Social Science & Medicine 73 (2011) 1477e1489

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Access to health care, reproductive health and disability: A large scale survey
in Sierra Leone
Jean-Francois Trania, b, *, Joyce Browneb, Maria Kettb, Osman Bahc, Teddy Morlaic,
Nicki Baileyb, Nora Groceb
a
Brown School of Social Work, One Brookings Drive, CB 1196, Washington University, St. Louis, MO 63130, USA
b
Leonard Cheshire Disability and Inclusive Development Centre, Department of Epidemiology and Public Health, University College London, 4 Taviton Street,
London WC1H 0BT, United Kingdom
c
Leonard Cheshire Disability, West Africa Regional Office, Sierra Leone

a r t i c l e i n f o a b s t r a c t

Article history: This is the first study to compare health status and access to health care services between disabled and
Available online 29 September 2011 non-disabled men and women in urban and peri-urban areas of Sierra Leone. It pays particular attention
to access to reproductive health care services and maternal health care for disabled women. A cross-
Keywords: sectional study was conducted in 2009 in 5 districts of Sierra Leone, randomly selecting 17 clusters for
Sierra Leone a total sample of 425 households. All adults who were identified as being disabled, as well as a control
Disability
group of randomly selected non-disabled adults, were interviewed about health and reproductive health.
Health care access
As expected, we showed that people with severe disabilities had less access to public health care services
Maternal health care
Reproductive health
than non-disabled people after adjustment for other socioeconomic characteristics (bivariate modelling).
However, there were no significant differences in reporting use of contraception between disabled and
non-disabled people; contrary to expectations, women with disabilities were as likely to report access to
maternal health care services as did non-disabled women. Rather than disability, it is socioeconomic
inequality that governs access to such services. We also found that disabled women were as likely as
non-disabled women to report having children and to desiring another child: they are not only sexually
active, but also need access to reproductive health services. We conclude that disparity in access to
government-supported health care facilities constitutes a major and persisting health inequity between
persons with and without disabilities in Sierra Leone. Ensuring equal access will require further
strengthening of the country’s health care system. Furthermore, because the morbidity and mortality
rates of pregnant women are persistently high in Sierra Leone, assessing the quality of services received
is an important priority for future research.
Ó 2011 Elsevier Ltd. All rights reserved.

Introduction maternal health services. General concern for slow progress in

The principle of equal access to health services stated in Article
25 of the United Nations Convention on the Rights of Persons with
Disabilities (CRPD) will not be achieved unless the general health
needs of disabled women and men in low income countries are
met. Nor will targets for Millennium Development Goals 4 on
gender equality or Millennium Development Goal 5 on maternal
health be achieved unless disabled women attain equal access to
* Corresponding author. Leonard Cheshire Disability and Inclusive Development
Centre, Department of Epidemiology and Public Health, University College London,
4 Taviton Street, London WC1H 0BT, United Kingdom. Tel.: þ44 0 20 7679 4886;
fax: þ44 0 20 7388 2291.
E-mail addresses: j.trani@ucl.ac.uk, jftrani@yahoo.fr (J.-F. Trani).
improving child and maternal health (Victora, Black, & Bryce, 2007)
is compounded when considering the situation of children and
women with disabilities. To date, the health of persons with disa-
bilities in developing countries has been neglected by literature,
and this is particularly true in post-conflict situations. The focus on
sexual and reproductive health, access to maternal health services,
and other obstetric outcomes for women with disabilities are rarely
studied due to assumptions that disabled women are not sexual
active and do not desire children (Groce & Trasi, 2004; UNDP,
2009).
Research on poverty and health focuses on the link between
poverty and vulnerability in general (Bornemisza, Ranson, Poletti, &
Sondorp, 2010; Patouillard, Goodman, Hanson, & Mills, 2007). This
literature shows inequalities in both access to general health care

0277-9536/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2011.08.040
1478 J.-F. Trani et al. / Social Science & Medicine 73 (2011) 1477e1489
and specifically to maternal health services where poverty has been
identified as a major cause for exclusion from antenatal and
maternal health services and is linked to higher maternal mortality
(Graham, Fitzmaurice, Bell, & Cairns, 2004; Houweling, Ronsmans,
Campbell, & Kunst, 2007; Victora et al., 2007). This is relevant to
persons with disabilities, who as a group, tend to be dispropor-
tionately poor.
If poverty is a major cause for exclusion from health services,
then being disabled compounds this exclusion. Much of the pub-
lished evidence suggests that socioeconomic circumstances of
persons with disabilities are often significantly worse than that of
the rest of the population and access to services more limited, even
where poverty is widespread throughout the entire community
(Elwan, 1999; Yeo & Moore, 2003). Indeed persons with disabilities
are more likely to be poor and unemployed, have less education,
live in rural areas, and have less access to health care facilities than
their non-disabled peers (Bremer, Cockburn, & Ruth, 2009; Filmer,
2008; Smith, Murray, Yousafzai, & Saonka, 2004; Stein, Stein, Weiss,
& Lang, 2009).
Only a tiny number of studies have looked at issues of access to
general and reproductive health care for persons with disabilities,
and even fewer have paid attention to maternal and child health
care, and differential access to such services by disabled and non-
disabled women (Becker, Stuifbergen, & Tinkle, 1997; Bremer
et al., 2009; Collins, Geller, Miller, Toro, & Susser, 2001; Gaskins,
1999; Groce, 2003; Trani, Bakhshi, Noor, Lopez, & Mashkoor,
2010; UNFPA, 2007; WHO & UNFPA, 2009).
Of the 179 countries assessed, Sierra Leone ranked lowest
overall in the Human Development Index in 2008 (UNDP, 2009); it
ranks 128th among 135 countries for which a Human Poverty Index
has been calculated (UNDP, 2009). The proportion of the population
below the poverty line of 1.25 USD per day is estimated at 47.7 per
cent. The country has recently emerged from a brutal decade-long
civil war during which civilians were victims of widespread
violence, including amputation of body parts, rape, and forced
labour (Ferme, 2001; Gberie, 2005; Mazurana & Carson, 2004).
Sexual and gender based violence was widespread during the
conflict and has continued to a lesser extent in the post-conflict
period (World Bank, 2009).
As a result of the conflict, the health care system, immunisations
and prevention of childhood illnesses programmes, as well as
systems to ensure access to food supplies, clean water, and basic
sanitation, were largely disrupted. Health indicators for Sierra
Leone reflect the impact of this decade of conflict: life expectancy at
birth is 39 years old for men and 42 years for women, while
maternal mortality rate (MMR) reaches 2000/100,000 live births
(UNICEF, 2005). It is estimated that 282 per thousand children die
before their 5th birthday e one of the highest rates in the world
(World Health Organization, 2006). A major cause of infant
mortality is malnutrition, though acute respiratory infections,
pneumonia, diarrhoeal diseases, typhoid fever, HIV/AIDS, and
tuberculosis are the other major causes of morbidity and mortality
(World Health Organization, 2007). Access to basic resources e safe
drinking water, improved sanitation and efficient health care
services e continues to be the most pressing priorities for the
health sector.
In light of these worrying statistics, the health status of persons
with disabilities is of particular concern. Yet even identifying the
disabled population is difficult: reported rates of disability within
Sierra Leone show considerable discrepancies, reflecting differences
in data collection, accuracy, and definition of disability. According to
the national census, 2.4% of the population is disabled, with the most
frequently reported impairment being the limited function of legs
(21%), visual impairments (19%), and blindness (7%). Only 9.5% of
persons with disabilities reported they were disabled as a direct
consequence of the war, however this still constitutes one in every
ten disabled people nationwide, a significant subgroup within the
larger disabled population (Statistics Sierra Leone, 2004). However,
the UNICEF Multiple Index Cluster Survey (MICS) found a disability
prevalence among children of 23% (Statistics Sierra Leone & UNICEF,
2007). There is also a strong regional difference in the prevalence of
disability reported e varying from 14% in the Western region to 37%
in the Southern region (Statistics Sierra Leone & UNICEF, 2007).
To address the important gap in the literature about the health
of disabled people, our study examined health status and access to
health services for persons with disabilities, with a particular focus
on access to maternal health services for women with disabilities,
in comparison to non-disabled members of the same community.
Our key question was how women and men with disabilities fare in
a society characterised by extreme poverty, limited resources, and
a potentially overwhelming set of competing development
demands.
Methodology
Study design and sampling
A cross-sectional study was conducted in 5 urban and peri-urban
districts of Sierra Leone representing all 4 provinces of the country:
an urban area (Freetown) and rural districts in Western province,
Koinadugu, and Bombali districts in Northern province, Bo district in
Southern province, and Kono district in Eastern province. It was
calculated that a sample of approximately 25 eligible households
from each of 17 clusters would be required to identify a represen-
tative sample of persons with disabilities, assuming a disability
prevalence of 5%, with a statistical power of 90%, a significance level
of 95%, and an estimated design effect of 2.5.
The first stage in the sampling was at the district-level. The
district population frame was determined by using data from the
2004 census. For the second stage of sampling, 2 villages or neigh-
bourhoods from each of the 5 district-level clusters were randomly
selected, except in Freetown where 3 clusters were selected to
account for the larger population size. For the third sampling stage,
approximately 25 households were randomly selected from each
village or neighbourhood for a total sample of 425 households
(Fig. 1). We interviewed disabled respondents as well as a control
group of 235 randomly selected non-disabled adults in the same
households and in households in the same community with no
disabled people living in them. If willing to participate, respondents
provided written or verbal consent. The rate of refusal was very
low (0.2%).
Variables and instruments
Socioeconomic (questionnaire module 1) and disability infor-
mation (module 2) was collected in each household by interview-
ing all 424 heads of household. Based on the International
Classification of Functioning, Disability and Health (ICF) (WHO,
2001) as well as the Capability Approach (Sen, 1995, 1999),
disability was defined as the interaction between an individual’s
restriction or lack of ability to perform everyday activities due to an
impairment in functioning within the environment in which that
person lives and the community and social resources, beliefs, and
practices that enable or prevent a person from participating in all
spheres of social life and taking decisions that are relevant to their
own future. The survey tool was based on a 27-items disability
screening tool using the ICF and previously developed and tested in
Afghanistan, another low-resource and conflict setting (Trani &
Bakhshi, 2008). This questionnaire was expanded to 35 items and
refined using a four-level Likert-type scale 1 ¼ no, never; 2 ¼ yes,
 J.-F. Trani et al. / Social Science & Medicine 73 (2011) 1477e1489 1479

Sierra Leone
Population: 6.440.053 (2004 census)
Administrative organisation: 4 provinces, 13 districts
Nationally representative random selection of
enumeration areas (EA)
Probability proportional to size random selection of
clusters within each EA
17 clusters selected from all 4 provinces:

Western province:
- Western Area Urban (Freetown): 1,173,022 (3 clusters)
- Western Area Rural: 174,249 (2 clusters)

Northern province:
- Koinadugu district: 265,765 (2 clusters)
- Bombali district: 424,100 (3 clusters)

Southern province:
- Bo district: 515,945 (4 clusters)

Eastern province:
- Kono districht 408.390 (3 clusters)

Random selection of 25 households in each

cluster

425 households randomly selected,

2190 individuals
Heads of household interviewed with modules 1 and 2 of
the questionnaire

931 children not eligible for interview

because the study focused on adults with
disabilities for access to maternal health

1259 adults screened for disability (module 2)

833 non-disabled individuals not
selected for the interview.
1 refusal to be interviewed
424 individuals interviewed with modules 3 to 7:
189 respondents with disabilities
235 non-disabled respondents randomly selected in same
households and in household where no one has been
identified as being disabled

189 men in sample were not included for the

maternal health care analysis.

235 women included in maternal health analysis:

- 102 women with disabilities
- 133 non-disabled women

135 women without a disability no disability 100 women with a disability

1

Fig. 1. Flow chart of sample selection approximately here.

sometimes; 3 ¼ yes, often; and 4 ¼ yes, constantly/always, then
adapted and tested for internal consistency in Sierra Leone (Cron-
bach’s a ¼ 0.85). Six types of disabilities were screened for: motor
or physical disabilities, sensory disabilities, learning and develop-
mental disabilities, behavioural disabilities mood and affect
disabilities and neurological disabilities. 189 disabled adults over 18
who scored positive (response either ‘2’, ‘3’ or ‘4’) on any of the 35
screening questions were all selected for interview.
Besides modules 1 and 2, we used a questionnaire comprising of
the following modules: 3- education; 4- health, reproductive health
and access to sanitation; 5- employment; 6- livelihoods and 7-
social participation. Preliminary household and community survey
instruments were designed based on existing questionnaires,
tested and validated in-country, literature reviews of existing
health studies, and input from local advisors. The instruments were
refined based on focus group discussions, input from key infor-
mants and pre-tests. Survey data were collected in June and July
2009 by 4 trained local enumerators and 2 supervisors, all of whom
had completed high school and were fluent in local languages of
Krio or Mende. The study was granted ethics approval by University
College London Research Ethics Committee.
Data analysis
We assessed the health situation of persons with disabilities with
a particular focus on access to maternal health services in Sierra
1480 J.-F. Trani et al. / Social Science & Medicine 73 (2011) 1477e1489
Leone. We controlled for factors shown to be independently asso-
ciated with disability, such as maternal health services and obstetric
history, desirability of pregnancy, location of habitation and ease of
access to health services. For example, in Kenya, (Magadi, Madise, &
Rodrigues, 2000) identified desirability of pregnancy, living in rural
area and living away from the health facility, being unmarried,
younger expectant mothers (<20 years) and being from a lower
socioeconomic status to be correlated with smaller frequency of
antenatal visits. Gyimah, Takyi, and Addai, (2006) looked at the
influence of religion on maternal health use in Ghana and found that
Muslim women and those from Traditional religion were less likely
than Christian women to make use of maternal health services. In
Mali utilisation of maternal health services was found to be influ-
enced by lack of transport and distance, the practices of other
women living in the vicinity, household poverty and existence of
personal problems (Gage, 2007). In Burkina Faso, an important
positive effect in access was found, especially among poor women,
after the integration of maternal health services into primary health
care services, highlighting the importance of close proximity
(Brazier et al., 2009).
In absence of any established cut-offs and any gold standard, we
used frequency of occurrence of items to elaborate an overall
prevalence score of disability. No sign of disability corresponds to
absence of positive answers to any of the 35 items (82.88% of the
total sample); ‘mild’ level of disability is reflected by one answer
“Yes, sometimes” to any of the 35 items (7.40%); ‘moderate’
disability when the respondent gave between 2 and 3 answers “Yes,
sometimes” or 1 answer “Yes, often” (5.25%); ‘severe’ more than 3
answers “Yes sometimes” or between 1 and 3 answers “Yes, often”
(2.05%) and very severe at least 1 answer “Yes constantly, always”
or more than 3 answers “Yes, often” (7.42%).
To check for robustness, we alternatively classified responses to
items according to the number of positive answers within each of
the six dimensions defined above and obtained a similar prevalence
score. Sensitivity analyses using this second categorisation yielded
similar findings. We regrouped the disability score in three cate-
gories: (1) no disability, (2) mild/moderate and (3) severe/very
severe disability. For purpose of simplicity, we will refer to (1) no
disability, (2) mild disability and (3) severe disability in the analysis.
We intended to identify to what extent the latter group is vulner-
able e i.e. more susceptible than the general population e to risk
factors that lead to poor health outcomes (Wagman, 2008).
We examined associations with self-reported health, access to
public and private health care facilities, food intake and access to
managed source of water and sanitation, use of contraception,
access to maternal health services, number of children and desire
for another child using binomial and one multinomial logistic
regression (for number of children). Self-reported health is
considered as a good appraisal of subjective health status, is widely
used and is sensitive to socioeconomic factors such as income and
social class (Chandola, Bartely, Wiggins, Schofield, 2003; Furnée
and Pfann, 2010).
Particular attention was paid to exploring associations between
disability, and other demographic and socioeconomic variables and
outcomes (use of contraception, access to obstetric health care,
number of children and women’s desire to have another child).
Four dimensions of maternal health services are included in the
‘access to obstetric health care’ outcome: antenatal care, presence
of a trained birth attendant at delivery, delivery in a hospital or
other health care facility, and the perceived availability of emer-
gency obstetric care. Number of children is widely used in research
to assess women’s obstetric history (Bekker & Dukel, 2005).
We adjusted for gender (except for maternal health care and
obstetric outcome models), severity of disability, age, marital status,
residence, education level, employment status (people who were
active on the either informal or formal labour market) and wealth
status. To assess the associated effects of gender, education and
employment with disability on various health outcomes, we intro-
duced three interaction terms for adult models (gender  severity of
disability, level of education  severity of disability and employment
status  severity of disability), using the last two terms only for the
models on women. We attempted to assess the combined effect of
being a woman and having a disability, being educated and being
economically active, on health and access to maternal health care.
This is consistent with existing literature that shows that disability
associated with other factors of low socioeconomic background
results in social exclusion and poverty (Groce, kett, Lang, Trani, 2011;
World Health Organization & World Bank, 2011; Yeo & Moore, 2003).
An asset index was calculated as a proxy of wealth status using
principal-components analysis. Three groups of asset levels were
derived from the first factor of the analysis (Filmer & Pritchett,
2001). This index is composed of 14 indicators referring to house-
hold or individual items (radio, television, video, mobile phone,
pots and pans, refrigerator, bed net, bicycle, motorbike, car, tractor,
generator, lamp, sewing machine). The analysis was carried out
using STATA 11. All statistical inferences were based on a 0.05
significance level and we adjusted for cluster effect using the Huber
White sandwich estimator.
Results
Table 1 summarises socioeconomic characteristics as well as
primary health and maternal health indicators comparing disabled
and non-disabled people by severity of impairment. We found
a disability prevalence of 17.12%, of which 12.65% scored mild to
moderate on the disability screening tool, and 4.47% scored severe/
very severe.
Socioeconomic characteristics
There is strong evidence (p < 0.0001) that a higher proportion of
people with severe disabilities was below 30 years of age (49.25%,)
and was single (46.27%,) compared to non-disabled people
(respectively 36.06% and 23.42%). A higher proportion of severely
disabled people than non-disabled people lived in urban areas
(p < 0.001). A slightly higher proportion of non-disabled (45.64%)
than disabled (44.78%, p ¼ 0.001) respondents never went to
school. Finally, a higher proportion of respondents with severe
disability (31.34%) than non-disabled respondents (36.12%,
p ¼ 0.019) belong to the lowest asset index group.
Health and reproductive health characteristics
The results show that 73.13% of respondents with severe disabil-
ities describe themselves as being in good or rather good health
compared to 89.11% of non-disabled respondents (p < 0.0001).
Public health efforts also reveal an interesting pattern. Generally
the level of immunisation is high, although relatively lower for
people with severe disabilities (74.63% compared to 88.14% for non-
disabled people; p ¼ 0.003). Comparable numbers of disabled and
non-disabled people reported having access to safe drinking water
(88%), but access to a managed water supply (pipe or hand pump)
was slightly lower amongst people with severe disabilities (53.73%
verses 58.46% for non-disabled or mild disabled; p ¼ 0.003).
Level of satisfaction with health care received is quite high:
80.6% of respondents with severe disabilities declared they were
satisfied or rather satisfied with health care services in Sierra Leone,
compared with 93.74% of non-disabled respondents (p < 0.0001).
In fact, some health indicators are surprisingly positive. 70.15% of all
disabled respondents and 85.07% of non-disabled respondents said
 J.-F. Trani et al. / Social Science & Medicine 73 (2011) 1477e1489
they could access a hospital in case of accident, injury or health
problem (p ¼ 0.001).
Persons with disabilities were more likely to use medication found
in street markets (p ¼ 0.011) and to try religious cures/prayers
(p < 0.0001) as part of their medical treatment. Average annual
individual health expenses represent a relatively high level of
household income: 4.2% for persons with severe disabilities and about
3% for non-disabled people. If we consider an average of 5 people per
household, health expenses present a significant burden for most
families, particularly if only one or two members are working.
Other indicators raise greater concern. Almost one third of
respondents, whether disabled or not, reported eating only one
meal a day. Although disabled people had greater access to flush
toilets, rates for all members of the community were low. Over half
of all respondents did not know where to go for an HIV test.
Finally, in terms of reproductive health, almost all non-disabled
adults (91.63%) reported being sexually active within the past year.
While these rates were lower for disabled individuals, it is note-
worthy that 58.21% of all persons with severe disabilities and
70.63% of all adults with mild disabilities reported being sexually
active. This contradicts common belief among the general public
and common assumptions within the medical and public health
circles, that persons with disabilities are not sexually active and
therefore in little need of sexual or reproductive health services
(WHO & UNFPA, 2009).
Questions on access to maternal health services were asked of
all women who had been pregnant in the past five years (n ¼ 119)
(Table 1. Women who had not been pregnant in the past 5 years
were not asked these questions and account for the missing data).
Access to antenatal care was reported by almost 90% of the total
selected sample and was slightly higher for those with a disability.
Almost an equally high proportion of women reported having had
a skilled birth attendant present during labour. Delivery in a clinic
or hospital was reported as being accessible to about 79% of the
total population, and there was no significant difference between
women with and without disability. Almost 75% of respondents,
both with and without disability reported having access to emer-
gency obstetric care in case of emergency. In total, 62% of respon-
dents reported having access to all four services. Access was found
to be higher in the group of women with disabilities compared to
women without disabilities. 30% of women with disabilities and
40% of those without reported incomplete access, with one or more
of the above services not available to them.
Contraception use is low throughout the population, with 67.3%
of the non-disabled respondents and 71% of persons with disabil-
ities reporting that they did not use any form of contraception
(p ¼ 0.733).
Adults with severe disabilities also reported being considerably
less knowledgeable about sex. When asked ‘who informed you about
sex?’ 38.81% of adults with severe disabilities reported never having
received any basic information, compared to 28.26% of non-disabled
individuals. Non-disabled respondents and individuals with mild
disabilities reported similar patterns of gaining information about
sex through the media. Interestingly, families were more likely to
provide sex education to disabled members than non-disabled
members, but the numbers were not high in either case. It was re-
ported that severely disabled adults were more likely than other
adults to be informed about sex by a teacher e 10.46% versus 7% e
with mild/moderate disabled respondents reporting only 5.56%.
Also interestingly, women with mild disabilities were more likely
to have large families with 4 or more children than either non-
disabled women or women with severe disabilities (p < 0.0001).
However, 23.89% of women with severe disabilities also had 4 or
more children, and 62.69% had at least one child. Finally, 55.63% of
all disabled women reported wanting another child.
1481
Multivariable models
Health and access to health care services
The association between self-reported health and socioeco-
nomic characteristics was also investigated (Table 2). In both
adjusted and unadjusted models, we found that people with
disabilities were more likely to declare being in poor health than
non-disabled people (model 1). In the adjusted model, people with
mild or severe disability were respectively 3.4 (95% confidence
interval, CI: 1.9e6.0) and 4.8 (95% CI: 0.8e27.3) times more likely to
declare being in poor health than non-disabled people were. There
was an extremely interesting exception however: people with
severe disabilities who worked were more likely to report being in
good health (OR 0.15 95% CI: 0.02e1.08). Similarly, more educated,
wealthier, younger and single respondents also reported higher
levels of perceived good health.
We also enquired about access to public health care services in
times of illness (health centres and hospitals, Model 2) and private
health care facilities (private clinics and doctors, Model 3). The
perceived access to public services varied significantly according to
age group, severity of impairment, and level of education. People
with mild or severe disability reported being less likely to access
public health care services than non-disabled people. It is of note
that people with severe disability working used more public health
care facilities but were less likely to use private facilities. Educated
and wealthy respondents, disabled or not, also used more private
facilities when health care was needed.
Health and well-being
In addition to access to health care, questions regarding access
to food, clean water and basic sanitation were also asked in an
attempt to identify factors related to health and well-being. Models
4 and 5 in Table 3 show the association between food intake and
access to a managed water source (pipe or pump) with the same
socioeconomic characteristics of respondents as in the previous
three models. Interestingly, non-disabled women were less likely to
eat three meals a day than non-disabled men. However this was the
opposite for women with disabilities compared to non-disabled
men. We found that poorest people were more likely to have an
insufficient daily food intake and rely on unmanaged water source.
Use of contraception
Model 6 in Table 4 reports the relationship between use of
modern contraception and socioeconomic characteristics. Young,
unmarried wealthier, and educated people were more likely to use
modern contraception whereas people living further away from the
urban areas, married and older people were less likely to use it.
Access to maternal health care services
Model 7 in Table 4 shows no significant difference between
disabled and non-disabled women in accessing these maternal
health care services. Yet, interestingly educated women with
disabilities reported lower access to maternal health care services
than uneducated non-disabled women. All women informed about
sexuality and those in the wealthiest group unsurprisingly reported
higher access to all maternal health care services. These findings
reflect a pattern of inequality in access to care linked to wealth
rather than impairment.
Obstetric outcome: number of children and desire for another child
Because research on family planning amongst persons with
disabilities has been sparse, particular attention was paid in this
study to asking disabled women about the number of pregnancies
they have had, the number of live births, the number of children
they now have and whether they would like additional children in
1482 J.-F. Trani et al. / Social Science & Medicine 73 (2011) 1477e1489

Table 1
Descriptive data surrounding health and level of disability in Sierra Leone based on random sample of N ¼ 2190 Households.

Non-disabled Mild/moderate Severe/very severe Total P value

disability disability

N Percent N Percent N Percent N Percent

Prevalence in total sample (n ¼ 2190) 1815 82.88% 277 12.65% 98 4.47%
Proportion of Households with a person 581 26.53% 1609 73.47%
with disabilities
Socioeconomic characteristics
(in sub-sample, n ¼ 424)
Gender (n ¼ 423)
Male 101 43.16% 53 43.44% 34 50.75% 188 43.31% 0.46
Female 133 56.84% 69 56.56% 33 49.25% 235 56.69%
Age groups (n ¼ 423)
18e29 84 36.06% 27 22.22% 32 49.25% 147 35.60% p < 0.0001
30e39 76 32.39% 19 15.87% 6 8.96% 105 30.42%
40e49 32 13.85% 20 16.67% 7 11.94% 62 13.97%
50> 41 17.7% 55 45.24% 19 29.85% 109 20.01%
Marital status (n ¼ 423)
Single, never married 56 23.42% 25 19.84% 31 46.27% 112 24% p < 0.0001
Married, partner or engage 127 54.06% 58 49.21% 22 32.84% 207 52.97%
Married, polygamous 27 14.15% 16 12.7% 3 4.48% 46 13.70%
Divorced or widowed 24 8.37% 23 18.25% 11 16.42% 58 9.33%
Residence (n ¼ 424)
Urban 130 54.36% 77 64.29% 50 74.63% 257 55.77% 0.001
Rural 105 45.64% 45 35.71% 17 25.37% 167 44.23%
Province of residence (n ¼ 424)
Western province 78 29.98% 43 37.30% 24 35.82% 145 30.69% 0.455
Northern 73 33.96% 41 32.54% 21 31.34% 135 33.76%
Southern 51 22.03% 19 15.08% 13 19.40% 83 21.47%
Eastern 33 14.03% 19 15.08% 9 13.43% 61 14.08%
Education (n ¼ 424)
No school 110 45.64% 55 43.65% 30 44.78% 195 45.47% 0.004
Primary education 34 16.01% 13 10.32% 8 11.94% 55 15.48%
Secondary education 77 34.74% 40 34.92% 26 38.81% 143 34.90%
tertiary education 14 3.61% 14 11.11% 3 4.48% 31 4.15%
Asset index (n ¼ 421)
Poorest (40%) 91 36.12% 37 29.6% 21 31.35% 149 35.50% 0.019
Middle (40%) 99 44.97% 49 39.2% 33 49.25% 181 44.73%
Richest (20%) 43 18.91% 35 31.2% 13 19.4% 91 19.76%
Health Indicators
Self-reported health
Good, rather good health (n ¼ 423) 208 89.11% 90 74.6% 49 73.13% 347 87.54% p < 0.0001
Poor, rather poor health 26 10.89% 32 25.4% 18 26.87% 76 12.46%
Perception of heath care services (n ¼ 424)
Very or rather satisfied with health care 219 93.74% 102 84.12% 54 80.6% 375 92.61% p < 0.0001
Not satisfied 16 6.26% 20 15.88% 13 19.4% 49 7.39%
Access to toilet (n ¼ 424)
Access to flush toilet 30 13.06% 27 24.6% 13 19.4% 70 14.08% 0.001
Use of traditional pit, open backed or field 205 86.94% 95 75.4% 54 80.6% 354 85.92%
Access to safe drinking water (n ¼ 422)
Access 210 88.26% 108 89.6% 58 87.88% 376 88.34% 0.897
No access 25 11.74% 13 10.40% 8 12.12% 46 11.66%
Type of water supply (n ¼ 424)
Managed water supply 141 58.46% 71 59.52% 36 53.73% 248 58.36% 0.716
Unmanaged water supply 94 41.54% 51 40.48% 31 46.27% 176 41.64%
Level of immunisation (n ¼ 421) 210 88.46% 104 7.10% 50 74.63% 364 87.87% 0.003
Not immunised 24 11.54% 16 12.90% 17 25.37% 57 12.13%
Nutrition (n ¼ 424)
One meal a day 28 11.92% 19 15.08% 14 20.9% 61 12.46% 0.061
Two meals a day 138 59.24% 54 42.86% 35 52.24% 227 57.87%
Three meals a day 69 28.84% 49 42.06% 18 26.86% 136 29.67%
Access to health care (n ¼ 424)
Can get medical care 229 97.71% 113 92.86% 56 83.58% 398 96.87% p < 0.0001
Cannot get medical care 6 2.29% 9 7.14% 11 16.42% 26 3.13%
Access by type of facility
(no access not shown)
Public/community health centre (n ¼ 424) 171 72.91% 64 53.17% 35 53.73% 271 70.87% p < 0.0001
Hospital (n ¼ 424) 204 85.07% 94 77.78% 47 70.15% 345 84.03% 0.001
Private doctor 71 27.33% 26 23.81% 10 14.93% 107 26.65% 0.060
Private clinic 70 26.91% 26 23.81% 10 14.93% 106 26.27% 0.074
Pharmacy (n ¼ 423) 185 80.43% 96 79.37% 51 76.12% 332 80.25% 0.683
Street/market (n ¼ 423) 74 31.67% 50 42.86% 28 41.79% 152 32.85% 0.011
NGO (n ¼ 424) 30 9.75% 15 11.9% 8 11.94% 53 9.98% 0.637
Traditional medicine/healer (n ¼ 424) 77 33.05% 44 34.92% 20 29.85% 141 33.06% 0.775
Religious cure, prayer (n ¼ 424) 78 31.91% 52 41.27% 38 56.72% 168 33.44% p < 0.0001
 J.-F. Trani et al. / Social Science & Medicine 73 (2011) 1477e1489 1483

Table 1 (continued )

Non-disabled Mild/moderate Severe/very severe Total P value

disability disability

N Percent N Percent N Percent N Percent

Access to maternal/child health care 107 83.94% 45 83.33% 29 93.55% 181 84.23% 0.348
Antenatal visit (n ¼ 206)
(no access not shown)
Birth attended by a professional 106 83.47% 46 92.59% 29 93.55 181 84.33% 0.072
birth attendant
Delivery in hospital 99 76.03% 41 83.33% 27 87.10% 167 76.82% 0.181
Access to emergency care 98 75.68% 38 77.78% 24 80.00% 160 75.94% 0.818
Health expenditure
Total average health expenditure (in SLL) 124354.2 111405.4 173335.7 114050.5
% of total average yearly HH income 3.0 2.7 4.2 3.1
Indicator of reproductive health
Sexual activity during last year (n ¼ 424)
Sexually active 215 91.63% 86 70.63% 39 58.21% 340 89.00% p < 0.0001
Not sexually active 19 8.38% 37 29.37% 28 41.79% 84 11.00%
HIV/AIDS test(n ¼ 423)
Tested HIV 46 19.95% 23 18.25% 11 16.42% 80 19.71% p < 0.0001
Tested for other STD 11 3.7% 12 12.7% 6 8.96% 29 4.51%
Never tested 179 76.35% 84 69.05% 50 74.63% 314 75.79%
Where to go for HIV/AIDS test? (n ¼ 423)
Nowhere to go for HIV test 1 0.48% 2 1.59% 4 5.97% 7 0.76% p < 0.0001
I know where to go 106 45.53% 54 44.44% 23 35.82% 183 45.11%
I don’t know where to go 126 53.99% 65 53.97% 39 58.21% 233 54.14%
Whoever informed you about sex? (n ¼ 423)
No one 69 28.26% 36 28.57% 26 38.81% 131 0.003
Radio, TV, else 66 30.01% 38 30.16% 14 20.9% 118 29.69%
Healthcare staff 50 19.08% 24 19.05% 10 14.93% 84 18.93%
Family member 15 6.94% 11 11.9% 6 8.96% 33 7.35%
Friends 19 8.7% 6 4.76% 4 5.97% 29 8.33%
Teacher 14 7% 7 5.56% 7 10.45% 28 7.03%
Contraception (n ¼ 424)
No contraception 156 67.37% 90 71.43% 48 71.64% 294 67.80% 0.733
Condom use 40 14.93% 17 16.67% 8 11.94% 65 14.94%
Oral or injectable method 35 15.83% 14 11.11% 10 14.93% 59 15.48%
Traditional or other method 4 1.87% 1 0.79% 1 1.49% 6 1.78%
Sexual violence (n ¼ 417)
Ever forced to have sex 19 8.18% 11 8.87% 8 12.31% 38 8.37% 0.737
Never forced to have sex 213 91.82% 109 91.13% 57 87.69% 379 91.63%
Reproductive health (n ¼ 421)
No pregnancy 42 19.27% 18 14.29% 25 37.31% 85 19.58% p < 0.0001
1/2 pregnancies 55 22.58% 30 26.98% 11 16.42% 96 22.65%
3/4pregnancies 56 21.49% 18 14.29% 15 22.39% 89 21.04%
>4pregnancies 81 36.66% 55 44.44% 14 23.89% 150 36.73%
Desire for a child (n ¼ 419)
Desire a child in the near future 158 66.16% 62 52.80% 38 58.46% 258 64.99% 0.006
Do not desire a child in the near future 75 33.84% 59 47.20% 27 41.54% 161 35.01%

Note: Chi-square p-value for comparison between disabled, mild/moderate and sever/very severe. Few non responses for some variables (below 2%).

future. In this paper we focus on the latter two indicators. We found
that degree of disability was not consistently associated with
number of children (Model 8, Table 5) and desire to have another
child (Model 9, Table 5).
Being educated was related to lower number of children, both
for disabled and non-disabled women. Poverty was strongly
predictive of a higher number of children. Educational attainment
however does not, in the adjusted model, seem to impact signifi-
cantly on desire to have another child; all women belonging to the
wealthiest asset index group were more likely to express a greater
desire to have another child.
Discussion
The findings of this study offer a pioneering contribution to
understanding the disparity in access to health care in a post-conflict
country. It is a well-established fact that the poor in low income
countries are usually more in need of health care than their wealthier
fellow citizens, and that wealth influences the odds of utilising health
services (Brazier et al., 2009; Graham et al., 2004; Houweling et al.,
2007). However, gaps in access to health care and health status also
exist between disabled and non-disabled people, whatever their
economic status. For instance, the survey demonstrated that disabled
people were more likely to report poorer health status than non-
disabled people. An extremely interesting exception to this was
those people with severe disabilities who have a paid work were
more likely to report being in good health. Access to both public/
community health care and hospitals were lower for disabled than
non-disabled individuals. Given the fact that overall persons with
disabilities are impoverished, and more likely to rely on public/
community health services or public hospitals, the difference in
access between disabled and non-disabled individuals is of particular
concern .The findings in Sierra Leone, unsurprisingly, also demon-
strate that people in the poorest wealth quintile had the worse access
to food, clean water, private health care services, and maternal
health care.
We already knew that disabled people experience the worse
health outcomes and are among the poorest (Elwan, 1999; Groce
et al., 2011). Therefore, there is a need for improvements in
health and access to health care services for persons with
 1484
Table 2
Logistic regression models for health status and health care access in Sierra Leone based on a random sample of N ¼ 424.

Model 1 Poor healtha Model 2 Access to public facilityb Model 3 Access to private facilityb

Crude 95% CI Adjusted 95% CI Crude 95% CI Adjusted 95% CI Crude 95% CI adjusted 95% CI
OR OR OR OR OR OR

J.-F. Trani et al. / Social Science & Medicine 73 (2011) 1477e1489

Female (ref. male) 0.87 0.40e1.88 1.09 0.35e3.34 2.15 0.77e5.97 1.63 0.49e5.32 1.22 0.72e2.06 1.31 0.67e2.53
Mild/moderate disability 2.79*** 1.50e5.20 3.38*** 1.90e5.99 0.39*** 0.19e0.83 0.36** 0.12e0.99 0.85 0.57e1.25 0.53* 0.24e1.14
(ref. non-disabled)
Severe/very severe disability 3.01*** 1.44e6.27 4.80* 0.84e27.3 0.25*** 0.09e0.73 0.03*** 0.00e0.15 0.46*** 0.25e0.86 2.58 0.41e16.2
Disabled women (interaction) 3.15*** 1.30e7.57 1.25 0.29e5.37 0.44 0.11e1.67 1.65 0.40e6.69 0.30** 0.11e0.80 0.09*** 0.02e0.41
Age group 30e39 (ref. 18e29) 3.25** 1.16e9.09 3.39** 1.03e11.1 2.12 0.50e9.10 2.92 0.57e14.8 2.29** 1.00e5.30 1.71 0.52e5.51
Age group 40e49 6.19*** 2.61e14.69 3.81* 0.87e16.5 0.44 0.12e1.67 0.57 0.13e2.50 1.33 0.52e3.38 1.67 0.49e5.61
Age group >50 5.91*** 2.24e15.62 3.63* 0.90e14.5 0.91 0.22e3.85 1.32 0.19e9.13 1.40 0.60e3.27 1.90 0.48e7.44
Married, partner 2.65*** 1.28e5.49 1.09 0.41e2.88 1.03 0.36e2.94 1.59 0.27e9.40 1.54 0.57e4.10 1.74 0.49e6.12
or engaged (ref. not married)
Married, polygamous 7.53 2.79e20.34 2.50 0.52e11.9 0.87 0.20e3.68 2.22 0.25e19.1 0.53 0.12e2.30 0.85 0.15e4.74
Divorced or widowed 3.73 1.40e9.96 1.35 0.26e6.87 1.04 0.38e2.88 1.02 0.18e5.65 3.34* 0.90e13.40 2.41 0.42e13.6
Rural (ref. urban) 1.78 0.75e4.22 1.38 0.52e3.65 0.83 0.34e2.01 1.03 0.49e2.15 0.43** 0.19e0.99 0.60* 0.32e1.10
Primary education 0.89 0.31e2.52 1.01 0.30e3.33 3.52** 1.17e10.62 4.18*** 1.68e10.3 4.19*** 1.35e12.88 3.92** 1.22e12.5
(ref. no education)
Secondary education 0.25*** 0.12e0.58 0.48* 0.20e1.09 1.24 0.44e3.56 1.16 0.25e5.26 2.70** 1.04e7.02 2.32* 0.91e5.86
Tertiary education 0.19*** 0.06e0.63 0.21** 0.05e0.87 4.76*** 1.42e15.94 10.80** 1.07e108.42 10.12*** 2.18e47.08 6.39*** 1.46e27.8
Educated disabled 1.66 0.61e4.50 2.29 0.45e11.3 0.30** 0.09e0.95 0.81 0.12e5.13 0.70 0.34e1.44 1.44 0.24e8.45
person (interaction)
Working (ref. not working) 1.10* 0.43e2.78 0.78 0.30e2.02 0.32*** 0.16e0.63 0.08*** 0.03e0.21 1.64 0.85e3.18 2.10** 1.07e4.09
Active disabled 0.54* 0.13e2.21 0.15** 0.02e1.08 0.59 0.19e1.79 45.96*** 10.1e208.19 0.26*** 0.09e0.67 0.14** 0.02e0.80
person (interaction)
Poorest group (ref. richest) 3.87** 1.22e12.28 2.10 0.56e7.76 0.92 0.21e4.01 1.71 0.25e11.4 0.26*** 0.12e0.58 0.30*** 0.11e0.76
Middle group 5.34*** 2.10e13.52 4.66*** 1.79e12.0 1.01 0.21e5.20 1.23 0.18e7.96 0.48*** 0.26e0.88 0.42*** 0.21e0.83

Note: CI, confidence interval; OR: odds ratio. Control for cluster effect. Significant at the ***1% level (p  0.01), **5% level (p  0.05), *10% level (p  0.10).
a
the baseline outcome is good health, the other category is bad health.
b
the baseline outcome is no access to public health facility, the other category is access.
 J.-F. Trani et al. / Social Science & Medicine 73 (2011) 1477e1489 1485

Table 3
Logistic regression models for food intake and access to water managed source in Sierra Leone based on a random sample of N ¼ 424.

Model 4 Access to fooda Model 5 Managed water supplyb

Crude 95% CI Adjusted 95% CI Crude 95% CI Adjusted 95% CI

OR OR OR OR
Female (ref. male) 0.70* 0.34e1.47 0.68* 0.28e1.60 1.46 0.82e2.59 1.58 0.83e2.96
Mild/moderate disability 0.76 0.42e1.37 0.67 0.28e1.56 1.05 0.63e1.75 0.76 0.43e1.30
(ref. non-disabled)
Severe/very severe disability 0.51*** 0.38e0.69 0.42 0.12e1.43 0.83 0.32e2.10 0.59 0.12e2.81
Disabled women (interaction) 1.03 0.39e2.77 4.86* 0.88e26.7 0.85 0.29e2.52 0.63 0.24e1.66
Age group 30e39 (ref. 18e29) 0.25*** 0.13e0.46 0.21*** 0.08e0.53 1.03 0.52e2.03 1.31 0.71e2.39
Age group 40e49 0.56 0.19e1.60 0.56 0.17e1.74 0.69 0.29e1.68 1.37** 0.66e2.83
Age group >50 0.58 0.18e1.84 0.44 0.10e1.80 1.10 0.41e2.91 2.93 1.24e6.89
Married, partner or engaged 0.52* 0.25e0.98 1.15 0.44e2.98 0.95 0.33e2.79 1.04 0.35e3.05
(ref. not married)
Married, polygamous 1.63 0.40e6.63 4.74* 0.89e25.0 0.22* 0.04e1.28 0.23** 0.05e0.95
Divorced or widowed 0.30** 0.10e1.00 0.56 0.13e2.35 0.70 0.29e1.72 0.48 0.15e1.42
Rural (ref. urban) 0.76 0.27e2.14 0.68 0.13e3.42 0.54 0.12e2.37 1.32 0.32e5.37
Primary education (ref. no education) 2.64 0.35e20.17 3.66 0.54e24.4 1.74 0.75e4.05 1.80 0.78e4.08
Secondary education 1.65 0.80e3.44 1.39 0.66e2.88 2.20* 1.00e5.31 1.51 0.81e2.80
Tertiary education 0.92 0.18e4.74 1.01 0.18e5.51 3.76* 1.01e15.25 2.23 0.71e7.01
Uneducated disabled person (interaction) 0.43** 0.22e0.86 0.20* 0.03e1.06 1.18 0.43e3.20 1.35 0.19e9.53
Working (ref. not working) 0.67 0.39e1.04 0.95 0.40e2.23 0.67 0.29e1.60 1.06 0.43e2.56
Active disabled person (interaction) 0.52 0.20e1.32 1.20 0.16e8.69 1.29 0.40e4.18 2.21** 0.98e4.98
Poorest group (ref. richest) 0.23*** 0.08e0.77 0.23** 0.06e1.03 0.18** 0.05e0.76 0.20*** 0.07e0.59
Middle group 0.27** 0.09e0.85 0.27*** 0.10e0.78 0.41* 0.13e1.30 0.42* 0.14e1.16

Note: CI, confidence interval; OR: odds ratio Control for cluster effect Significant at the ***1% level (p  0.01), **5% level (p  0.05), *10% level (p  0.10).
a
the baseline outcome is one meal a day, the other category is two or three meals a day.
b
the baseline outcome is unmanaged water supply, the other category is managed water.

disabilities. This is of even greater concern when, as in Sierra Leone,
disabled people represent a large section of the population. Our
finding of a 17% disability prevalence rate in urban and peri-urban
areas is significantly above the 2004 census estimates, but in line
with the findings of the Multiple Indicator Cluster Survey (MICS)
data for Sierra Leone which showed that 23% of children were
identified as disabled countrywide (Ferme, 2001). We found that
73% of households in our survey have a disabled member, which in
turn, is likely to have a significant socioeconomic impact at the
household level and on the population as a whole (Becker et al.,
1997; Gaskins, 1999; Trani & Bakhshi, 2011). Meeting their needs
for better health would contribute to achieving the MDGs,
promoting equity and improving socioeconomic development
nationwide (Marmot & Commission Social Determinants, 2007).
Yet the study provides no strong evidence of differences in
perceptions of health status or satisfaction with health services

Table 4
Logistic regression models for use of contraception and maternal health care access in Sierra Leone based on a random sample of N ¼ 424 and N ¼ 235.

Model 6 Use of modern contraceptiona Model 7 Access to maternal health careb

Crude 95% CI Adjusted 95% CI Crude 95% CI Adjusted 95% CI

OR OR OR OR
Female (ref. male) 1.44 0.72e2.91 1.06 0.44e2.49 NA NA
Mild/moderate disability 0.84 0.46e1.53 0.99 0.55e1.76 0.85 0.34e2.13 0.51 0.13e1.87
(ref. non-disabled)
Severe/very severe disability 0.81 0.48e1.36 2.58 0.52e12.6 1.79 0.45e7.21 11.73 0.09e1574.93
Disabled women (interaction) 0.84 0.43e1.63 0.81 0.27e2.40 NA NA
Age group 30e39 (ref. 18e29) 0.89 0.52e1.53 0.93 0.40e2.16 0.64 0.29e1.43 0.70 0.24e2.07
Age group 40e49 0.35*** 0.15e0.79 0.57 0.18e1.76 0.19** 0.03e1.11 0.11** 0.02e1.01
Age group >50 0.21*** 0.10e0.45 0.30*** 0.10e0.84 1.32 0.10e17.09 0.65 0.04e12.66
Married, partner or engaged 0.45*** 0.25e0.87 0.82 0.32e2.05 0.43 0.13e1.45 0.26*** 0.11e0.63
(ref. not married)
Married, polygamous 0.14*** 0.05e0.45 0.51 0.09e2.64 0.36 0.09e1.64 0.13* 0.01e1.15
Divorced or widowed 0.64 0.24e1.65 1.05 0.27e4.05 1.70 0.13e13.61 0.96 0.16e5.92
Rural (ref. urban) 0.38** 0.17e0.85 0.61 0.23e1.56 1.23 0.40e3.86 2.07 0.38e11.18
Primary education (ref. no education) 1.55 0.90e2.80 1.24 0.69e2.21 0.93 0.23e3.76 0.85 0.11e6.63
Secondary education 3.93*** 2.14e7.19 2.05** 1.02e4.11 1.56 0.52e4.67 0.90 0.21e3.90
Tertiary education 7.52*** 2.27e24.84 4.07*** 1.32e12.5 0.89 0.08e11.83 0.21 0.01e6.01
Educated disabled person (interaction) 1.07 0.43e2.66 0.44 0.08e2.11 0.74 0.21e2.57 0.03** 0.00e1.11
Working (ref. not working) 0.78 0.44e1.39 1.35 0.60e3.00 1.14 0.35e3.70 1.71 0.50e6.02
Active disabled person (interaction) 0.48* 0.15e1.51 0.27** 0.08e0.83 2.63 0.32e21.72 1.81 0.08e442.70
Poorest group (ref. richest) 0.37** 0.14e0.97 0.88 0.27e2.87 0.33* 0.07e1.67 0.30 0.04e2.15
Middle group 0.51 0.19e1.41 0.65 0.19e2.12 0.21*** 0.06e0.83 0.22** 0.05e0.98
Informed about sexuality 2.19 1.00e4.86** 1.61 0.70e3.66 2.68*** 1.14e6.35 4.96*** 1.77e13.91
(ref. not informed)

Note: CI, confidence interval; OR: odds ratio. Controlled for cluster effect Significant at the ***1% level (p  0.01), **5% level (p  0.05), *10% level (p  0.10).
a
the baseline outcome is no use of modern contraception, the other category is use.
b
the baseline outcome is no access or incomplete access to maternal health care services (antenatal service, trained birth attendant, delivery in hospital and emergency
service), the other category is access.
 1486
Table 5
Logistic regression models for number of children and desire for another child in Sierra Leone based on a random sample of N ¼ 235.

Model 8: number of childrena Model 9 Desire for another childb

1e3 children 4 or more children

Crude 95% CI Adjusted 95% CI Crude 95% CI Adjusted 95% CI Crude 95% CI Adjusted 95% CI

J.-F. Trani et al. / Social Science & Medicine 73 (2011) 1477e1489

OR OR OR OR OR OR
Female (ref. male) NA NA NA NA NA NA
Mild/moderate disability 1.76* 0.80e3.88 2.80* 0.78e10.12 2.79** 1.20e6.54 4.20** 1.12e15.80 0.49** 0.24e0.97 0.61 0.20e1.81
(ref. non-disabled)
Severe/very severe disability 1.04 0.47e2.30 3.50 0.18e69.35 0.82 0.28e2.45 1.72 0.10e32.72 0.58 0.27e1.28 0.61 0.16e2.38
Disabled women (interaction) NA NA NA NA NA NA
Age group 30e39 (ref. 18e29) 11.72*** 3.68e38.34 7.94*** 1.74e36.29 25.25*** 6.24e102.17 24.11*** 4.91e118.62 0.34*** 0.14e0.80 0.20*** 0.09e0.48
Age group 40e49 2.30 0.36e14.73 0.72 0.08e6.37 11.47** 1.46e90.51 3.69 0.29e47.07 0.05*** 0.02e0.16 0.03*** 0.01e0.15
Age group >50 3.37 0.45e25.05 1.31 0.11e15.44 19.04*** 3.33e108.84 13.84*** 2.12e90.18 0.07*** 0.02e0.23 0.02*** 0.00e0.09
Married, partner or engaged 18.54*** 7.78e40.21 10.92*** 2.59e46.08 54.95*** 10.34e291.98 16.27*** 1.92e137.64 0.65 0.33e1.27 7.20*** 2.21e23.38
(ref. not married)
Married, polygamous 6.59** 1.28e33.72 3.34 0.14e80.19 118.36*** 11.97e1169.54 16.25* 0.45e598.34 0.26 0.03e2.36 3.57 0.29e43.94
Divorced or widowed 8.34*** 3.60e19.29 4.05** 0.96e17.35 18.66*** 2.70e129.00 3.23 0.35e30.05 0.25*** 0.10e0.68 2.53 0.39e16.57
Rural (ref. urban) 1.89* 0.91e3.92 0.95 0.40e2.28 7.09*** 2.59e19.46 4.00** 1.01e16.35 0.38*** 0.21e0.68 0.44 0.15e1.31
Primary education (ref. no education) 0.49 0.28e0.82 1.11 0.26e4.72 0.23** 0.06e0.83 0.67 0.17e2.61 1.32 0.47e3.69 0.97 0.20e4.59
Secondary education 0.15*** 0.09e0.22 0.43 0.06e3.47 0.03** 0.01e0.12 0.28 0.03e2.43 3.70*** 1.57e8.70 2.01 0.50e8.22
Tertiary education 0.12* 0.05e0.25 0.20 0.01e7.54 0.07*** 0.01e0.60 0.56 0.01e31.09 1.75 0.34e8.83 0.86 0.06e13.23
Educated disabled person (interaction) 0.42** 0.17e1.01 0.19 0.02e2.41 0.37* 0.11e1.20 1.46 0.23e9.18 1.22 0.49e3.02 1.16 0.26e5.22
Working (ref. not working) 2.76** 1.17e6.57 0.75 0.22e2.54 3.87** 1.13e13.23 0.56 0.11e2.76 0.73 0.33e1.60 1.15 0.51e2.58
Active disabled person (interaction) 2.01 0.41e10.31 1.74 0.07e49.35 0.99 0.05e21.08 1.72 0.01e286.24 0.97 0.21e4.43 0.53 0.02e22.26
Poorest group (ref. richest) 3.31** 1.18e9.26 1.09 0.23e5.29 16.63*** 5.10e54.18 3.16 0.56e18.02 0.17*** 0.08e0.38 0.05*** 0.01e0.21
Middle group 2.05 0.68e6.19 0.95 0.25e3.65 7.09*** 2.61e19.27 4.19*** 1.26e14.00 0.23*** 0.12e0.48 0.06*** 0.02e0.21
Informed about sexuality 0.43* 0.17e1.04 0.65 0.07e5.95 0.25** 0.09e0.76 0.46 0.04e5.28 0.86 0.38e1.96 0.47 0.18e1.25
(ref. not informed)

Note: CI, confidence interval; OR: odds ratio. Controlled for cluster effect. Significant at the ***1% level (p  0.01), **5% level (p  0.05), *10% level (p  0.10).
a
the baseline outcome is no children, the other two categories are 1e3, 4 or more children.
b
the baseline outcome is no other child wanted, the other category is another child wanted.
 J.-F. Trani et al. / Social Science & Medicine 73 (2011) 1477e1489
between disabled and non-disabled individuals. Disabled people
indicated they were in good health (73%) and were satisfied with
public health care services available (80%). These are unexpected
results: others studies have usually found that disabled people are
excluded from both public and private health care services (Groce
et al., 2011; Trani & Loeb, in press) and that public health care
systems do not reach vulnerable groups (Brazier et al., 2009;
Castro-Leal, Dayton, Demery, & Mehra, 2000; Chowdhury et al.,
2006; Zere, Moeti, Kirigia, Mwase, & Kataika, 2007). One possible
explanation for this counterintuitive result is that the overall state
of health and well-being for all Sierra Leoneans continues to be
extremely low, and responses from persons with disabilities are
comparable to much of the rest of the population. Given the
preceding decade of war and social disruption, it is possible that
few in Sierra Leone e disabled or non-disabled e expect much from
their health care services. However, this is not conclusive as in the
aftermath of conflict, a range of interventions and services were
made available by the government, UN agencies and NGOs, which
may have reached many who went without services in the civil war.
Certainly, levels of immunisation coverage for both disabled and
non-disabled groups are high.
However, some indicators are of concern: access to managed
water supply and sanitation facilities for persons with disabilities
was relatively poor, and health expenses remained high comp-
ared to family income. These findings suggest that improved
service coverage is needed to provide universal, free and equi-
table access to health care. Given the existing gap between access
to general health care by disabled people in comparison to non-
disabled individuals, improvement in public health services may
lead to a widening the gap between disabled and non-disabled
people.
Evidence from our research suggests that poor uneducated
people in general less frequently accessed private doctors and
clinics but not public health facilities. Findings also show that
disabled people had less access to public facilities, and even when
working, disabled people, had less access to private facilities than
non-disabled working people. Thus, disability may be a source of
exclusion per se. It may also be a factor e in association with low
socioeconomic status e to low usage of health care services. In
other words, people with disabilities tend to have less access to
health care because they have fewer opportunities for education,
job training and employment and are thus, at the end of the day,
poorer. Programmes aiming at improving access to public health
services should account for this, and prioritise disabled people from
low socioeconomic groups.
Interestingly, our findings did not show any significant differ-
ences between disabled and non-disabled women in accessing
maternal health care services. Between 78% and 88% of women
reported having access to any of the four types of maternal health
care services and 62% indicated having access to all four, which also
correspond with earlier observations in the CWIQ (Statistics Sierra
Leone, 2007) and DHS (Statistics Sierra Leone, 2008). However, this
reported relative availability of access to maternal health services
for both disabled and non-disabled women is still surprising given
the high rate of maternal mortality in Sierra Leone. This unexpected
result is in contrast with two small qualitative studies conducted in
Cameroon and Zambia (Bremer et al., 2009; Smith et al., 2004). In
the Zambian capital of Lusaka, disabled women reported various
barriers in accessing reproductive health services including nega-
tive attitudinal barriers by health care providers who assumed that
women with disabilities were and should be, sexually inactive. This
study also found that there was a tendency for midwives and
nurses to over-refer women with disabilities to tertiary facilities out
of fear of complications. This may also explain why disabled women
in Sierra Leone reported higher rates of access to maternal health
1487
care facilities than non-disabled women, although further research
is needed to determine this.
Nevertheless, if women are routinely being over-referred to
more advanced clinical services just because they are disabled, such
referrals constitute an additional barrier to accessing care because
of the increased costs, distance and time needed to get pregnant
women to such facilities. Such findings have already been reported
in Cameroon where pregnant disabled women reported they fear
being sent to health care centres even in urban areas, due to high
out-of-pocket costs and physical barriers (Bremer et al., 2009). As
these studies in Zambia and Cameroon were qualitative in nature
they do not quantify the differences in access or perceived barriers.
In Sierra Leone, in urban and peri-urban areas, comparable barriers
were not reported as major limitations to women with disabilities
in accessing maternal health care services.
Education, which provides both a greater knowledge base and
more income potential, is one of the most important determinants
to access to general health care and to maternal health services
(Glei, Goldman, & German, 2003). Although educated people in our
study more frequently reported being in bad health, they had better
access to managed water sources, to public and private health care
services, and were more likely to use contraception. In contrast, we
found that educated women were not significantly more likely to
access maternal obstetric health care when compared to unedu-
cated non-disabled women e which may reflect issues around
quality of services.
The effect of education may also be seen in the fact that
educated disabled women were more likely to have fewer children,
as is true of women more generally. This is an important finding.
Unfortunately however, disabled women were significantly less
likely to receive any sex education than non-disabled women, even
in societies where education for all women is low (UNFPA, 2007).
The results underscore the importance of including persons with
disabilities e and disabled women in particular e in educational
initiatives in general and reproductive health initiatives in partic-
ular, if effective headway is to be made in family planning.
Finally, this survey found that while men and women with
disabilities did not report as high a rate of sexual activity, birth
rates, or desire for an additional child as their non-disabled peers,
the vast majority of all disabled persons were sexually active, had
families of two or more children and wanted more children in
future. This is, we argue, a wholly original finding in the literature
to date.
Our data should be interpreted in light of several limitations.
The possibility of a chance finding should be considered, especially
given some unexpected results. Notably, only 119 women answered
the questions on pregnancy and family planning as this was the
number that had been pregnant in the last five years. In order to
refute the possibility of a chance finding, a comparable study, with
a larger sample should repeat the same survey questions. Aside
from Freetown, the four other regions in Sierra Leone surveyed
were provincial towns or villages. Although these villages were
relatively distant from urban areas (at least a 30 min drive), they
were still accessible by car and there was regular contact with the
urban area. Therefore these areas should not be considered remote
rural areas, but peri-urban settlements. Thus, this study provides
insight into the situation in urban and peri-urban settings only.
Future research will be needed to assess the situation in more
remote rural areas of Sierra Leone, which we anticipate may differ
significantly from findings in this study. The possible differences
between urban and rural populations may be of particular concern,
because of our finding that persons with disabilities rely more
heavily on public/community health services and hospitals.
Currently in rural Sierra Leone such public/community health
centres and hospitals are largely unavailable. Also, although this
1488 J.-F. Trani et al. / Social Science & Medicine 73 (2011) 1477e1489
study finds high reported rates of access to maternal health care
facilities such findings do not correspond with the high morbidity
and mortality rates of pregnant women found in current statistics
from Sierra Leone. It is possible that a discrepancy exists between
what women consider adequate maternal health care services and
international standards for care. Thus, assessing the quality of
services received is an important research question for the future.
Conclusion
This study is one of the first to look at access to general health care
and reproductive health patterns for persons with disabilities in
urban and peri-urban Sierra Leone. It found that people with
disabilities did have good access to public health care facilities,
although not at rates comparable to those of non-disabled people. For
that small percentage of the population who can afford private
doctors and clinics, however, there was no significant difference
between disabled and non-disabled people access to health care. It is
in rural areas that we noted the need to a greater reliance on currently
less available public health care facilities by persons with disabilities.
The fact that we have not found a significant difference between
disabled and non-disabled women in reproductive health practices
or expectations underscores the need to revisit the misconception
that persons with disabilities are sexually inactive, do not want, and
do not plan for or have a family. Such findings are important in
order to advocate for equal access to reproductive health services e
including family planning and maternal health services. We argue
that as the process of reconstruction proceeds in post-conflict
countries, the gap between the most vulnerable groups and the
rest of the society might widen. Yet, as countries such as Sierra
Leone continue to rebuild after conflict, the need to develop
services for all from the ground up may offer a unique window of
opportunity for the inclusion of persons with disabilities in new
health services. Our study results may be generalisable to other
urban and peri-urban areas in Africa and other developing coun-
tries, and we encourage other researchers to pursue comparable
studies in order to generate an evidence base from which to inform
future policy and programming.
Acknowledgements
We would like to thank all the participants in this study, as well
as supervisors and interviewers for their commitment to this study.
We are grateful to Ellie Cole and Anu Bakhshi for very useful
comments on earlier versions of this paper. We are also grateful to
the two anonymous reviewers who made critical suggestions to
improve this paper. This study was funded by Leonard Cheshire
Disability.
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