Almost all participants were male; even though the literature reports a significant association between male gender and an increased risk of amputation compared to female persons with diabetes , the WHO reports that disability is slightly more common in women than in men (19.2% of women and 12% of men) . Globally, women make up three-fourths of persons with disabilities in low and middle-income countries (LMIC) . However, in Lebanon, out of the 114,000 persons with disabilities (holding a disability card from MoSA), 62% are males and only 38% are females . Consequently, there is a discordance between global-level data and local-level data. The gender distribution of our included participants might be related to the cultural norms and social traditions women with disabilities are affected by in a developing country such as Lebanon. Women with disabilities are recognized to be multiply disadvantaged, experiencing exclusion on account of their gender and their disability . They are more prone to abuse, maltreatment, and negligent treatment .
As we were not able to capture the women’s perspective on access to health services, we believe that it would have been concordant with the global literature that women have lower access to health care. In general, women have different health needs compared to men . They have a higher risk of violence, lower access to health care (primary, secondary, and sexual reproductive health care), and exposure to risks related to water and sanitation. “Women with disabilities, of all ages, often have difficulty with physical access to health services. Women with mental disabilities are particularly vulnerable, while there is limited understanding, in general, of the broad range of risks to mental health to which women are disproportionately susceptible as a result of gender discrimination, violence, poverty, armed conflict, dislocation, and other forms of social deprivation” .
One of the main barriers discussed by all the interviewees was Lebanon’s current economic crisis. Lebanon has rushed into a financial crisis since the end of 2019 where a fast cut in capital inflows triggered the collapse of the banking sectors and the exchange rate . In early 2021, the Lebanese lira has lost more than 80% of its value resulting in major price increases across goods and services . The economic crisis has been further exacerbated by the COVID-19 pandemic and the August 4, 2020, Beirut Port blast, pushing more than half of the population below the poverty line and resulting in many households struggling with access to basic services, besides healthcare . In 2020, the vulnerability of Syrian refugees had also worsened after 90% of the households were found to live under the extreme poverty line compared to 55% in the previous year . Participants reported that they did not have a sufficient income, and many were financially dependent on their caregivers or friends and relatives, knowing that only 20% of PWDs were employed in 2016, 5 years before the current financial crisis . The increase in prices of basic foods made it difficult for people with diabetes to maintain a healthy and diverse diet, low in carbohydrates and sugar . Besides maintaining a balanced diet, people living with diabetes and physical disabilities needed access to several health services, including medication, medical consultation, physical therapy sessions, blood tests, medical imaging exams, and hospitalization in case of development of complications. Respondents noted a shortage in medications and an increase in anxiety that came with struggling to ensure their monthly needs. With the devaluation of the Lebanese Lira, pharmaceutical importers have been falling short in supplying drugs since June 2020 and patients have been substituting their medications with generic ones when possible and available .
The financial barrier was a major obstacle in accessing healthcare among PWDs. This is consistent with the results from a literature review on barriers to healthcare services for people with disabilities in developing countries, which also highlighted the cost associated with getting to and receiving healthcare as one of the main obstacles . A policy brief on improving healthcare access for persons with disabilities in Lebanon reported that the most commonly cited barrier to accessing healthcare among respondents was financial ability (78.5%) . In fact, in our study, interviewees reported having neither insurance nor NSSF as a vital reason for not being able to access healthcare services. They elaborated on the need to pay for these services out of pocket or go to some services that are partially or fully covered by humanitarian organizations or PHCs whenever available. The Lebanese Social Security system has “serious shortcomings in terms of coverage” where around 40% of the Lebanese population is outside any insurance system, 40 to 50% are not registered in the National Social Security Fund, and only 8% have private insurance . The decree of Law 220/2000 has not been issued leaving the most vulnerable groups, like PWDs, outside the framework of the coverage . As for refugees with disabilities, humanitarian agencies like the United Nations High Commissioner for Refugees (UNHCR) partially subsidize some health services, and patients must cover the rest . Even though some stated to receive free services from PHCs and other organizations, transportation was still an important obstacle brought up that is consistent with other findings in Lebanon [5, 10] and developing countries . Many participants noted the increase in the cost of transportation in both public and private ones. Healthcare institutions were not possible for PWDs to be accessed through walking. No one drove on his or her own, so they sometimes missed their appointments as their ride was dependent on either the money available in their pockets or on someone else’s schedule.
Contrary to other studies conducted in Lebanon, none of the interviewees reported that local healthcare centers lacked proper infrastructure, such as elevators and ramps to accommodate them . They all agreed that facilities were well equipped to a certain extent. One respondent, however, raised the issue of not finding a tight parking spot. Law 220/2000 considers it a right to have close and accessible parking spots for PWDs, yet centers in congested areas lack this right .
However, the study found a recurring barrier at the household level. Participants raised the concern of not being able to overcome their front doorsteps, which for some was a barrier for leaving their homes by themselves in the first place. Amputees had to always rely on friends, family, neighbors, or even paramedics to carry them down the stairs, an undesired feeling expressed by everyone.
Participants were generally positive regarding the attitudes of healthcare providers, predominantly with their physicians, but some acclaimed that their amputation was a consequence of health providers’ malpractice. Participants expressed that some hospitals, especially rural and public ones were not financially, nor resources supported to deliver high-quality care . PWD sometimes had to travel farther to receive the care they needed because health facilities in rural regions, as also mentioned by the interviewees, were under-equipped and sometimes lacked the required service . Refugees also pointed out that certain hospitals refused their admission, limiting their access to certain institutions even when it is their right to access any. Health facilities and hospitals are overburdened, preventing them from offering adequate services to citizens and refugees .
Rehabilitation is crucial to meet the needs of PWDs and gain independence, yet rehabilitation among amputees with diabetes is challenging. Since one of the comorbidities related to diabetes is the delay in wound healing, sores and infections common in the stump can create an interruption in the rehabilitation process .
Stigmatization and marginalization were considered essential barriers in accessing healthcare services aligned with studies conducted in developing countries [10, 38]. The Lebanese society perceives PWDs as passive community members; conversely, PWDs feel isolated and struggle to find opportunities to be active participants and give back to the community . The community’s attitude towards PWD amplifies the feelings of shyness, rejection, and lack of confidence, and these negative feelings drive PWDs to become ashamed and not leave their houses to obtain proper health services [10, 45]. Favoritism or ‘wasta’ in Arabic was an additional issue raised in this study where interviewees expressed how they witnessed inequitable service delivery in some PHC and organizations. Favoritism echoes with previous findings not only in accessing services but also in granting and distributing a disability card [3, 5].
The lack of assistance to accompany a PWDs was another barrier that resonated with findings reported in the literature [38, 46, 47]. A meta-synthesis of qualitative studies exploring the barriers to primary healthcare services experienced by PWDs in LMICs reported that PWDs often feel the need to be accompanied by family members or friends when seeking care . Another study conducted in Malawi, a low-income country, also reported that the lack of an assistant to accompany a PWDs to health facilities as a barrier  Similarly, findings from a qualitative study conducted in Cameroon and India , reported comparable results. In our study, participants explained that they always preferred to have someone with them when seeking healthcare services to assist them physically and emotionally and not having such assistance would be a reason for not getting the care they needed. Even when participants expressed the need to have company, they felt like an extra burden on their caregivers. PWDs suffer from depression, loneliness, and believe to be a burden on their families [17, 48]. Psychological support was not something participants aimed to seek. Aligning with the Arab culture, there is still a culture of refusal in accepting psychological help among many, mainly due to stigma and misconception . The study also showed that people with disabilities were unaware of the services offered. Lack of information and knowledge regarding healthcare services, referrals, and centers has been already reported elsewhere [5, 10, 47].
COVID-19- related barriers
The changes caused by the COVID-19 pandemic further altered social and lifestyle habits and exacerbated existing barriers. With lockdown measures and physical distancing, PWDs became even more vulnerable, as they depend on services and other people to meet their needs, making them more susceptible to the virus, particularly in the Global South . Unfortunately, there is no data on emergency planning for PWDs, and existing guidelines are not consistent or do not apply to the COVID-19 pandemic . The COVID-19 precautionary measures are sources of stress and fear for many PWDs, especially when seeking in-person care .
Additionally, PWDs might fail to get the proper maintenance for their devices; also, they might fail to seek medical treatment and rehabilitation, increasing chronic, acute, and secondary health conditions [17, 51]. Even before the COVID-19 pandemic, PWDs were at higher risk of social isolation and loneliness . The public health guidelines of lockdowns and physical distancing created further social exclusion among PWDs, who cannot self-isolate or be physically distant, as they rely on assistance for personal care, medication, and food delivery. The measures to mitigate the spread of the virus lead to more social isolation, segregation, creating more mental health strain, instead of protecting and supporting PWDs’ rights and needs .
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