Influence of education on sexual and reproductive health service utilization for persons with disabilities in nationwide Bangladesh: an explanatory sequential mixed-methods study

Background Persons with disabilities comprise more than one billion people in the world, yet they are one of the most discriminated groups and face significant health disparities. Particularly in developing countries, which contain 80% of the entire population with disabilities, these individuals experience major barriers in accessing sexual and reproductive health (SRH) services. Education is an important factor that greatly affects individuals' SRH service utilization. Hence, we sought to investigate the relationship between education and SRH service utilization for persons with disabilities in Bangladesh. Methods Using an explanatory sequential mixed-methods design, a total of 5000 persons with disabilities were surveyed for the quantitative component and 15 mini-ethnographic case studies were conducted with persons with disabilities for the qualitative component. Chi-squared tests and logistic regression analyses were performed on the survey data, while the qualitative interviews were coded and their SRH themes synthesized accordingly. Results Our quantitative findings show that education statistically significantly increases persons with disabilities' SRH service utilization of antenatal care, delivery care, postnatal care, and family planning (P < 0.05). Interestingly, for persons with disabilities, primary education shows increased adjusted odds of family planning use but is likely not enough to increase antenatal care, delivery care, or postnatal care use; secondary or post-secondary education may be required to improve utilization of these latter services. Qualitative findings support the association between higher education levels and greater SRH service use. Persons with disabilities of lower educational attainment held misinformation and distrust in SRH services and experienced mistreatment by SRH healthcare providers, discouraging them from seeking future SRH services. Conclusions We report that higher formal education level is associated with greater SRH service use for persons with disabilities in Bangladesh. Formally educating persons with disabilities expands their SRH knowledge and familiarity with SRH services, as well as leads to more economic opportunities so they can afford SRH services. Increasing formal education levels for persons with disabilities, paired with integrating comprehensive sexuality education (CSE) in their schools, will likely help close the gap in SRH health disparities for this vulnerable population. Plain Language Summary Out of more than one billion persons with disabilities in the world, 80% of them live in developing countries. Persons with disabilities commonly face discrimination and health disparities, particularly experiencing major barriers in accessing sexual and reproductive health (SRH) services. Education is a key factor that often leads to social and economic empowerment, which positively contributes towards individuals' SRH service utilization. In this paper, we examined the relationship between education and SRH service utilization for persons with disabilities in Bangladesh. We surveyed persons with disabilities across all of Bangladesh on their utilization of SRH services and conducted mini-ethnographic case studies with selected participants to more deeply understand their SRH issues and SRH service utilization. Our survey findings show that education significantly increases persons with disabilities' SRH service utilization of antenatal care, delivery care, postnatal care, and family planning in Bangladesh. Interestingly, for persons with disabilities, primary education may only be able to increase family planning use while secondary or post-secondary education may be required to increase antenatal care, delivery care, and postnatal care use. Our qualitative findings support the association between higher education levels and greater SRH service use. Persons with disabilities of higher education prioritized obtaining formal SRH services from qualified health care providers, even when financially constrained, while lower educated participants tended to be misinformed and distrustful of formal SRH services. We recommend helping persons with disabilities attain higher formal education levels and including comprehensive sexuality education (CSE) in their schools, as it likely will reduce SRH health disparities for this vulnerable group.

Automated summary

There is a significant association between education level and SRH service utilization for persons with disabilities. Higher education levels increase the utilization of antenatal care, delivery care, postnatal care, and family planning services for persons with disabilities. Primary education may only increase the use of family planning, while secondary or post-secondary education may be required for the utilization of antenatal care, delivery care, and postnatal care.