Summary of key findings

This study presents the results of a mixed-methods study that explored the sexual lives, experiences and reproductive health outcomes among PwDs in two districts of Ghana. The quantitative results showed that most PwDs have ever had sex. Sexual activity was associated with disability severity and age. About 16% did not use condom during their first sex and this was influenced by educational level, with those with secondary or higher level having the lowest odds. The results also showed that some PwDs had sex before age 18 years, with males being less likely to engage in early sexual intercourse compared to females. The results further showed that 3% had multiple sexual partners. It was also revealed that 44% had ever tested for their HIV status, with those aged 30–39, higher education, and married individuals having higher odds. However, males have lower odds of testing compared to females.

The majority (89.5%) rated their SRH status as good. Individuals with junior high school and senior high school educational levels, those earning GHC300 and above, and those with a duration to the nearest health facility over 60 min have higher odds to rate their SRH as good. However, males and non-Akans were less likely to self-rate their SRH as good. The results also showed that 5.7% indicated they had ever had an STI. It was also found that 6.4% of women with disability experienced unintended pregnancies and this was associated with SHS/tertiary education levels and NHIS subscription.

Approximately 21.6% had ever terminated a pregnancy, with 36.9% of these terminations being unsafe. About 65% of PwDs had experienced IV. Specifically, 59.7%, 25.6%, and 9.2% had experienced emotional, physical, and sexual violence, respectively. The visually impaired and those with severe disabilities, individuals earning GHC300 and above, those living in large households have higher odds of being abused. The qualitative data revealed five themes. These comprised curiosity to engage in sexual activities, feelings of despair and insecurity with abled partners, preference for sexual relationships with other PwDs, IV and its perpetrators, and adverse sexual and reproductive health outcome. The findings have implications for policy and practice regarding the SRH needs and rights of PwDs in Ghana. They suggest the need for accessible and comprehensive SRH education and services for PwDs, as well as mechanisms to prevent and address cases of IV against them. They also highlight the importance of empowering PwDs to make informed and autonomous decisions about their SRH, as well as fostering a supportive and inclusive environment for them.

Synthesis with previous evidenceSexual lives and experiences of persons with disability

The majority (91%) of the respondents indicated that they have ever engaged in sexual activity, contradicting the general notion that PwDs are asexual [65]. Previous studies in several LMICs including Burkina Faso [67], Cameroon (80%) [68], Haiti (49%), Rwanda (53%), Timor-Leste (51%), and Uganda (53%) [69] and Ethiopia (59.9%) [39] have reported high prevalence of sexual activity among PwDs. In this study, individuals with severe disabilities showed a reduced likelihood of engaging in sexual intercourse compared to those with mild disabilities, while age was positively associated with the odds of ever engaging in sexual activity, consistent with findings from previous studies [30, 34, 70]. Other studies found high rates of sexual activity among women with disabilities, young people with disabilities in Ethiopia [71, 72], adult women in Sierra Leone [73], and visually impaired and deaf adult women in Ethiopia [74]. However, a low rate of sexual activity (48%) was found among young people in Uganda [35]. Nevertheless, a scoping review in LMICs highlights the neglect of disability and sexuality, indicating the need for further exploration in this domain [12]. Possible reasons for the reduced likelihood of engaging in sexual activity among individuals with severe disabilities could be cultural beliefs, stigma, self-stigma, and discrimination attached to disability.

The study found that 15.1% had their first sexual intercourse before age 18, and males were less likely to engage in early sexual intercourse compared to females. The qualitative findings revealed that the majority of PwDs initiated their sexual life around age 30 to 40 years due to factors such as difficulty finding sexual partners and the perception that having a sexual partner would increase their burden. This highlights the necessity of sexual education for PwDs and self-efficacy. Additionally, the study found that 3.0% had multiple sexual partners, which was similar to what was reported as 1.4% in Uganda [75]. But the prevalence is lower than the 12.5% reported in Burkina Faso [67, 76] and 58.6% reported in Ethiopia [71]. Qualitative findings indicated that although some participants had more sexual partners in their lifetime, most of these relationships were not concurrent. Such relationships expose PwDs to different sexual partners and increase their risk of contracting STIs, including HIV and AIDS [67, 76].

Approximately 16.4% did not use condoms during their first sexual experience. Safe initiation of sexual behaviours is usually recommended and the possibility of continuing with these behaviours are high. However, individuals with SHS or higher educational levels had lower odds of using condoms during their first sexual encounter than those with no formal education. Previous studies have also reported low condom usage among PwDs, ranging from 22 to 37% [67, 70]. Yet, this study’s finding is slightly lower than what was reported in previous studies [67, 70]. Inconsistent results may be attributed to factors such as the time considered, study population, and gender disparities in contraceptive options. This finding highlights the need for increased education and behavioural change communication to promote safe sexual practices among PwDs. The findings have implications for policy and practice regarding the SRH needs and rights of PwDs in Ghana. They suggest the need for accessible and comprehensive SRH education and services for PwDs, as well as mechanisms to prevent and address cases of IV against them. They also highlight the importance of empowering PwDs to make informed and autonomous decisions about their SRH, as well as fostering a supportive and inclusive environment for them.

The study revealed that only 44% of the respondents had ever tested for their HIV status. The odds of testing were higher for PwDs aged 30–39, senior high school or tertiary and married individuals, but lower for males than females. These findings are consistent with previous studies that reported similar prevalence rates of HIV testing among PwDs in LMICs and suggested that demographic characteristics influence sexual behaviours of PwDs, including HIV testing [72, 77, 78]. The health outcome model [40,41,42] provides a theoretical explanation for the associations between age, marital status, and Christianity with HIV testing, as it posits that individual characteristics affect health outcomes. According to this model, as PwDs age, they are more likely to marry, and some marriages, especially Christian marriages, require HIV testing. Moreover, the model suggests that higher educational level enhances health awareness and behaviours, such as knowing one’s HIV status [79].

Interpersonal violence and its perpetrators against persons with disabilities

The findings indicate that 65% of PwDs had experienced some form of violence, with 6% facing combined sexual, emotional, and physical abuses. Emotional abuse was the most prevalent (59.7%), followed by physical abuse (25.6%) and sexual abuse (9.2%). While males reported more emotional violence, females experienced more sexual violence. These findings are consistent with Opoku et al.’s [21] rate of 68.3% in Ghana but higher than Hughes et al.’s [80] rate of 24.3%. Individual characteristics, as suggested by the health outcomes model, influenced violence experiences, especially for those with visual impairments and severe disabilities. This is in line with studies in several LMICs [81,82,83,84,85,86] that reported similar associations. The study addresses a critical aspect of the 2030 Agenda by emphasising disability-disaggregated data to ensure inclusivity. However, most existing research on violence against PwDs focuses on women and sexual violence [87,88,89]. Therefore, these findings underscore the need for inclusive violence prevention and response programs since IV is mostly a continuum [53], regardless of gender.

The study also showed that household size, disability type, and income level were associated with violence experiences. Larger households appear to expose PwDs to higher violence risk than smaller households. Both qualitative and quantitative findings indicate that family members, neighbours, and strangers, including intimate partners, are major perpetrators of emotional and physical violence [19, 87, 90]. Despite this, most survivors do not report incidents, echoing prior studies that this is especially true for survivors of sexual violence, particularly women [19, 87, 90].

Those with visual impairments and severe disabilities were more likely to experience violence than those with physical impairments. Previous studies have reported similar findings [19, 81]. The possible explanation is that these categories of PwDs rely on others for most of their daily activities compared to the physically impaired. The study further unveils that higher-income PwDs are more susceptible to violence, consistent with research indicating that PwDs who earn more than their partners may experience violence [20]. This could be due to partners or family members seeking control over economic resources, potentially leading to physical and emotional violence. The qualitative phase highlighted the widespread nature of violence across societal levels. Nonetheless, individuals in trusted positions like doctors, police, and teachers may misuse their authority to perpetrate violence, especially against women with disabilities. This underscores PwDs’ vulnerability to violence and emphasises the necessity for multifaceted efforts to address this issue.

Sexual and reproductive health outcomes among persons with disability

The study also found a 6.4% prevalence of unintended pregnancy among women with disabilities. This rate varies across different LMICs, as shown by comparable studies that reported prevalence rates ranging from 9.2% in Haiti to 47.1% in Mali, 28.8% in Nigeria, 29.8% in Pakistan, 23.0% in Rwanda, 26.9% in Senegal, 12.0% in South Africa, and 24.7%-40% in Uganda [35] and from 15.4% to 67% in Ethiopia [22, 74, 91]. A higher rate of 53% was reported in the USA [32]. The qualitative findings corroborated the quantitative results and indicated that unintended pregnancy was a common occurrence among PwDs. The multivariable analysis indicated that individuals with SHS or tertiary education and NHIS subscription had lower odds of experiencing unintended pregnancy. This supports the health outcomes framework which states that individual characteristics and health policies influence health outcomes [40,41,42]. For example, those who are educated are exposed to various strategies to prevent unintended pregnancy including abstinence and contraceptive usage. With NHIS subscribers, they can easily seek SRH services which could prevent them from unintended pregnancy. Some unintended pregnancies resulted in pregnancy termination, with 21.6% of respondents reporting termination experiences. However, 36.9% of these procedures were self-reported to be conducted unsafely, highlighting the need for education and interventions to promote appropriate medical care for pregnancy-related care. This implies that unintended pregnancy is a major issue among PwDs globally calling for measures to improve appropriate contraceptive use among PwDs.

The prevalence of self-reported STIs in this study was 5.7%. Participants self-reported STIs such as gonorrhoea, syphilis, HIV and Chlamydia, in the qualitative data. This prevalence is comparable to the rates reported among the general male population in Ghana (6.0%) [92] and 3.8% in sub-Saharan Africa [93]. Previous studies among PwDs in LMICs found varying STIs-HIV prevalence rates ranging from 0.6% in Niger to 25.3% in Ethiopia [68, 76, 94]. A systematic review on HIV among PwDs also found prevalence rates between 1.1% and 29% [95]. The differences in the study findings could be due to variations in the study population, time, and measurement of the outcome variables. These findings imply the urgent need to demystify the general assumption that PwDs do not have sex [65] which negatively impacts their sexual behaviour and use of SRH services increasing their risk of STIs, including HIV and AIDS [37]. Nonetheless, the prevalence of self-reported STIs in this study could be due to underreporting and social desirability biases. For example, only 44% indicated that they have ever tested for their HIV status. Research indicates that PwDs often hold misconceptions about their risk of STIs exposure and may avoid accessing STI services due to the fear of stigma [75, 96]. These challenges are exacerbated by the lack of disability awareness and training among healthcare providers, limited access to STIs testing information and services, and communication barriers [78, 97].

About 10.5% of PwDs rated their SRH as bad/poor. Self-rated SRH was associated with education, income, duration to the health facility and sex. This finding is consistent with the prevalence reported in previous Ghanaian studies [98, 99]. Discussing the findings within the health outcomes model shows that those with high level of education and income had higher odds of reporting good SRH status [40,41,42]. Those who are educated are more likely to recognise health problems and seek prompt care when needed. In addition, recognising the need to access healthcare alone is not enough, but money is required to pay the cost associated with health seeking. Distance to the health facility has various impacts on the health and health seeking behaviour of PwDs. The literature indicates rich people can afford healthcare more easily, leading to better healthcare access and longer life expectancy [99, 100]. High income enables the ability to purchase healthcare services, and research has shown that it also provides a favourable living environment that positively impacts health [99, 101]. The findings on the association between sex and self-rated SRH is different from what was reported by Debpuur et al. [98]. They found that women were more likely to self-rate their health status as bad. The possible explanation for the differences in study findings could be that females are more likely to notice SRH problems due to their reproductive make-up and seek more SRH services compared to men [102].

Implications for policy and practice

The study findings have significant practical and policy implications. First, the results reveal that most PwDs have ever had sex, but misconceptions about their sexuality and fear of stigma hinder their access to SRH services, including HIV testing [75, 96]. Addressing these issues requires behavioural change programs to promote safe sexual practices and encourage PwDs to seek SRH for STIs and safe abortion services.

Secondly, the findings indicate that both male and female PwDs experience various forms of violence. Interventions to combat violence against PwDs should target both genders and raise awareness of the negative effects of violence. Additionally, self-stigma and societal normalisation of violence against PwDs should be addressed through intensified education for PwDs and community members. The perpetrators of violence against PwDs come from various sources within the community. This highlights the vulnerability of PwDs to violence at all levels of society, necessitating immediate and pragmatic interventions to protect them. Therefore, national policies, such as the Disability Act 715, the criminal justice system, and the health system, should adopt systematic and standardised methods for assessing and recording possible violence against PwDs. Additionally, the reluctance of PwDs to disclose violence due to a lack of awareness of their rights, fear of losing social support, and disability-related financial assistance should be acknowledged and addressed.

Thirdly, the prevalence of adverse SRH outcomes, such as STIs, unplanned pregnancy, and unsafe abortion, underscores the need for targeted efforts and the development of new interventions to address these issues effectively. Finally, the SRH of PwDs is a growing public health concern, while a majority of PwDs rated their SRH status as good, many still reported experiencing various SRH problems, including STIs and sexual dysfunction. This study indicates that individuals with higher wealth and higher levels of education experience better SRH compared to those with lower economic status. Hence, it is essential to prioritise the SRH, education and economic security of PwDs. Government is encouraged to enhance economic and social integration through policy decisions. For instance, providing more formal education and economic support to PwDs can improve their socio-economic status and positively impact their SRH.

Strength and limitations

The combined analysis of quantitative and qualitative data unveiled the intersection of factors across various levels of influence, offering significant insights for understanding the sexual experiences, behaviour, and reproductive health outcomes of PwDs. The sample size was relatively large and as a result the findings can be generalised to the study population in this study’s setting.

However, the study employed cross-sectional design hence, only associations could be established but not causal interpretation of the findings. The qualitative phase however, explored the possible reasons for some of the behaviours considered in the study. All the indicators of sexual behaviours and reproductive health outcomes such as STIs, sexual violence and pregnancy termination were self-reported. As a result, self-reported bias and recall biases cannot be overruled coupled with the sensitive nature of sexual behaviour and abortion. It is therefore possible that some of these indicators are either underreported or overreported. Evidence suggest that PwDs tend to underreport sexual violence due to the stigma attached to it [21, 90]. This fear of relationship breakdown and further stigmatisation discourages them from reporting such cases [21, 76, 90]. However, the respondents were assured of confidentiality and the need to provide accurate responses which made it possible for some of the sexual violence survivors to share their ordeals for the first time. Participants from the quantitative phase who showed interest and consented to participate in the qualitative phase were those who took part, which could contribute to selection bias. The study only included two categories of PwDs–physical and visual impairments. Self-rated SRH was measured with a single item question asking respondents to provide an overall assessment of their SRH health. However, it is widely used in surveys to gauge the health status of populations [99, 103].