Abstract
Background
Family quality of life (QoL) is a central outcome in disability research, but its distribution across living contexts remains insufficiently defined. Structural differences in service provision between urban and non-urban areas are assumed to influence family outcomes, yet evidence linking service context to family-reported QoL is scarce, particularly in Central and Eastern Europe. In Bulgaria, where specialized services are concentrated in urban areas, this study evaluates urban–rural differences in family QoL.
Methods
Cross-sectional pilot study conducted in 2025 among caregivers of children with autism spectrum disorder (ASD), cerebral palsy (CP), and typically developing controls (n = 36) in Bulgaria, within the NutriLect project. Family QoL was the primary outcome, measured using an adapted Beach Center Family QoL Scale across five domains. Urban versus non-urban residence was the main exposure. Differences in QoL were assessed using Mann–Whitney U and Kruskal–Wallis tests. Associations were estimated using Spearman’s rank correlation coefficients, and effect sizes were calculated.
Results
Urban families reported lower overall QoL than non-urban families (4.31 ± 0.71 vs 4.60 ± 0.41; U = 108.0, p = 0.178; d = 0.48), with consistently lower scores across domains and a significant difference in support and resources (3.65 vs 4.53; U = 78.0, p = 0.047; d = 0.95). QoL was lower in families of children with ASD and CP compared to controls, although differences were not statistically significant (H = 0.64, p = 0.726). QoL was not associated with household income, marital status, or caregiving arrangement; higher maternal education showed a borderline association with QoL (U = 21.5, p = 0.057).
Conclusions
Lower family QoL in urban settings was driven by deficits in support and resources rather than differences in diagnosis or socioeconomic factors. Strengthening coordinated, family-centered support systems may be more effective than increasing service availability alone.
Key messages
• Lower family QoL in urban settings was driven by reduced support and resources rather than differences in diagnosis or socioeconomic characteristics.
• Differences in QoL were not explained by service availability alone, indicating the importance of how support is organized and experienced.