**4.3 Parental factors**

The study discovered that participants were generally aware of some of the factors that influence access to healthcare services among children with CP. A study conducted by Khartri and Karkee [14] showed that distance to health facilities, social support, age, the behavior of health workers, and access to quality health services shapes how parents access healthcare for their children and themselves. This finding is in agreement with Boz et al. [21] study on "The affecting factors of healthcare

#### *Access to Healthcare Services Among Children with Cerebral Palsy in the Greater Accra Region… DOI: http://dx.doi.org/10.5772/intechopen.106684*

services demand in terms of health services use: A field application in Edirne city" found that personal income, gender, attitudes, and behaviors of physicians affect access to healthy demand. In the same study, it was reported that family members, perception of economic level, attitudes, and behaviors of physicians were found to influence health demand. Findings from this current study revealed that participants know about disability regarding the causes, signs, and symptoms as well as treatment for children with CP. This positively influenced parents' access to healthcare for their children with CP. This finding is consistent with Matt's [22] study on "Perception of disability among caregivers of children with disabilities in Nicaragua" which found that parents with higher education have a better understanding and knowledge of their children's disability and frequently access health care services for their wards than parents with lower or no education. The current study findings also agree with Khatri and Karkee's [14] assertion that illiterate parents who belong to the lowest wealth quintile have lower access and use of healthcare for their children with CP.

Also, considering the causes of disability, this current study revealed that respondents know the causes of disability. Findings from the study showed that disability can be caused by disease and neurological problems leading to brain damage. This finding is in agreement with the Center for Diseases Control and Prevention [23] assertion that risk factors such as infections during pregnancy, premature birth, and diseases like jaundice can cause CP.

Respondents in this study linked signs and symptoms of CP to poor eye contact, poor posture and balance, communication difficulties, and impaired fine and gross motor function. This finding agrees with the CP Alliance [24] assertion that children with CP show signs and symptoms like swallowing difficulties, poor muscle spasms, low muscle tone, poor muscle control, reflexes, and posture, drooling, developmental delay, gastrointestinal problems, and not walking by 12–18 months. It was found from this study that treatment for children with CP includes physiotherapy, occupational therapy, and speech and language therapy. This finding is consistent with the CP Guide [25] statement that children with CP can improve their motor skills with alternative therapy, medication, and surgery through multidisciplinary teams such as neurologists, orthopedic surgeons, developmental pediatricians, physiotherapists, occupational therapists, nutritionists, respiratory therapists, psychologists to assess ability and behavior and speech and language, therapist.

It was also found in this study that perceptions of parents about their children's disability (CP) also influence their decision to access healthcare for their children with CP. It was also established that stigmatization, discrimination, disrespect, loneliness, depression, and suicidal ideation are linked to disability (CP). This is similar to Physioplus's [26] assertion that families with a child with a disability are more prone to depression, suicide, financial problem, relationship challenges, divorce, and bankruptcy. This statement is also in line with another study by Butchner [27] on "society's attitude towards persons with disabilities" which found that society perceives that disability is a curse and punishment from ancestors and gods. Also, Duran and Ergun [28] in their study on "The stigma perceived by parents of children with disability: an interpretative phenomenological analysis study in Balikesir found that the majority of people often have negative perceptions and stigmatizing attitudes towards children with disabilities (CP) and their families. In the same study, it was found that parents of children with disabilities cope with insults and rude behaviors from community members while they struggle with the challenges of their children with CP. This is similar to a previous study by Opoku et al. [6] who affirmed that persons with disabilities are severely stigmatized, discriminated against, and excluded from all forms

of the development process resulting in limiting their opportunities to be engaged in decision-making and accessing healthcare.

Income was found from this current study to influence parents' access to health care services for their children with CP. Respondents emphasized that the level of income of a parent is dependent on the kind of job the parent does. This present study revealed that parents of children with CP who have no jobs find it difficult to access healthcare services for their wards due to the cost of treatment. This finding is in line with DeVoe et al. [29] assertion that children with CP from lower-income families experience more gaps in healthcare than children with CP from higher-income families.

Moreover, this study discovered that transportation is another factor that influences access to health care. Findings from this study indicated that transportation cost, distance to the nearest health facility, and stigmatization from drivers, passengers, and bus conductors (mate) influence respondents' ability to access healthcare services for their children with CP. A previous study showed that healthcare utilization is influenced by the direct costs of healthcare services, travel time, and patient income [30]. This is in line with another study conducted by Bulamu Healthcare [31] in Uganda which specified that patients complain about poor sanitation, lack of drugs and equipment, long waiting times, rude behavior of health workers, and poor referrals. However. in that same study it was revealed that over 8000 rural Ugandans travel as far as 50 miles to attend a Bulamu weeklong medical camp for healthcare.

Also, findings from this present study showed that respondents are not satisfied with the waiting time and cost of health care services. Respondents from this present study linked healthcare satisfaction to quality health care, waiting time for treatment, and cost-effectiveness of healthcare services. This assertion is consistent with Khatri and Karkee's [14] statement that quality health care accounts for patient satisfaction especially in terms of waiting time, cost of service, coordination, information, and physician's behavior. This finding agrees with Janzek-hawlat's [3] findings that some physicians in public health facilities can be very rude due to the workload mounted on them.

#### **4.4 Healthcare factors**

Considering specialized services available, the present study found that respondents were informed about the available specialized services for their children with CP. It was discovered that speech and language therapy, physiotherapy, occupational therapy, behavioral therapy, augmentative communication, and dietary were some of the specialized services available but scarce and that makes it difficult to access healthcare for their children due to waiting time for treatment. Respondents in this present study believed that children who can access these services will be able to walk, interact with others through play, learn social skills, seat properly, and have good muscle and neck control as well as good balance and body posture. This finding agrees with Balcı's [32] study on "Current Rehabilitation Methods for Cerebral Palsy" which found that children with CP that undergo muscle strengthening training, manual stretching, massage, neurodevelopmental treatment, conductive education, speech and language therapy, occupational therapy, and dieting have good body posture, balancing, neck coordination, strong muscle control and can walk sometimes. However, the lack of appropriate services for individuals with CP is a significant barrier to health care. For instance, qualitative research in Uttar Pradesh and Tamil Nadu states of India revealed that after the cost, the lack of services in the area was the second most significant barrier to using health facilities [8, 9].

#### *Access to Healthcare Services Among Children with Cerebral Palsy in the Greater Accra Region… DOI: http://dx.doi.org/10.5772/intechopen.106684*

Also, it was found from this current study that proximity to an available health facility is another factor that influences access to healthcare for children with CP. From the study, respondents were discouraged to access the nearest health facility when transportation and distance to the health facility are problems. This finding is similar to Awoyemi et al. [33] study on "Effect of Distance on Utilization of Health Care Services in Rural Kogi State in Nigeria" which found that distance and total cost of healthcare affects the utilization of both public and private hospitals. This finding also agrees with Nesbitt et al. [34] study on "Barriers and facilitating factors in access to health services in the Republic of Moldova" which found that distance from a health service provider, travel time, and waiting time to see a health professional is are strong factors that influence access to health care.

Moreover, the availability of specialists in hospitals was found in this present study to be scarce in most hospitals, and because of that, only a few respondents travel a long distance to access these specialized services for their wards. This finding is consistent with WHO [35] reported that the registered number of rehabilitation specialists is far below the required minimum of 750 per 1 million even in developed countries. In addition to this, the present study revealed that most public and private hospitals are not environmentally friendly for children with CP who use wheelchairs. Respondents asserted that most public hospitals do not have elevators and ramps making it difficult to access healthcare services for their wards. This finding is in line with Jamshidi et al. [36] study on "The effects of environmental factors on the patients' outcomes in hospital environments: A review of the literature" found that medical equipment adaptability, unit layout, room features, ramps, and elevators affect patients' access to healthcare. Another study by Douglas and Douglas, [37] revealed that patients' need for personal space, a homely welcoming atmosphere, a supportive environment, ramps, and elevators influence access to their healthcare. Cristina and Candidate [11] also found in their study that out of 256 respondents, 9 (4%) were not able to access the building and 47(18%) were not able to be transferred from their wheelchair to the examination table.

It was also found from this study that some healthcare providers discriminate against parents of children with CP when seeking primary healthcare services and physiotherapy. This finding agrees with the WHO [8, 9] report that parents of children with disabilities face stigmatization and discrimination in most health facilities. This finding is also in line with Rogers et al. [38] study on "Discrimination in healthcare settings is associated with disability in Older Adults: Health and Retirement Study, 2008-2012" which revealed that 12.6% experienced discrimination infrequently whilst 5.9% experienced discrimination frequently.
