Access to sexual and reproductive health and rights services among women with disabilities: a cross-sectional study from Murang’a South, Central Kenya

Abstract

Background

Sexual and Reproductive Health and Rights (SRHR) are fundamental human rights. However, Women with Disabilities (WWDs) experience persistent barriers limiting equitable access. Despite efforts toward inclusivity, empirical evidence on service utilisation patterns and determinants in sub-national Kenyan contexts, remains limited. This study examined access to SRHR services among WWDs in Murang’a South, Central Kenya.

Methods

An analytical cross-sectional study design was employed, with a sample size of 325 WWDs aged 15–49 years. Data were collected using structured questionnaires and analysed using Kobo Toolbox (v2021.2.4) and Python (v3.13.1). The data were presented in tables. Descriptive statistics summarised participant characteristics using frequencies and percentages. Access to SRHR services was treated as a binary outcome (≥ 1 visit vs. none in the past year) and bivariate logistic regression analysis was conducted to examine associations between variables, with results reported as crude odds ratios (CORs) at 95% confidence intervals.

Results

Overall, 67.69% of WWDs reported access to SRHR services, while 32.31% reported none. Family planning services were the most accessed (89.09%). Access to HIV/STI testing and prevention (20%), Maternal Health Services (9.55%), safe and post-abortion care (2.27%) and Reproductive cancer screening (4.09%), were relatively low. Access was significantly associated with disability type, age, education, marital status, income, sexual activity, and religion. Women with mental disabilities had the lowest access odds (COR = 0.94; 95% CI: 0.39–2.26). Access increased with age. WWDs aged 36–42 years (COR = 36.67; 95% CI: 12.96–103.73) and 43–49 years (COR = 21.50; 95% CI: 7.06–65.45) had significantly higher odds of accessing SRHR services. WWDs who had attained tertiary education (COR = 5.66; 95% CI: 1.23–25.98), who were married (COR = 6.89; 95% CI: 3.27–14.50), were protestants (COR = 2.36; 95% CI: 1.44–3.87) and who were sexually active (COR = 6.49; 95% CI: 3.98–10.58), were significantly more likely to access SRHR services. Stigma (COR = 0.07; 95% CI: 0.02–0.22), restrictive norms (COR = 0.22; 95% CI: 0.11–0.45), and gender power dynamics (COR = 0.55; 95% CI: 0.28–1.07) markedly reduced access. Health-facility factors, including provider communication, privacy, confidentiality practices, physical accessibility, distance to facilities, and availability of disability-inclusive information, were also significant determinants.

Conclusion

SRHR service access among WWDs in Murang’a South, Central Kenya remains highly uneven, highlighting persistent inequities that warrant the need to engage with healthcare providers to understand their perspectives and barriers to inclusive care; strengthen disability-inclusive training and cultural competence to improve knowledge, address negative attitudes, and ensure privacy, thereby making clinical environments safe and comfortable for WWDs.

Introduction

Persons with Disabilities (PWDs) constitute the world’s largest minority group, with approximately 1.3 billion people affected [1]. The global prevalence of disability is higher in women than in men, with 19% of women and 12% of men affected. In low- and middle-income countries, women are estimated to make up as many as 75% of PWDs [2]. In Kenya, according to the 2019 census, the prevalence of PWDs was 2.2% (0.9 million people) and higher in women at 2.5% compared with 1.9% of men. The prevalence rate of disability was higher in rural areas than in urban areas at 2.6% (0.7 million) and 1.4% (0.2 million) respectively [3]. In many low- and middle-income countries (LMICs), disability is still framed within medical or charitable models, often neglecting rights-based approaches/social models of disability, that promote inclusion and autonomy [4].

Sexual and Reproductive health and rights (SRHR) are fundamental human rights, essential for health, dignity and well-being of all individuals [5]. Globally, an estimated 214 million women lack access to essential SRHR services such as contraception, resulting in unintended pregnancies and unsafe abortions. Evidence indicates that women with disabilities engage in sexual activity at rates comparable to women without disabilities. For example, a study in the United States, found similar patterns of sexual debut and exploration among women with disabilities [6]. Regionally, in countries such as Sierra Leone, between 2010 and 2020, 58% of persons with severe disabilities and 71% of persons with less severe disabilities were sexually active, while in Uganda, 77% of WWDs had experienced pregnancy [7, 8]. Therefore, WWDs just as other women in the society need to access sexual and reproductive health services to optimise their health status. However, evidence from sub-Saharan Africa consistently shows that WWDs face significantly lower access to SRHR services, including reduced use of preventive services (e.g., cervical cancer screening), limited contraceptive uptake, restricted access to safe abortion care, and inadequate availability of disability-inclusive SRHR information in Braille and sign language [9–11]. In Ethiopia, UNFPA reported low contraception awareness and STI knowledge among WWDs, yet 52% were sexually active without protection; 75% of these were aged 15–19, 59% had multiple partners, and 40% engaged in casual or commercial sex. Widespread supply- and demand-side barriers further lowered service coverage and resulted to poorer outcomes for WWDs, especially in rural settings [12]. Despite protections under the United Nations Convention on the Rights of Persons with Disabilities (CRPD), WWDs often face systematic discrimination, limiting access to SRHR services and resulting in higher unmet contraceptive needs, poor maternal outcomes, limited STI/HIV services, forced sterilisation, denial of marriage and parenting rights, gender-based violence, and exclusion from SRHR care [13–15].

SRHR access varies by disability type and severity: physical disabilities restrict mobility, sensory disabilities create communication gaps, and mental or intellectual disabilities lead to consent challenges, exclusion in SRHR conversations and paternalistic control [9]. Socio-demographic factors such as age, education, marital status, religion and income, further stratify access. Lower education and income correlate with reduced SRHR uptake while younger WWDs often lack age-appropriate, disability inclusive sexuality education. Marital status can influence both social acceptability of a WWD and SRHR provider responsiveness. This is supported by studies in Uganda, which uncovered how gender and disability discrimination, compounded challenges like insufficient infrastructure and poor access to SRHR services [16–18]. Community attitudes, including beliefs that disability is a curse or burden, reinforce stigma, limit sexual agency, and exclude WWDs from SRHR education and family planning programmes. Stigma results in social isolation, reduced decision-making power, and higher vulnerability to Sexual and Gender-Based Violence (SGBV). Patriarchal norms restrict autonomy, fuelled by assumptions of asexuality, unfitness for motherhood, or hypersexuality. Additionally, community perceptions influence family support for care-seeking for WWDs, prioritisation of inclusive SRHR programming and SRHR provider attitudes [19, 20].

Inclusive health facilities are essential, yet negative provider attitudes, low competence in provision of disability-inclusive SRHR, insufficient disability inclusive training, lack of communication adaptations, physical inaccessibility, and high direct and indirect costs disproportionately disadvantage WWDs. Such facility level challenges may reduce effective coverage of SRHR services for WWDs [9, 21].

Despite growing insights on SRHR access barriers for WWDs in Kenya, no comprehensive research has targeted rural and underserved settings like Murang’a South [9]. National data gaps, including, limited disability-disaggregated SRHR data [22, 23], hinder targeted policy and service design, which could otherwise advance progress towards achieving the Sustainable Development Goals (SDGs) of universal and fair access to comprehensive SRHR services. This study therefore investigated factors associated with SRHR service accessibility for WWDs in Murang’a South. The findings aim to support progress toward SDG 3 and 5 on health, well-being, gender equality, and disability inclusion.

Materials and methods

Study site

Murang’a County is one of the 47 semi-autonomous regions of Kenya, located in the Central area of the country. It is divided into five administrative areas referred to as Sub-Counties: Murang’a East, Murang’a South, Gatanga, Kandara, and Kigumo Sub-counties. According to the most recent estimates, Murang’a County has a population of approximately 47,000 people with disabilities, which is 4.4% of the population. Among the Sub-counties in Murang’a County, Murang’a South, was of particular interest as it is predominantly rural, and has a high percentage of women and girls living with disabilities. According to recent census data, there are approximately 2,700 WWDs in Murang’a South subcounty. Additionally, it faces numerous challenges, including high poverty rates and limited facilities that cater to the SRHR needs of PWDs [24].

Study design

The study employed an analytical cross-sectional research design. Quantitative data was collected through structured survey questionnaires. The study was conducted between January 2023 and August 2024.

Sampling

The study employed probability sampling techniques. A sampling frame1 comprising 2,700 registered women with disabilities was obtained from the County Disability Office under the Kenya National Council for Persons with Disabilities (NCPWD), from which eligible participants aged 15–49 years were selected using simple random sampling. Registration on this list requires documentation of disability status, typically including a medical assessment from a registered clinician, followed by community-based verification process by NCPWD officers. The sample size was determined using Cochran’s formula for finite populations. The calculation is presented as follows:

Where n = Sample size of finite population.

• N = Population size

• Z = Standard normal deviate at 95% Confidence Level (1.960)

• p = Proportion of Population that has a certain characteristic (50%)

• q = 1 - p

• d = Desired level of precision (5%)

Substituting these values into the formula, yielded a minimum sample size of 336 participants. This was allocated to the different types of disability; physical, mental, sensory and intellectual, calculated using prevalence rates from the 2019 Kenya Census disability statistics for Murang’a County [25]. Trained disability representatives of each administrative ward in the Sub-County together with the research assistants, made initial home visits to the selected participants, during which they introduced the study, objectives, screened for eligibility and scheduled interview appointments at times and locations convenient to the participants, such as their homes or community halls. For women with hearing or speech disabilities, the disability representatives arranged for sign language interpreters to be present during recruitment and the consent/assent process. For women with intellectual disabilities, recruitment involved consultation with primary caregivers/trusted family members, while ensuring that assent was obtained from the participant herself wherever possible, alongside informed consent from a legally authorised representative in accordance with Kenyan national guidelines on research involving vulnerable populations. Written informed consent was obtained from all participants using plain language information sheets. For participants unable to read, the information was read aloud in Kiswahili or Kikuyu and a thumbprint was accepted in lieu of a signature. All recruitment and engagement procedures were approved by the institutional research ethics committee.

The inclusion criteria were as follows:

• WWDs that had a manageable disability with a capability to understand and participate in the study procedures to a reasonable extent.

• WWDs that had either a sensory, mental, physical, or intellectual disability.

• Participants that provided consent/assent to participate in the research study or had a legally authorized guardian who provided consent on their behalf.

Data collection tools

The research instruments for this study were designed by the principal investigator under the supervision of faculty from the Department of Community Health, Epidemiology and Biostatistics at Mount Kenya University’s School of Public Health. The development of the tools was guided by the study’s conceptual framework, which was informed by the Crenshaw’s intersectionality theory, and by a review of existing literature on barriers to SRHR access for WWDs, including validated instruments from similar LMICs contexts. A structured survey questionnaire was developed to collect quantitative data. The questionnaire consisted of four main sections: (i) demographic information of respondents, including age, education level, marital status and type of disability influencing access to SRHR services (ii) socio-cultural factors including community norms, stigma and family support; and (iii) health facility factors, such as availability of services, accessibility and healthcare provider attitudes. The questionnaire was designed using simple, clear language in English and was translated into Kiswahili (Kenyan National Language) and the Native language (Kikuyu) to accommodate participants language preferences.

Prior to the main data collection, the questionnaires were pilot tested twice within a neighbouring Sub-County with similar characteristics as the study area. The pilot involved a sample of 15 WWDs. For validity testing, a convergent construct validity method was used. The correlation between the two pilot tests was computed, yielding a Pearson correlation coefficient of r = 0.81, indicating strong construct validity. For reliability testing, a test-retest reliability method was employed. The same instruments were administered twice, two weeks apart, to the same pilot group. The correlation coefficient obtained was r = 0.84, indicating strong internal consistency and reliability. Based on the pilot findings, minor revisions were made to improve clarity, question wording, sequencing and contextual appropriateness of certain items before administering the final instruments. The pilot testing also confirmed that the tools were appropriate for use across different disability types, with accommodations such as simplified language for participants with intellectual disabilities and sign language interpretation for those with hearing disabilities.

Data collection methods and procedures

A request for authorization was submitted to the Mount Kenya University Public Health Graduate School (Ref No: MPH/2022/45497). Ethical clearance was also obtained from the Mount Kenya University Ethics and Review Committee (Ref No: MKU/ISERC/3351). Before collecting data, the study obtained ethical clearance (Ref No: 820482) from the National Commission for Science, Technology and Innovation (NACOSTI). Ethical clearance was also obtained from the Director of Public Health Research Murang’a County as well as the NCPWD Murang’a County Director (Ref No: 21/12/2023). Quantitative data was collected through Kobo Toolbox Version v2021.2.4. Considering the various disability groups represented by the research participants, the data collection process was tailored to accommodate their specific requirements. For women with mental and intellectual disabilities, interview questions were translated into simplified language and delivered vocally. For those with sensory disabilities, specialized approaches were adopted: women who were deaf were interviewed with the aid of a skilled sign language interpreter, while those who were blind were engaged in face-to-face interviews. Lastly, for women and girls with physical disabilities, in-person, face-to-face interviews were carried out to ensure a comprehensive understanding of their perspectives.

While women with disabilities were the primary respondents, caregivers were only involved when necessary and with the explicit consent of the participant. Caregiver involvement was limited to providing supplementary clarification on non-sensitive matters, such as confirming demographic information or logistical details, and did not extend to questions regarding SRHR experiences, needs or access. Caregivers were only consulted in depth when the participant explicitly requested assistance or had communication difficulties that could not be otherwise accommodated and their input was clearly distinguished from the participant’s own responses during data analysis. All interviews were conducted in a private setting to ensure confidentiality and protect participants’ privacy.

Study variables

Dependent variable

Level of access to SRHR services was the dependent variable in this study. This was determined by the number of visits to SRHR facilities and utilisation of essential SRHR services within the past 12 months (May 2023 – May 2024) from the point of time during data collection. Access was considered in terms of availability, inclusivity and responsiveness of services and coded as a binary variable: ‘access’ (≥ 1 visit) and ‘non-access’ (0 visits).

Independent variables

The independent variables were grouped into three categories. At the individual level, determinants included socio-demographic characteristics such as disability type, age, education, religion, marital status, income and sexual-health characteristics. These determinants were analysed to give an outlook on how individual backgrounds influenced access to SRHR among WWDs. At the socio-cultural level, determinants included cultural norms and beliefs, stigma and discrimination, gender roles and power dynamics and community perceptions towards the intersection of SRHR and disability. These were analysed to capture societal attitudes, traditions and community perceptions that shape the ability of WWDs to access SRHR services and exercise their SRHR rights. At the health facility level, determinants included healthcare staff attitudes and perceptions, healthcare provider communication and confidentiality practices, geographical and cost of services, accessibility and inclusiveness of healthcare facilities and availability of inclusive SRHR services. These were analysed to understand the institutional and systemic factors within healthcare settings that hindered the provision of SRHR services to WWDs.

Data analysis

Data collected was analysed using Kobo Toolbox analyser version v2021.2.4 and python libraries version python 3.13.1. Descriptive statistics were first used to summarise participant characteristics and study variables. Categorical variables were presented using frequencies and percentages. The dependent variable, access to SRHR services, was treated as a binary outcome. It was categorised into two distinct groups, based on the frequency of visits to a preferred health facility, between May 2023 – May 2024: Access (defined as ≥ 1 visit) and non-access (defined as ˂ 1 visit). Bivariate Logistic regression was then used to examine crude associations between each independent variable and access to SRHR services among women with disabilities. Independent variables were entered into the model simultaneously and included individual-level factors, socio-cultural factors and health facility–level factors. The results were reported using Crude Odds Ratios (CORs) with 95% confidence intervals (CIs) to estimate the independent association between each determinant and the likelihood of accessing SRHR services. Haldane–Anscombe continuity correction was applied in response categories with zero counts to allow estimation of CORs. Statistical significance of the CORs was tested using Wald χ² statistics, with p < 0.05 considered significant.

Results

The study considered only the appropriately completed and returned surveys. After data cleaning, 325 questionnaires were deemed suitable for analysis, yielding a response rate of 96.73%.

Types of disabilities

Out of the sample population studied, 39.08% had sensory disabilities, 35.08% had physical disabilities, 15.38% had intellectual disabilities, and 10.46% had mental disabilities. This has been illustrated in Table 1.

Table 1.

Disability modalities distribution among participants (n=325)

Disability				Frequency (N)	%
Physical				114	35.08
Sensory	Type	N	%	127	39.08
	Visual impairment	61	53.51
	Deaf-Blind	35	30.70
	Hearing Impairment	31	27.19
Intellectual				50	15.38
Mental				34	10.46

Social demographic characteristics of the participants

As indicated in Table 2, with regards to religion, 54.46% were Protestants, 31.38% were Catholics, 12.31% were Muslims, and 1.85% practiced other traditional religions. Majority of WWDs had attended school (86.46%), with secondary education being the highest level attained by 40.21%. On literacy levels, 84.62% of the women with disabilities indicated that they could read and write clearly. Regarding marital status, 64.31% indicated that they were single, 28% indicated that they were married, and 7.70% indicated that they were separated. On income sources, 67.38% of the WWDs relied on family members for support, 15.69% relied on their self-employment income, 11.69% relied on spousal support, and 15.23% relied on paid employment income.

Table 2.

Socio-demographic characteristics distribution among participants (n = 325)

Variable	Participant Response	Frequency (N)		%
Age	15–21 Years		34	10.46
	22–28 Years		86	26.46
	29–35 Years		91	28.00
	36–42 Years		75	22.86
	43–49 Years		40	12.30
Religion	Protestants		177	54.46
	Catholics		102	31.38
	Muslims		40	12.31
	Traditional Religions		6	1.85
School Attendance	Attended School		281	86.46
	Never attended School		44	13.54
Highest Level of Education	Primary		56	19.93
	Secondary		113	40.21
	Technical/Vocational		83	29.54
	Tertiary		29	10.32
Literacy Levels	High		275	84.62
	Low		50	15.38
Marital Status	Single		209	64.31
	Married		91	28.00
	Separated		25	7.70
Occupational Status	Unemployed		114	35.08
	Students		70	21.54
	Self-employment		51	15.84
	Paid employment		17	5.23
	Volunteerism		3	0.92
Income Sources	Family Support		219	67.38
	Self-employment		51	15.69
	Spousal support		38	11.69
	Paid employment		17	5.23
Income Range	< 10,000 KES		9	2.77
	10, 000–15,000 KES		129	36.69
	15,000–20,000 KES		70	21.54
	20,000–25,000 KES		43	13.23
	> 25,000 KES		74	22.77

Level of access to sexual and reproductive health and rights services

The level of access was determined by the number of visits to SRHR facilities and utilisation of essential SRHR services within the past 12 months (May 2023 – May 2024) from the point of time during data collection. Essential SRHR services included; Family Planning Services, Comprehensive Sexual Education (CSE), HIV/STI testing and prevention services, Maternal Health Services, Reproductive Cancer Screenings, Safe and Post-abortion care and Sexual and Gender-Based Violence (SGBV) response and prevention.

Access to SRHR services was reported among 67.69% of women with disabilities. Conversely, 32.31% of the WWDs, reported non-access, indicating they had not visited a health facility for SRHR services within the same period (Fig. 1).

Fig. 1.

The distribution of SRHR access and non-access levels as determined in this study

WWDs utilised a range of healthcare facility types when seeking SRHR services. Community health centres were the most commonly used (79.49%), followed by public health facilities (70%) and missionary health facilities (67.09%). Private health facilities (50%) and specialised family planning clinics (53.85%) were less frequently utilised. These patterns of facility utilisation are presented in Fig. 2.

Fig. 2.

Utilisation of SRHR services by type of health facility

The level of access on specific SRHR services was uneven. Family planning services were the most accessed by 89.09%, followed by Comprehensive Sexual Education (49.09%) and Sexual and Gender-Based Violence response and prevention (38.18%). Access to HIV/STI testing and prevention (20%), Maternal Health Services (9.55%) and Reproductive cancer screening (4.09%), were relatively low. Only 2.27% of WWDs had accessed safe and post-abortion care services. This has been illustrated in Table 2.

Individual level determinants influencing access to SRHR services

The type of disability, age, religious practice, level of education, marital status, income status and sexual activity status, significantly influenced access to SRHR services, as presented in Table 2. Women with sensory disabilities (COR = 8.75; 95% CI: 3.69–20.72) and physical disabilities (COR = 5.64; 95% CI: 2.40–13.27) had significantly higher odds of accessing SRHR services compared to those that had intellectual disabilities. No statistically significant difference in SRHR service access was observed between women with mental disabilities and those with intellectual disabilities (p = 0.898). Access increased with age, with WWDs aged 36–42 years (COR = 36.67; 95% CI: 12.96–103.73) and 43–49 years (COR = 21.50; 95% CI: 7.06–65.45) having significantly higher odds of accessing SRHR services. Educational attainment was also a significant determinant, with WWDs who had attained tertiary education (COR = 5.66; 95% CI: 1.23–25.98) being more likely to access SRHR services than those who had never attended school. WWDs who were married, had higher odds of access to SRHR services (COR = 6.89; 95% CI: 3.27–14.50), compared to single women. Women earning less than 10,000 KES had significantly lower odds of accessing SRHR services (COR = 0.10; 95% CI: 0.01–0.78). Increasing income (> 25,000 KES) was associated with lower odds of accessing SRHR services (COR = 0.21; 95% CI: 0.12–0.38). Sexually active WWDs were significantly more likely to access SRHR services (COR = 6.49; 95% CI: 3.98–10.58) compared to women who were sexually non-active. Finally, WWDs who identified as Protestants had significantly higher odds of accessing SRHR services (COR = 2.36; 95% CI: 1.44–3.87). Women who identified as Muslims showed no statistically significant difference in access to SRHR services compared to Catholics (COR = 1.14; 95% CI: 0.55–2.35). Similarly, women who reported other religious affiliations also did not show a significant2 association with SRHR service access (COR = 1.52; 95% CI: 0.26–8.82).

Socio-cultural factors influencing access of SRHR services

Restrictive cultural norms; such as beliefs that disability is a curse, that WWDs are asexual and unfit for marriage or motherhood, and that they should be hidden from public view, significantly influenced access to SRHR services as presented in Table 3. Strong disagreement with the belief that these norms influenced their access to SRHR services, was associated with significantly higher odds of service utilisation (COR = 35.74; 95% CI: 4.75–268.63). On the other hand, strong agreement with such norms was associated with lower odds of service utilisation (COR = 0.22; 95% CI: 0.11–0.45). Similarly, WWDs who disagreed (COR = 326.79; 95% CI: 19.95–5354.2) or strongly disagreed (COR = 272.14; 95% CI: 16.69–4437.6) with experiences of stigma and discrimination were more likely to access SRHR services, whereas strong agreement with experiences of stigma and discrimination was associated with reduced access (COR = 0.07; 95% CI: 0.02–0.22). Moreover, strong disagreement (COR = 29.03; 95% CI: 6.64–126.9) and disagreement (COR = 17.36; 95% CI: 6.98–44.52) showed that traditional gender roles and power dynamics influenced WWDs access to SRHR services, and was strongly associated with increased access.

Table 3.

Types of SRHR services accessible among participants in the past 12 months (n = 325)

SRHR Resource	Access of SRHR Services	%	Non-access to SRHR Services	%
Family Planning Services	196	89.09	24	10.91
Comprehensive Sexual Education	108	49.09	112	50.91
HIV/STI testing and prevention services	44	20.00	176	80.00
Maternal Health Services	21	9.55	199	90.45
Reproductive Cancer Screenings	9	4.09	211	95.91
Safe and Post abortion care	5	2.27	215	97.73
Sexual and gender-based violence (SGBV) response and prevention	84	38.18	136	61.82

Health facility factors influencing the accessibility of SRHR services

Health facility factors such as; Healthcare staff attitudes and perceptions, Healthcare provider communication and confidentiality practices, geographical and cost-associated factors, accessibility and inclusiveness of healthcare facilities and availability of inclusive SRHR services in the healthcare facilities significantly influenced the access of SRHR services for WWDs.

Healthcare staff attitudes and perceptions

WWDs who reported that they were able to freely ask SRHR related questions to healthcare providers during seeking care had significantly higher odds of accessing SRHR services, while those who were unable to do so had limited odds of access (COR = 0.12; 95% CI: 0.05–0.31). Additionally, comfortability in discussing SRHR issues was strongly associated with access, with WWDs who strongly disagreed that they felt comfortable, showing significantly lower odds of accessing services (COR = 0.08; 95% CI: 0.02–0.29), whereas neutral responses were associated with higher odds of access (COR = 3,45; 95% CI: 1.04–11.45). Perceived sensitivity and cultural competence of healthcare providers showed mixed associations, with agreement that providers were culturally competent associated with lower odds of access (COR = 0.12; 95% CI: 0.02–0.63) compared to strong agreement (Table 4).

Table 4.

Association between different individual determinants and level of access to SRHR services (n = 325)

Variable	Demographic	Access to SRHR Services	Non-access to SRHR Services	Crude Odds Ratio (CORs)	95% Confidence Intervals
Disability Modality	Intellectual Disability (ref a)	12	22	1.00	-
	Mental Disability	17	33	0.94	0.39–2.26
	Sensory Disability	105	22	8.75 ***	3.69–20.72
	Physical Disability	86	28	5.64 ***	2.40 -13.27
Age group	15–21	17	17	2.50 *	0.99–6.30
	22–28 (ref)	16	40	1.00	-
	29–35	56	37	3.78 ***	1.90–7.52
	36–42	88	6	36.67 ***	12.96–103.73
	43–49	43	5	21.50 ***	7.06–65.45
Religious Practices	Catholic (ref)	58	44	1.00	-
	Muslim	24	16	1.14	0.55–2.35
	Other	4	2	1.52	0.26–8.82
	Protestant	134	43	2.36 ***	1.44–3.87
Level of Education	Never attended school (ref)	31	13	1.00	-
	Primary	37	19	0.82	0.36–1.89
	Secondary	83	30	1.16	0.53–2.54
	Technical/Vocational	42	41	0.43 **	0.20–0.94
	Tertiary (University/College)	27	2	5.66 **	1.23–25.98
Marital Status	Single (ref)	119	90	1.00	-
	Separated	19	6	2.39	0.90–6.38
	Married	82	9	6.89 ***	3.27–14.50
Income Status	< 10,000 Kes	0	9	0.10 **	0.01–0.78
	10,000–15,000 (ref)	109	20	1.00	-
	15,000–20,000	47	23	0.37 **	0.20–0.70
	20,000–25,000	24	19	0.23 ***	0.11–0.49
	> 25,000	40	34	0.21 ***	0.12–0.38
Sexual activity status	Sexually non-active (ref)	47	67	1.00	-
	Sexually active	173	38	6.49 ***	3.98–10.58

^*p < 0.01, ^**p < 0.05, ^***p < 0.001

^aref- Reference categories were selected based on the hypothesized lowest-access group informed by existing literature (e.g., intellectual disability as reference) or, where no clear hypothesis existed, the most populous category to maximize statistical stability

Healthcare provider communication and confidentiality practices

WWDs who reported that their SRHR-related questions were adequately answered by healthcare providers had significantly higher odds of accessing SRHR services while those whose questions were not adequately addressed, had lower odds of access (COR = 0.12; 95% CI: 0.05–0.13). Furthermore, the absence of sufficient privacy and confidentiality at health facilities during SRHR service access by WWDs was strongly associated with reduced access, with women reporting lack of privacy showing lower odds of access compared to those who experienced adequate privacy and confidentiality (COR = 0.13; 95% CI: 0.07–0.23) (Table 5).

Table 5.

Association between different socio-cultural factors and level of access to SRHR services (n = 325)

Variable	Participant Response	Access of SRHR Services	Non-access to SRHR services	Crude Odds Ratio (CORs)	95% Confidence Intervals
Cultural Norms and Beliefs/ Community Perceptions (Do you believe cultural beliefs and attitudes in your community influence your access to sexual and reproductive health resources as a woman with a disability)	Agree (ref)	70	41	1.00	-
	Neutral	11	2	3.22	0.68–15.32
	Disagree	60	12	2.93 **	1.35–6.38
	Strongly Agree	18	49	0.22 ***	0.11–0.45
	Strongly disagree	61	1	35.74 ***	4.75–268.63
Stigma and Discrimination (I experience cultural or social stigmas associated with disabilities that affect my access to sexual and reproductive health services.)	Agree (ref)	28	50	1.00	-
	Neutral	23	2	20.54 ***	4.45–94.78
	Disagree	91	0	326.79 ***	19.95–5354.2
	Strongly Agree	2	53	0.07 ***	0.02–0.22
	Strongly disagree	76	0	272.14 ***	16.69–4437.6
Gender Roles and Power Dynamics (Traditional gender roles and expectations have influenced your access to sexual and reproductive health services)	Agree (ref)	31	45	1.00	-
	Neutral	57	2	41.37 ***	9.46–180.9
	Disagree	73	6	17.36 ***	6.98–44.52
	Strongly Agree	19	50	0.55	0.28–1.07
	Strongly disagree	40	2	29.03 ***	6.64–126.9

^**p < 0.05, ^***p < 0.001

Geographical and cost-associated factors

Distance to the nearest healthcare facility was strongly associated with access to SRHR services. WWDs residing more than 1 km from a healthcare provider had significantly lower odds of accessing SRHR services (COR = 0.02; 95% CI: 0.01–0.04), compared to those living within 0.5 km of a facility. In contrast, living 0.5–1 km from a facility was not significantly associated with access (p = 0.458). Regarding cost-associated factors, affordability of charges (p = 0.637), proximity to residence (p = 0.185) and perceived helpfulness of healthcare providers (p = 0.313) did not show statistically significant associations when compared to preference for physical accessibility of facilities (Table 6).

Table 6.

Association between healthcare staff attitudes and perceptions and level of access to SRHR services (n = 325)

Variable	Demographic	Access of SRHR Services	Non-access to SRHR services	Crude Odds Ratio (CORs)	95% Confidence Intervals
Ability of SRHR healthcare providers to adequately answer SRHR questions posed by WWDs	Yes (ref)	65	5	1.00	-
	No	155	100	0.12 ***	0.05–0.31
Comfortability of WWDs in discussing SRHR issues with SRHR health providers	Strongly Agree (ref)	19	5	1.00	-
	Agree	54	17	0.84	0.26–2.67
	Neutral	118	9	3.45 **	1.04–11.45
	Disagree	12	20	0.16 **	0.04–0.61
	Strongly Disagree	17	54	0.08 ***	0.02–0.29
Demonstration of sensitivity and cultural competence by SRHR health providers	Strongly Agree (ref)	9	3	1.00	-
	Agree	6	17	0.12 *	0.02–0.63
	Neutral	67	16	1.40	0.33–5.99
	Disagree	45	26	0.58	0.14–2.39
	Strongly Disagree	93	43	0.72	0.18–2.93

^*p < 0.01, ^**p < 0.05, ^***p < 0.001

Accessibility and Inclusiveness of healthcare facilities

WWDs who identified private health facilities as their primary source of SRHR services were significantly less likely to have access (COR = 0.43; 95% CI: 0.21–0.88), compared to those using Public Health facilities. Community health centers showed the highest likelihood of access, though it was not statistically significant (COR = 1.66; 95% CI: 0.83–3.33). In terms of accessibility, there was a gradient, with those who strongly disagreed that facilities are physically accessible having significantly lower odds of utilisation (COR = 0.42; 95% CI: 0.20–0.89), compared to those who strongly agreed. With regards to inclusiveness, WWDs who strongly disagreed that their preferred facility had disability-friendly pathways were less likely to access services (COR = 0.16; 95% CI: 0.06–0.41), than those who strongly agreed (Table 7).

Table 7.

Association between healthcare provider communication and confidentiality practices and level of access to SRHR services (n = 325)

Variable	Demographic	Access of SRHR Services	Non-access to SRHR services	Crude Odds Ratio (CORs)	95% Confidence Intervals
Ability of SRHR healthcare providers to adequately answer SRHR questions posed by WWDs	Yes (ref)	65	5	1.00	-
	No	155	100	0.12***	0.05–0.13
Provision of privacy and service provider confidentiality	Yes (ref)	153	24	1.00	-
	No	67	81	0.13***	0.07–0.23

^***p < 0.001

Table 9.

Association of accessibility and inclusiveness of healthcare facilities and level of access to SRHR services (n = 325)

Variable	Demographic	Access of SRHR Services	Non-access to SRHR services	Crude Odds Ratio (CORs)	95% Confidence Intervals
Facilities where SRHR services can be obtained	Public Health Facility (ref)	70	30	1.00	-
	Private Health Facility	21	21	0.43 **	0.21–0.88
	Community Health Centres	62	16	1.66	0.83–3.33
	Specialised Family Clinics	14	12	0.50	0.21–1.20
	Missionary Health facilities	53	26	0.87	0.47–1.63
Facilities are easily and physically accessible	Agree	22	13	0.54	0.22–1.35
	Disagree	83	37	0.71	0.36–1.41
	Neutral	31	12	0.82	0.34–2.01
	Strongly Agree (ref)	47	15	1.00	-
	Strongly Disagree	37	28	0.42 **	0.20–0.89
Facilities are disability inclusive	Agree	75	10	1.75	0.61–5.03
	Disagree	43	13	0.77	0.27–2.19
	Neutral	42	30	0.33 **	0.13–0.84
	Strongly Agree (ref)	30	7	1.00	-
	Strongly Disagree	30	45	0.16 ***	0.06–0.41

^**p < 0.05, ^***p < 0.001

Availability of inclusive SRHR services in the healthcare facilities

Availability of inclusive SRHR services in healthcare facilities significantly influenced WWDs access to SRHR services. WWDs who strongly disagreed that materials were available in formats accessible to them were less likely to have accessed SRHR services (COR = 0.14; 95% CI: 0.05–0.37), compared to those who had materials in accessible formats (Table 8).

Table 8.

Association between geographical and cost-associated factors and level of access to SRHR services (n = 325)

Variable	Demographic	Access of SRHR Services	Non-access to SRHR services	Crude Odds Ratio (CORs)	95% Confidence Intervals
Proximity to the nearest healthcare provider	< 0.5 km (ref)	93	5	1.00	-
	0.5–1 km	97	3	1.74	0.40–7.48
	> 1 km	30	97	0.02 ***	0.01–0.04
Preferences of the choice of a particular SRHR provider	Ability to use Physical facilities (ref)	23	13	1.00	-
	Ability to afford charges	54	37	0.82	0.37–1.83
	Near Proximity to the residence	133	45	1.67	0.78–3.57
	Healthcare providers are helpful	10	10	0.57	0.19–1.71

^***p < 0.001

Table 10.

Association between availability of inclusive SRHR services and level of access to SRHR services (n = 325)

Variable	Demographic	Access of SRHR Services	Non-access to SRHR services	Crude Odds Ratio (CORs)	95% Confidence Intervals
SRHR services and services are disability-inclusive and accessible	Agree	23	1	2.67	0.30–24.11
	Disagree	55	19	0.34 **	0.12–0.98
	Strongly Agree (ref)	43	5	1.00	-
	Neutral	21	13	0.19 **	0.06–0.62
	Strongly Disagree	78	67	0.14 ***	0.05–0.37

^**p < 0.05, ^***p < 0.001

Discussion

The study’s findings demonstrate that access to Sexual and Reproductive Health and Rights (SRHR) services among WWDs remains uneven, shaped by intersecting individual, socio-cultural, and health-system factors. Although over two-thirds of WWDs reported some level of access within the past 12 months, 32.31% reported a lack thereof, thus indicating infrequent engagement with SRHR services. This infrequent engagement suggests that access, when it occurs, may be reactive rather than continuous or preventive, underscoring persistent gaps even within settings where services nominally exist. These findings are consistent with a Ghanaian study by Seidu, who despite reporting a high access of SRHR services (94.3%) among Persons with Disabilities, he also noted that, there are significant gaps and challenges with regards to age group, disability type, misconceptions, beliefs, and service non-functionality that directly impact their access to these vital services [26]. The study findings are also consistent with those of Obaga’s, who noted a moderate access of SRHR resources (71.4%) among youth with disabilities in Kisii County, Kenya [27]. All these studies highlight a relatively moderate access of SRHR resources (over 50%), which potentially stemmed from common policy efforts, though the difference in the level of access may reflect context-specific barriers between the study populations.

Access to specific SRHR services among WWDs was uneven. Family planning services were the most accessed among WWDs (89.09%), aligning with broader SRHR utilisation patterns in sub-Saharan Africa, where contraceptive services are often the most visible and actively promoted SRHR intervention [21, 22, 28, 29]. However, access to other essential SRHR services was substantially lower, including reproductive cancer screening (4.09%), sexual and gender-based violence (SGBV) response and prevention (38.18%), comprehensive sexual education (CSE) (49.09%), and safe and post-abortion care (2.27%), indicating significant service fragmentation. A comparison with indicators from the Kenya Demographic and Health Survey (KDHS) 2022 for Murang’a County, reveals pronounced inequities in SRHR access between women with disabilities and women in the general population. While contraceptive uptake appears comparable (88% in the general population versus 89.09%) among WWDs, this similarity obscures differences in service accessibility and quality experienced by WWDs. For example, whereas the women in the general population demonstrate high utilisation of skilled antenatal care (96%) and HIV testing (92%), utilisation among WWDs was markedly lower at 9.55% and 20%, respectively. Similarly, uptake of reproductive cancer screening and SGBV-related healthcare services was substantially lower among WWDs (4.09% and 38.18%) compared to the general population (15% and 64%). Although abortion is underreported (< 1%), a slightly higher proportion of WWDs (2.27%) reported accessing safe abortion and post-abortion care. Additionally, fewer than half of WWDs (49.09%) reported having received comprehensive sexual education, reflecting partial but insufficient access to inclusive CSE [30–35]. These disparities likely reflect structural barriers within the health system, limited provider capacity, persistent stigma, and the prioritisation of select SRHR services over comprehensive, inclusive care for WWDs, whose sexuality is often marginalised or denied. These findings are consistent with studies from Ethiopia, Uganda, and Bangladesh, which similarly report high utilisation of family planning services among WWDs but persistent gaps in access to comprehensive sexual education and other essential SRHR services [36, 37].

Disability type strongly influenced access, with women with intellectual and mental disabilities having the lowest access rates (35.29% and 34% respectively). This finding indicates that these groups face the most profound barriers to SRHR access. Existing literature from similar LMICs contexts suggest potential explanatory factors including communication barriers, provider bias, and limited availability of tailored information for women with cognitive and psychosocial disabilities [9, 38, 39]. Similarly, a study focusing on the accessibility and utilisation of SRHR services among people with disabilities in Nepal highlighted those with intellectual and mental disabilities faced more significant barriers, leading to lower utilisation of these services [40]. Access in the Nepal study, increased with age, with older WWDs significantly more likely to utilise SRHR services. This pattern may reflect increased reproductive health needs over time or greater autonomy in healthcare decision-making or already established pathways to healthcare by older women, leading to fewer barriers. Conversely, younger WWDs may face compounded barriers related to ageism, disability stigma, and restrictive socio-cultural norms surrounding youth sexuality. This potential disparity echoes findings from a study by [41] who found that young WWDs face multiple and often intersecting barriers that hinders full utilisation of SRHR services. The findings from this study also contradict those of Matin et al. (2021), which suggest that being older negatively impacts access to healthcare for WWDs [42]. Religious affiliation showed limited influence overall, although Protestant affiliation was associated with higher access (COR = 2.36; 95% CI: 1.44–3.87), suggesting that faith-based norms and institutional linkages may shape SRHR engagement differently across denominations. These differenced may be potentially influenced by varying doctrinal teachings on sexuality and family planning, differing levels of openness to SRHR education and the influence of religious leaders and faith-based health institutions on community attitudes and health-seeking behaviours. Supportively, a study in Uganda found that religious and cultural beliefs influence utilisation rates of SRHR services and in particular, Catholic and Muslim communities often view contraceptive use as contrary to divine plans, leading to lower utilisation rates [43]. Educational attainment emerged as a significant determinant, reinforcing the role of health literacy, empowerment, and navigation skills in enabling access. WWDs who had attained tertiary education, were associated with higher access (COR = 5.66; 95% CI: 1.23–25.78) and these results align with findings by Badu et al. (2018), who identified education as a key facilitator in accessing reproductive health information and services among PWDs in the resource-limited Ashanti and Brong Ahafo regions of Ghana [44]. Furthermore, being married, was strongly associated with higher utilisation (COR = 6.89; 95% CI: 3.27–14.50), suggesting that marriage may legitimise SRHR needs for WWDs within both healthcare settings and broader social contexts. This finding aligns with that of Mac-Seing et al. (2022), who revealed that PWDs who were single, separated, divorced, or widowed had lower odds of regularly accessing SRHR services [45]. Income presented a complex and counterintuitive pattern. While women earning less than 10,000 KES had significantly reduced odds of access (COR = 0.10; 95% CI: 0.01–0.78), higher-income groups (> 25,000) also demonstrated lower odds (COR = 0.21; 95% CI: 0.12–0.38), compared to the reference group. This may reflect unmeasured confounders such as reliance on informal care, alternative service pathways, opportunity costs, or differing health-seeking preferences among higher-income WWDs. It also highlights that financial capacity alone does not guarantee access when structural and attitudinal barriers persist [46]. Sexual activity status was a strong predictor of access (COR = 6.49; 95% CI: 3.98–10.58), indicating that SRHR services are often sought primarily in response to sexual engagement rather than as part of preventive or rights-based care. Similarly, in Ethiopia, a community survey found that among WWDs that were cohabiting or living with a sexual partner, had a 33.3% uptake of at least one SRH service, far higher than in women without such partnerships [47].

Cultural norms, stigma, discrimination, and gendered power dynamics emerged as some of the strongest determinants of access. Strong disagreement with restrictive cultural beliefs, stigma, and discriminatory experiences was associated with dramatically higher odds of service utilisation, while strong agreement with these barriers significantly reduced access. These findings underscore how internalised stigma and socially reinforced exclusion can directly suppress health-seeking behaviour [9]. They also highlight the role of agency, self-perception, and resistance to marginalising norms in enabling access to SRHR services. These findings are consistent with those of Maleki et al., (2024) which highlighted that systemic prejudice and discrimination against WWDs are deeply rooted in societal attitudes and entrenched disability and gender-based stereotypes [48]. Mac-Seing et al., (2020) also revealed that WWDs were often stigmatized as a result of physical and communication barriers and emphasized that they were particularly at risk of discriminatory practices when seeking maternal healthcare services [49].

WWDs’ perceptions of healthcare staff attitudes were critical determinants of SRHR access. The ability to freely ask SRHR-related questions and feel comfortable discussing sensitive issues was strongly associated with service utilisation. Conversely, discomfort and communication barriers significantly reduced access, reinforcing the centrality of provider-client interactions in shaping SRHR outcomes for WWDs. This finding aligns with that of Neupane et al., (2024), who found that there was a gender bias, limited effort to provide adequate information to WWDs, and to understand their needs while accessing SRHR services [50]. Mixed findings regarding perceived cultural competence suggest variability in provider behaviour and differing interpretations of respectful care, pointing to the need for standardised disability-sensitive training. Healthcare provider communication, confidentiality practices and service delivery further influenced access. Adequate responses to SRHR questions and assurance of privacy and confidentiality were strongly associated with utilisation, highlighting that technical competence alone is insufficient without trust, discretion, and respectful engagement. Ganle et al., (2020) reported similar findings when he noted that healthcare providers lack professional skills to deal with PWDs. Further and regular training of healthcare providers on how to provide SRHR services to PWDs in a respectful and non-judgmental manner was recommended [9]. The findings are also in alignment with those of Casebolt (2020), who reported that healthcare providers felt unprepared to provide SRHR care to WWDs and did not receive sufficient training on handling WWDs SRHR issues [11]. Distance to healthcare facilities was a major barrier, with WWDs living more than 1 km away showing dramatically reduced odds of access (COR = 0.02; 95% CI: 0.01–0.04). This finding reflects the compounded effects of mobility limitations, transport costs, and environmental barriers. Interestingly, preferences related to affordability, proximity, and provider helpfulness did not independently predict access, suggesting that physical distance may overshadow other cost-related considerations when mobility constraints are present. Besoain-Saldaña et al., (2023) reported similar findings and noted that, financial difficulties in paying high costs of SRHR services and the cost of transportation to health centres limited the access of SRHR services by WWDs [51]. Accessibility and inclusiveness of healthcare facilities significantly shaped access. Reliance on private facilities was associated with reduced access (COR = 0.43; 95% CI: 0.21–0.88), while community health centres demonstrated higher, though non-significant, likelihood of utilisation (COR = 1.66; 95% CI: 0.83–3.33). This finding suggests that decentralised and community-based service delivery platforms may offer a more accessible and acceptable entry point for WWDs, possibly due to reduced physical barriers, familiarity, or perceived inclusivity. The relatively lower utilisation of private facilities may reflect cost constraints, limited disability accommodations, or weaker linkages between disability and SRHR services. Physical accessibility and disability-inclusive infrastructure were decisive factors, with lack of accessible pathways and inclusive design substantially reducing access. Finally, the availability of inclusive SRHR information materials was strongly associated with service utilisation. The absence of materials in accessible formats significantly limited access, underscoring the importance of information accessibility as a foundational component of SRHR service delivery for WWDs. These findings are consistent with those of Singh et al., (2024) who noted that weak coordination and implementation of guidelines for disability inclusive health services in Nepal, barred PWDs from utilizing inclusive SRHR services [52].

Conclusion and recommendation

The study demonstrates that access to SRHR services among WWDs in Murang’a South is highly uneven across facilities, service types, and individual characteristics. Essential services such as HIV/STI prevention, maternal health, cancer screening, and abortion care remain severely underutilized. Access is significantly shaped by disability type, age, education level, marital status, income status, and sexual activity, with women with mental and intellectual disabilities, young women, single women, those with low income and the sexually inactive, exhibiting the lowest access rates. Socio-cultural factors, including stigma and discriminatory norms, gendered power dynamics, and negative community perceptions, further restrict access. WWDs perceptions on health facility factors, particularly provider attitudes, communication and confidentiality practices, lack of disability inclusive SRHR service pathways, accessibility and inclusiveness of healthcare facilities, geographical and cost-associated barriers, also significantly influenced service utilisation. These findings highlight persistent SRHR access inequities among women with disabilities. To increase effective access, there is need to: (i) engage with healthcare providers to understand their perspectives and barriers to inclusive care; (ii) strengthen disability-inclusive training and cultural competence to improve knowledge, address negative attitudes, and ensure privacy, thereby making clinical environments safe and comfortable for WWDs; and (iii) support healthcare providers to systematically collect disability status data at the point of care to enable disability-responsive service delivery and ongoing monitoring of access.

Study limitations

One limitation of this study is the potential for social desirability bias, as the sensitive nature of SRHR topics may have led participants to underreport experiences or provide socially acceptable responses. Additionally, the data collection tools were designed to assess overall access to SRHR services rather than to quantify unmet need. The sampling frame was derived from the National Council for Persons with Disabilities (NCPWD) register, which requires clinical documentation and community-based verification for inclusion; however, registration is voluntary and not universal in Kenya. As a result, the sample reflects only women with disabilities who are formally registered and may exclude unregistered individuals, including those hidden due to stigma, thereby limiting representativeness. Furthermore, while the sample size was adequate for descriptive and bivariate analysis, it was modest for more complex multivariable modelling; consequently, the study employed bivariate logistic regression, and findings should be interpreted as exploratory, without adjustment for potential confounders. Additional limitations include possible underreporting of disability cases, limited generalizability beyond the study area, temporal context-specific influences, and the use of sign language interpreters, which may have affected the depth and accuracy of responses.

Abbreviations

WWDs

Women with Disabilities

SRHR

Sexual and Reproductive Health and Rights

KDHS

Kenya Demographic and Health Survey

CSE

Comprehensive Sexuality Education

SGBV

Sexual and Gender-Based Violence

HIV

Human Immunodeficiency Virus

STI

Sexually Transmitted Infection

COR

Crude Odds Ratio

CI

Confidence Interval

PWDs

Persons with Disabilities

LMICs

Lower-and-Middle Income Countries

UNCRPD

United Nations Convention on the rights of Persons with Disabilities

UNFPA

United Nations Population Fund

KES

Kenyan Shilling

NCPWD

Kenya National Council of Persons with Disabilities

NACOSTI

National Commission for Science, Technology and Innovation

MPH

Master of Public Health

MKU

Mount Kenya University

Authors’ contributions

AS conceptualised the study and led data collection and analysis. All authors contributed to the design of the methodology, drafting of the manuscript, interpretation of findings, critical review of the manuscript, and approval of the final version for publication.

Funding

This study did not receive any specific funding from public, commercial, or not-for-profit funding agencies.

Data availability

Data obtained for the study are not publicly available for ethical reasons but are available upon reasonable request from the corresponding author, subject to ethical approval and data protection considerations.

Declarations

Ethics approval and consent to participate

The following ethical clearance was obtained: National Commission for Science, Technology and Innovation clearance (Ref No: 820482). Additional approvals were obtained from The Mount Kenya University Ethics and Review Committee clearance (Ref No: MKU/ISERC/3351) and from the Director of Public Health Research and NCPWD Murang’a County Director (Ref No: 21/12/2023). All study procedures were conducted in accordance with the ethical principles outlined in the WMA Declaration of Helsinki, 2024. Comprehensive information about the study was provided to the participants and their written informed consent was obtained prior to their inclusion in the study. Competent adults and emancipated minors who understood the nature, purpose, risks, and benefits of participating in the study provided informed consent. Non-emancipated minors who participated, gave their informed assent in order to respect their developing autonomy and involve them in decision-making to the extent that they could understand. Additionally, consent from their parents or legal guardians was also obtained. Consent and assent procedures were adapted to participants’ specific disability needs to ensure informed and ethical participation. Where appropriate, caregivers provided supportive clarification bud did not consent on behalf of participants. All research assistants received training on ethical conduct and confidentiality and signed confidentiality agreements to safeguard participants’ sensitive information.

Consent for publication

Not applicable. No individual-level data or identifying information are reported in this manuscript.

Competing interests

The authors declare no competing interests.