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There is growing evidence showing that people with disabilities face more frequently socioeconomic inequities than their non-disabled peers. This study aims to examine to what extent socioeconomic consequences of disability contribute to poorer access to sexual and reproductive health (SRH) services for Cameroonian with disabilities and how these outcomes vary with disabilities characteristics and gender. It uses data from a population-based survey conducted in 2015 in Yaounde, Cameroon. Mediation analysis was performed to determine how much of the total association between disability and the use, satisfaction and difficulties to access SRH services was mediated by education level, material wellbeing lifetime work participation and availability of social support. Overall, disability was associated with deprivation for all socioeconomic factors assessed though significant variation with the nature and severity of the functional limitations was observed. Lower education level and restricted lifetime work mediated a large part of the association between disability and lower use of HIV testing and of family planning. By contrast, while people with disabilities reported more difficulties to use a SRH service, no mediating was identified. In conclusion, Cameroonians with disabilities since childhood have restricted access to SRH services resulting from socioeconomic factors occurring early during the life-course.
This population-based cross-sectional study took place in Yaoundé between 2 October 2014 and 30 November 2015. A multistage sampling strategy was used to randomly select people with disabilities and matched controls from households of the general population (Appendix A). All people aged 15 to 49 years with severe difficulties in at least one domain or with some difficulties in at least two domains of the Washington Group Short Set (WGSS) questionnaire for ≥12 months were considered as living with disabilities and eligible for the study [31]. This tool includes a small number of questions covering six functional domains or basic actions: seeing, hearing, walking, cognition, self-care and communication. Each question asks the respondent to rate on a four-point scale how much difficulty he/she has experienced in the domain (Appendix B). For each person with a disability included in the study, a control of similar age and sex, living in the same enumeration area but in a different household and not meeting the functional limitation criteria was recruited. For this analysis, the study population was restricted to participants with physical and/or sensory (visual and hearing) difficulties that occurred before the age of 10 years (and their matched controls) in order to ensure a chronological sequencing of disability and of the potential mediating factors assessed. Face-to-face structured interviews were conducted at the home of the eligible subjects to collect data on their life-course history of employment, resources, sexual partnership and fertility using the life-grid method [32], on their activity limitations, on their knowledge on HIV and family planning and on their use of family planning, HIV testing and main other SRH services (maternal services, sexually transmitted infection testing and treatment services, gynaecological and urological consultations). Details of the survey methods and procedures have been described elsewhere and the life-grid method is presented in Appendix C [33,34]. Different aspects of access to SRH services (use, coverage, satisfaction and reported barriers) were considered in this analysis and were explored through the analysis of the following four outcomes: (1) use of maternal care, (2) satisfaction and difficulties to access SRH services, (3) use of modern methods of family planning (oral or injectable contraceptives, implants, male and female condoms, male or female sterilization), (4) use of HIV testing services. Use of maternal care included the use of antenatal visit and/or maternal care for giving birth and/or post-delivery care and was assessed among women who ever get pregnant. Satisfaction with SRH services was measured by asking participants to report if they experienced any difficulty the last time they used or wanted to use a SRH service and to rate with a visual scale their satisfaction with this service. The nature of the difficulties was assessed using open questions in order to not influence the participant response but responses were collected using a list of pre-determined items for better standardization. Use of family planning and HIV testing was assessed among sexual experienced participants. Conditional logistic regression was used to compare binary outcomes between people with disabilities and those without, overall and by subgroups defined by sex, the nature of the main activity limitation(s) (physical/visual/hearing) and its severity (mild versus severe or total). Mediation analysis was conducted to determine how much of the total association between the different outcomes and disability was mediated by unfavourable socioeconomic condition. The following potential mediators reflecting different aspects of the “multidimensional” poverty were considered; education level, lifetime work participation, household material wellbeing and availability of support from the social network [35]. Lifetime work participation was the proportion of the lifetime since the age of 10 years during which the participant was working or studying. A broad definition of work was used that included domestic and informal work. Household material wellbeing was measured by an index computed from household assets using the principal component analysis [36]. Availability of social support from the personal social network was measured by the number of people close to the participant who could provide support. The decomposition of the association between disability and SRH services access outcomes into indirect (i.e., mediated by unfavourable socioeconomic condition) and direct (not mediated) effects was conducted using structural modelling to account for the sequential ordering of the mediators (Figure 1). First, the total association between disability and each SRH service access outcome was estimated using a logistic regression adjusted for age, sex and childhood socioeconomic condition. Reported experience of insufficient food and poor housing at the age of 10 years old and of not having been raised by both parents were used as surrogate measures for unfavourable socioeconomic condition during childhood. Then, the association between each SRH services access outcome and the mediating factors was assessed using logistic regression adjusted for the same factors (i.e., age, sex and childhood socioeconomic condition). Of the potential mediators, only those significantly associated with disability and with the outcome were included in the subsequent mediation analysis. In the third step, the association between the mediating factors and disability status was modelled and, then, used to estimate the direct effect of disability on the SRH service access outcome using logistic regression with inverse probability weighting (IPW) [37,38,39]. With this method, observations are weighted by the inverse of the predicted probability of disability conditional on mediating factors and adjustment factors, so that disability and mediating factors become independent. The indirect effect of the mediators was assessed in a sequentially ordered manner to account for the life-course structure of the data and post-treatment confounding assumptions [38]. Because the education level could affect the other mediating factors (work, material wellbeing and social support), it was considered as the distal factors on the pathway between disability and outcomes (Figure 1) [13,40]. Social support and material wellbeing were considered as proximal mediating factors and lifetime work participation was in between. The sequential approach allows a decomposition of the total indirect effect into the indirect effect mediated through the most distal mediating factors (e.g., education level), the remaining indirect effect mediated the next proximal mediating factor (e.g., lifetime work participation) and so forth. Confidence intervals were computed using the bootstrap method with 1000 samples. Because of the limited sample size, it was only possible to perform the mediation analysis with the overall study population and not by subgroup. Data analysis was performed using R and statistical was set to 5% [41]. Conceptual model for direct and indirect pathways between disability and access to sexual and reproductive health (SRH) services. All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki and the protocol was approved by the “Comité d’Ethique pour la Recherche en Santé Humaine” in Cameroon (project identification code: 2014/03/431/L/CNERSH/SP) and “Comité Consultatif de Déontologie et d’Ethique” from the Institut de Recherche pour le Développement.
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