Background: People with disabilities are at higher risk of adverse coronavirus disease 2019 (COVID-19) outcomes. Additionally, measures to mitigate COVID-19 transmission have impacted health service provision and access, which may particularly disadvantage people with disabilities.

Objectives: To explore the perspectives and experiences of people with disabilities in accessing health services in Zimbabwe during the pandemic, to identify perceived challenges and facilitators to inclusive health and key actions to improve accessibility.

Methods: We used in-depth interviews with 24 people with disabilities (identified through purposive sampling) and with 10 key informants (from expert recommendation) to explore the impact of COVID-19 on access to health care. Interviews were transcribed, coded and thematically analysed. We used the disability-inclusive health ‘Missing Billion’ framework to map and inform barriers to inclusive health care during COVID-19 and disparities in outcomes faced by people with disabilities.

Results: People with disabilities demonstrated good awareness of COVID-19 mitigation strategies, but faced difficulties accessing COVID-19 information and health services. Challenges to the implementation of COVID-19 guidelines related to a person’s functional impairment and financial ability to do so. A key supply-side constraint was the perceived de-prioritisation of rehabilitation services. Further restrictions on access to health services and rehabilitation decreased an individual’s functional ability and exacerbated pre-existing conditions.

Conclusion: The immediate health and financial impacts of the COVID-19 pandemic on people with disabilities in Zimbabwe were severe. Government departments should include people with disabilities in all communications and activities related to the pandemic through a twin-track approach, meaning inclusion in mainstream activities and targeting with specific interventions where necessary.

Keywords: disability; COVID-19; Zimbabwe; qualitative; equity; Missing Billion; inclusion; health system; health access.

Background

People with disabilities experience inequities in health access and outcomes, and these are potentially magnified with respect to coronavirus disease 2019 (COVID-19) (Shakespeare, Ndagire & Seketi 2021a). Estimates from the UK show that at least 58% of deaths related to COVID-19 between January 2020 and February 2021 were amongst people with disabilities, although they only made up 17% of the population (Bosworth et al. 2021). The increased risk of people with disabilities to COVID-19 mortality appears to occur for a combination of reasons, including higher risk of contracting the disease (e.g. difficulties socially isolating, lack of accessible guidance on preventing infection) and vulnerability to more severe morbidity (e.g. on average older with more pre-existing conditions and more likely to live in deprived circumstances) (Shakespeare et al. 2021). People with disabilities will also often need routine health care, such as a supply of medication and physiotherapy, which may be disrupted because of COVID-19, leading to further decreased physical and mental health and functioning (Shakespeare et al. 2021b; Steptoe & Di Gessa 2021).

Limited available data suggests that the impacts of COVID-19 on people with disabilities are also noted in low and middle-income countries (LMICs), including Zimbabwe. For instance, a rapid mixed-methods review on the impacts of COVID-19 on people with disabilities and its effect on the health delivery system in Zimbabwe found that there were no structures in place in 2020 to accommodate testing of people with disabilities. They had limited access to COVID-19 information, and most health delivery services were inaccessible (Manikai 2020). Organisations of persons with disabilities (OPDs) were not actively engaged or consulted in the formulation, development or implementation of the National COVID-19 Response Plan (Manikai 2020). The report concludes that the barriers to accessing routine health care and the inequity that people with disabilities experience has limited their self-efficacy and further marginalised people with disabilities in Zimbabwe. Moreover, health workers found implementing the measures particularly difficult without access to water, personal protective equipment (PPE) and daily income (Mackworth-Young et al. 2021). The devastating economic effect that public health measures such as curfews, bans on transport and lockdowns have on populations that are largely dependent on the informal economic sector were also highlighted (Dzobo, Chitungo & Dzinamarira 2020).

There has been a lack of consideration, however, of the experiences of people with disabilities in accessing health care during COVID-19 and the impact thereof on health outcomes in Zimbabwe, or other LMICs. This information is needed to inform how health systems should be strengthened to offer a disability-inclusive COVID-19 response. The ‘Missing Billion’ Report (Hogan 2020; Litullo 2019) (Figure 1) provides a framework for how to identify components of the health system that require strengthening in order to provide disability-inclusive health. The framework proposes consideration of barriers and facilitators from the perspective of people with disabilities – ‘demand’ (e.g. affordability), service providers – ‘supply’ (e.g. accessible health facilities) and at the systems level (e.g. leadership).

Evidence is lacking for Zimbabwe on what the perceived challenges and facilitators were to inclusive health during the COVID-19 pandemic, and key actions to improve accessibility and design of the health system for inclusion. We aimed to explore the perspectives and experiences of people with disabilities in accessing health services in Zimbabwe during the pandemic to identify perceived challenges and facilitators to inclusive health and key actions to improve accessibility.

Methods

Our methodological approach and consequent reporting were underpinned by the Consolidated Criteria for Reporting Qualitative Research (COREQ) statement, which is a 32-item checklist (Tong, Sainsbury & Craig 2007).

Study design

This qualitative study was undertaken alongside a companion study to understand the access to health services for people with disabilities in Zimbabwe prior to COVID-19 (Smythe et al. in press). This qualitative study focused on experiences and perceptions of people with disabilities in accessing health care during the COVID-19 pandemic and key actions to improve accessibility.

Setting

The study was conducted in the capital city Harare and rural and urban areas of Gutu between 31 May and 12 June 2021. The focus was on the public health sector that primarily services the low-income and informal settlement populations. Participants included 24 people with disabilities in Gutu and 10 key informants from local and national health authorities in Gutu and Harare.

Participants

We used purposive sampling to recruit people with disabilities through non-governmental organisations (NGOs) and OPDs. The NGOs and OPDs recommended information-rich cases and provided the researchers with a contact list. People with disabilities were then purposively selected to ensure representation by impairment type or condition (e.g. physical, sensory, intellectual), age (children, working-age, older adults), gender and level of support needed for daily life (e.g. none or minimal, ongoing health care or social service needs, requiring carer support for activities of daily living) (Table 1). We used expert recommendation to recruit key informants. Key informants were selected based on their pivotal role and experience in disability programming. All participants were approached through telephone calls. Two individuals who agreed to be interviewed were subsequently unable to take part in the interviews because of health-related concerns.

Data were collected through in-person interviews at the home of people with disabilities and at the place of work of key informants. The majority of participants were interviewed face-to-face. Carer or proxy interviews were used for children below the age of consent (10 years as per national guidelines) and for people with severe difficulties understanding or communicating even with available adaptations (e.g. people with hearing loss, illiterate and with no knowledge of sign language; people with severe intellectual or cognitive impairments). Children aged 10 years or older but below the age of consent participated in interviews with parental consent and individual assent.

Inclusion of people with disabilities was supported through the provision of psychological support services when needed, sign language interpretation, accessible interview sites and transport, use of available district psychological services and researchers skilled at communicating with people with cognitive impairments.

Data collection

Interview guides with questions and prompts (Appendices 1 and 2) were developed and cognitively tested for understanding and administered in English or Shona by trained research assistants. The research assistants were three women with disabilities who had completed tertiary education. They underwent a one-day online training that included presentation of the study protocol and qualitative methods. Next, they attended a two-day in-person training on data collection, with ongoing mentoring and support provided by the study team. No interviews were repeated and transcripts were not returned to participants for comment. Interviews took between 30 and 60 min and were audio recorded with written consent from the participants. Field notes were made during and after the interviews.

Data management and analysis

These processes were the same as for the companion paper (Smythe et al., in press). All interviews were transcribed verbatim for analysis and translated into English where necessary. Data were managed using NVivo 12. Interview transcripts and detailed notes were analysed using thematic analysis (Guest, Macqueen & Namey 2012). A coding framework was developed using the semi-structured interview guide as a starting point, which was adapted to include additional codes and themes emerging from the data. An allied health professional and epidemiologist from Zimbabwe, with experience in both qualitative and quantitative research methods (TS) coded the interview transcripts to identify the key themes emerging from the data. These were discussed across the entire team, including the research assistants, and analysis was evaluated by research team members (TM, SM, TK and SR), to ensure that interpretations were credible and valid. Regular discussions with the research team took place throughout the data analysis phase to ensure content validity and context.

To explore inclusive health practices during the COVID-19 pandemic, we applied the Missing Billion health system framework (Figure 1) (Hogan 2020; Litullo 2019) to map and inform the perceived and experienced barriers and facilitators to health services. We undertook a narrative synthesis of the findings and reported the results alongside the framework. The predominant focus was on the service delivery components of the framework, including the demand and supply-side perspectives.

Ethical considerations

Ethical approval for the study was granted from the Medical Research Council of Zimbabwe (MRCZ) (No MRCZ/A/2731) and the Institutional Review Board at London School of Hygiene & Topical Medicine (No 22138 – 2).

The main ethical considerations were the same as for the companion study (Authors, under review, Part 1). We managed participant expectations by describing in detail the nature and detail of our study. We assured confidentiality by not linking any data to particular participants. Informed consent was sought after providing a written information sheet and reiterating the information verbally in the language of choice (English or Shona). The research assistants facilitated referrals, as necessary, to medical services and/or OPDs. All interviewees were compensated for their time and transport was reimbursed.

Results

Data are presented under the five themes that comprise the Missing Billion framework (Kuper & Heydt 2019) on demand and supply side factors for service delivery: demand – autonomy and awareness, affordability; supply – human resources, health facilities, specialised services and assistive technology. Table 2 provides an overview of the themes and sub-themes identified.

Demand-side factors

Challenges and facilitators from the perspective and experience of the person with disabilities (i.e. ‘demand-side’) were observed in awareness about COVID-19 mitigation, autonomy to implement these strategies, and affordability.

Demand – Autonomy and awareness

People with disabilities generally demonstrated good awareness of COVID-19 mitigation strategies, and required actions. Masking, washing hands and keeping distance from others were most commonly mentioned. These measures were mainly learnt about through the radio, and from community leaders. Caregivers spoke of people with hearing impairments facing problems with communication; they were excluded from understanding messaging on the radio, which left them marginalised from the spoken world. In addition, masking created a barrier to communication, where:

People with visual impairment also reported informational barriers as they were reliant on others to share current information:

One of the OPDs that we interviewed highlighted that people with disabilities had many unanswered questions and did not often know what information to believe. The rumours spread fear and uncertainty, for example:

Difficulties arose for people with disabilities in the implementation of COVID-19 guidelines. Many caregivers and people with disabilities experienced exclusion, fear and pain when attempting to follow national guidelines. The demands of physical distancing limited people’s ability to communicate and participate in daily life. People with physical impairment who required a caregiver for mobility experienced greater isolation and limited independence because of caregivers’ fear of being unable to comply with physical distancing guidelines:

Attempting to adhere to recommendations created pain and discomfort for people with albinism, who have skin that is sensitive:

With regard to the ability to adhere to guidance, the main challenges to implementation of COVID-19 guidelines related to a person’s functional impairment and financial ability to do so. Physical distancing and self-isolation measures were not feasible for some people with disabilities who relied on caregivers. Those that required assistance for daily activities experienced greater anxiety with regard to physical contact with their caregiver, and in relation to fear of transmission of COVID-19 through their metal assistive product. For example:

People with physical impairments who required assistance for mobility experienced limited ability to access water, and people with visual impairments voiced concern about whether the water would be clean or not:

Caregivers reported that explaining mitigation strategies to people with intellectual impairment was challenging and often unsuccessful:

The lack of access to transport to attend hospital check-ups and the presence of roadblocks to minimise movement led to additional challenges for people with disabilities and impacted their functioning. While the restrictions were the same for everyone, the ability to follow these measures was further limited by administration requirements to access transport. This difficulty was also reported by many OPDs. One representative highlighted:

Regarding the perceived excess risks of COVID-19, people with disabilities viewed the risk of contracting COVID-19 differently, and this perception depended on their social contact, beliefs about their physical strength, the state of their immune systems, and the extent to which they were reliant on others for daily care. Those who were already isolated did not perceive COVID-19 as a greater risk than people without disabilities, and they reported spending most of the day alone and with no meaningful activity and contact with other individuals:

The pandemic highlighted the extent of how fragile the social bonds for people with disabilities were, and a key feature was perceived personal vulnerability because of being reliant on others. Participants felt an extra burden of responsibility to protect themselves and their own health, whilst the perception was that people without disabilities may not adhere to COVID-19 regulations as required:

However, vulnerability was felt more acutely by those who perceived their bodies to be weaker:

Anxiety and strain were also experienced by caregivers who perceived people with disabilities as being at greater risk of contracting COVID-19, as summarised by the following quotes:

This meant that additional strain was experienced by caregivers as they did not rely on external help. The perceived need to keep people with disabilities safe created pressure for families.

Demand – Affordability

Lack of affordability created tensions between public health advice and the ability to practise them effectively:

When asked what is used when there is no soap, one person with disability replied that where water was scarce or inaccessible that ‘we use ashes’ (Participant 23).

People with disabilities felt forgotten and alone when faced with the additional challenge of having to prioritise their general health and prevent further impairment against that of COVID-19 prevention measures:

Increased pressures on social protection schemes intensified economic and social exclusion of persons with disabilities. People with disabilities believed that their livelihoods were disproportionately impacted and this was reinforced by the experiences of OPDs:

Livelihoods were linked to quality of, and ability to access health services. Whilst some health services were offered for free at clinics, NGOs and representatives for mission hospitals no longer came to local clinics, and if medications or services were not available, people with disabilities had no other option because of their limited ability to pay. People with disabilities experienced a disproportional impact and consequences of the already inadequate health systems.

Supply-side factors

Challenges and facilitators from the perspective of the health system (i.e. ‘supply-side’) were observed in human resources, appropriate health facilities and specialised services.

Supply – Health facility availability

Measures to mitigate COVID-19 transmission have directly and indirectly impacted health service provision and access, including through supply chain disruption and diverting resources. People with disabilities believed that their needs did not matter as restrictions mandated by the government, which were aimed at stemming the spread of COVID-19, severely limited their access to basic health services:

Health care provider attitude and competence emerged as factors influencing the perceived supply of health services. People with disabilities avoided seeking health services due not only to fears of becoming infected with COVID-19 and the punitive action for breaching measures such as movement restrictions, but also as a result of the poor interpersonal relationship with health care providers:

Greater disruptions in other medical supply chains further limited health service provision:

Supply of medications were limited at source, and OPDs no longer received their regular donations:

Different mitigation strategies were implemented to overcome these gaps in availability. For instance, community support and ‘togetherness’ was key to being able to access basic health needs:

There were some examples where the health services helped overcome these issues by strengthening outreach to the community:

Supply – Specialised services and assistive technology

Rehabilitation services were deprioritised because of the COVID-19 exposure risk to patients and staff: ‘Rehabilitation centres were not available because they involve a lot of physical contact, so the government dissuaded people from running operations during the pandemic’ (Key Informant 10). However, the services remain limited as ‘community rehabilitation is not being practised these days because of lack of resources’ (Key Informant 05). The need for assistive products and interventions that can optimise functioning do not stop because of COVID-19, yet services to provide these have been reduced:

This reinforced the belief of people with disabilities that their lives are less valued in Zimbabwe society, as demonstrated by the following quotes: ‘After being looked down upon, this type of treatment also reduces the confidence of disabled people’ (Key Informant 01), and ‘we feel like the government is not interested in addressing the needs of people with disabilities. NGOs come here and they don’t include us either’ (Key Informant 03).

Outcomes and impact on functioning

All participants raised concerns that a singular focus on prevention and treatment of COVID-19 led to a severe disruption in medical treatment, health services and rehabilitation. Long periods of isolation heightened mental health, economic and financial pressures, and all people with disabilities that we spoke to shared a belief that they experienced worsening health and well-being during this time:

People with disabilities reported experiencing burns from uncontrolled seizures near open fires, worsening eyesight without access to glaucoma medication (via eye drops that reduce eye pressure and thereby protecting the optic nerve) and poorer mental health as a result of psychiatric medications being unavailable at clinics and unaffordable at private chemists.

The well-being of people with disabilities was also affected, and they reported increased fear and anxiety that centred around medical stockouts and deterioration of their pre-existing condition:

The national COVID-19 response limited access to both general health care and rehabilitation, which exacerbated pre-existing conditions and decreased the functional abilities of people with disabilities.

Discussion

The immediate health and financial impacts of the COVID-19 pandemic on people with disabilities have been disproportionate and severe. Our study has highlighted inequities in society and structural shortcomings within Zimbabwe where the needs of people with disabilities have not been protected in rural or urban areas. While people with disabilities demonstrated good awareness of COVID-19 mitigation strategies, demand was limited by difficulty accessing COVID-19 information and health services. A person’s functional impairment and socio-economic status were barriers to implementation of COVID-19 guidelines. Supply was constrained by perceived de-prioritisation of rehabilitation services; people with disabilities felt abandoned and forgotten and experienced heightened fear and anxiety. Further restrictions on access to health services and rehabilitation decreased their functional ability and exacerbated pre-existing conditions. Uncertainty in outcome or standard of care emerged as a key recurring experience, which created distress, a sense of fear and a loss of hope.

Further deprioritising people with disabilities during the COVID-19 pandemic has heightened their marginalisation and experiences of inequity. Barriers to accessing care were similar to non-pandemic times (Authors, under review, Part 1), where the demand for health services was limited by health literacy affordability of services, and supply of health services was constrained by perceived poor capacity of health workers to treat people with disabilities, discrimination and inaccessible information and infrastructure. This study found that these everyday barriers were heightened during the pandemic, for example, where physical accessibility affected implementing basic hygiene measures. Our data call attention to the exclusion of people with disabilities and suggest that many people with disabilities and their families have felt abandoned and forgotten during the pandemic, similar to other findings globally (Shakespeare et al. 2021). People with disabilities have not been considered or involved in planning of measures taken to contain the COVID-19 pandemic. A qualitative analysis of media from Ghana, Guinea, Liberia, Niger, Nigeria and Sierra Leone found that people with disabilities were often not consulted during policymaking and thus were deprived from effectively benefitting from the special initiatives that governments took to fight COVID-19 (Saalim et al. 2021). This is a pattern that has been repeated (Kuper et al. 2020; Reichenberger et al. 2020; Shakespeare et al. 2021a, 2021b).

Our key findings are similar to those in South Africa, where exclusion of people with disabilities was exacerbated by the national COVID-19 response (Ned et al. 2020). Key disability-specific health services were not considered as essential services during the initial stages of lockdown, and people with disabilities experienced limited healthcare and rehabilitation access, which was influenced by structural failings (McKinney, McKinney & Swartz 2021). A qualitative study in Uganda found that the national COVID-19 response limited access to health and rehabilitation services for children with disabilities and called for greater attention to this marginalised group and their families when implementing mitigation measures and long-term responses (Mbazzi et al. 2021).

The need for additional support and targeted mental health services was highlighted by the impact of COVID-19 on anxiety and depression. During the first COVID-19 lockdown in Zambia and Sierra Leone, a survey of 468 children and young people who have disabilities and are disadvantaged found that participants had increased anxiety and fear (Sharpe et al. 2021). In Ethiopia, a high prevalence of depression, anxiety and insomnia was found in 423 respondents of a survey of people with disabilities (Necho et al. 2021) and these findings are echoed in the UK, where people with physical disabilities were found to be at particular risk for emotional distress, poor quality of life and low wellbeing during the COVID-19 pandemic (Steptoe & Di Gessa 2021).

With regard to meeting daily needs, the survey in Zambia and Sierra Leone (Sharpe et al. 2021) also showed that nearly 91% of participants reported that they needed considerable additional support with regard to finance, food and schooling. People with disabilities in the UK also experienced difficulty in meeting their daily needs (Shakespeare et al. 2021b). In Uganda, families of children with disabilities had difficulties meeting daily basic needs as they were unable to work and had no income during the COVID-19 related lockdown (Mbazzi et al. 2021).

Despite these findings on impact on healthcare and rehabilitation access, mental health and meeting everyday needs, there remain gaps in evidence. While there is evidence for impact on mortality for the UK, where 58% of deaths related to COVID-19 between January 2020 and February 2021 were amongst people with disabilities, although they only made up 17% of the population (Bosworth et al. 2021), data are limited in other settings. There is a lack of data being collected at national and international levels on impacts on people with disabilities, both in terms of infection and mortality rates, and the impact on poverty, employment, education and isolation in the community (Meaney-Davis 2020).

Our study has limitations that need to be considered when interpreting the results. This is a qualitative study, limited to a modest-sized group of people with disabilities living in rural and urban areas of Zimbabwe. A larger sample could have improved inter-group comparisons (e.g. differences between age groups) and generalisability to different health system contexts. Nevertheless, checks were in place to strengthen the integrity of data and interpretations, which included researchers with disabilities being trained to undertake the qualitative data collection, which likely improved data quality through strengthening the rapport of the interviewer and participant. However, the interviewers may also have brought their own biases to the interview, based on their personal experiences. Additionally, no interviews were repeated nor transcripts returned to participants for comment, and all the transcripts were coded by a single coder. We therefore had several checks in place to strengthen the integrity of data and interpretations. These included involving research assistants, who collected the interviews in data analysis and interpretation, and ongoing discussions amongst the whole team throughout data collection and analysis, particularly on our positionality and reflexivity. The Missing Billion framework provided a structure for consideration of challenges and solutions to inclusive health. We used this framework to consider demand and supply-side service delivery factors in this study but did not address systems-level factors such as governance and leadership. Strengths of our study include that face-to-face interviews were possible within the timeframe of the national COVID-19 response. We achieved both breadth and depth of functional impairment and age range.

There are many important lessons that are being learned on how to create a disability-inclusive COVID-19 response, including in low-resources settings. Government departments should meaningfully engage people with disabilities or their representative organisations to facilitate appropriate planning. A twin-track approach that addresses the general population needs as well as the specific needs of people with disabilities is required to include people with disabilities in all pandemic response communications and activities. This includes providing public health communication, including information on COVID-19 prevention and government response measures in accessible formats. Identifying and removing barriers to prevention measures for COVID-19 may include measures such as providing additional support and equipment to carers of people with disabilities. Collecting and analysing disability-disaggregated data, and gathering lessons learned on what works in disability inclusion in COVID-19 responses will inform financial measures and economic planning. Finally, strengthening referral of people with disabilities to social protection schemes will facilitate food and other distribution from accessible locations.

Conclusion

People with disabilities are a diverse group and are disproportionately impacted by COVID-19, both directly because of infection and indirectly because of restrictions to reduce the spread of the virus. Access to health care was limited in both rural and urban areas in Zimbabwe because of supply- and demand-side barriers. Seizing opportunities to prevent people with disabilities being further left behind and building on decades of progress on disability rights and economic empowerment may mitigate the widening of health inequalities in Zimbabwe.

Acknowledgements

We would like to thank Florence Saburi for her support in data collection as well as the community health projects for their support to this project. We also thank participants for their willingness to share their experiences with us.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

H.K. and S.R. conceptualised the study. S.M. and T.M. led data collection. T.S. conceptualised and led writing and analysis of this manuscript supported by H.K. T.M., S.M., T.K., H.K. and S.R. contributed to serial drafts of the study. All authors read and approved the final manuscript

Funded by AHRC, Grant Ref: AH/V01353X/1. The Arts and Humanities investigate the values and beliefs which underpin both who we are as individuals and how we undertake our responsibilities to our society and to humanity globally. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The datasets generated and analysed during the current study are not publicly available, as the small number of people with disabilities makes data potentially identifying, but are available from the corresponding author on reasonable request.

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

References

Bosworth, M.L., Ayoubkhani, D., Nafilyan, V., Foubert, J., Glickman, M., Davey, C. & Kuper, H., 2021, ‘Deaths involving COVID-19 by self-reported disability status during the first two waves of the COVID-19 pandemic in England: A retrospective, population-based cohort study’, Lancet Public Health 6(11), E817–E825. https://doi.org/10.1016/S2468-2667(21)00206-1

Dzobo, M., Chitungo, I. & Dzinamarira, T., 2020, ‘COVID-19: A perspective for lifting lockdown in Zimbabwe’, The Pan African Medical Journal 35, 13–13. https://doi.org/10.11604/pamj.2020.35.2.23059

Guest, G., Macqueen, K. & Namey, E., 2012, Applied thematic analysis, Sage, London.

Hogan, A.J., 2020, ‘Assessing global health care: The lens of disability’, American Journal of Public Health 110, 138–139. https://doi.org/10.2105/AJPH.2019.305479

Kuper, H., Banks, L.M., Bright, T., Davey, C. & Shakespeare, T., 2020, ‘Disability-inclusive COVID-19 response: What it is, why it is important and what we can learn from the United Kingdom’s response’, Wellcome Open Research 5, 79. https://doi.org/10.12688/wellcomeopenres.15833.1

Kuper, H. & Heydt, P., 2019, The Missing Billion: Access to health services for 1 billion people with disabilities, viewed 20 February 2022, from https://www.lshtm.ac.uk/TheMissingBillion.

Litullo, C., 2019, ‘Prioritising disability in universal health coverage’, The Lancet 394(10194), 187. https://doi.org/10.1016/S0140-6736(19)31638-1

Mackworth-Young, C., Chingono, R., Mavodza, C., Mchugh, G., Tembo, M., Dziva Chikwari, C. et al., 2021, ‘Here, we cannot practice what is preached’: Early qualitative learning from community perspectives on Zimbabwe’s response to COVID-19’, Bulletin of the World Health Organisation 99(2), 85–91. https://doi.org/10.2471/BLT.20.260224

Manikai, G., 2020, Rapid impact assessment of COVID-19 on persons with disabilities in Zimbabwe, UNESCO Regional Office for Southern Africa, Social and Human Sciences Sector, Harare.

Mbazzi, F.B., Nalugya, R., Kawesa, E., Nimusiima, C., King, R., Van Hove, G. et al., 2021, ‘The impact of COVID-19 measures on children with disabilities and their families in Uganda’, Disability & Society 34(5), 1233. https://doi.org/10.1080/09687599.2020.1867075

McKinney, E.L., McKinney, V. & Swartz, L., 2021, ‘Access to healthcare for people with disabilities in South Africa: Bad at any time, worse during COVID-19?, South African family practice : official journal of the South African Academy of Family Practice/Primary Care 63(1), e1–e5. https://doi.org/10.4102/safp.v63i1.5226

Meaney-Davis, J., 2020, What evidence and data is available on the potential financial and economic impacts of COVID-19 on people with disabilities? What measures can be taken to limit the negative economic consequences for people with disabilities?, viewed 20 February 2022, from https://www.sddirect.org.uk/media/2063/query-no-42-economic-impacts-of-covid-19.pdf.

Necho, M., Birkie, M., Gelaye, H., Beyene, A., Belete, A. & Tsehay, M., 2021, ‘Depression, anxiety symptoms, insomnia, and coping during the COVID-19 pandemic period among individuals living with disabilities in Ethiopia, 2020’, PLoS One 15(12), e0244530. https://doi.org/10.1371/journal.pone.0244530

Ned, L., Mckinney, E., Mckinney, V. & Swartz, L., 2020, ‘COVID-19 pandemic and sisability: Essential considerations’, Social and health Sciences 18, 136.

Reichenberger, V., Alburquerque, M., David, R.B., Ramos, V.D., Lyra, T.M., Brito, C.M.M. et al., 2020, ‘The challenge of including people with disabilities in the strategy to address the COVID-19 pandemic in Brazil’, Epidemiologia e Serviços de Saúde 29, e2020770. https://doi.org/10.1590/s1679-49742020000500023

Saalim, K., Sakyi, K.S., Fatema Tuz, Z., Morrison, E., Owusu, P., Dalglish, S.L. & Kanyangarara, M., 2021, ‘Reported health and social consequences of the COVID-19 pandemic on vulnerable populations and implemented solutions in six West African countries: A media content analysis’, PLoS One 16, e0252890. https://doi.org/10.1371/journal.pone.0252890

Shakespeare, T., Ndagire, F. & Seketi, Q.E., 2021a, ‘Triple jeopardy: Disabled people and the COVID-19 pandemic’, The Lancet 397(10282), 1331–1333. https://doi.org/10.1016/S0140-6736(21)00625-5

Shakespeare, T.W.N., Brunner, R., Cullingworth, J., Hameed, S., Scherer, N., Pearson, C. et al., 2021b, Disabled People in Britain and the Impact of the COVID-19 Pandemic. Preprints 2021, 2021010563.

Sharpe, D., Rajabi, M., Chileshe, C., Joseph, S.M., Sesay, I., Williams, J. et al., 2021, ‘Mental health and wellbeing implications of the COVID-19 quarantine for disabled and disadvantaged children and young people: Evidence from a cross-cultural study in Zambia and Sierra Leone’, BMC Psychology 9, 79. https://doi.org/10.1186/s40359-021-00583-w

Smythe, T., Mabhena, T., Murahwi, S., Kujinga, T., Kuper, H. & Rusakaniko, S., in press, ‘A path toward disability-inclusive health in Zimbabwe Part 1: A qualitative study on access to healthcare’, African Journal of Disability 11(2022).

Steptoe, A. & Di Gessa, G., 2021, ‘Mental health and social interactions of older people with physical disabilities in England during the COVID-19 pandemic: A longitudinal cohort study’, The Lancet Public Health 6(36), e365–e373. https://doi.org/10.1016/S2468-2667(21)00069-4

The Missing Billion Initiative, Good Practice Compendium, viewed n.d. from https://www.themissingbillion.org/new-index

Tong, A., Sainsbury, P. & Craig, J., 2007, ‘Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups’, International Journal for Quality in Health Care 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042

Appendix 1: Interview guide for people with disabilities

Purpose: To gain insights into people with disabilities’ access to health care services and their experiences when accessing or receiving care.

Good morning/afternoon. My name is _____________. I am representing ZAPP/PATAM/LC in conducting a research entitled: Building back better: Disability-inclusive health as a legacy of the COVID-19 pandemic in Zimbabwe. You are invited to participate as a key informant as an individual with disability to share your experiences so that we can gain insights into people with disabilities’ access to health care services and their experiences when accessing or receiving care. This guide will be provided with the Information and Consent Sheet. Your responses will be treated with utmost confidentiality and your name and identity will remain anonymous. If you have questions about this research please feel free to ask any questions. You are free not to answer any questions you feel you can’t and also to stop the interview. Thank you in advance for your co-operation. The interview will take 30–60 min.

Prompts: Sources of income? Is there anyone else in the household who has major illness or disability? If so, who and what is their condition?

Now we are going to talk about your disability/impairment, and feel free again not to answer what you can’t answer and/or stop this interview.

Prompts: Daily activities such as going to the bathroom, dressing, eating, going out – who helps or supports them and how? If yes, who and how? If not, why do you think that is?

Prompts: Do you have any health concerns? What is the main one that worries you? What are any co-morbidities you might have due to/caused by your impairment (if applicable)?

Prompts: (alter based on national policies/advice from local authorities): Social distancing? Self-isolating? Frequent hand-washing? Wearing masks?

Follow-up question/probe: For each measure mentioned but not done: You mentioned [preventative measure] is a way to prevent getting coronavirus. What challenges, if any, do you face in following this? What, if anything, would help you to do [preventative measure]?

Follow-up question/probe): For each measure followed: Please tell me more about how you are doing this. What challenges, if any, do you face following this? What or who has helped you follow this?

Now I would like to know more about your needs and activities, and whether these have changed since the new rules/arrangements because of COVID-19. So, for each, I would like you to think of a normal w eek before COVID-19, and then think about this week…

Prompts: What types of health services or products (e.g. medications, assistive devices such as a wheelchair, walking stick, hearing aids, etc.) do you use on a regular basis for your impairment? How do you typically access these?

If you do not use these services, why not? (e.g. don’t need them, cannot afford, don’t know how to access them).

Prompts: Still able to access the same health services/products for your impairment?

Prompts: What types of health services or products (e.g. medications) do you use on a regular basis for your general health? How do you typically access these?

Thinking of a recent experience (pre-COVID), could you tell us step-by-step? How do you get to the clinic? At the clinic: how was physical accessibility, signage, experience of health care providers, price, equipment for their specific needs, denied care/treated differently from other patients? What worked well and what was difficult?

Have you ever been ill and didn’t access health services? Why? Focus on last two times.

Prompt: Still able to access the same health services/products for your general health?

If no: how have you been managing without these services/products? What challenges made it difficult for you to access these services/products?

If yes: what, if any, challenges have you faced accessing these services/products? What, if anything, has helped you maintain access to these services/products?

Prompts: What does having access to health care mean? Do you think that your health care needs are the same or different from people who don’t have your impairment/disability? Do you feel you receive the same or different quality of health care services as others? Do you feel you are treated same or differently?

Are there any other important issues which we haven’t covered which you would like to comment on or that you feel are important to addressing access to health care for people with disability?

Thank you for taking the time to talk with me/us today. We have learned a great deal from you and your experiences. If you have any questions from our discussion please feel free to ask them.

Appendix 2: Interview guide for key informants

Good morning/afternoon. My name is __________________. I am representing ZAPP/PATAM/LC in conducting a research entitled: Building back better: Disability-inclusive health as a legacy of the COVID-19 pandemic in Zimbabwe. You are invited to participate in as a key informant as an individual with disability to share your experiences on disability to build the evidence base that characterises the impacts of the coronavirus pandemic amongst people with disabilities. This guide will be provided with the Information and Consent Sheet. Your responses will be treated with utmost confidentiality and your name and identity will remain anonymous. If you have questions about this research please feel free to ask any questions. You are free not to answer any questions you feel you can’t. Thank you in advance for your co-operation. The interview will take 30–60 min.

I’m now going to ask you some questions about the impact of COVID-19 on different areas of daily life that people in your area may have experienced. [Note to interviewers: start by asking about all people and then focus in on people with disabilities]

Original Research

A path toward disability-inclusive health in Zimbabwe Part 2: A qualitative study on the national response to COVID-19

Tracey Smythe, Thubelihle Mabhena, Shepherd Murahwi, Tapiwanashe Kujinga, Hannah Kuper, Simbarashe Rusakaniko

Abstract

Background

Methods

Study design

Setting

Participants

Data collection

Data management and analysis

Ethical considerations

Results

Demand-side factors

Demand – Autonomy and awareness

Demand – Affordability

Supply-side factors

Supply – Health facility availability

Supply – Specialised services and assistive technology

Outcomes and impact on functioning

Discussion

Conclusion

Acknowledgements

Competing interests

Authors’ contributions

Funding information

Data availability

Disclaimer

References

Appendix 1: Interview guide for people with disabilities

Appendix 2: Interview guide for key informants