Published on October 03rd, 2023.
| Received: 22-Aug-2023Revised: 24-Sep-2023Accepted: 28-Sep-2023Online first: 02-Oct-2023 |
Abstract
School of Special Education, Leadership and
Professional Studies Missouri State University,
Springfield, Mo 65897, United States
Email:
At a high-level meeting of policy managers of the Africa Leadership Forum in Nigeria, a consensus definition of health was formulated as a state in which the individual is physically fit, enjoys spiritual, psychic and psychological balance, and has access to a balanced nutritive diet and a good environment (Obasanjo & Mabogunje, 1991). On a specific level, healthcare refers to a system that involves the maintenance and the improvement of medical services in order to cater to the health needs of the population, including the poor, the aged, and persons with disabilities (PWDs). While healthcare coverage is being provided universally and financed from taxes in 13 OECD countries - including Australia, Canada, Japan, Norway, South Korea, and the United Kingdom - (Paris et al., 2010), most countries in Africa are far from achieving a healthcare system that is accessible, affordable, and of sufficiently high quality (Oleribe et al., 2019; United Nations Department of Public Information, 2017; World Health Organization, 2021). Furthermore, while governments of many OECD countries have assumed direct responsibility for the healthcare needs of their citizens, sub-Saharan African countries have failed to sustain their commitment to this fundamental human right, as enshrined in the United Nations Convention on the Rights of Persons with Disabilities (United Nations, 2006; United Nations, 2015). Regrettably, the Covid-19 pandemic has further deepened Africa’s health inequalities at all levels of healthcare (Demissie, et al., 2020). Consequently, Nigerians with disabilities continue to experience uncertainty as a result of the recent pandemic (Samaila et al., 2020; Thompson et al., 2021).
Meanwhile, inclusive healthcare aims to ensure the removal of all barriers, making accommodations and providing disability-friendly healthcare services that involve people with health disparities (LeDuc, 2022). The overall purpose of inclusive health care is to improve the health outcomes for all people. LeDuc (2022) further identifies some common barriers for inclusive healthcare to include: 1. care that is too expensive, 2. care that is based on stereotypes, 3. care delivered in a language a person does not speak without any options for translation, and 4. care in spoken or written language that cannot be accessed due to sensory disabilities like hearing or visual impairments.
In general, a healthcare provider’s attitude is critical in delivering a high-quality experience for the patient. This is especially true for patients with disabilities in countries in which there is still widespread stigma against PWDs. In 2020, the World Bank estimated that nine percent of the population age 60 or over and seven percent of the population over age five experience some level of difficulty in at least one domain. Hence, encountering a PWD in a Nigerian healthcare setting should be fairly frequent for most providers. In a study of 267 undergraduate health sciences students at Obafemi Awolowo University, southwestern Nigeria, the researchers (Olaoye, et al., 2017) found that 63% of aspiring professionals had a “positive” attitude toward PWDs, over 70% had “good” knowledge of disabilities, but the large majority (92%) had experienced little or no contact with PWDs. In a study in southeastern Nigeria at Nnamdi Azikiwe Teaching Hospital, Ihegihi et al. (2022) recruited 293 healthcare professionals. Responses to their questionnaire assessed three components (knowledge, attitude, and perception) regarding PWDs. The researchers found that participants expressed “fair” levels of knowledge, attitude, and perception towards. PWDs. Ajuwon et al. (2020) surveyed 203 providers in southwestern Nigeria, University College Hospital, Ibadan, using an instrument yielding scores on three factors of interaction with PWDs, namely: discomfort, information, and vulnerability. They found that workers providing direct-care vs. indirect-care had lower discomfort, and workers with higher information scores had both a lower level of training on treating PWDs and a lower knowledge of legislation and policies pertaining to PWDs.
According to Anaemene (2016), UCH was the first higher healthcare training institution in Nigeria. It is situated in Ibadan, one of the largest cities in West Africa. UCH was established in 1957 by an act of Parliament primarily as a teaching hospital to serve the then new College of Medicine of the University of Ibadan, and to undertake teaching, research and routine medical services. Scott-Emuakpor (2010) noted that medical training there was fashioned after the British system. The pre-clinical work was done in Ibadan; the clinical work was done in teaching hospitals in England, while the degrees awarded were London University degrees. By 1957, all aspects of the training were done in Ibadan, but the degrees were still that of London University, whose officials conducted the examinations in Ibadan. In fact, it was not until 1967 that the University of Ibadan granted its own degrees.
UCH was initially commissioned with 800 bed spaces. Presently, the hospital has over 1000 bed spaces, and an occupancy rate ranging from 55-60%. Today, UCH has become a revered seat of medical excellence, with its graduates employed in prominent positions in hospitals, federal, state and local health ministries and agencies, and the private sector throughout the country and beyond. This tertiary care facility and its community-based appendages draw thousands of patients with disabilities annually.
The purpose of this study was to collect and analyze open-ended comments from both “direct” and “indirect” healthcare providers regarding government policies and programs and both societal and personal attitudes towards PWDs. It was anticipated that these comments would lead to recommendations for overall improvement of healthcare services by the government, refining messaging for educating the general public about PWDs, and improving the patient-healthcare provider relationship. These comments were collected as part of a larger disability-focused project in a tertiary care facility in Nigeria.
The researchers conducted a survey to measure the attitudes of healthcare providers at UCH towards PWDs who utilize the hospital services. The Institutional Review Boards of Missouri State University, U.S.A. and the College of Medicine, Ibadan, Nigeria approved the study. In all, five hundred (500) questionnaires were distributed in the 20 UCH clinics during the last quarter of 2015 and the first quarter of 2016. A total of 250 questionnaires were collected. However, only 203 returned questionnaires were determined to be of adequate quality. The researchers used IBM SPSS version 24 to conduct the analysis.
The questionnaire’s cover letter provided an explanation of the study, and defined disability as “an impairment in body functions that imposes limitations in activity or restricts how an individual participates in the society” (modified from U. S. Department of Health and Human Services, 2011). Section one of the questionnaire measured respondents’ demographic and experiential characteristics. The second section comprised items from the Interaction with Disabled Persons (IDP) Scale (Gething, 1994). That analysis has been published elsewhere (Ajuwon et al., 2020). The purpose of the current analysis is to evaluate, from a qualitative standpoint, the third and final section of the questionnaire. Here, the respondents were asked to provide any additional comments, based on their perspectives.
The researchers entered literally all the comments as text strings. An open coding strategy along the lines of Strauss and Corbin (1990) was applied to develop and define conceptual categories from the open-ended comments. Using this strategy, each sentence or paragraph was segmented into meaningful expressions which could be described in a short phrase and assigned a tentative code. Hence, the comments written by a single participant could be represented by more than one code.
Next, the similarities and differences among comments within a code and between codes were evaluated. Over the course of multiple iterations, some codes were added or redefined and expressions were reassigned accordingly. This approach allowed the conceptual categories and their definitions to develop naturally based on the meaning emerging from the data.
Of the 203 participants with complete questionnaires, 81 (39.9%) provided additional comments. Their demographic and experiential characteristics are shown in Table 1. Seventy percent of these participants were female. Ages ranged from 18 to 60, with half falling from 34 to 43 years. Eighty-one percent were classified as direct-care providers based on job title, and half reported a tenure of one to five years in their current position at UCH.
With respect to experiential characteristics, nearly 60 percent reported having either daily or weekly contact with PWDs, and almost one-third stated that their knowledge of legislation and policies in Nigeria with respect to PWDs was either none or poor. Nearly one-third reported that they had received no training on treating PWDs, yet only 12 percent stated that their confidence in treating PWDs was either low or very low. The distributions of these characteristics between those who did and did not provide comments were compared in order to assess potential response bias. No statistically significant differences were found based on either a test of association and/or a measure of symmetry.
Table 2 provides a list of the 10 final conceptual categories and their definitions. These categories align under three broader groupings. Under the first grouping are comments in which the participants advocate that institutions should take specific actions to improve the lives of PWDs. This grouping encompasses government policies or legislation, healthcare facility policies or training, the application of universal design principles, and public education through the media. The second grouping includes comments advocating for changes in perception or attitude by society as a whole to improve the status of PWDs. This grouping encompasses acceptance of and taking responsibility for PWDS, empowering PWDs, believing that PWDs have hidden talents, and believing that the risk of becoming disabled is universal or exogenous. Under the third grouping are comments in which participants convey an aspect of his/her own perception or attitude towards PWDs. This grouping encompasses both negative (i.e., fear of disability or negativity) and positive (i.e., compassion or admiration) feelings.
| N | % | |
| GenderFemaleMale | 5724 | 70.429.6 |
| Age18-33 years34-43 years44-60 years(missing) | 2040201 | 25.050.025.0- |
| Direct/indirect care providerDirecta Indirect(missing) | 64152 | 81.019.0- |
| Time in present position1-5 years6-10 years11-31 or more years(missing) | 4118211 | 51.222.526.2- |
| Prior contact with PWDsDailyWeeklyAt least once/month or once/3 monthsLess frequently | 27201222 | 33.324.714.827.2 |
| Training on treating PWDsNoneSomeHigh (at least 40 hours)(missing) | 254871 | 31.260.0 8.8- |
| Confidence in treating PWDsVery low or lowAverageHigh or very high | 104922 | 12.360.527.2 |
| Knowledge of legislation and policies pertaining to PWDsNone or poorAverageGood or very good(missing) | 2539161 | 31.248.820.0- |
The frequency of occurrence for the final conceptual categories is shown in Table 3, together with their percent distributions based on 104 total comments and on 81 participants providing those comments. The most frequent category is that of advocating for government policies or legislation, at 31% of participants. The second most frequent category is advocating for acceptance and responsibility, cited by 22%. Advocating for empowerment and belief in hidden talents are equally frequent at 15% of participants. Advocating for healthcare worker training or facility policies and a fear of disability or negativity towards PWDs are the next most frequent categories at 10% each.
| Category | NComments | %commentsa | %participantsb |
| 25854 | 24.08.74.83.8 | 30.99.96.24.9 | |
| 1812127 | 17.311.511.56.7 | 22.214.814.88.6 | |
| 85 | 7.74.8 | 9.96.2 |
The number and percent of participants providing one or more comments within each of the three groupings (not shown) provides additional information.
The greatest number of participants (44 or 54%) advocated for a positive change in societal perception or attitude toward PWDs. Thirty-six or 44% of participants advocated for actions beneficial to PWDs to be taken by various institutions. Only 12 or 15% of participants commented on their own perception or attitude towards PWDs.
Listed below are examples from each of the 10 conceptual categories:
“I believe that putting disability policies and laws in place in Nigeria would help in educating health workers and general populace in dealing with people with disability.”
“Government should implement more policies in favor of persons with disabilities especially in terms of employment, empowerment and good access to medical care.”
“…the Government needs to do more in making life more comfortable for people with disabilities like supportive care and training.”
“Enable laws and hospital policies to protect them. The Hippocratic oath might not be enough in guaranteeing optimal care for this category of people.”
“Healthcare professionals should have positive attitudes towards persons with disabilities in their care or environment. Healthcare professionals should see them as human beings with rights in the society.”
“Hospital planning of structures and accessibility to the disabled should be done with these people in mind.”
“More modern schools for specific disabilities should be constructed and old ones refurbished.”
“There should be ongoing education through media on societal commitment to people with disabilities.”
“I feel there is much to be done on awareness of prevention and management of the disabled and the role of the public towards people with disabilities.”
“People with disabilities should be regarded or treated as normal people and accepted in the society.”
“Disability is a new form of life which everybody in that position has to accept in good faith. Early understanding of this will not make that person to be an "object of pity" by others.
Disability is not a disease per se, but a new way of life.”
“The disabled are part of us. They are human beings just like us. Whoever falls into this situation should be taken care of properly. We should not treat the disabled as enemies, but rather, as friends.”
“I will advise that anybody with a disability should be treated with love, and they should be given tender care.”
“Offering a helping hand to those with disabilities and encouraging disabled people can boost their morale.”
“People with disabilities should not be stigmatized, instead, there should be opportunities and ways of improving themselves.”
“More attention should be given in order to give people with disabilities a sense of belonging and a better life.”
“Physical or mental disabilities might be limiting, but do not rob the optimistic people of their potential.
Many are doing better than some without disabilities. It is a matter of knowing there is a disability surrounded with potentials that can be developed.”
“There is ability in disability.
Disabled people can reach their highest potential through favorable government policies and legislations.”
“I encourage everyone to treat people with disabilities nicely because it could have been anyone. They should see them as brothers and sisters and equally show them love.”
“This is not of their own making to be disabled. They need our help and we must help them.”
“Sometimes I pray for God's protection from any misfortune that can lead to my being disabled when I see disabled persons. … I dislike seeing them begging on the street.”
“I am afraid to look at a person with a disability straight in the face because I always pity their condition. … If you pity any disabled, there will be a reward from God.”
“I admire the courage of persons with disability who still try to make something good out of their lives.”
“Each time I meet people with disabilities I have great compassion for them. I feel like I should have a power within me that could rehabilitate or deliver them from that state of disability immediately.”
It is instructive that Nigerian healthcare providers, in their “additional comments”, would emphasize such diverse issues, ranging from governmental responsibilities down to the level of the individual when it comes to making healthcare equitable and available for persons with disabilities.
This observation implies that healthcare providers, overall, recognize the multidimensionality of this problem.
The value of an efficient healthcare system in any country cannot be overlooked because better health is central to human happiness and well-being. This is why the healthcare sector makes an important contribution to economic progress, as healthy populations live longer, are more productive, and have more savings. Many factors influence health status, including the providers’ attitudes, beliefs, and knowledge of their patients. These attributes are critical in dealing with special populations, especially in developing countries that are yet to domesticate international agreements on health services.
In this paper, we examined the open-ended comments from 81 healthcare providers from UCH who participated in a study regarding attitudes towards disabilities in Nigeria. Eighty-one percent (81.0%) of these respondents were “direct” healthcare providers. Using qualitative methods, we classified the unsolicited comments into three major categories (see Table 3).
The first grouping focused on “institutional-level actions advocated”, i.e., the respondents suggested ideas that are desirable at the institutional level. “Government policies or legislation” were the most frequently cited suggestions in this grouping. We believe that such policies or laws, when properly implemented, would lead to the allocation of appropriate resources for the targeted populations, and the recognition of practical strategies for developing inclusive services that would promote the rights of PWDs within home, school, and community settings.
Recently, the Nigerian government signed into law the Discrimination Against Persons with Disabilities (Prohibition) Act (2018). Notable among its provisions are the requirements that the “government shall guarantee that persons with disabilities have unfettered access to adequate healthcare without discrimination on the basis of disability” (para. 21 p10), and that “A public hospital where a person with communicational disability is medically attended to shall make provision for special communication” (para. 24, p. 10). It is anticipated that this legislation will provide the springboard for healthcare providers and others to become more cognizant of the need to institute reforms that will enable them to interact more positively with patients with disabilities. In regard to “healthcare worker training or facility policies”, researchers and the stakeholders have passionately advocated for sensitization training that should be organized in collaboration with the country’s recognized disabled peoples’ organizations (Ajuwon & Brown, 2011; Eleweke & Ebenso, 2016; United Nations, 2006). This type of collaboration has the potential to increase healthcare providers’ knowledge and understanding of the complex issues that impact patients and their families or caregivers as they seek advice or treatment in clinical settings.
Within the second grouping, “societal-level changes advocated,” empowerment stood out as a key concern.
This is understandable given that society’s misconceptions of disabilities can manifest even in the healthcare sector (World Report on Disability, 2011; World Health Organization, 2021). Therefore, healthcare providers need to empower PWDs (including those with intellectual disabilities, and vulnerable women and girls) so they can acquire the requisite skills to improve their quality of life. Ultimately, this would position these PWDs to evolve into autonomous citizens, free to make their own choices and decisions, and fully take part in all aspects of society.
It is instructive that respondents expressed their views on the “hidden talents” and the “exogenous nature” of disability. Such perceptions are important because they help to reinforce the dignity and self-worth of patients with disabilities. Thus, as healthcare providers interact and/or treat their patients with disabilities, it is desirable they avoid discriminatory practices and negative behaviors.
This perspective is also in alignment with the report of the 2011 Nigerian survey on disabilities, where it was recommended that “government needs to seriously redeem itself, formulate the necessary policy, and enact the necessary legislation prohibiting all forms of discrimination against PWDs” (Federal Ministry of Women Affairs, 2011, p. 128).
The last grouping, “individual-level perception or attitude,” contains comments which project discomfort and fear associated with disability and, in contrast, the admiration of PWDs engendered by their courage. When society as a whole identifies with issues of disability, the quality of life of PWDs and their families or caregivers will be enhanced, and they will be motivated to seek assistance from service providers without inhibition.
However, as reported from interviews with a cross-section of Nigerians living with disabilities (Jayeola, 2022), the issue of access to health services even in government hospitals remains a challenge for PWDs. In an earlier national study in the country, it was revealed that among the respondents from 78 hospitals, nearly all (93%) felt that PWDs had been given inadequate attention, and 55% felt that PWDs had experienced discrimination from persons who refused to “identify” with them (Federal Ministry of Women Affairs, 2011, (pp. 102-103). In order to give concrete meaning to government and international policies, healthcare workers will require periodic training aligned with practical and inclusive experiences so they can develop positive dispositions towards their patients with disabilities.
The current study has some inherent limitations. First, it is based on a sample of healthcare providers from a single tertiary facility. Second, the investigation is a convenience sample of direct and indirect healthcare providers in that while an initial 500 questionnaires were distributed around the 20 hospital clinics, just 250 (50%) were returned. Third, due to resource constraints, the authors did not arrange for an independent scholar to verify the themes that emerged from the results.
Disabilities in Nigeria are caused by a multitude of factors, most of which are still very difficult to remedy (Ajuwon et al., 2020; Federal Ministry of Women Affairs, 2011). This suggests that disability and PWDs will continue to be an integral part of the Nigerian society; hence, there is need for the government and the stakeholders to be in the forefront of combatting discriminatory practices in healthcare, education and other social services.
The government’s inability to effectively tackle the country’s enormous healthcare challenges has resulted in the continued fragile nature of the healthcare system (Aregbeshola, 2019). As a result, individual citizens in both rural and urban centers continue to bear the burden of an inequitable healthcare system, not seeking healthcare, and ultimately forced to pay out of pocket for even basic medical services.
The current level of research in healthcare and disability services is inadequate. Such research is necessary to construct a framework for best practices for healthcare workers who are required to treat PWDs. More than ever, there is a conscious awareness of the growing number of children, youths and adults who will acquire disabilities, and who will subsequently rely on effective healthcare services.
Moving forward, it is recommended that all impediments to healthcare and social services for PWDs and their families be identified and removed. Such a strategy would be in consonance with Goal 3 of the United Nations Sustainable Development Agenda (2015), which aims to “ensure healthy lives and promote well-being for all at all ages.” Specifically, policy managers of health services must enhance physical access and transportation, including the construction of ramps, adapted examination tables, and related facilities (United Nations Department of Economic and Social Affairs, 2016). A second recommendation is the necessity to promote information and communication materials for use by patients with disabilities, for example, the provision of materials in braille and large print for patients who are blind or partially sighted, respectively, simple language and pictures for those with learning disabilities, as well as the availability of sign language interpreters for persons who are deaf. Third, in compliance with the recognition that persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination, we recommend the enforcement of the principle of “respect for privacy” of these citizens to protect their personal, health and rehabilitation information on an equal basis with others (United Nations Convention on the Rights of Persons with Disabilities, art. 22, 2006). This means setting up offices to discuss confidential health and social matters of PWDs. This will of course imply setting aside extra time, care and attention to adequately observe and fully meet the unique needs of PWDs.
In summary and based on the Nigerian Constitution which states that the nation should ensure that there are adequate medical and health facilities for all persons (Constitution of Nigeria, 1999), it follows that the government should establish universal health coverage, including financial risk protection, access to essential healthcare services, and access to safe and affordable medicines and vaccines for all. The successful establishment of universal health coverage should effectively discourage the “shopping for a cure” syndrome which typically originates from superstitious beliefs and causes parents and PWDs themselves to expend enormous financial resources on their search for a “cure” before seeking rehabilitation or educational interventions (Ajuwon & Brown, 2011). The policy managers must move beyond the rhetoric of increasing the recruitment, training and retention of the health workforce, and to arrest the “brain drain” that has characterized the healthcare sector in the country in the past 30 years. Finally, the process of training healthcare providers must emphasize the need for greater awareness, knowledge and understanding of the complex needs of PWDs and their families or caregivers.
The authors have no conflict of interest.
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