

Age Group of People with People without

Age Group of People with People without

Age Group of People with People without

Table 6. Results of studies measuring adherence.

3.5.4. Health Expenditure

3.5.5. Health Insurance Coverage

Table 7. Results of studies measuring insurance and expenditure.

3.5.6. Barriers to Access

Table 8. Barriers to accessing health services reported in included studies.

World report on Disability (2011) [1]

Danquah et al. (2015) [16]

Marella et al. (2016) [52]

Murthy et al. (2014) [33]

Rahim et al. (2014) [40]

Eide et al. (2015) [51]

3.5.7. Quality of Services

4.1. Overview of Results

4.2. Consistency with Previous Literature

4.3. Strengths and Limitations of the Review

Supplementary Materials: The following are available online at http://www.mdpi.com/1660-4601/15/9/1879/

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