Access to Healthcare Services Among Children with Cerebral Palsy in the Greater Accra Region of Ghana

Abstract

Children with cerebral palsy have quite a lot of challenges in accessing health care than those without disabilities. The purpose of the study was to explore the factors that influence parents in accessing healthcare services for their children with cerebral palsy. This study used a qualitative cross-sectional design using phenomenology. A total of 15 participants comprising parents of children with disabilities and healthcare providers provided data through in-depth interviews following written informed consent. Fifteen in-depth interviews were conducted. The interviews were recorded digitally and transcribed verbatim. Thematic analysis was adopted in the analysis of the data using Nvivo 12. Fifteen IDIs were completed: 10 parents of children with cerebral palsy and 5 healthcare providers. The study findings revealed individual factors such as transportation cost, distance to a health facility, and stigmatization as well as healthcare factors such as availability of specialized services, the attitude of health professionals, the physical environment of hospitals, and the availability of rehabilitation specialists influence parents access to healthcare services for their children with cerebral palsy. Access to healthcare services for children with cerebral palsy is influenced by individual factors (parental) and healthcare factors.

1. Introduction

The World Disability report shows that approximately 15% of the global population are people with disabilities making them the largest minority group in the world [1]. WHO estimated that nearly 3% of the global population has cerebral palsy (CP) [2]. According to Janzek-hawlat [3] persons with CP experience discrimination in healthcare more than the general population. The Convention on the Right of Persons with Disabilities (CRPD) affirms that persons with disabilities have the right to achieve their highest standard of health care, without any discrimination [4]. However, the health care needs of children with CP are poor, particularly in low- and middle-income countries. In Africa, parents of children with CP experience social isolation from family, friends, and community members, discrimination from peers, transportation problem, and a financial challenge because of unemployment [5]. Aside from these challenges, parents of children with CP also experience challenges with the healthcare system including lack of provision of assistive devices, attitudes of healthcare professionals, and high cost of healthcare services [5]. In Ghana, parents of children with CP also face similar challenges in accessing health facilities, these are due to inaccessible environment, distance to a health facility, transportation, discriminatory attitudes of health workers, neglect, stigmatization, and inadequate healthcare services [6, 7, 8, 9].

Access to healthcare is a development issue, as well as a question of the realization of rights. A significant focus of Sustainable Development Goal 3 “Good Health and Well-being” is to advance access to healthcare services for All through the behavior accomplishment of Universal Health Coverage (UHC) [10]. Despite this, children with CP experience financial, structural, and social problems in accessing healthcare services [11]. According to WHO [2] children with CP usually do not benefit from health promotion and prevention programs because they are scarcely targeted. This study is therefore designed to employ qualitative design using phenomenology to identify the factors that influence access to healthcare services for children with CP in the Greater Accra Region of Ghana.

2. Methods

2.1 Research design

The study used a qualitative cross-sectional design using phenomenology to assess the knowledge of parents of children with CP on National Health Policy, explore the perceptions of parents of children with CP on the implementation of the National Health Policy in Ghana, identify parental factors and healthcare factors that influence access to healthcare services for children with CP. Phenomenology allows participants to share their perceptions, feelings, and lived experiences in accessing healthcare services for their wards with CP and how these experiences influence their ability to access healthcare for their children with CP.

2.2 Study area

The study was conducted in the Greater Accra Region (GAR) of Ghana because there are quite a lot of parents of children with CP and an existing self-help group (Figure 1). There are over 500 parents of children with CP and about 20 existing self-help groups in GAR. The study considered the Special Mothers Project self-help group in Okponglo in the Greater Accra Region. The Special Mothers Project has been existing for the past 7 years and is open to every parent of children with disabilities especially those with children with cerebral palsy. GAR is the capital town of Ghana and has the smallest area of Ghana’s sixteen (16) administrative regions. GAR can be found in the South-East part of the country and it is surrounded on the north by the Eastern Region, on the east by the Volta Region, on the south by the Gulf of Guinea, and on the west by the Central Region. GAR is divided into sixteen districts and its political administration is through the local government. Each district is administered by a Chief Executive who represents the central government.

Figure 1.

Map showing health districts in Greater Accra. Source: Google Maps [12].

2.3 Study participants

The study participants were parents of children with CP between the ages of 3 to 17 years who attend a special school in the Greater Accra Region, this is because 17% of children are diagnosed with CP within the age range and healthcare providers who provide services to children with CP within the study period will be part of the study (Table 1).

Characteristics of Participants	Number of Participants
	Parents for IDIs	Healthcare providers for KIIs
Special schools
Woodfield Manor Special School	5	—
Dzorwulu Special School	5	—
Health Facility
Cocoa Clinic (Private)	—	1
Alpha Medical Center (Private)	—	1
La General Hospital (Public)	—	1
Achimota Hospital (Public)	—	1
Kaneshie (Public)	—	1
Sex
Male	1	3
Female	9	2
Age (years)	Children with CP
3–10	10
11–17	5
20–29	1
30–39	7	4
40+	2	1
Educational Level
No Formal Education	—	—
Primary	1
JHS/SHS	6
Tertiary	3	5
Religion
Christianity	9	5
Islam	1
Occupation
Trader	5
Teacher	3
Student/Unemployed	2
Occupational Therapist		2
Physiotherapist		2
General Health Practitioner		1
Marital Status
Single	6	4
Married	4	1

Table 1.

Socio-demographic characteristics of participants.

2.4 Selection of study participants

The respondents for this study were recruited using a purposive sampling technique. This sampling technique is a non-probability sampling used to select participants based on the experiences and characteristics they possess that best fit for the study. The inclusion and exclusion criteria were considered in selecting the participants for the study. Parents of children with CP who met the inclusion criteria were purposively sampled at home for an interview in the study. Three (3) participants were selected each day for the in-depth interview (IDI) while the key informant interview (KII) was also used for healthcare workers who met the inclusion criteria until the point of saturation was reached. Saturation was determined when no new information was emerging from the study participants. A total of fifteen (15) participants reached saturation, including 10 parents of children with CP and 5 health care providers. The study purposefully identified and selected ten (10) children with CP who are eligible for the study at the school level based on age, sex, and disability and proceeded to their homes to consent to their parents or caregivers for recruitment for an in-depth interview.

Also, five (5) health facilities both private and public in the Greater Accra Region were selected for key informant interviews based on specialized and generalized healthcare services provided. Five (5) eligible healthcare providers within the selected health facilities who directly offer healthcare services to children with CP were purposively selected for the study based on a particular set of characteristics such as experience, skills, knowledge, and highest educational level for a KII. This is to get an adequate number of participants for the study.

2.5 Data collection methods

The study used both IDIs and KIIs to collect primary data from study participants. IDIs were steered within the homes of identified parents of children with CP at their convenience. Also, all KIIs were steered within the work premises of the identified healthcare provider upon appointment. The IDIs and KIIs were directed by an interview guide containing questions and probes that directed the interviewer.

2.6 Selection of study participants

The respondents for this study were recruited using a purposive sampling technique. This sampling technique is a non-probability sampling used to select participants based on the experiences and characteristics they possess that best fit for the study. The inclusion and exclusion criteria were considered in selecting the participants for the study. Parents of children with CP who met the inclusion criteria were purposively sampled at home for an interview in the study. Three (3) participants were selected each day for the IDI while the KII was also used for healthcare workers who met the inclusion criteria until the point of saturation was reached. Saturation was determined when no new information was emerging from the study participants. A total of fifteen (15) participants reached saturation, including 10 parents of children with CP and 5 health care providers. The study purposefully identified and selected ten (10) children with CP who are eligible for the study at the school level based on age, sex, and disability and proceeding to their homes to consent to their parents or caregivers for recruitment for IDIs. Also, five (5) health facilities both private and public in the Greater Accra Region were selected for KII based on specialized and generalized healthcare services provided.

2.7 Data collection tools

An interview guide, a field notebook, a voice recorder, and a field diary were used to collect data during the study. The interview guide for both IDIs and KIIs contained questions and probes on; the knowledge of parents on the Persons with Disability Act of Ghana, NHIS, perceptions of parents about the implementation of the National Health Policy in Ghana, parental factors in accessing health care, healthcare factors (challenges), and specialized services available for children with CP. Both in-depth interviews and key informant interviews were recorded using a voice recorder and field diary to take key notes found on the field.

2.8 Data analysis

All IDIs and KIIs were recorded with the participants’ permission. Interviews conducted in the local dialect were transcribed literally into English by the research assistant who was conversant with the language. All transcriptions were confirmed and transported into Nvivo version 12. The coding of themes was developed thematically in line with the objectives of the study and emerging themes in the field. The inductive and deductive approaches were used in the coding process. Themes were summarized into appropriate sub-headings using queries. A codebook was developed for themes that will emerge during interviews on the field and appropriate excerpts were used to support the theme.

3. Results

3.1 Knowledge of National health policy in Ghana

The study revealed that the majority of the participants had a fair knowledge of the National Health Policy in Ghana, and explained it as a policy that aims to promote health for everyone in Ghana. Some participants also explained the National Health Policy according to their understanding of health in the Persons with Disability Act (Act 715) and the NHIS in Ghana (Table 2). The participants were therefore asked about their knowledge of health in the Persons with Disability Act. The participants described health in the Persons with Disability Act as a means of getting access to healthcare services without any barriers and discrimination. Participants believed that the health in Persons with Disability Act means having access to healthcare services without any discrimination, physical and attitudinal barriers as well as accessing free specialized services in the public health facilities (Figure 2). The belief of having access to healthcare services without any barrier was universal among the participants. Those who hold these beliefs also indicated that the persons with disability act mandate the State to provide financial support to persons with disabilities. The study showed that the participants were knowledgeable about the NHIS. The respondents emphasized how the NHIS serves as a safety net and has replaced the cash-and-carry system of service delivery. Some of the respondents also attributed the NHIS as the means of ensuring sustainable financing for health.

Concepts	Operational definitions
Approachability/Accommodation	The extent to which health care services are provided in different ways to meet the health needs of clients irrespective of barriers.
Acceptability	The level of comfort existing between client and provider with fixed characteristics including sex, age, race, ethnicity among others.
Affordability	The relationship between providers charges and the client’s ability to pay for services; Cost of service covered by health insurance and client’s ability to pay the amount left.
Appropriateness	The ability of health providers to properly use health services, products, and resources for the benefit of clients.
Availability	Provider’s ability to have all the required resources needed to meet the client’s health needs.

Table 2.

Dimensions of access to health care services.

Source: [13].

Figure 2.

Conceptual framework- Factors influencing access to healthcare (Adapted from the WHO; International classification of functioning, disability, and health [8, 9].

3.2 Perception of the implementation of the National health policy in Ghana

The study findings showed that participants agreed on the implementation of the National Health Policy of Ghana. Participants were asked questions about their perception of health in the implementation of the Persons with Disability Act and on the NHIS (NHIS). Some of the perceptions revealed in this study were the ineffectiveness of the Persons with Disability Act, poor quality health service, and less health service coverage by the NHIS. It also showed that participants were unanimous on the health service coverage by the NHIS. All participants acknowledged that the NHIS does cover some aspects of healthcare services like consultation fee, patient card, half of the lap fees, part of medication, and one-month cost of physiotherapy but does not cover tertiary services like surgery and some specialized services like speech and language therapy, occupational therapy among others. Participants revealed in the study that these tertiary and specialized services are constantly needed by children with CP.

3.3 Parental factors

The choices made by parents as to whether to seek healthcare for their children with CP is dependent on other factors. According to Khatri and Karkee [14], parental factors are more likely to shape the health-seeking behavior of individuals. Study participants were therefore asked questions on parental factors that can influence access to healthcare services for children with CP. From the study findings, participants mentioned knowledge of disability, perception about disability (CP), income spent on child’s health care, transportation cost, and satisfaction as factors that influence access to healthcare services for children with CP (Figure 2).

3.3.1 Causes of disability

Concerning knowledge of the causes of disability, some participants attributed it to spirituality, brain damage (medical condition), and diseases. Some participants believe that haters from families can make a child have a disability through witchcraft and voodoo especially when the child has a bright future. The study revealed that parents with such beliefs do not seek medical care for their children but rather seek spiritual healing for their children with CP.

3.3.2 Symptoms of CP

Regarding the signs and symptoms of CP, the following were mentioned: poor eye contact, poor posture, and balance, communication, as well as impaired fine and gross motor function.

3.3.3 Treatment

Considering treatment, the majority of the respondents believed that CP cannot be treated (cured) but can be managed through the following means: Specialized healthcare services including physiotherapy, occupational therapy, speech and language therapy, and generalized healthcare services including primary healthcare like screening and health checkups. The majority of the respondents with this knowledge seek healthcare for their children with CP as revealed in this study.

3.3.4 Perceptions of disability

The results of the study also revealed that respondents share different perceptions of disability. Some of the respondents mentioned that disability can result in stigmatization, discrimination disrespect, loneliness, depression, and even suicide. Respondents agreed that when someone has a disability stigmatization and discrimination inevitably lead to depression, loneliness, and suicidal ideation. The study showed that respondents with such perceptions feel reluctant to seek healthcare for their wards with CP with the fear of being stigmatized and discriminated against. Some participants also mentioned that disability can be frustrating and lead to the loss of a job.

Participants believed that negative perception about disability may lead to less access to healthcare services for children with CP while the positive perception may lead to frequent access to healthcare services. Respondents with a negative perception of disability do not seek regular healthcare for their children with CP but rather go to seek spiritual healing for their wards with CP. Also, it was revealed that respondents with positive perceptions frequently seek healthcare for their children with CP.

3.3.5 The financial burden on a child with CP health care

The study showed that the majority of the respondents are not able to access healthcare for their wards with CP as they spend a greater part of their income on their child’s health. Participants agreed that the healthcare needs of children with CP are a lot and most expensive. They stated that specialized services like physiotherapy, occupational therapy, speech and language therapy, and special nutrition help to manage children with CP but these services are expensive and sometimes they find it difficult to access (Figure 2). However, some participants also specified that because of the expensive nature of specialized services they tend to do basic physiotherapy for their wards in their homes since they cannot keep up with the services in the hospitals. Participants were unanimous on how they spend so much money on both primary and secondary healthcare services for their children with CP and this discourages them from accessing healthcare services for their children with CP. Parents of children with CP all agreed that income level may influence access to healthcare services in either a positive or negative way depending on the kind of job a parent has (Table 2). The study revealed that access to healthcare services for children with CP is higher among parents with a higher income than those with a lower income. Some participants also stated that the kind of job one does determine the level of income.

3.4 Transportation

The study revealed that parents of children with CP do experience transportation problems and that discourages them from accessing healthcare services for their children with CP. All participants agreed that transportation is another factor that influences access to healthcare services. The majority of the participants stated that their means of transportation to the hospital is public transport (trotro, taxi, uber). All participants mentioned that transportation problems include access to public transport, transportation cost, and stigmatization in public transport.

Concerning access to public transport majority of the respondents agreed that most public transport designs are not accessible and friendly to children with CP. This makes it difficult for them to access public transport to a health facility. It was also revealed in this study that all respondents agreed there is no designated space for persons with disabilities inside public transport. This makes them feel very uncomfortable when using public transport to a health facility. Findings from this study showed that respondents who use public transport do not frequently access healthcare services for their children with CP as they are discouraged from all the hustle and frustration, they face from accessing public transport.

Some of the participants asserted that transportation cost to the closest health facility is expensive and, in most cases, uber or taxi drivers do not want to render services to them due to their children with disabilities. Participants also believed that commercial drivers (uber and taxi) charge them a higher cost because of their children with disabilities. The study found that passengers, conductors (mate), and commercial drivers (trotro) do stigmatize parents of children with CP when boarding a car to a health facility. Study participants specified that passengers do not want to sit by them with the belief that they will end up having a child with a disability and also bus conductors (mate) and commercial drivers (trotro) also ask them to pay for the entire seat or else they will not pick them up. This discourages parents from accessing healthcare for their children with CP.

Also, some respondents mentioned that stigmatization from passengers, bus conductors, and drivers do put them off sometimes and not access healthcare for their child with CP.

3.4.1 Satisfaction

The results of the study showed that participants agreed that satisfaction with health care services does influence their access to healthcare. The participants attributed satisfaction to quality health care, waiting time for treatment, and cost-effectiveness of healthcare services. Respondents explained quality health care as the one that is considered to be safe, efficient, inclusive, patient-centered, timely, and that makes customers happy. Respondent also believed that when patients do not get quality healthcare, they may reduce the number of times they visit a particular health facility or they may stop accessing health care from those particular health facilities.

3.5 Identification of health service needs (health care factors)

From the study findings, participants were generally able to identify healthcare factors that include specialized services availability, proximity to an available health facility, availability of specialist healthcare providers, accessibility of building and equipment, and healthcare provider’s attitude do influence access to healthcare services for children with CP (Figure 2).

3.5.1 Availability of specialized services

Respondents mentioned some specialized services that health facilities need to make available for children with CP, these include speech and language therapy, physiotherapy, occupational therapy, behavioral therapy, augmentative communication, and dietary approaches. Respondents believed that these specialized services help children with talking, walking, participating in the activities of daily life (such as brushing teeth and getting dressed), interacting with others, learning social skills, and managing their emotions. Study participants mentioned that they feel encouraged to access health care from health facilities that provide specialized services.

3.5.2 Proximity to an available health facility

All study participants mentioned that distance from a patient’s (clients) home to the nearest health facility can influence access to health care. Participants believed that clients are discouraged to access the closest health facility when they face a transportation problem and have to travel far distances. However, clients whose home is not too far from the nearest hospital is encouraged to access healthcare for their child with CP.

3.5.3 Availability of specialist healthcare providers

From the study findings, participants acknowledged and stated that the availability of rehabilitation specialists in health centers influences their access to healthcare for their children with CP. Respondents asserted that some hospitals have specialized services written on their signboards but do not provide such services because specialists are scarce. This influences their decision to access healthcare services from certain health facilities. Respondents believed that rehabilitation specialists like physiotherapists, speech and language therapists, and occupational therapists are very few and scarce in Ghana, especially in the rural areas. Respondents also asserted that they have to travel long distances to access these specialized services in the urban centers which sometimes transportation cost and rehabilitation cost becomes a challenge to them.

3.5.4 Accessibility of building and equipment

Study participants agreed that many health centers are not disability-friendly. They linked the accessibility of the building to the physical environment of the health facility including entrance to consulting rooms, OPD, and top floors. Some participants also stated that equipment like standing frames, power tables, parallel bars, and stand-assist devices in most hospitals are not friendly to children with CP (Table 3). Participants believed that most rehabilitation equipment in certain hospitals is meant for stroke patients and not for children with CP.

Accommodations	Suggested approaches
Using features of universal design equipment	Height-adjustable examination tables, seated scales, accessible wheelchair diagnostic equipment including mammography equipment
Structural modification of facilities	Configuring the layout of clinical examination rooms, installing ramps and grab rails, ensuring barrier-free path from transit to the clinic, widening doorways, installing lifts, modifying washrooms (toilet and urinal), providing adaptable seats for those who cannot stand.
Communicating health information in appropriate formats	A health care provider can provide health information in large prints, braille, picture format, audio, or even in the video; speaking clearly and slowly to clients to ensure understanding, providing sign language interpreting services.
Using alternative models to deliver health service	Using mobile clinic services, telemedicine, assistance with transportation to a health facility.

Table 3.

Reasonable accommodation and suggested approaches.

3.5.5 Healthcare providers attitude

Attitudes of healthcare providers play a significant role in parents’ decisions to access health care for their children with disabilities. Some participants acknowledged the fact that not all healthcare providers’ attitude is bad. However, the majority of the respondents stated that their experience with healthcare providers has been bad and that discourages them from accessing healthcare for their children with CP. It was strongly perceived that bad behavior like discrimination from healthcare providers towards parents of children with CP would rather discourage them from accessing health care.

4. Discussion

4.1 Knowledge of National health policy

The level of knowledge of the National Health Policy was well known among almost all the participants as it was considered a policy that aims to promote health for everyone in Ghana. This view is similar to Vartan and Montuschi’s [15]‘s assertion that the national health policy has been developed to promote, restore, and maintain good health for all people living in Ghana. Participants also explained their knowledge of the national health policy from the persons with disabilities Act perspective as a means of getting access to healthcare services without any barrier or discrimination. This finding in this study is consistent with the Americans with Disability Act (1990) Section 504 of the Rehabilitation Act that forbids discrimination based on disability and also the Person with Disability Act (2006) of Ghana Section 4 (1) and (6) that prohibit discriminate, exploit or to subject a person with disabilities to abusive or degrading treatment.

The present study findings indicate that the majority of the respondents had sufficient knowledge regarding the NHIS (NHIS) describing it as a safety net that replaces the cash and system of service delivery in Ghana. This finding is in agreement with a study conducted by Akande and Akande [16] on “The Awareness and Attitude of Practitioners on NHIS in Llorin showed that all respondents were aware of the scheme but only a few did not know. Another study conducted by Dixon et al. [17] on “Ghana’s NHIS: a national level investigation of members’ perceptions on service provision in Ghana” found that the NHIS replaces cash-and-carry, which required individuals to make a payment from their pockets at service usage. However, another study by Gopalan and Durairaj [18] showed that better-educated individuals can access diverse sources of information, correctly process and take advantage of benefits than those who are less educated and those without formal education. Those who could not afford to spend more on the healthcare needs of children with CP may adopt other coping mechanisms such as alternative care, presenting late at the health facilities, or not receiving care at all.

4.2 Perception of implementation of National health policy

Findings from this current study revealed that respondents are influenced in accessing health care for their wards even when they are insured as they perceived the implementation of the National Health Policy to be ineffective concerning poor-quality health service for the insured. This finding is similar to Bruce et al. [19] study results on “The perceptions and experiences of health care providers and clients in two districts in Ghana” which showed that insured clients are not satisfied with the healthcare they received and perceived that they were given poorer quality services and tend to wait longer as compared to those making Out of Pocket Payment (OOP). The present study also revealed that the implementation of the National Health Policy is ineffective as respondents perceived that it does not cover major specialized services and treatment for children with CP. This study finding is in contrast to Dalinjog and Laar’s [20] study on “The effectiveness of the National Health Policy in Ghana” which found that both insured and uninsured respondents had positive perceptions and were satisfied with the care provided.

4.3 Parental factors

The study discovered that participants were generally aware of some of the factors that influence access to healthcare services among children with CP. A study conducted by Khartri and Karkee [14] showed that distance to health facilities, social support, age, the behavior of health workers, and access to quality health services shapes how parents access healthcare for their children and themselves. This finding is in agreement with Boz et al. [21] study on “The affecting factors of healthcare services demand in terms of health services use: A field application in Edirne city” found that personal income, gender, attitudes, and behaviors of physicians affect access to healthy demand. In the same study, it was reported that family members, perception of economic level, attitudes, and behaviors of physicians were found to influence health demand. Findings from this current study revealed that participants know about disability regarding the causes, signs, and symptoms as well as treatment for children with CP. This positively influenced parents’ access to healthcare for their children with CP. This finding is consistent with Matt’s [22] study on “Perception of disability among caregivers of children with disabilities in Nicaragua” which found that parents with higher education have a better understanding and knowledge of their children’s disability and frequently access health care services for their wards than parents with lower or no education. The current study findings also agree with Khatri and Karkee’s [14] assertion that illiterate parents who belong to the lowest wealth quintile have lower access and use of healthcare for their children with CP.

Also, considering the causes of disability, this current study revealed that respondents know the causes of disability. Findings from the study showed that disability can be caused by disease and neurological problems leading to brain damage. This finding is in agreement with the Center for Diseases Control and Prevention [23] assertion that risk factors such as infections during pregnancy, premature birth, and diseases like jaundice can cause CP.

Respondents in this study linked signs and symptoms of CP to poor eye contact, poor posture and balance, communication difficulties, and impaired fine and gross motor function. This finding agrees with the CP Alliance [24] assertion that children with CP show signs and symptoms like swallowing difficulties, poor muscle spasms, low muscle tone, poor muscle control, reflexes, and posture, drooling, developmental delay, gastrointestinal problems, and not walking by 12–18 months. It was found from this study that treatment for children with CP includes physiotherapy, occupational therapy, and speech and language therapy. This finding is consistent with the CP Guide [25] statement that children with CP can improve their motor skills with alternative therapy, medication, and surgery through multidisciplinary teams such as neurologists, orthopedic surgeons, developmental pediatricians, physiotherapists, occupational therapists, nutritionists, respiratory therapists, psychologists to assess ability and behavior and speech and language, therapist.

It was also found in this study that perceptions of parents about their children’s disability (CP) also influence their decision to access healthcare for their children with CP. It was also established that stigmatization, discrimination, disrespect, loneliness, depression, and suicidal ideation are linked to disability (CP). This is similar to Physioplus’s [26] assertion that families with a child with a disability are more prone to depression, suicide, financial problem, relationship challenges, divorce, and bankruptcy. This statement is also in line with another study by Butchner [27] on “society’s attitude towards persons with disabilities” which found that society perceives that disability is a curse and punishment from ancestors and gods. Also, Duran and Ergun [28] in their study on “The stigma perceived by parents of children with disability: an interpretative phenomenological analysis study in Balikesir found that the majority of people often have negative perceptions and stigmatizing attitudes towards children with disabilities (CP) and their families. In the same study, it was found that parents of children with disabilities cope with insults and rude behaviors from community members while they struggle with the challenges of their children with CP. This is similar to a previous study by Opoku et al. [6] who affirmed that persons with disabilities are severely stigmatized, discriminated against, and excluded from all forms of the development process resulting in limiting their opportunities to be engaged in decision-making and accessing healthcare.

Income was found from this current study to influence parents’ access to health care services for their children with CP. Respondents emphasized that the level of income of a parent is dependent on the kind of job the parent does. This present study revealed that parents of children with CP who have no jobs find it difficult to access healthcare services for their wards due to the cost of treatment. This finding is in line with DeVoe et al. [29] assertion that children with CP from lower-income families experience more gaps in healthcare than children with CP from higher-income families.

Moreover, this study discovered that transportation is another factor that influences access to health care. Findings from this study indicated that transportation cost, distance to the nearest health facility, and stigmatization from drivers, passengers, and bus conductors (mate) influence respondents’ ability to access healthcare services for their children with CP. A previous study showed that healthcare utilization is influenced by the direct costs of healthcare services, travel time, and patient income [30]. This is in line with another study conducted by Bulamu Healthcare [31] in Uganda which specified that patients complain about poor sanitation, lack of drugs and equipment, long waiting times, rude behavior of health workers, and poor referrals. However. in that same study it was revealed that over 8000 rural Ugandans travel as far as 50 miles to attend a Bulamu weeklong medical camp for healthcare.

Also, findings from this present study showed that respondents are not satisfied with the waiting time and cost of health care services. Respondents from this present study linked healthcare satisfaction to quality health care, waiting time for treatment, and cost-effectiveness of healthcare services. This assertion is consistent with Khatri and Karkee’s [14] statement that quality health care accounts for patient satisfaction especially in terms of waiting time, cost of service, coordination, information, and physician’s behavior. This finding agrees with Janzek-hawlat’s [3] findings that some physicians in public health facilities can be very rude due to the workload mounted on them.

4.4 Healthcare factors

Considering specialized services available, the present study found that respondents were informed about the available specialized services for their children with CP. It was discovered that speech and language therapy, physiotherapy, occupational therapy, behavioral therapy, augmentative communication, and dietary were some of the specialized services available but scarce and that makes it difficult to access healthcare for their children due to waiting time for treatment. Respondents in this present study believed that children who can access these services will be able to walk, interact with others through play, learn social skills, seat properly, and have good muscle and neck control as well as good balance and body posture. This finding agrees with Balcı’s [32] study on “Current Rehabilitation Methods for Cerebral Palsy” which found that children with CP that undergo muscle strengthening training, manual stretching, massage, neurodevelopmental treatment, conductive education, speech and language therapy, occupational therapy, and dieting have good body posture, balancing, neck coordination, strong muscle control and can walk sometimes. However, the lack of appropriate services for individuals with CP is a significant barrier to health care. For instance, qualitative research in Uttar Pradesh and Tamil Nadu states of India revealed that after the cost, the lack of services in the area was the second most significant barrier to using health facilities [8, 9].

Also, it was found from this current study that proximity to an available health facility is another factor that influences access to healthcare for children with CP. From the study, respondents were discouraged to access the nearest health facility when transportation and distance to the health facility are problems. This finding is similar to Awoyemi et al. [33] study on “Effect of Distance on Utilization of Health Care Services in Rural Kogi State in Nigeria” which found that distance and total cost of healthcare affects the utilization of both public and private hospitals. This finding also agrees with Nesbitt et al. [34] study on “Barriers and facilitating factors in access to health services in the Republic of Moldova” which found that distance from a health service provider, travel time, and waiting time to see a health professional is are strong factors that influence access to health care.

Moreover, the availability of specialists in hospitals was found in this present study to be scarce in most hospitals, and because of that, only a few respondents travel a long distance to access these specialized services for their wards. This finding is consistent with WHO [35] reported that the registered number of rehabilitation specialists is far below the required minimum of 750 per 1 million even in developed countries. In addition to this, the present study revealed that most public and private hospitals are not environmentally friendly for children with CP who use wheelchairs. Respondents asserted that most public hospitals do not have elevators and ramps making it difficult to access healthcare services for their wards. This finding is in line with Jamshidi et al. [36] study on “The effects of environmental factors on the patients’ outcomes in hospital environments: A review of the literature” found that medical equipment adaptability, unit layout, room features, ramps, and elevators affect patients’ access to healthcare. Another study by Douglas and Douglas, [37] revealed that patients’ need for personal space, a homely welcoming atmosphere, a supportive environment, ramps, and elevators influence access to their healthcare. Cristina and Candidate [11] also found in their study that out of 256 respondents, 9 (4%) were not able to access the building and 47(18%) were not able to be transferred from their wheelchair to the examination table.

It was also found from this study that some healthcare providers discriminate against parents of children with CP when seeking primary healthcare services and physiotherapy. This finding agrees with the WHO [8, 9] report that parents of children with disabilities face stigmatization and discrimination in most health facilities. This finding is also in line with Rogers et al. [38] study on “Discrimination in healthcare settings is associated with disability in Older Adults: Health and Retirement Study, 2008-2012” which revealed that 12.6% experienced discrimination infrequently whilst 5.9% experienced discrimination frequently.

5. Conclusion

The study established that many respondents believed that most healthcare facilities are not physically accessible due to the absence of ramps and elevators. Respondents are discriminated against and stigmatized both in hospitals and on public transport. It was also found that many public means of transport are not accessible to children with CP. Respondents believed that the National Health Policy is ineffective and the NHIS does not cover a wide range of services for children with CP. Moreover, the study also pointed out that the majority of the respondents seek medical care for their children with CP however others also seek spiritual healing for their children with CP.