Access to basic needs and health care for Malawian prosthetic and orthotic users with lower limb physical disabilities: a cross-sectional study

Abstract

Purpose

To investigate access to basic human rights such as health, a standard of living adequate for health, education, work, marrying and establishing a family, and voting for prosthetic and orthotic users with lower limb disabilities in Malawi.

Materials and methods

A cross-sectional design and a questionnaire were used to collect data from 83 participants.

Results

Most participants reported their overall physical and mental health as good (60 [72%] and 50 [60%], respectively) and said they could access medical care (69 [83%]). Fifty (60%) participants had access to food, 72 (87%) had access to basic water, and 55 (66%) lived in housing adequate for their health. Most participants had studied in school (74 [89%]) but only 27 (33%) of the participants were working. Forty-three (52%) were married and 53 (64%) had children. Seventy-six (92%) participants could vote if they wished.

Conclusions

Rurality and high costs of transport and medication increase the barriers to accessing several basic human rights for people with lower limb physical disabilities. Interventions to target these barriers and increase access to secondary school, employment, and income could improve health equity for people with physical disabilities in Malawi and similar contexts.

Implications for Rehabilitation

• In Malawi, the convention on the rights of persons with disabilities is yet to be implemented.

• Policy makers in Malawi need to take actions to increase access to regular and specialized healthcare services for persons with physical disabilities including financial support to afford medications and transport to reach health services.

• Policy makers in Malawi need to take actions to increase access to secondary and higher education, and employment for persons with physical disabilities to increase their possibilities to earn an income.

Keywords:

• Africa
• disabilities
• Malawi
• United Nations Convention of People with Disabilities
• basic needs

Introduction

People with disabilities are a disadvantaged population globally and face multiple barriers to inclusion in society. The situation is even worse for people with disabilities living in low-income countries, who have additional challenges often related to lack of food, water [1], and health care [2,3]; conflict; poor infrastructure [4]; and poverty [4,5]. People with disabilities have more needs for health care and rehabilitation services than people without disabilities [4,6–8], and these are often unmet [4,9,10]. More than 1 billion people have some form of disability, 80% of whom live in low- and middle-income countries [4]. People with disabilities are defined by the United Nations Convention of People with Disabilities as “those who have a long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others” [11], this paper concerns people with lower limb physical disabilities. Disability is a human rights issue because of the stigmatization, discrimination, and inequities people with disabilities struggle with in their daily lives [12]. People with disabilities in low- and middle-income countries are often denied human rights [4] such as the right to health [13], the right to education [5,14], and the right to work [15]. The environmental, physical, social, cultural, and economic barriers faced by people with disabilities are also called the social determinants of health [4,13,16–18], and they negatively impact health [2,6–8,19–21], education [5], and employment opportunities [5,21,22]. Functional limitations had a substantial negative effect on subjective the well-being and labor activities of people with functional disabilities in Malawi [9], and the costs of assistive devices and related services increased their economic hardship [21–23]. Social determinants such as place of birth and access to food, housing, education, employment, and transportation [24,25] all affect overall health. Discrimination against people with disabilities including persons with physical disabilities health care workers is also a problem in many low- and middle-income countries [4,5] Together, social determinants and discrimination increase people with disabilities’ risks of several other health conditions [4] such as infections and impaired mental health [21].

The Universal Declaration of Human Rights states that all human beings, including marginalized groups, are entitled to human rights and freedom [26]. Governments have the obligation to make decisions that promote and protect those human rights. To protect the human rights of people with disabilities the United Nations convention of people with disabilities has compiled 50 articles with guiding principles for member states [11]. This human rights framework can be used to address health inequities caused by social determinants among people with disabilities [12,25,27]. Historically, the medical aspect of disability has been central in efforts to address health among various populations. In the last decade, the roles of the social and physical environment and human rights for people with disabilities have become more prominent [25].

Malawi is a small sub-Saharan country with a population of 18 million people where approximately 85% live in rural areas [28] and 51% live below the poverty line [29]. According to the Fourth Integrated Household Survey 2016–2017 [30], 56% of the population in Malawi are >20 years old. Most health care is provided by the government free of charge to citizens. The most common diseases are malaria, lower respiratory infections, diarrhea diseases, conditions arising during perinatal period, and human immunodeficiency virus. The school system is divided into three levels: primary, secondary, and tertiary; however, only the primary level is mandatory. Literacy rates among people ≥15 years is 73%, but 14% have never attended school. Eighty-eight percent of people aged 15–64 years performing income-generating activities, yet the unemployment rate among people aged 15–24 years is 16%. Many Malawians struggle to access adequate food but have access to basic water [30]. However, Malawian schools provide limited access to needed water and sanitation for students with disabilities [31]. The voting age in Malawi is 18 years [30]. Malawi have ratified the United Nations convention of people with disabilities [11], created a national policy on equalization of opportunities for persons with disabilities [32] and a disability act [33]. The 2018 census report that 10% of the population aged 5 years and older had least one type of disability, and 27% of persons with disabilities reported difficulties to walk [34]. In the current study people with disabilities of investigation were defined as people with a lower limb disorder who use assistive devices such as prostheses, orthoses, wheelchairs, and crutches [23]. Research can contribute to increase awareness to inform policy development and promote rehabilitation services and access to assistive mobility devices and human rights of persons with lower limb disabilities in Malawi, and to address inequities caused by the social determinants of health [4,25].

Our aim was to investigate access for Malawians prosthetic and orthotic users with lower limb disabilities to basic human rights such as health, a standard of living adequate for health, education, work, marrying and establishing a family, and voting. A further aim was to investigate differences among subgroups based on gender, level of income, and residential location.

Materials and methods

A quantitative cross-sectional study design was applied. A questionnaire was used to collect self-reported data on the access to basic human rights among people with lower limb disability that have received rehabilitation service and were using assistive devices.

Sampling and participants

The study was a part of a larger project that investigated the Malawian prosthetic and orthotic users’ mobility and satisfaction with their lower limb assistive device(s) [23]. The authors sampled from one of the three prosthetic and orthotic centers, using the only one with contact information to patients and a minimum of 2 years register available. Participants were included if they met the following criteria: aged ≥16 years, had a lower limb disability, and had received services at the prosthetic and orthotic center within the last two years. A total of 196 participants fulfilled the inclusion criteria, but contact details for only 148 patients were available from the register. A local staff member tried to contact all 148 patients, reached 97, and invited those 97 to participate. As the participants lived throughout the country, they were offered paid travel by public transport. Fourteen dropped out due to difficulties traveling on public transport (n = 3), illness (n = 2), or unknown reasons (n = 9). A final total of 83 participants were included.

Participants’ demographics and characteristics are presented in Table 1. The mean age of the participants was 35.5 years (range 16–74 years), and the median was 33 years. The mean years that participants had lived with their disability was 11.8 years, (range 1–46 years), and median was 7 years.

Table 1. Participants’ demographics and characteristics (N = 83).

Variables	n	%
Gender
Female	36	43
Male	47	57
Age
16–29 years	29	35
30–74 years	51	61
Residential location
Urban area/city	41	49
Rural area/village	42	51
Level of income
No income	36	43
Income sometimes	29	35
Regular income from employment	18	22
Type of disability
Symes or trans-tibial amputation	38	46
Trans-femoral amputation^a	26	31
Ankle/foot orthotic use	8	10
Knee/ankle-/foot orthotic use	11	13
Cause of lower limb disability for prosthetic users
Road traffic accidents	15	18
Non healing wounds and fractures	12	15
Accidents	10	12
Congenital disorders corrected by surgery	7	8
Cancer	8	10
Diabetes	4	5
Malpractice in healthcare	2	2
Opportunistic infections related to HIV + TBC	1	1
Snake bites	2	2
Violence	2	2
Undefined cause	2	2
Cause of lower limb disability for orthotic users
Polio	6	7
Accident	2	2
Paraplegic/hemiplegic	5	6
Opportunistic infections related to HIV + TBC	2	2
Stroke	2	2
Undefined cause	1	1
Walking distance with assistive device
Not at all, 0 m	5	6
A few meters	15	18
Approximately 100 m	14	17
Approximately 1 km or more	49	59
Ability to move around in the home
Yes, without any difficulty	65	80
Yes, with difficulty	12	21
No, not at all	3	4
Ability to walk on uneven ground/roads
Yes, without any difficulty	48	59
Yes, with difficulty	28	34
No, not at all	6	7
Type of assistive device
Symes or trans-tibia prosthesis	33	40
Trans-femoral prosthesis^b	27	33
Bilateral prosthesis	4	5
Ankle/foot orthosis	5	6
Double knee/ankle/foot orthosis	12	15
Trans-tibia amputation/ankle-foot orthosis	1	1
General condition of device
Never used/broken/cannot be used	9	10
In use, but needs repair	44	48
In use, good condition	40	42
Ability to cover costs of receiving the service appliances, incl. travel to and accommodation at rehab centers
Yes	15	18
No	68	82

^a Includes knee disarticulation and use of extension prosthesis.

^b Includes knee disarticulation prosthesis or extension prosthesis.

Instrument

Background questions on the characteristics and demographics were developed by author LM [23]. The questionnaire used was originally developed in English and translated to Bengali by Borg et al. for study in Bangladesh based on the United Nations convention of people with disabilities [35]. The questionnaire comprised the six domains of basic human rights; Article 23 Respect for home and the family, Article 24 Education, Article 25 Health, Article 27 Work and employment, Article 28 Adequate standard of living and social protection and Article 29 Participation in political and public life [11]. The English version of the questionnaire was translated to achieve a Chichewa version that was conceptually equivalent and acceptable to the participants. To achieve this, we had the questionnaire forward translated, translations were reviewed and the agreed translation was, back-translated, pre-tested, and used in cognitive interviews following the World Health Organization’s guidelines for translation [36]. The forward translation from English to Chichewa was conducted by three different translators, and the back-translation by a fourth; all translators had a work background in rehabilitation. LM compared the translations with the original questionnaire and found them identical. A pilot test of the questionnaire was performed with five participants to ensure cultural validity.

Data collection

The National Health Sciences Research Committee of Malawi approved the study. Information about the study was given in Chichewa or in English and written consent was given by all participants. Public transport costs were covered for those participants who had to travel the average cost was two USD and prosthesis and orthosis services was offered if needed. The questions were read face-to-face in Chichewa to 52 participants by a research assistant and in English to 28 participants by LM. All interviews took place at the prosthetic and orthotic center.

Data analysis

Descriptive statistical analyses were conducted for all variables in each of the six areas: right to health, right to a standard of living adequate for health, right education, right to work, right to marry and found a family, and right to vote.

Chi-square tests were used to compare proportions between groups. Fischer’s exact test was used for analyses of subgroups with few participants. The variables used for comparison were gender (female; male), level of income (no income; irregular income; regular income), and place of living (urban; rural area). Chi-square tests were performed for all subgroups against the six described basic human rights. Due to limited sample size, some response alternatives were combined when comparing proportions. When comparing access to food, water, clothes, medical care, and caring for children, the response alternatives “always” and “most of the time” were combined, as were “seldom” and “never.” The “divorced,” “separated,” and “widowed” marriage options were also combined in group comparisons. The work options “no, never worked” and “I am a housewife” were combined, as were the “other” and do not know” reasons for stopping work. To compare mental and physical health, the options “very good” and “good” were combined, as were “bad” and “very bad.” The reasons for having no access to medical care were recoded into “could not afford transport,” “doctors’ fee,” “no transport available,” and “other”. To compare reasons for not being able to buy medicine, the options “could not afford transport” and “other” were combined. All analyses were performed in SPSS (SPSS Inc., Chicago, IL) and p ≤ 0.05 was considered statistically significant.

Drop-out analysis

Chi-square tests were used to discover any significant difference in the distribution of men and women among those who participated in the study (n = 83) and those who did not (n = 113). The results showed no difference between men and women (p > 0.05). Neither was there any significant difference in the distribution of level of injury (above knee; below knee impairment) between participants and excluded candidates (p > 0.05). T-test showed no significant difference in age between those who were included (mean 35.6 years) and those who were not (mean 39.6 years; p > 0.05). Information about age was available for 97 of the 113 who were not included.

Results

Access to health and a standard of living adequate for health

Responses to questions about the rights to health and to a standard of living adequate for health are presented in Table 2. Sixty (72%) participants reported their overall physical health as “good” or “very good”; 50 (60%) reported their mental health as “good” or “very good”; 69 (83%) reported having access to medical care, and 61 (74%) that they could buy medicine when needed during the pgast year. The most common reason for not accessing medical care or medicine was not being able to afford transport, doctor’s fee, or medicine. About half of the participants who required medical care outside home during the past year were able to access services. Malaria 20 (20%), diabetes four (5%), and abdominal pain two (2%) were the most common types of illness requiring outside medical care.

Table 2. Responses of questions regarding; right to health; right to a standard of living adequate for health.

Variables	n	%
Physical health considering sickness, illness, injury, or disease, n = 83
Very good	34	41
Good	26	31
Moderate	14	17
Bad	6	7
Very bad	3	4
Mental health considering anxiety, fear, fatigue, tiredness, hopelessness, n = 82
Very good	22	27
Good	28	34
Moderate	20	24
Bad	9	11
Very bad	3	4
Illness requiring medical care outside the home (past year), n = 79
Yes	38	46
No	41	49
Could not access medical care when needed (past year), n = 82
Yes	13	16
No	69	83
The most important reason for not accessing medical care when needed, n = 13
No transport available	1	1
Could not afford transport	7	8
Could not afford doctors fee	1	1
Other	4	5
Could not buy medicine when needed, n = 82
Yes	21	25
No	61	74
The most important reason for not buying medicine when needed, n = 20
Could not afford transport	2	2
Could not afford medicine	17	21
Other	1	1
Possibility to eat food three times a day, n = 83
Always	40	48
Most of the time	10	12
Seldom	30	36
Never	3	4
Regularly access to basic water, n = 83
Always	63	76
Most of the time	9	11
Seldom	10	12
Never	1	1
Access to clothes appropriate for weather, n = 83
Always	31	37
Most of the time	18	22
Seldom	12	15
Never	21	25
Access to necessary medical care, n = 82
Always	31	37
Most of the time	13	16
Seldom	29	35
Never	9	11
Live in a house adequate for health, n = 83
Adequate	27	33
Reasonably adequate	28	34
Not adequate	28	34

Fifty (60%) participants were “always” or “most of the time” able to eat three times a day. That ability was significantly better for those in urban areas than those in rural areas (31 [76%] vs. 19 [45%]; p = 0.005). In addition, 72 (87%) participants reported that they had access to basic water “always” or “most of the time.” Access was again significantly better for urban participants (41 [100%]) than for rural (31 [74%]; p < 0.001). Forty-nine (59%) participants reported having access to weather-appropriate clothing “always” or “most of the time.” Those with regular income had significantly better access to appropriate clothing (17 [94%]) than those with no income (19 [53%]) or irregular income (13 [46%]; p = 0.003).

Forty-four (53%) participants reported that they could access necessary medical care when needed “always” or “most of the time.” Those living in urban areas had significantly better access to necessary medical care (28 [70%]) than those in rural areas (16 [38%]; p = 0.004). Also, the group with regular incomes had significantly higher access to medical care (17 [94%] reported “always” or “most of the time”) than those with no income (17 [49%]) and irregular income (10 [35%]; p < 0.001).

Fifty-five participants (66%) reported living in housing that was “adequate” or “reasonably adequate” for health. Significantly more participants with regular income reported that they live in a house “adequate” for health (11 [61%]) than those with no income (13 [36%]) or irregular income (3 [10%]; p = 0.003).

Access to education and employment

Responses to questions about the rights to education and to work are presented in Table 3. Seventy-two (87%) participants reported that they can read a letter and 73 (88%) that they can write a letter. The ability to read and write a letter was significantly higher among those in urban areas (40 [98%]) than those in rural areas (33 [77%]; p = 0.004 for reading and 0.015 for writing). Seventy-four participants (89%) had studied in school, with those living in urban areas (41 [100%]) more likely than those living in rural areas (33 [(81%]; p = 0.003). Fifty-four (65%) had not completed secondary school. In the group with regular income, significantly more had completed secondary school (10 [56%]) than those with no income (14 [39%]) or irregular income (5 [17%]; p = 0.022). Participants in urban areas (22 [54%]) were more likely than those in rural areas (7 [17%]) to have completed secondary school, (p < 0.001). Six (15%) participants living in urban areas had completed a degree vs. 0 (0%) in rural areas (p = 0.012). The most commonly completed degrees were accounting (2 [2%]), information technology (2 (2%), and human resources 2 (2%). Fifty-nine (71%) participants reported that they were not currently studying. Participants with no income were studying at a significantly higher rate (16 [44%]) than those with regular (5 [28%]) and irregular incomes (3 [10%]; p = 0.011). Seventy-four (89%) participants reported that they had not studied as far as planned. The most common vocational trainings completed by the participants was needlecraft and tailoring (4 [5%]).

Table 3. Responses of questions regarding right to education and right to work.

Variables	n	%
Can read a letter, n = 83
Yes	72	87
No	11	13
Can write a letter, n = 83
Yes	73	88
No	10	12
Have studied in school, n = 82
Yes	74	89
No	8	10
Attended adult literacy classes to read and write, n = 83
Yes	5	6
No	78	94
Completed secondary school, n = 83
Yes	29	35
No	54	65
Completed higher secondary school, n = 83
Yes	9	11
No	74	89
Completed any degree, n = 83
Yes	6	7
No	77	93
Completed any vocational training, n = 82
Yes	41	49
No	41	49
Currently studying (including part-time studies), n = 83
Yes	24	29
No	59	71
Studied as far as planned, n = 82
Yes	8	10
No	74	89
Currently working, n = 83
Yes	27	33
No, but have worked before	25	30
No, never worked	28	34
I am a housewife	3	4
Reasons for stop working, n = 27
Retired	5	6
Fired	3	4
Other	6	7
Illness	4	5
Disability	8	10
Do not know	1	1
Reasons for not working, n = 27
Cannot work	1	1
Could not get a job	11	13
Do not want to	1	1
Family duties	1	1
Other	13	16

Only 27 (33%) of the participants were working. Participants with a regular income had a significantly higher working rate (15 [83%]) than those with irregular (9 [31%]) or no income (3 [8%]; p< 0.001). The most common reason to stop working was disability. Difficulty finding a job was the most common reason for not working (Table 3). The participants’ most common current or latest reported jobs were selling (9 [11%]), teaching (7 [8%]), farming (6 [7%]), guard (3[4%]), and mechanics (3 [4%]).

Rights to marry, establish a family, and vote

Responses to questions about the rights to marry, establish a family, and vote are presented in Table 4. Forty-three (52%) participants were married and 53 (64%) had children (mean number of children = 4.1; range 1–9). In the group with regular income, significantly more participants took care of the children “often” or “always” (13 [87%]) than in the groups with irregular income (3 [15%]) and no income (3 [17%]; p < 0.001). Seventy-six (92%) participants reported that they could vote if they wished to, and 57 (69%) participants had voted in the general election.

Table 4. Responses of questions regarding right to marry and found a family; right to vote.

Variables	n	%
Married, n = 83
Yes	43	52
No, never been	31	37
Widowed	3	4
Divorced/separated	6	7
Have children, n = 83
Yes	53	64
No	30	36
If yes, how often do you take care of the children, n = 52
Never	10	12
Seldom	23	28
Often	5	6
Always	14	17
Vote if I want, n = 83
Yes	76	92
No	1	1
Not applicable	6	7
Vote in the general election, n = 83
Yes	57	69
No	18	22
Not applicable	8	10

Discussion

Most participants with lower limb disabilities reported their overall physical and mental health as good and said they could access medical care and buy medicine. About two-thirds of participants were able to eat three times a day, had access to basic water, and lived in a house adequate for health. Most participants had studied in school and could read and write, but only a third had completed secondary school and very few had completed a degree. A third of the participants were working, about half were married and/or had children, and almost all reported they could vote if they wished.

Environmental and economic barriers

The majority reported they had regular access to basic water. In northern Malawi [31] about half of the students with disabilities faced barriers including the uneven pathways to water source and difficulties operating the hand-pump accessing water and sanitation facilities at school. A household survey of over 9000 participants in Malawi, South Africa, Sudan, and Namibia showed that socioeconomic status was significantly and negatively associated with environmental barriers [2]. The differences between the groups with and without disabilities were largest for transportation, the natural environment, and access to healthcare services [2]. Most participants with lower limb disabilities reported that they could access medical care when needed, but some of the most important reasons for being unable to access health care were no available transport and high costs of transport and doctors’ fees. This corresponds to study in Malawi where children with physical disabilities report the need to be carried to, from and around the health facility due to lack of transport and disability friendly infrastructure at the health centers [37]. About half of the participants used their prostheses and orthoses despite that they were broken and in need of repair (Table 1). The public transportation cost, average two USD to reach the prosthetic and orthotic center was reported as reason why they had not come to the center to repair their broken assistive devices before participation in the study. This is consistent with the findings from Malawi, Botswana, and South Africa [38] and the household survey in South Africa, Sudan, Malawi, and Namibia [2], where for people with disabilities in rural areas an inadequate transport system is a major barrier to accessing education and health services. Costs for health care services [4] and transportation are two main reasons why people with disabilities do not access health care [2,22,39]. Most participants with lower limb disabilities could buy medicine when needed, but the most important reason not to buy medicine was the high cost. People with disabilities in low- and middle-income countries have higher medical costs than people without disabilities and are more likely to live in poverty than people without disabilities [4,7].

Family, education, work, and income

Half the participants with lower limb disabilities were married, and more than half had children. Similar results were reported in Malawi, where 27% of persons with disabilities were married and 60% had children [40]. About 90% of participants with lower limb disabilities had studied in primary school. This result corresponds with 72% of people with disabilities receiving primary education in Malawi [41] and 88% of all Malawian children attending primary school [30]. Most of the participants with lower limb disabilities had not completed secondary school or higher secondary school, which corresponds to findings that children with disabilities in 30 low-income countries are as likely to attend primary school but less likely to attend secondary school than children without disabilities [42]. Children with disabilities in Malawi reported challenges to accessing education related to lack of appropriate clothing, transport, school materials because of poverty and school infrastructure as well as negligence by teachers and peers [37]. People with disabilities in Malawi have been refused attendance at secondary school, although in numbers lower than in the other five southern African countries [41]. Very few participants in our study had completed any degree or had studied as far as they planned; this result is similar to that in the study in southern Africa [41]. Almost 90% of our participants could read and write a letter, higher than the literacy level of the general population [30] and the 57% of people with disabilities in the other Malawi study [41]. One explanation might be that about 40% of the participants in the other study had visual, hearing, or emotional impairments, which could exacerbate their ability to read and write [41], while our participants were selected for lower limb disabilities. About two-thirds of our participants, 67% were not currently working, about the same as the 62% of the people with disabilities in the other Malawian study [41]. Most of our participants were not working, which was consistent with results from Ghana [15], South Africa [35], and a literature review conducted in 35 low- and middle-income countries [43], showing that people with disabilities have higher rates of unemployment than people without disabilities. Participants reported that their main reason for stopping work was their disability, and for not working it was their inability to find a job. People with disabilities experience more exclusion from work and education than people without disabilities [4,5,40]. They also face higher levels of economic hardship than people without disabilities [5,43]. Participants with regular income had significantly better access to: appropriate clothes, housing adequate for health, and medical care, and they more often completed secondary school, worked, and took care of their children than participants with irregular or no income. Findings indicated no significant difference in income level between the group with disability who completed vocational training and those who had not. This is inconsistent with findings from Ghana, where vocational training was correlated with self-employment [15], and the southern African study, which indicated a relationship between practical skills, such as sewing and agriculture, and employment [40].

Residential area and gender

Participants with lower limb disabilities living in rural areas have less access to food, basic water, medical care, and education than those in urban areas. Basic water is less accessible in rural areas in Malawi [1]. The ability to read and write was also significantly lower among participants in rural areas. All participants living in urban areas had studied in school and more had completed secondary school or a higher degree than people in rural areas. People with disabilities living in urban areas in the southern African study including Malawi were also found to be more likely than people with disabilities in rural areas to be currently studying, to have studied as far as planned, and to have had access to vocational training [40].

The results indicate no significant differences in access to human rights between men and women. This is consistent with the southern African studies including Malawi in which no differences in access to education and employment between men and women were presented [40]. A systematic literature review covering equality challenges and opportunities for women with disabilities in low- and middle-income countries, however, indicated that women with disabilities had fewer opportunities for education and employment than men with disabilities [14].

Social determinants of health

Social determinants of health occur various layers of a person’s environment: the overall structural environment where people live, including such factors as school policies and transportation systems, and the conditions under which people live and work, including education and employment opportunities, housing, and access to food, water, and health care services [44]. The supportive atmospheres of family and the community as a whole are closer layers of social determinants within which is the layer of individual lifestyle factors and genetic factors that outside agencies cannot influence [44]. Results indicate that people with lower limb physical disabilities in Malawi face limitations on their educational and work opportunities, high costs for transportation and medical care, and exclusion from various arena due to their place of residence, which inequities are all related to the social determinants of health. Importantly, people with disabilities’ impairments are often made worse by living in an unsupportive social and physical context. If policy makers truly desire to improve the health and well-being of their population, including people with disabilities, they need to recognize and implement strategies to improve the social determinants of health. This begins with unconditional respect for all people and promotion of their basic human rights [12]. Implementation of policy on equalization of opportunities for persons with disabilities [32] and the disability act [33]. The path to equal health for people with physical disabilities is not determined by just one solution. Interventions targeting several determinants of health are needed to equalize health opportunities for people with physical disabilities since this vulnerable group is affected both directly and indirectly by their impairment(s).

Limitations is a small sample size and that the study do not include persons with lower limb disabilities than have not had access to rehabilitation and assistive technology. Risk for type I errors have been considered, however, if applying p ≤ 0.01 as statistically significant instead of p ≤ 0.05 only one result was no longer significant; the ability write a letter was not significantly higher among those in urban areas than those in rural areas. Only one of the three prosthetic and orthotic centers was included in sample as only one center had contact details in the register. A limitation is that the results are only generalizable to similar contexts. Further limitation is that no specific validation study of the Chichewa version of the questionnaire has been carried out.

Conclusions

Transportation and health care costs were barriers in accessing health care for people with lower-limb physical disabilities in Malawi and similar low-income contexts.

About half of people with disabilities in our study were married and more than half had children. The supportive atmosphere of family and access to a social network contributes for gaining access to basic human rights. In Malawi, people with lower limb physical disabilities had good access to primary education, but their access to secondary and higher education was poor. Most people with lower limb physical disabilities were unemployed and had no income. Education and employment are areas that need to be addressed to improve access to basic human rights. Living conditions such as rurality, inadequate transportation systems, and the high costs of medication increase barriers to several basic human rights for people with lower limb physical disabilities. It is important to recognize this vulnerable group’s right to opportunities for living a healthy life equal to those enjoyed by people without disabilities. Interventions to target the social determinants of health are needed to improve health equity for people with physical disabilities since they are affected by their impairment both directly and indirectly. The human rights framework can act as a tool to guide governments and policy makers to take responsibility for the inequitable health effects caused by the social determinants of health for people with lower limb physical disabilities in Malawi and similar contexts.

Acknowledgements

The authors gratefully acknowledge the assistance of Tone Oygard, Manager Prosthetist/Orthotist, at the 500 miles Prosthetic and Orthotic Centre at Kamuzu Central Hospital in Lilongwe, Malawi, who provided administrative and logistical support including; translations, patient recruitment, and facilitation of follow-up sessions for patients in need of repair to their assistive devices.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability

The data used for this paper can only be available on a reasonable request.

Additional information

Funding

Funding for this research was provided by the Faculty of Medicine, Lund University; and the Folke Bernadottes Foundation.