Barriers in accessing care services for physically disabled in a hospital setting in Riyadh, Saudi Arabia, cross-sectional study.

Objective: The aim of this study was to identify the significant difficulties in access to health care services experienced by patients with physical disabilities. Method: A cross-sectional study at King Abdul Aziz Medical City, Riyadh, Saudi Arabia on 235 persons with physical disability, from 1 January to 30 June 2014.
Results: A total of 88% of the people with disability reported having the need for someone to accompany them. Over 52% were unsatisfied with parking, 49.8% with the waiting area, 51.3% with wheel-chair services, and nearly 45% were unsatisfied with toilet facilities for the physically disabled. Those who were wheel-chair bound had statistically significant lower mean score for satisfaction with services and facilities related to parking area, reception, and appointment, elevator, and physiotherapy.The majority were satisfied with the attitude of the clinical staff.
Conclusion: The majority of patients with physical disability require assistance and cannot move around independently in the healthcare facilities. Nearly half of these patients face several challenges in accessing health care services and are unsatisfied with the services received. Patients with physical disability who are wheel-chair bound have a lesser degree of satisfaction than those who are not wheel-chair bound.

Introduction

Equity in health ‘implies that ideally everyone should have a fair opportunity to attain their full health potential and more pragmatically, that none should be disadvantaged from achieving their potential’ [1]. A number of studies have shown that disabled people experience various negative health inequalities compared to those who are not disabled [2-4], particularly inequality in access to healthcare service [5].

Depending upon the WHO definition of physical disability [6] it is estimated that 3.73% of the Saudi population has functional disabilities [2] and 33% of all disability is physical disability [7]. Research is limited on the prevalence and incidence of disability [2].

Relative to the general population, people with disabilities are more likely to be sedentary and to have more health problems [8]. Access barriers are experienced at different points throughout a person’s healthcare journey and come in many different forms: structural, communicational, emotional and social barriers. People with disability have more challenges than people without disability to reach the clinic.

Subject and methods

Study protocol

Approval for study was obtained from Institutional Review Board at King Abdullah International Medical Research Center. Cooperation with physiotherapy, outpatient clinics, wheel-chair services, occupational therapy, prosthetic department and neuro rehabilitation staff was obtained. All physically disabled adults attending King Abdul-Aziz Medical City in Riyadh, Saudi Arabia (between 1 January and 30 June 2014) were eligible to be enrolled for answering the questionnaires after they agreed to participate. A total of 235 participant were included. Patients excluded were those with learning, intellectual and mental disabilities, as well as children below age of eighteen.

A cross-sectional study design was adopted in this study. The questionnaire was developed after a thorough literature review [5,6,9]. The British standard design of buildings (developed by the BSI group) and their approaches to meet the needs of patients with disabilities was used in formulating the questions [9]. It is a widely used standard that covers accessibility to building.

Data entry and analysis

Data were entered and analyzed using SPSS version 20. Categorical data were summarized using frequency and percentage. Continuous variables were described using the mean and standard deviation. To be able to assess and compare the level of satisfaction each answer on the Likert scale was awarded points on a discrete range between −2 (indicating strongly disagree) and +2 (indicating strongly agree). Mean satisfaction score for each domain was then calculated and compared between different groups. The significance of the differences in mean scores was tested using student t-test. P-value of 0.05 or less was considered statistically significant. In addition, subjects who scored +1 and +2 on Likert scale items were considered satisfied. Subjects who were neutral about the service or scored negative on the scale were considered unsatisfied.

Results

Baseline characteristics (see Table 1)

All participants in the research were physically disabled. Figure 1 represents the cause of participant’s disability. In the following subsections, analysis was presented for participants’ satisfaction of NGHA (National Guard Health Affairs) hospital properties and services. Table 2 represents percent of the participants who were unsatisfied about the service.

Figure 1.

Cause of participant’s disability.

Table 2.

Percent unsatisfied with healthcare service /structure.

Questionnaire item		Unsatisfied frequency %
1.	Waiting area: Comfortable seat	136 (60)
2.	Waiting area: Priority in waiting	143 (63.3)
3.	Toilets: Used by disable people only	152 (66.4)
4.	Toilets: Door opens outward	144 (63.2)
5.	Toilets: Emergency button or telephone	146 (65.8)
6.	Disable parking used by disable people only	149 (64.8)
7.	Parking sufficiency	184 (79.3)
8.	Sufficient space between each parking	164 (71.6)
9.	Requested by phone	177 (79)
10.	Sufficiency of wheel chair	148 (67)
11.	Quality of wheel chair	134 (62.3)
12.	Use of wheel chair independently	146 (65.2)

As illustrated in Table 2, participants who were unsatisfied with priority in waiting and seat comfort of the waiting area was 63% and 60% of dissatisfaction respectively.

There are three items which got the high percent of dissatisfaction about the fourteen items in the toilet section of the questionnaire. They are the non-presence of emergency button in the toilet (65.8%), toilets’ door open outward (63.2%), and their usage only by non-disable people (66.4%).

There are eight items analyzed in the parking sections. Three of them showed high percent of dissatisfaction. They are the parking sufficiency (79.3%), space between parking (71.6%) and the use of parking by disabled people (64.8%). On the other hand most of the participants agreed with the availability of automatic door in the hospital entrance with the (77.3%).

For wheel-chair services, there are four items which most participants seem to be not satisfied with. They are the ability to request the service by phone (79%), the sufficiency of the chairs (67%), using the wheel chair independently (65.2%) and quality of the chairs (62.3%).

As illustrated in Table 3 hospital physicians, nurses, physiotherapists and reception staff deal with the disabled people in a very polite and professional way. This can be concluded from the high percent of satisfaction among the participants.

Table 3.

Percent satisfied with healthcare staff.

Questionnaire item	Satisfied frequency %
Physicians
1. Polite and respective	190 (83.3)
2. Consider my special needs	175 (77.4)
3. Asked question to me directly	179 (78.9)
Nurses
1. Polite and respective	191 (83.8)
2. Consider my special needs	172 (75.8)
3. Asked question to me directly	184 (80.3)
Physiotherapist
1. Polite and respective	174 (78.4)
2. Consider my special needs	159 (71.9)
3. Asked question to me directly	168 (75.7)
Reception staff
1. Polite and respective	166 (73.5)
2. Consider my special needs	148 (64.6)
3. Asked question to me directly	153 (66.8)

Table 4 shows that mean score of hospital’s parking, wheel-chair services and waiting area were significantly low.

Table 4.

Mean score of all hospital services for disabled persons.

Service (score range)	N	Mean	Standard deviation	Min	Max
Parking ((−16)-16)	209	0.3	7.10	−16	14
Slope ((−18)-18)	195	2.48	7.11	−16	16
Stairs ((−12)-12)	182	2.8	4.73	−12	12
Wheel-chair services ((−16)-16)	195	−0.28	7.39	−16	16
Reception and appointment ((−10)-10)	212	1.3	4.80	−10	10
Waiting area ((−14)-14)	205	0.74	6.75	−14	14
Elevators ((−12)-12)	194	2.78	5.46	−12	12
Toilet ((−28)-28)	181	2.71	12.26	−28	28
Clinic and doctors and nurse ((−20)-20)	204	7.33	7.57	−16	20
Physiotherapist and reception ((−12)-12)	216	5.54	4.80	−12	12

Table 5 represents the relationship between being wheel-chair bound and being unsatisfied. There was significant relationship between being wheel-chair bound and being unsatisfied with hospital parking, reception and appointment services, elevators and physiotherapy. Participants who were wheel-chair bound were more unsatisfied than those who were not, with a significant p value less than 0.05.

Table 5.

Relationship between being wheel-chair bound and being unsatisfied with hospital services; and the relationship between disability period and being unsatisfied.

Service	Wheel-chair bound	N	Mean	Std. deviation	t	P	Mean difference
Parking score total	Yes	109	−.53	7.68	2.07	.040	2.05
	No	94	1.52	6.22
Reception and appointment score total	Yes	109	.39	5.18	3.12	.002	2.05
	No	98	2.44	4.15
Elevator score total	Yes	103	1.83	5.69	3.09	.002	2.42
	No	85	4.25	4.88
Physiotherapy score total	Yes	111	4.86	4.42	2.46	.015	1.60
	No	98	6.46	4.99
Service	Disability period	N	Mean	Std. deviation	t	P	Mean difference
Stairs score	≤ year	62	1.32	4.59	2.24	.027	1.91
	> year	51	3.24

Table 5 shows the significant relationship between disability period and being unsatisfied. Participants who were disabled for one year or less are more unsatisfied about the hospital stairs with p-value less than 0.05.

Discussion

Principal findings

Patients with physical disability face a lot of challenges in accessing health care services and are largely unsatisfied with the services provided to them. Several of these patients require assistance and cannot move around the healthcare facility independently.

Strengths and weaknesses of study

BSI British standard design of buildings [9] and their approaches to meet the needs of disabled people was used in formulating the questions. A list of variables was obtained from the British standard to formulate the research questionnaire.

We recognized different challenges while conducting the research in Saudi Arabia. Sensitivity of the disability still considered socially unacceptable. Many patients with disability are grossly limited to the activities they can participate in. We faced many cases of patients with disability who agreed to fill up the questionnaire, then their relatives refused the idea and persuaded them not to fill the questionnaire. The behavior of their relatives demonstrates that there is a degree of power imbalance between the patient and their caretakers. It is also worrisome that the caretakers hold a degree or dominance over the patients. There were also difficulties that came from the patient. Educational level stands as one of the big obstacle, as many patients with physical disability are poorly educated [10,11]. This became apparent as many of them struggled to read and understand the questionnaire, requiring assistance from others. Moreover, time and effort was a barrier of not participating of the staff.

Despite our best attempts, there are indeed some limitations in out study. We did not stratify all the different types of disability and correlate those with percent satisfaction. In our research, only physical disability was considered and other kinds of disabilities such as blindness, deafness and mental disability were not considered. Children were also excluded from the study. These can be candidates for future researches.

There are also other services in the hospital which were not considered in this research such as pharmacy services, laboratory services, telephone services and in-patient services. These are also candidate areas for future researches.

Relation to other studies

We used BSI variables to determine patient satisfaction about hospital services. Most of the previous studies were qualitative studies, differences in methods make comparisons with previous work difficult.

In our study, 88% of the people with disability reported having the need for someone to accompany them. This is higher than what has been reported by Castro et al. (2011) at rate of 50% [12].This can show how difficult it is for person with disability to come to the hospital and to use the services alone.

29% of the participants found their parking used by patients without physical disability. This supports the notion that the general population is not highly respectful to those with physical disability. It also demonstrates lack of strict implementation of parking regulations. In terms of parking sufficiency, 79.3% of the participants found their parking insufficient. This could be explained in one of two ways. First, the number of the parking spots could be insufficient in comparison to the number of patients with physical disability who visited the hospital. Second, there may be an adequate number of spots, but their use by healthy people makes it insufficient. Moreover, 71.6% of the participants found not enough space between the parking to allow them to get from the car and use the wheel chair. Because of this, they are forced to come to the hospital only with the help of others. The parking issue was also reported by Castro et al. in their qualitative study in 2011 as one of the main obstacles and difficulty in accessibility to health services [12].

Toilets were found to be used by non-disabled people, as noted by 66.4% of our participants. In fact, people with disability should be able to find and use suitable toilet easily and safely. Lack of emergency button or phone in the toilet was reported by 65.8% of our participants. It is very important for the restroom to have emergency alarm. In fact, patients with multiple co-morbidities and using several medications are at high risk of fall. Availability of the emergency button can prevent injury. The absence or inadequacy of adapted toilets with alarms was also reported as a difficulty in accessibility to health services by Castro et al. [12].

A total of 10% of the participants found difficulties when they moved between the hospital facilities. The difficulties because the buildings were not designed to have allocated space for patients with physical disability, and also because the buildings are over-crowded. These difficulties usually delay patients when they are arriving for their appointments. Patients also found it difficult to move from one facility to another due to the far distance between the facilities. Similar difficulty was reported by Mari-Lynn et al. in their qualitative study [13].

There was significant correlation between being wheel-chair bound and being unsatisfied with hospital parking, reception and appointment services, elevators and physiotherapy. Participants who were wheel-chair bound were more unsatisfied than those who are not with a significant p value less than 0.05.

Similar result was found by Lisa I. Iezzoni et al. in their research 2002 [14].

Improving hospital parking, reception and appointment services to accomplish their needs will certainly improve their satisfaction.

Implication of study

Poorly designed buildings can create significant barriers for people who have mobility impairments. People with disability have more challenges on accessing health care services. There is a significant relationship between being wheel-chair bound and being unsatisfied about hospital services.

We still need more research about disability in Saudi Arabia. There is not enough data about prevalence, incidence or types of disability.

Table 1.

Baseline characteristics of participants.

Baseline characteristics	Frequency	Percentage %
Gender of the patient
Male	110	48.5
Female	117	51.5
Visiting the hospital alone
Yes	25	10.6
No	207	88.1
Disability period
Disabled since birth	13	5.9
Disabled after birth	207	94.1
Disability duration
Being disabled for one year or less	79	54.9
Being disabled for more than one year	65	45.1