Access to Sexual and Reproductive Health and Rights Services for Young Women with and Without Disabilities During a Pandemic

Abstract

Young women with and without disabilities in South Africa experience challenges accessing sexual reproductive health and rights (SRHR) services, and this may increase during a crisis. We conducted a longitudinal cohort study with 72 young women with and without disabilities (18–25 years) in eThekwini, South Africa (2020–2022) via a series of in-depth interviews including quantitative and qualitative data on participants’ experiences during the COVID-19 pandemic and access to SRHR. Participants reported that barriers to accessing SRHR services included lockdown regulations, prioritization of COVID-19 at health care facilities, fear of COVID-19 infection, transport challenges, and youth-unfriendly clinics. Participants with disabilities experienced additional barriers to SRHR services, including ongoing (inaccessible services) and pandemic-specific (e.g., masks making lipreading impossible) barriers. Participants reported both non-partner and partner violence, with women with disabilities reporting this more frequently, physical and sexual partner violence, as well as physical and emotional abuse from caregivers. Participants with disabilities were not reporting incidents of violence to caregivers or officials because they had ‘normalized’ the experience of violence, were not believed when trying to disclose, feared that reporting would increase their problems, or could not access services due to disability-related barriers. Inclusive and accessible SRHR information, education, and services are needed. This includes disability-specific staff training, disability audits, and caregiver support and training.

1. Introduction

Sexual Reproductive Health and Rights (SRHR) are a focus of public health interventions in South Africa [1,2]. SRHR center around each individual’s autonomy and ability to make informed choices regarding their sexual health and reproduction and enables them to enjoy the highest attainable standard of health. To enjoy this standard of health, people need access to accurate SRHR information, the prevention and treatment of sexually transmitted diseases (STIs), contraception, pregnancy and maternity services, and protection from violence, stigma, and abuse [1].

Despite important achievements, many sexual reproductive health conditions and issues are still of concern in South Africa. Globally, the South African population still has among the highest prevalence rates for HIV (13.5%), gonorrhea (5.1%), chlamydia (10.3%), and syphilis (0.5%) [2,3,4,5]. Women are particularly affected by HIV, STIs, unintended pregnancies, and gender-based violence (GBV) [2]. For instance, the South African HIV prevalence in 2022 was 13.5% for the general population between 15 and 49 years but 24.1% for women [2]. The prevalence of gender-based violence (GBV) is incredibly high, with an average of 40,000 cases of rape being reported to the police annually in the past decade [6,7]. Furthermore, a 2010 population-based estimate for Gauteng found that 13% of women had experienced physical intimate partner violence (IPV) in the past year and between 28 and 37% of men had ever perpetrated rape [8].

Within South Africa, the province of KwaZulu-Natal (KZN) has one of the highest HIV prevalence (17.6%) and incidence rates, with rates of new infections being the highest in girls and young women between the ages of 15 and 24 years [3]. In addition, KZN has the highest teenage pregnancy rate in South Africa, with 24.7% of live births from adolescent mothers [9]. Hence, adolescent girls and young women in KZN are at particular risk of exposure to HIV and STIs, but are also at risk for unintended pregnancies and GBV.

Prior to the COVID-19 pandemic, evidence globally and in South Africa revealed that people with disabilities experience challenges in accessing health care and multiple inequalities in health, education, and living conditions [10,11,12,13,14,15]. These challenges translate into negative health outcomes for people with disabilities. Worldwide people with disabilities experience a 9.6–30.6 year life expectancy gap when compared to their peers without disabilities (South Africa: 21 year gap) [16]. Similarly, compared to children without disabilities, children with disabilities have a higher risk of mortality. People with disabilities have lower vaccination coverage and higher cancer and diabetes risks compared to those without disability [14,17]. While less is known about sexual and reproductive health among young people with disabilities, evidence indicates that they are equally likely to be sexually active as their peers without disabilities and that their sexual lives are often hampered by social and structural barriers to the full expression of their sexuality [18,19]. In addition, women with disabilities are two times more likely to be infected with HIV or experience intimate partner violence, and these risks increase with the severity of disability and deprivations [20,21,22,23]. Despite these risks, people with disabilities often struggle to access health care, including SRHR services. Barriers to access are exacerbated by physical movement and communication limitations, the negative and stigmatizing attitudes of health care workers with limited knowledge and awareness about SRHR needs among people with disabilities, and the lack of disability-inclusive SRHR and sexuality education programs in many settings [24,25,26].

During the pandemic, access to SRHR services decreased. VanBenschoten et al.’s (2022) global systematic review of studies on access to SRHR services during the global COVID-19 pandemic found that women and girls were less likely to access contraceptives, safe abortion, GBV, STI, and HIV services during the pandemic [27]. The review articulated that barriers to accessing SRHR services included challenges in accessing transport, financial hardships or limited resources, and legal restrictions to movement, for example the enforced lockdowns and curfews. However, the review also revealed that there was limited coverage of data generated among marginalized sub-populations, one of those being young people with disabilities [27]. Other literature suggests that young people, particularly young women and girls, experience multiple barriers to accessing SRHR services and that these barriers increased during the COVID-19 pandemic [28,29,30,31]. For instance, Baker et al.’s (2023) survey in the Eastern Cape Province of South Africa revealed that young people had challenges in accessing SRHR services and were often turned away because clinics were “overwhelmed and prioritized COVID-19” [32]. The study also found that many young people did not visit clinics for fear of contracting COVID-19 or lacked transport and financial support to travel to clinics [32]. Similarly, Burger et al.’s 2020 evidence brief on the consequences of the COVID-19 pandemic in the South African public health sector showed that there was a reduction in young people’s primary health care utilization, including HIV testing and accessing contraceptives [33].

There is some evidence suggesting that the COVID-19 pandemic presented additional challenges for people with disabilities’ access to health care services and their participation in society [12,15,34,35]. During the pandemic, people with disabilities reported experiencing violations around their rights to life, access to health, education, and food; were exposed to exploitation, violence, and abuse; were not able to live independently; and were not included in their communities [12,15,36,37,38,39,40,41]. However, less is known about the experience of people with disabilities and SRHR during the COVID-19 pandemic in low income settings including South Africa. One South African paper indicates that young people with disabilities in the Eastern Cape had more difficulties accessing HIV services during the pandemic [32]. The UNFPAs global synthesis work suggests that people with disabilities experienced challenges accessing SRHR services (describing physical, attitudinal, and communication barriers) and were increasingly exposed to GBV [15]. Furthermore, the Afrique Rehabilitation and Research Consultants (ARRC) report on the daily lives of adolescent girls and young women with disabilities and the UN 2020 report on the impact of COVID-19 on women and girls with disabilities both suggest that this group experienced barriers to accessing health care and education, including SRHR services [15,42]. To our knowledge, no published studies have compared the access to SRHR services between young people with and without disabilities during the pandemic. In addition, little evidence is available on the experience of specific vulnerable sub-groups such as young women with disabilities, how their experience compares to young women without disabilities, and how they accessed SRHR services during the COVID-19 pandemic. Such comparisons are important to understanding if barriers to health care access were related to challenges that all young people experience and if some barriers were specific to young women with disabilities.

We therefore undertook the Forgotten Agenda study to understand how young women with and without disabilities experienced access to SRHR services during the COVID-19 pandemic in KwaZulu-Natal and how their experience differed depending on disability status and COVID-19 lockdown levels.

2. Methods

2.1. Study Design and Background

We conducted a longitudinal study with 72 young women aged 18 to 25, including 37 participants with no disabilities and 35 with disabilities [43]. The study was conducted in eThekwini KwaZulu-Natal (KZN), South Africa, during the COVID-19 pandemic, which was accompanied by different lockdown regulations from March 2020 to March 2022. During the pandemic, South Africa underwent 5 distinct COVID-19 waves including a very strict lockdown with enforced stay-at-home orders (March–May 2020) and several differently adjusted lockdown levels thereafter. During the initial strict lockdown in March to May 2020 (level 4 and 5), government regulations did not clearly specify that SRHR services were part of the essential services that primary health care needed to provide during a pandemic [32,44]. During the soft lockdown in July 2021, the KZN province also experienced severe civil unrest, leading to the destruction of critical infrastructure, shops, and offices [45]. Hence, the presented study was undertaken during disruptive times in which disaster management approaches were implemented.

To better understand the experience of young women with disabilities during these disruptive times, we conducted a study following young women with and without disabilities of similar ages, socio-economic backgrounds, and life stages (just completed or enrolled in studies) throughout the pandemic. The study included a mixed method approach with quantitative, qualitative, and photovoice methods to understand the participants’ experiences of SRHR before and during the COVID19 pandemic. The design used a convergent parallel approach where the data were collected simultaneously but analyzed separately and were then utilized to compare the statistical results with the qualitative findings. Thematic analysis was utilized for this purpose.

2.2. Sampling

The study applied purposeful and respondent-driven sampling to include young women (age 18–25 in 2020) without and with different types of disabilities who were enrolled in or had completed their studies at various tertiary institutions in eThekwini (Figure 1).

Eligibility criteria for participating in the study for both groups of women (with and without disabilities) were as follows:

(1)

being female aged ≥18 to 25,

(2)

completed studies (within the last year) or enrolled in a tertiary institution,

(3)

willing to self-report on their sexual reproductive health, sexuality, and experience of the COVID-19 lockdown and its impact on their lives,

(4)

able to understand an accessible version of the questionnaire, and

(5)

conversant in English, isiZulu, or sign language.

2.3. Recruitment

Peer-to-peer recruitment was utilized to identify participants. Recruitment started after ethical clearance was provided. Seed participants [8] were selected with the support of local civil society organizations and public or campus clinics who serve young people or people with disabilities. They were contacted telephonically or via WhatsApp. These seed participants and various organizations and health facilities assisted in recruiting other participants (peer-to-peer recruitment) of a similar age and disability status. Before recruitment, the potential participants were screened to assess if they met the eligibility criteria. The eligibility screening was conducted face-to-face for women who were deaf (the paper uses ‘the Deaf’ in recognition of the participants preferred identify) and via phone or WhatsApp for all other participants with verbal consent, followed by written confirmation via WhatsApp.

Disability status was established during the screening through participant self-identification, and their schooling history was checked against the Washington Set of Disability Questions (disability had been identified for all participants with disabilities during their school career).

After the screening process, informed consent processes were offered face to face for the Deaf as this was needed to enable proper communication using sign language [43]. All other participants were offered information, and consent processes were completed over phone and/or WhatsApp. Information about the study was provided in writing, verbally, or through sign language. The consent forms used accessible formats adapted by research assistants with disabilities using simplified language and pictures to overcome communication barriers. Eligible participants who signed the informed consent (physically or electronically) were enrolled into the study.

2.4. Data Collection

Two waves of interviews were conducted telephonically for all hearing participants in adherence with COVID-19 lockdown restrictions at the time of the interviews and face to face for the Deaf. In both waves, interviewers followed a semi-structured interview guide that included a quantitative set of questions (cross-sectional) as well as open-ended questions prompting participants to report on their living situation, livelihood/food security, experience and worries about COVID-19, mental health, SRHR, as well as exposure to violence. The quantitative part included a combination of the following: (a) sets of questions developed for the project (e.g., COVID symptoms and testing based on Department of Health information) and (b) country-validated or standardized sets of questions such as the UNICEF list of menstrual hygiene materials, the South African Demographic Health Survey (SADHS 2016) pregnancy prevention options list [46], the UNFPA rapid assessment tool for SRH and HIV linkages [47], types of dwelling as per Stats SA 2011 Census [48], the CES-D-10 for depression [49], the Household Hunger Scale (HSS) [50], and the WHO domestic violence questionnaire for exposure to partner and non-partner violence [51].

The interview guide used accessible formats to overcome communication barriers, including picture material illustrating the questions and simplified language [43]. Each interview lasted approximately one hour and was conducted in English, isiZulu, or sign language. Interviews were repeated in two waves, prompted at different time points: before the COVID-19 pandemic (retrospective—prior to pandemic), during the strict COVID-19 lockdown (retrospective current—3 months before interview one), and after the softer lockdown phases (retrospective current—3 months before interview two). All interviews were audio-recorded or video-recorded (for the Deaf). Participants received mobile data and took WhatsApp or phone calls in their homes at a time and place convenient but also safe for them [52]. Deaf participants attended face-to-face interviews at the research office. The study staff engaged with participants via WhatsApp before every interview to ensure the safety of participants and agreed on a suitable place and time for both the remote WhatsApp and face-to-face interviews [52].

Quantitative data were entered into Kobotoolbox (version 2.021.24), and qualitative data were transcribed and translated into English with two research assistants checking all data entries. The completed transcripts and debrief reports were saved on the research organization’s secure shared drive, only accessible to study staff.

2.5. Data Analysis

The qualitative, quantitative, and photovoice data were combined for each participant to develop a case study report and description for each participant. The individual case study reports were entered and analyzed using thematic content analysis and NVIVO (version 12). Themes emerging from the data were used to develop a codebook. The major themes emerging were as follows: (1) experiencing COVID-19 symptoms and the impact of lockdown on stage of life and livelihoods; (2) mental health and coping; (3) access to SRHR services and commodities; and (4) experience of violence and intimate partner violence. The themes relevant to accessing SRHR services and commodities and experiences of partner and non-partner violence are presented in this paper, alongside the complimenting quantitative data.

The quantitative data were analyzed using statistical analysis software, R (version 4.4.1) [53]. Descriptive statistics were developed for all questions and summarized for all women as well as for the group of women with and without disabilities separately in order to assess differences. Significance testing was carried out using Fisher’s Exact Test for categorical variables and t-tests for continuous variables. Three significance tests were run for each variable, looking at the differences between women with and without disabilities at each point in time. p values less than 0.05 were considered to be significant.

2.6. Ethics

The South African Medical Research Council Ethics Board provided clearance for this study. All participants took part in the informed consent procedures and signed the consent form. Participants who needed further support or counseling had access to the study nurse and counselor, who provided additional referrals where necessary.

The research team comprised the principal investigator, co-investigators, a study coordinator, and research assistants, some of whom had disabilities themselves. The fieldwork was supported by three young female research assistants, two of whom spoke fluent isiZulu and the other sign language. All research team members were highly experienced research staff with prior qualitative research experience and training.

The research team presented the results through several webinars as well as in validation workshops with participants and representatives from tertiary institutions and the Department of Health. Through the validation workshops, the results were discussed and some themes were further explored.

3. Results

3.1. Study Participants

A total of 72 young women participated in this study, including 37 participants without disabilities and 35 with disabilities. The participants’ ages at the start of the study ranged from 18 to 25 years, with an average age of 21.38 years for women without disabilities and 22.0 for those with disabilities (

Table 1. Demographic characteristics of women recruited for semi-structured interviews on SRHR services.

Variables	Pre-COVID-19		Strict Lockdown		Soft Lockdown		p
	Women Without Disability	Women with Disability	Women Without Disability	Women with Disability	Women Without Disability	Women with Disability
n	37	35	37	35	29	27
Age in 2020 (mean (SD))	21.38 (2.52)	22.00 (2.00)
Student in 2020 (%)	31 (83.8)	33 (94.0)
Number of intimate partners in the past year (mean (SD))	1.46 (0.69)	1.51 (1.87)	1.14 (0.45)	2.00 (2.38)	1.11 (0.32)	0.74 (0.53)	##
Currently in an intimate relationship = Yes (%)	28 (75.7)	18 (51.4)	28 (75.7)	18 (51.4)	19 (65.5)	18 (66.7)	*, ^^^
Living with main intimate partner = Yes (%)	3 (8.1)	1 (3.4)	0 (0.0)	1 (5.6)	0 (0.0)	0 (0.0)
CES-D Score (mean (SD))			15.86 (6.49)	14.80 (5.54)	11.03 (4.71)	11.33 (5.09)
CES-D >10 = TRUE (%)			31 (83.8)	28 (80.0)	14 (48.3)	16 (59.3)
Number of people living in residence (mean (SD))	3.35 (2.29)	6.69 (8.91)	5.97 (2.87)	6.26 (2.62)	5.52 (3.71)	4.81 (2.94)	*
Type of residence (%)							***
Separate/backyard dwelling	15 (40.5)	28 (80.0)	37 (100.0)	34 (97.1)	27 (93.1)	25 (92.6)
Student residence	22 (59.5)	7 (20.0)	0 (0.0)	1 (2.9)	2 (6.9)	2 (7.4)
Experience of COVID-19 symptoms in the last months? = Yes (%)			24 (64.9)	19 (54.3)	15 (51.7)	14 (51.9)
Tested for COVID-19 = Yes (%)			4 (16.7)	3 (15.8)	4 (26.7)	6 (42.9)

Women with disabilities included women with physical, hearing, visual, and mild/moderate intellectual impairments. Significance test comparing women with and without disabilities pre-COVID-19: * < 0.05, *** < 0.001. Significance test comparing women with and without disabilities during strict lockdown: ^^^ < 0.001. Significance test comparing women with and without disabilities during soft lockdown: ^## < 0.01.

). Furthermore, 84% of women without disabilities and 94% of women with disabilities were enrolled into or had completed tertiary education (within the last year) at the start of the COVID-19 pandemic (the rest were about to enroll). All student participants accessed some form of student stipend, bursary, or other government support grant.

Most participants were in intimate relationships at the time of the interviews; women without disabilities (75.7%) were more likely to be in an intimate partnership than women with disabilities (51.4%) during the strict lockdown. Few participants cohabited with a partner before or during the strict lockdown. Our previous paper revealed that the participants’ living conditions changed for all participants during the strict lockdown, with women living with their immediate family trying to juggle studying and household demands while also missing their friends and social lives [43]. While women with disabilities were already reporting living in larger households prior to the lockdown, women without disabilities reported an increase in the number of people living with them during the strict lockdown (Table 1). All the women (except one) who lived in student residences prior to COVID-19 were living out of residences during the hard lockdowns. The latter is due to women without disabilities moving from student residences to their family’s main homestead or house during the strict lockdowns [43].

The mean scores for depressive symptoms reported by participants in Table 1 were higher at the first interview (15.86 with disability/14.80 without disability), coinciding with the duration of the strict lockdown, and decreased for both groups at the follow-up interview (11.03 with disability/11.33 without disability) during the soft lockdown. A large number of participants scored as having depressive symptoms (CESD-10 score over 10). This was higher at interview one (83.8% with disability/80% without disability) than at interview two (48.3% with disability/59.3% without disability). There were no significant differences in depressive symptoms between women with and without disabilities at both time points in terms of the mean scores or the percentage of women experiencing depressive symptoms. We also found no significant differences in the proportions of the population reporting symptoms or testing for COVID-19 among women with and without disabilities.

3.2. Themes

Below, we summarize the results for the emergent qualitative sub-themes related to SRHR: (1) accessing SRHR services and commodities, (2) disability-related barriers to SRHR services, and (3) experiences of partner and non-partner violence and access to support. We present the results relating to these themes, starting with the cross-sectional part of the interviews followed by the qualitative data fitting this theme.

3.2.1. Accessing Sexual and Reproductive Health (SRHR) Services and Commodities

The data revealed information about the participants’ usage of SRHR services and commodities prior to the COVID-19 pandemic and during both the strict and soft lockdown.

SRHR Service Usage

Participants’ usage of any SRHR services declined from pre-lockdown to the strict lockdown for both groups of women (overall p value pre vs. strict lockdown: 0.001). Use of any SRHR services was still lower than pre-pandemic levels at interview two (soft lockdown). In particular, the usage of STI management, HIV testing and counseling, and pregnancy testing declined for both groups during the strict lockdown and rose in the soft lockdown, but not yet to pre-COVID levels.

Participants without disabilities reported more usage of any SRHR services prior to and during the COVID-19 pandemic than participants with disabilities. However, we found no significant differences between participants with and without disabilities for the overall utilization of SRHR services at different pandemic time points. Significantly higher proportions of those without disability used STI management (strict lockdown), HIV testing, and pregnancy and antenatal services (before lockdown) compared to those with disability. Although the usage of family planning services, GBV services, abortion care, and gynecological examinations declined in the hard lockdown and rose in the soft lockdown, there was no statistically significant difference between the participants with a disability and those without. (

Table 2. Utilization of sexual and reproductive health and rights services.

SRHR Services Used/Access During the Period	Pre-COVID-19		Strict Lockdown		Soft Lockdown		p
	Women Without Disability	Women with Disability	Women Without Disability	Women with Disability	Women Without Disability	Women with Disability
n	37	35	37	35	29	27
Family Planning and contraceptives = Yes (%)	21 (56.8)	16 (45.7)	12 (32.4)	10 (28.6)	13 (44.8)	10 (37.0)
Prevention and management of Sexually transmitted infection = Yes (%)	23 (62.2)	14 (40.0)	9 (24.3)	7 (20.0)	13 (44.8)	5 (18.5)	#
Prevention and management of gender-based violence = Yes (%)	4 (10.8)	3 (8.6)	2 (5.4)	3 (8.6)	3 (10.3)	2 (7.4)
Prevention of unsafe abortion and management of post-abortion care = Yes (%)	5 (13.5)	3 (8.6)	0 (0.0)	1 (2.9)	2 (6.9)	0 (0.0)
HIV Testing and Counseling = Yes (%)	30 (81.1)	18 (51.4)	12 (32.4)	8 (22.9)	19 (65.5)	16 (59.3)	*
Psycho-social support = Yes (%)	7 (18.9)	8 (22.9)	6 (16.2)	4 (11.4)	7 (24.1)	3 (11.1)
Routine gynecological examination (includes Breast cancer screening, Pap smear and cervical cancer screening) = Yes (%)	7 (18.9)	3 (8.6)	0 (0.0)	3 (8.6)	1 (3.4)	3 (11.1)
Pregnancy testing = Yes (%)	24 (64.9)	10 (28.6)	12 (32.4)	5 (14.3)	10 (34.5)	7 (25.9)	**
Antenatal clinic and maternal health services = Yes (%)	11 (29.7)	2 (5.7)	8 (21.6)	1 (2.9)	5 (17.2)	3 (11.1)	*, ^^^
No SRHR service usage (%)	3 (8.1)	8 (22.9)	13 (35.1)	16 (45.7)	3 (10.3)	6 (22.2)

Women with disabilities included women with physical, hearing, visual, and mild/moderate intellectual impairments. Significance test comparing women with and without disabilities pre-COVID-19: * < 0.05, ** < 0.01. Significance test comparing women with and without disabilities during strict lockdown: ^^^ < 0.001. Significance test comparing women with and without disabilities during soft lockdown: ^# < 0.05.

).

The qualitative data provided more insight into the participants’ choices and issues around the utilization of SRHR services. Participants with and without disabilities discussed several reasons for not utilizing SRHR services. Many participants explained that they had limited contact with their partners during the ‘strict lockdown’ and therefore did not see the need for these services. They also reported feeling anxious about using public transport or going to clinics as they feared COVID-19 infection. The long queues at the clinics also discouraged them.

“It didn’t continue (going to SRHR services) … it was PrEP and prevention pills, during level 5 I didn’t really go get my pills. I didn’t go to the clinic unless I felt …. I was not sexually active, so I was just like I’m not going to go for my contraceptives or my PrEP pills.”

(23-year old woman without disabilities, strict lockdown)

“I didn’t access contraceptives during level 5 and 4 because I was not sexually active.”

(23-year old woman with intellectual disability, strict lockdown)

“Accessing the clinic was difficult because the queues were very long. I just left and went back home.”

(20-year old Deaf woman, strict lockdown)

Some participants shared that public clinics did not provide SRHR services during the strict lockdown, reporting that nurses focused on COVID-19, that they did not see SRHR as an essential service (only essential services were allowed during strict lockdown), and that some clinics ran out of stock (e.g., 3-month contraceptive injections). Participants explained that they did not feel that their SRHR needs were taken seriously and that they were asked to come back after the pandemic was over.

“They [nurses] took COVID-19 patients more [seriously] so they were the essential patients rather than us who came for injection and other prevention methods, they said it is not essential, they don’t take it serious, if you want to prevent come back after the pandemic is lowered down.”

(23-year-old woman without disability, strict lockdown)

“I did not go to the clinic …some of my appointments were postponed because of COVID-19, especially level 4 & 5. It was critical that time.”

(20-year old blind woman, strict lockdown)

Furthermore, participants explained that the attitudes of clinic staff affected their decisions about accessing contraceptives and other SRHR services. They revealed that moving home for the ‘strict lockdown’ also meant for many participants changing their SRHR service facility from youth-friendly campus clinics to community clinics. They described the campus clinics as very helpful, while clinics in their communities were perceived as less youth-friendly and supportive, not providing the same quality of information and counseling.

“It is actually very helpful when staff (at the campus clinics) is friendly because you get to ask more questions, you find out more such as PrEP (Pre-exposure Prophylaxis) even if you didn’t know about it, because the person is friendly you get to ask for information …, whereas back home you find that they (clinic staff) are shouting at you or complaining about this and this…you go there … they are not giving you proper instructions, it becomes difficult, you just want to do whatever you are there for and then leave. You will not even say let me do an HIV test, you just gonna want to be out of the place as soon as possible.”

(23-year old woman without disability, strict lockdown)

The clinics nurses say that a “girl should stay pure and it is not easy to go to the clinic to access SRHR services, they will look at you with a devils eye.”

(19-year-old woman without disability, strict lockdown)

“My boyfriend buys condoms from shops. I sometimes have sex without condoms—skin to skin—because I won’t go to the clinic [community public health care] because the nurses won’t help me.”

(25-year-old Deaf woman, soft lockdown)

SRHR Commodities

The changes in the available SRHR services and spending less time with partners had a specific effect on the utilization of pregnancy prevention options. Participants with and without disabilities used a variety of pregnancy prevention methods prior to the pandemic, including condoms, injectables, periodic abstinence, early withdrawal, and emergency contraception (

Table 3. Utilization of pregnancy prevention methods.

Pregnancy Prevention Methods Applied in the Period	Pre-COVID-19		Strict Lockdown		Soft Lockdown		p
	Women Without Disability	Women with Disability	Women Without Disability	Women with Disability	Women Without Disability	Women with Disability
n	37	35	37	35	29	27
IUD (intrauterine devices) = Yes (%)	1 (2.7)	0 (0.0)	1 (2.7)	0 (0.0)	1 (3.4)	0 (0.0)
INJECTABLES—3 MONTH DEPO = Yes (%)	10 (27.0)	11 (31.4)	4 (10.8)	6 (17.1)	2 (6.9)	8 (29.6)	#
INJECTABLES—2 MONTH NUR-ISTERATE = Yes (%)	5 (13.5)	1 (2.9)	2 (5.4)	0 (0.0)	3 (10.3)	3 (11.1)
IMPLANTS = Yes (%)	3 (8.1)	1 (2.9)	1 (2.7)	0 (0.0)	2 (6.9)	0 (0.0)
PILL = Yes (%)	3 (8.1)	4 (11.4)	2 (5.4)	2 (5.7)	4 (13.8)	3 (11.1)
MALE CONDOM = Yes (%)	30 (81.1)	22 (62.9)	20 (54.1)	12 (34.3)	19 (65.5)	17 (63.0)
EMERGENCY CONTRACEPTION = Yes (%)	18 (48.6)	7 (20.0)	4 (10.8)	1 (2.9)	7 (24.1)	5 (18.5)	*
Periodic abstinence = Yes (%)	16 (43.2)	11 (31.4)	12 (32.4)	6 (17.1)	4 (13.8)	6 (22.2)
Early withdrawal = Yes (%)	20 (54.1)	19 (54.3)	10 (27.0)	10 (28.6)	9 (31.0)	9 (33.3)
Other (IUD/female condom) = Yes (%)	1 (2.7)	1 (2.9)	1 (2.7)	0 (0.0)	2 (6.9)	2 (7.4)
No contraceptive method (not including abstinence or withdrawals) = Yes (%)	0 (0.0)	9 (25.7)	11 (29.7)	18 (51.4)	5 (17.2)	7 (25.9)	***

Women with disabilities included women with physical, hearing, visual, and mild/moderate intellectual impairments. Significance test comparing women with and without disabilities pre-COVID-19: * < 0.05, *** < 0.001. Significance test comparing women with and without disabilities during soft lockdown: ^# < 0.05.

). Female condoms were only used by one participant with disabilities.

From prior to the pandemic to the strict lockdown, the self-reported utilization of all pregnancy prevention methods dropped (overall cohort pre vs. strict lockdown p value of 0.001), except for those that were not utilized significantly prior to the pandemic (e.g., IUDs, implants). This drop recovered to some extent in the soft lock down (overall cohort strict vs. soft lockdown p value of 0.035), but utilization did not reach pre-pandemic levels in most categories.

Through the qualitative data, participants revealed why they were less likely to use pregnancy prevention methods during the COVID-19 pandemic. Some participants explained that they were not with their partners during the ‘strict lockdown’ and therefore did not feel the need to access contraceptives or condoms. They explained they were not sexually active during this time and would wait until the strict lockdown was over to receive more contraceptives, as well as HIV prevention methods such as PrEP. Other participants explained that they had tried to access contraceptives during the strict lockdown and had struggled, but most were able to access condoms. Some shared their worries of becoming pregnant.

“I did not even ask about it [contraceptives] I just said I will continue when I am back in Durban. … during level 5 [2020] I didn’t really go to get my pills. I didn’t go to the clinic, I was not sexually active, so I was not going to go for my contraceptives or my PrEP pills.”

(25-year-old woman without disability, strict lockdown)

“During the lockdown level 4 in 2020, everything was hard like getting contraceptive, injections or pills. There was a free box of condoms there (clinic) that you can help yourself. I fear of getting pregnant, so I use condoms.”

(22-year old Deaf woman, strict lockdown)

Despite the challenges with accessing SRH services and contraceptives during the ‘strict lock down’, participants reported that they had little or no challenges to access condoms and that they accessed these products through clinics, shops, friends, or families.

“I get free condoms from the clinic. If none there, I will either buy them from the shops or get one from a friend.”

(24-year old Deaf woman, soft lockdown)

Most participants used disposable sanitary pads (94.6% of participants without disabilities and 97.1% of participants with disabilities) and some tampons (24.3% of participants without disabilities and 8.6% of participants with disabilities) prior to the pandemic (

Table 4. Accessing menstrual hygiene products.

Menstrual Hygiene Products Used During the Period	Pre-COVID-19		Strict Lockdown		Soft Lockdown		p 1
	Women Without Disability	Women with Disability	Women Without Disability	Women with Disability	Women Without Disability	Women with Disability
n	37	35	37	35	29	27
Disposable sanitary pad = Yes (%)	35 (94.6)	34 (97.1)	32 (86.5)	33 (94.3)	27 (93.1)	23 (85.2)
Reusable pad = Yes (%)	0 (0.0)	2 (5.7)	0 (0.0)	1 (2.9)	0 (0.0)	2 (7.4)
Menstrual cloth = Yes (%)	0 (0.0)	2 (5.7)	1 (2.7)	1 (2.9)	0 (0.0)	0 (0.0)
Tampon = Yes (%)	9 (24.3)	3 (8.6)	7 (18.9)	4 (11.4)	4 (13.8)	5 (18.5)
Menstrual cup = Yes (%)	2 (5.4)	0 (0.0)	2 (5.4)	0 (0.0)	2 (6.9)	0 (0.0)
Other = Yes (%)	1 (2.7)	0 (0.0)	4 (10.8)	1 (2.9)	1 (3.4)	1 (3.7)

Women with disabilities included women with physical, hearing, visual, and mild/moderate intellectual impairments. ¹ Significance test comparing women with and without disabilities: no significance.

). Two participants with disabilities made use of reusable pads and the menstrual cloth, and two participants without disabilities utilized the menstrual cup.

The qualitative data confirmed that participants with and without disabilities did not experience challenges when accessing menstrual products. Participants explained that they had accessed these products through campus clinics and shops prior to the ‘strict lockdown’. They also revealed that they were able to stock up before the ‘strict lockdown’, thereafter acquiring the products from clinics, friends or family, distribution points from the Department of Health and community donations, and in shops.

“I had no challenges obtaining sanitary pads. There were people from the Department of Health who were distributing pads around my home, at bus stops, halls and mobile clinics.”

(21-year-old woman without disability, strict lockdown)

“I was using sanitary pads that my aunt bought me and had no problem getting them.”

(22-year old woman with intellectual disability, strict lockdown)

While some women reported that menstrual products were donated in their communities, some expressed a preference to purchase their own sanitary pads as they did not always feel that the sanitary pads provided by clinics were suitable for their needs.

“I buy period pads from the shops not the clinic. Why because it’s not the same and it [the pads from the clinic] is very uncomfortable and too big.”

(24-year old deaf women, soft lockdown)

3.2.2. Disability Related Barriers to SRHR Services

Overall, participants with disabilities were less likely to utilize some SRHR services prior to and during the COVID-19 pandemic (significant for HIV, pregnancy testing, antenatal visits before lockdown, and STI testing during the strict lockdown). Prior to the pandemic, 22.9% of participants with disabilities did not use any of the SRHR services prompted on our questionnaire (Table 2) and 25.7% had not used any form of contraceptives prior to the pandemic (Table 3). This number doubled during the ‘strict lockdown’. There was no difference between women with and without disabilities in accessing menstrual products.

The qualitative data revealed that participants with disabilities experienced additional barriers in accessing SRHR services, which they both experienced prior to and during the COVID-19 pandemic. These included challenges with physical accessibility and communication support at the clinic, insufficient time seeing nurses, and stock outs.

For instance, the Deaf participants described issues around communication methods, with staff not being able to communicate in sign language or provide participants with interpreter support. Hence, the Deaf participants could only access services with the assistance of family or friends and, in the absence of those, had to use pen and paper. The Deaf participants explained that this kind of communication does not provide them with comprehensive information, may even lead to wrong information, and is experienced as very stressful.

At the clinic, the nurses don’t know sign language and there were no interpreters to help me. The only option was to write on paper to ask for something. Even that was hard because my written English was limited and even the nurses battled to understand me. I was worried about wrong information and miscommunication. Very stressful.

(23-year old Deaf women, before lockdown)

Stock outs and a lack of communication from nurses was another issue identified by a blind participant, who felt that she was wasting her time at the clinics and had to seek care from a privately paid doctor.

“At the clinic, sometimes, they do not have injections, and this is why I started going to the doctor, I would rather pay money—I would rather pay money than to go for nothing.”

(20-year old blind woman, soft lockdown)

Another participant with physical disabilities described her ordeal in accessing contraceptives during the pandemic. The participant explained that she had to travel to several clinics and was refused services for different reasons, including stock outs, being perceived as not needing the injectables, or not belonging to the clinic’s catchment area.

“I stopped using the 3-month-depo in September (2020) because I went to the clinic and when I arrived at the clinic I was told there were no more 3-month-depo injections—I went to another clinic and I got a big problem there, they told me to take off my panty as they wanted to see if I am bleeding, it was wrong and they told me they couldn’t give me because I am not bleeding, when I went to another clinic they ask me where I stay and why I didn’t go to the clinic in my area.”

(24-year old woman with physical disability, soft lockdown)

The same participant described that in the absence of contraceptives, she opted for early withdrawal and emergency contraceptives, which she perceived as ‘cleaning herself from sperm’.

“I used 3 Month Depo and then practiced early withdrawal and accessed medication (emergency contraceptives) from the pharmacy for cleaning myself from sperm.”

(24-year old woman with physical disability, soft lockdown)

The same participant also described the challenges she experienced in receiving assistance when she had medical complications. The participant revealed that clinic staff had little time for her and did not assess her condition properly, and they simply provided her with pills, thus delaying identifying the infection.

“When I got to the clinic I reported my illness but they did not check anything and only handed me pills, I drank the pills as there was nothing much I could do, the pills did not help me and I landed up in hospital. They just gave me pills without checking what was wrong with me. I got to the hospital I was told that I have got an infection and they injected me and gave me more pills.”

(24-year old woman with physical disability, soft lockdown)

Participants with disabilities also shared what enabled them to access SRHR services. Participants reported that campus clinic staff were more supportive of their needs and were better able to explain the available options for pregnancy prevention and SRH services. These staff members were described as “gentle”, which enabled the participants to make informed decisions.

“…I accessed these services at the (University name) clinic and staff was very helpful and explained everything I needed to know. … They said I made the best decision, and they were very gentle.”

(21-year-old blind woman, before lockdown)

In the absence of supportive clinic staff, participants reported that they relied on family members, friends, and partners, describing that without their support, accessing services was particularly difficult.

“It [support from family members] helps but without them it [communicating with health care staff] is very difficult.”

(24-year-old Deaf woman, before and during lockdown)

However, when participants with disabilities had to involve family members, friends, or partners, they do not have the same confidential experience as women without disabilities; in some cases, their support person was able to control them. For instance, one participant described that prior to COVID-19, her mother used to initiate visits to SRH services and used these visits to check on whether her daughter was sexually active.

“My mother took me to the clinic to have an HIV test and was negative. My mother wanted to check on me to see if I had sex or not because I was studying in Cape Town for two years, far away from her.”

(22-year old Deaf woman, before lockdown)

Without supportive staff or significant others who accompanied participants during a clinic visit, participants experienced frustrations with staff hurrying them along; however, they also implemented some techniques to overcome barriers themselves. The Deaf participants described some of the communication techniques they used in the absence of sign language interpretation. This included writing on pieces of papers or pointing at posters. During the pandemic, going to a clinic was not always possible, and in the absence of being able to engage with nurses, women explained that they fell back to condoms and early withdrawal as prevention techniques.

“Before COVID I got the 3-month injection, I point to it on a poster, now I buy condoms and practice early withdrawal to prevent falling pregnant.”

(25-year-old deaf woman, soft lockdown)

“I only went for HIV and TB test. The nurses were ok but no patience though. The nurses always say hurry up because the queues are long. They don’t have time to understand or take trouble with me. I am very disappointed. I communicate on paper, very simple like WANT HIV OR TB TEST, NEGATIVE OR POSTIVE?”

(22-year-old deaf woman, soft lockdown)

Many of the disability-related barriers to accessing SRHR services were already prevalent before the COVID-19 pandemic. However, the Deaf participants who were able to communicate using lipreading and voicing described new barriers related to mask wearing. They described that masks prevented them from using lipreading as an alternative form of communication. One of the participants described that because of the mask, she needed to revert to her sisters to assist her with communicating with the nurses.

“My sister comes with me to the clinic to help to communicate with the nurses for me. It is easier that way. If I go by myself it is a lot harder, no sign language there. Can’t lipread because of the mask. I can write on paper, but my written English can also be confusing or misunderstanding.”

(23-year-old deaf woman, soft lockdown)

3.2.3. Experiences of Partner and Non-Partner Violence and Accessing Support

Participants also discussed their experiences of non-partner and intimate partner violence (IPV). Overall, just under 20% of participants reported experiencing some form of IPV in the months prior to the ‘strict lockdown’ in 2020 (

Table 5. Exposure to non-partner and intimate partner violence.

Types of Violence	Pre-COVID-19		Strict Lockdown		Soft Lockdown		p
	Women Without Disability	Women with Disability	Women Without Disability	Women with Disability	Women Without Disability	Women with Disability
n	37	35	37	35	29	27
Non-partner physical violence = Yes (%)	3 (8.1)	4 (11.4)	1 (2.7)	4 (11.4)	0 (0.0)	2 (7.4)
Non-partner sexual violence = Yes (%)	1 (2.7)	2 (5.7)	0 (0.0)	1 (2.9)	0 (0.0)	0 (0.0)
Intimate partner emotional violence = Yes (%)	6 (16.2)	6 (17.1)	4 (10.8)	3 (8.6)	3 (10.3)	3 (11.1)
Intimate partner physical violence = Yes (%)	3 (8.1)	6 (17.1)	1 (2.7)	2 (5.7)	0 (0.0)	1 (3.7)
Intimate partner sexual violence = Yes (%)	0 (0.0)	5 (14.3)	0 (0.0)	1 (2.9)	0 (0.0)	1 (3.7)	*
Any non-partner violence = Yes (%)	3 (8.1)	6 (17.1)	1 (2.7)	5 (14.3)	0 (0.0)	2 (7.4)
Any intimate partner violence = Yes (%)	8 (21.6)	6 (17.1)	4 (10.8)	3 (8.6)	3 (10.3)	3 (11.1)

Women with disabilities included women with physical, hearing, visual, and mild/moderate intellectual impairments. Significance test comparing women with and without disabilities pre-COVID-19: * < 0.05.

). This declined during the ‘strict lockdown’, with participants reporting fewer experiences of IPV, as they usually had limited or no contact with their partners. Participants with disabilities reported more sexual partner violence at all time points compared to those without disabilities. There were no significant differences in the other forms of partner or non-partner violence between the two groups, except for intimate partner violence before the lockdown.

The qualitative data revealed that some of the participants with and without disabilities experienced emotional, physical, and sexual violence from intimate partners, with emotional partner violence occurring at all time points. Participants without disabilities reported experiencing high levels of emotional/psychological and physical violence, with partners threatening, controlling, or pushing them. This included descriptions of slapping and the destruction of property, such as smart phones.

“…when I was visiting him, … he said I must open my phone and when I refused to open my phone because he doesn’t open his phone for me … then he slapped me, beat me and threatened to stab me. He said I must open my phone and he smashed my phone.”

(19-year-old woman without disability, soft lockdown)

Participants with disabilities described particularly traumatic incidents of both partner and non-partner sexual and physical violence prior to the COVID-19 pandemic. They also explained that they were discouraged from reporting violence or that cases were simply not followed through. Incidences of sexual violence did occur in the participant’s living spaces. For instance, one of the participants described a non-partner rape incident in a student residence, while another described an incident in her home. The extracts reveal the physical and psychological trauma of participants and the consequences on their sexual, reproductive, and mental health. They also reveal the participant’s perceptions of their perpetrators who they believed were perceiving them as easy targets because of their disability. The extracts also show the challenges of these survivors with disabilities who struggled to find support from family, friends, and the justice system.

“He assaulted, raped me in the student residence because I do not have the power and strength to fight him, …. the security guard said that she cannot do anything (take a report) because I signed him out … I felt so dirty … my friend didn’t believe me … and I had to have another operation as the rape loosened the screws in my hip.”

(25-year-old woman with a physical disability, before lockdown)

“While visiting my mom in the Eastern Cape her boyfriend attempted to have sex with me, but I refused. My mom came in while he was in bed with me trying to force me to have sex with him. I was taken to the clinic for a checkup. He was not arrested, and I did not go back to Eastern Cape, I don’t like going there because of what happened…The second incident happened when I was raped by my cousin, I fell pregnant and later terminated the pregnancy.”

(25-year-old woman with intellectual disability, soft lockdown)

One participant with a disability also described violence executed by her partner (boyfriend). She was one of the few participants who lived with their partner during the soft lockdown. She described serious changes in the behavior of her partner including emotional, physical, and sexual violence. The participant also described her challenges with communication and that because of the absence of sign language interpretation at the clinic, she had to go with the perpetrator to the clinic in order to seek medical assistance. She also explained that no counseling or GBV services were initiated.

During COVID-19 everything was more stressful. My boyfriend insulted, humiliated me, and yelled at me. Sometimes the physical abuse included slapping and sex without consent and humiliating sexual activities. He goes on a Friday to drink and comes back home drunk. He hadn’t been like that before the COVID pandemic. One night he hurt me so bad that he had to take me to the clinic the next day. There was no counseling available as there was no interpreter.

(22-year-old deaf woman, soft lockdown)

Furthermore, participants with disabilities also described non-partner abuse or violence but did not always identify this as violence. They described verbal and physical abuse in the workplace and at home (caregivers and other family members). Some participants with disabilities shared that in the workplace, line managers and colleagues sometimes abused them and that it was difficult to prove sexual harassment in the workplace.

At home, participants with disabilities described abuse related to not meeting expectations of household work (e.g., cooking or cleaning). Participants with disabilities did not always identify verbal abuse as violence, but rather excused this behavior as being normal, “putting them into shape”, or “fixing them”. Similar descriptions did not occur in the group of participants without disabilities. In our validation workshop, participants with disabilities explained that the verbal abuse they experience is not always identified as such because they “have learnt to see this behaviour as normal”, something that happens to them frequently, something that some of them have internalized as their fault and therefore do not perceive as abuse anymore.

“My line manager stopped harassing me after I confronted him, but he was thereafter rude and found the faults in my work. …I just wanted my contract to come to an end … one of my colleagues advised me that the next time I go to his office I must try and record him so I can have more evidence because previously one colleague reported this manager and the victim lost the case because of not enough evidence.”

(22-year-old woman with intellectual disability, soft lockdown)

My mother would shout at me and I feel suppressed by her. My mother resents me because I am broken (deaf), I cannot communicate with her and she forces me to clean and cook. My mother would shout at me to cook and make ‘bad facial expressions’ to show me hear disapproval.

(22-year-old deaf woman, strict lockdown)

“Something had happened at home and I did not acknowledge it, when I was confronted about it, since I have got a tendency to roll my eyes, I rolled my eyes and looked at my mother up and down, my father asked me why I rolled my eyes at my mother, which was when he back slapped me and then I cried…You know how parents are when they hit you, it is like they are putting you in shape or they are fixing you, so I did not take it as abuse.”

(21-year-old woman with intellectual disability, strict lockdown)

Participants with and without disabilities reported very little use of formal counseling support. The most common source of support came from family or friends. However, this kind of support was only available for those participants who had a trusted person. Participants with disabilities often reported additional attitudinal, physical, and communication barriers that hindered them from seeking help. One participant explained that she had experienced physical and emotional violence by her family as well as her previous boyfriend. In both situations, the participant did not feel that people would understand and listen to her, but rather feared that she would face further problems or be further violated.

“My mother often slaps my face. I also fought with my older sister. I never told anyone or reported them. I kept everything to myself, I don’t want problems—miscommunication and people won’t believe me. I suffer quietly … My ex-boyfriend treated me badly. I kept quiet about it because if I told someonemy ex-boyfriend would find out and would hurt me, worse than before. I never went for counseling because there is no interpreter to help me. They also don’t know the Deaf culture. They won’t understand.”

(24-year-old Deaf woman, strict lockdown)

Another participant with disability reflected on how the family was dealing with her rape, which included the proposal to conduct a cleansing ceremony with the perpetrator and survivor both being involved. The participant (survivor) did not want to engage with the perpetrator on this traditional platform and rather considered that her attacker was not held to account. The results of this attack had far reaching consequences for this participant, who had to terminate a pregnancy and who tested positive for HIV after the incident. It is noteworthy that despite this experience, the participant did not seem to realize that she had likely contracted HIV from being raped.

“He raped me and slapped me and I then reported him to my aunt and told her what he had done to me. He denied it. My aunt then told the rest of the family and they said he is supposed to do a cleansing ceremony, but I don’t want anything to do with him. It’s ok even if he is not arrested… I am not sure where I contracted HIV.”

(24-old woman with intellectual disability, soft lockdown, who terminated pregnancy)

4. Discussion

This paper describes the experiences of women with and without disabilities and their access to SRHR services during the COVID-19 pandemic in KwaZulu-Natal. Overall, the results indicate that while access to many SRHR services was more difficult for all participants during the pandemic, participants with disabilities experienced additional barriers, some of which preceded the pandemic.

Compared to pre-pandemic levels, participants with and without disabilities reported a lower usage of contraceptives and less testing or screening for HIV, STIs, cancer, and pregnancies during the different pandemic lockdown levels. A lack of sexual activity due to not being in lockdown with their partners, fear of contracting COVID-19, neglect of SRHR services by health care workers through prioritizing COVID-19, and youth-unfriendly clinic staff were reasons that both groups of young women referred to in their interviews. Of particular concern might be the usage of early withdrawal or emergency contraceptives, suggesting that young women do not always have access to the needed contraceptives or the necessary information about the high failure rates of these methods.

The results mirror the literature focusing on young people during the pandemic. Baker’s, Burger’s, and VanBenshoten’s studies already identify the limited demand (less sexual activity during lockdowns), the prioritization of COVID-19 over SRHR services, the fear of contracting COVID-19 at health facilities, and transport and financial issues as barriers that young people experienced when trying to access SRHR during the pandemic [27,32,33]. These barriers were also reported by our participants regardless of disability status. For the overall cohort, our study also reveals different experiences that young women have when accessing clinics in urban tertiary institutions versus community clinics. For many young people, moving back to their homes during the pandemic meant moving back into a youth-unfriendly clinic setting, in which young women felt less supported in accessing SRHR services. The literature and our results therefore clearly call for continued efforts to strengthen SRHR service delivery through youth-friendly and inclusive practices in all public clinics, as well as methods to ensure that young people’s SRHR, in particular those of young women with disabilities, are not left behind during a crisis.

Part of SRHR is menstrual health, which in many low- and middle-income settings is still a challenge for young women. The literature indicates that girls and young women in these settings have significant challenges accessing menstrual health products, including during and before the pandemic [54,55,56]. Our participants indicated that they were able to access menstrual products at all stages, with most of them using sanitary pads. The results show that women were able to buy sanitary pads or were able to obtain them from clinics, family, or through government and community initiatives. This is different from other studies during the pandemic who revealed that women and girls in South Africa experienced difficulties in accessing menstrual products during the pandemic [54,55].

While the continued access to sanitary pads during the pandemic is a promising result in this cohort, it also indicates that other menstrual products, such as tampons or menstrual cups, are still underutilized not only during the pandemic, but also during pre-pandemic times. These results tie in with other studies focusing on menstrual health in South Africa. For instance, an OXFAM study in schools in KwaZulu-Natal revealed that when girls have access to menstrual hygiene products, 88% of these products are sanitary pads, 7% are sanitary cloths, 4% are tampons, and 1% are menstrual cup [56]. This clearly indicates a need for strengthening the knowledge, acceptability, and affordability of alternatives to the over-reliance on sanitary pads.

One of the main contributions of this paper is the attempt to compare experiences between women with and without disabilities, who come from similar socio-economic backgrounds and are at a similar life stage as a student. We have seen this approach as useful because disability itself is associated with disparities, in particular an increased vulnerability to poverty, which by itself has an impact on people’s ability to access SRHR services [15,24,31,57]. All our participants were students, about to register, or just completed their studies at the start of the study. All of them had accessed student stipends or government grants to finance their studies, which in South Africa is based on a financial needs assessment; hence, participants, although coming from lower socio-economic backgrounds, were cushioned by these stipends or grants [58]. Yet, those with disability still reported less access and usage of SRHR services compared to those without disabilities.

Firstly, participants with disabilities described attitudinal and communication barriers. Clinic staff based at tertiary institutions were described as more helpful. However, during the pandemic, participants had to utilize community clinics near their homes and reported that the staff in these clinics did not have time for them, did not engage with them on needed services, or simply could not communicate with them. In particular, the Deaf participants described that they were unable to communicate with staff as they did not know sign language. These participants described that in the absence of such support, they had to rely on written language, point to infographics, or rely on support from family members or friends. In the absence of needed support and information from clinic staff, two scenarios emerged for our participants with disabilities. On the one hand, insufficient communication and time lead to incomplete information, frustrations, and a lack of confidence among women with disabilities. However, correct information and autonomy is needed to make informed decisions. On the other hand, the lack of support forced some participants with disabilities to use friends and family when utilizing SRHR services. The results include several examples where such support was insufficient and, in some cases, abusive. For instance, the mother of one of our participants exploited the support needs of her daughter to check whether she was sexually active and her HIV status, while in another case, the abusive boyfriend accompanied a participant to the clinic when she needed treatment after his violent attack. Under such circumstances, women with disabilities could not the receive confidential care and support which would enable them to make informed decisions regarding their health and wellbeing.

Our study also revealed that many of the disability-related challenges to access SRHR services already existed prior to the pandemic. Some of these challenges are summarized in the existing literature as attitudinal, physical, financial, and communication barriers to health care access [14,59,60]. Our participants with disabilities described some of these ‘pre-pandemic barriers’, including negative attitudes (staff not being patient and accommodating of their disability) and accessibility (not providing services in accessible formats or spaces). In addition, some barriers where ‘pandemic-specific’, such as the inability to use lipreading during mandatory mask wearing. Similar ‘pandemic-specific’ barriers are described in the literature, which shows that mask/shield wearing and social distancing impacted the ability of people with disabilities to communicate and gain support [41,61]. For instance, shields made the use of sign language difficult (as some signs use the head), masks made hearing difficult for those with hearing impairments, caused anxieties amongst those with autism, and made lipreading impossible, and social distancing was contradictive to blind people needing guidance through touch [41,61,62]. Considering these challenges, the Department of Women Youth and Persons with Disabilities’ report on COVID-19 criticizes the fact that “no guidelines were issued by government to address accessibility” [61]. The ‘pre-pandemic’ and ‘pandemic-specific’ barriers clearly indicate a need for disability-inclusive SRHR policies and programs, the disability-related training of health care staff, the auditing of health facilities in terms of their disability accessibility, and the inclusion and development of protocols that allow for the accommodation of people with disabilities during a pandemic.

Secondly, participants with and without disabilities described episodes of partner and non-partner violence prior to and during the pandemic. Overall, the number of reported violent incidences were not particularly high in our cohort considering that this study took place in a country with epidemic levels of gender-based violence. For instance, the 2016 South African Demographic Heath Survey found 21% of ever-partnered women over 18 years had experienced physical violence, with 8% experiencing it in the 12 months prior to the interview. Younger women were more likely to report physical violence in the past 12 months [7]. In addition, reports indicate that there was a 30% increase in GBV cases during the pandemic globally [63].

The lower reporting of violence in our cohort may be for two reasons. On the one hand, all except one participant reported that they were not living with their intimate partners during the pandemic. By default, these women did not experience intimate partner violence and the lockdown therefore had a ‘protective’ effect on young women. Not being married or living with their partners is common in KwaZulu-Natal, where there is a particularly low rate of marriage [64]. On the other hand, our research team had to interview participants over the phone, which limits the ability to create a supporting environment that enables the disclosure of violence (see limitations).

Despite the limitations, participants with disabilities reported more frequent sexual intimate partner violence, severe episodes of violence, as well as additional challenges in reporting violence and accessing care and support. This aligns with research globally which found that women with disabilities have a twofold increased risk of experiencing IPV and that this risk increases with the severity of the disability [23]. Participants with disabilities also revealed that they experienced violence in the home and the workplace. The testimonies also suggest that some women with disabilities did not perceive abusive behavior as such. Some also shared that their perpetrators perceived them as unable to report violence and therefore saw them as easy targets of violence. Hence, women with disabilities may have less knowledge about their rights and what constitute violence, are seen as easy targets of violence, and experience more severe and frequent assaults and abuse.

In addition to partner violence, participants with disabilities also reported violence perpetrated by their caregivers/parents. This type of violence was reported in relation to failed communication with their family members or perceived inadequacy to complete household tasks. Caregiver violence was particularly reported (and normalized) by our Deaf participants, most of whom were not able to communicate with their caregivers/parents who could not speak sign language. In our previous paper, we revealed that these participants described themselves as isolated and unable to communicate with their families at home [43]. Isolation increases the risk of abuse and violence and points towards the urgent need to provide caregiver training prior to any crisis and to provide the support of the families of people with disabilities during crises. Similar experiences of caregiver violence were not reported by the participants without disabilities, who actually reported enjoying staying and engaging with their families during the strict lockdown [43].

Despite these high-risk factors, few of our survivors with disabilities reported incidences of violence, gained support from family or friends, or accessed support services. There are several emerging barriers that are related to the lack of reporting, seeking support, and accessing services in these survivors. The first barrier is related to a lack of autonomy and awareness, with some participants having limited knowledge of what entails abuse and violence. For instance, abuse from caregivers was ‘normalized’ by some participants with disabilities. The second barrier is related to the availability and acceptability of support and services, with participants explaining that they feared that they would not be taken seriously by family, friends, or persons of authority when reporting violence or that they feared that they would experience further ‘problems’ or violence from the perpetrators. The third barrier is related to participants’ ability to access health and GBV services. In particular, the Deaf participants found it difficult to access services after they experienced violence or abuse, as the health care staff were not able to communicate with them. In light of these challenges disability-inclusive GBV policies and programs, disability audits of post-GBV care services, and staff training on GBV and disability are essential next steps.

Furthermore, the scarce literature that exists suggests that people with disabilities lack access to SRHR information, have less knowledge about SRHR/GBV, experience additional layers of discrimination that enhance exposure to violence, and experience barriers to SRHR services [24,26,59,65,66]. This study additionally revealed the ‘normalization’ of intimate partner and carer/family violence among young women with disabilities, which may be a consequence of long-term experiences of violence, discrimination, and absence of support. Hence, the results from the literature and our study clearly call for the need to provide information and education about SRHR and GBV to young women with disabilities, interventions to enable caregivers to provide better care and support, and approaches to increase inclusion and accessibility in SRHR and GBV service delivery.

Limitations

The study has several limitations. Firstly, we only followed a small group of participants in KwaZulu-Natal, all of them being linked to tertiary education in eThekwini. Hence, overall, the participants may be better educated and have better living conditions than other young people their age. The results are therefore an example of experiences and not representative of the population in KwaZulu-Natal or South Africa. The sample size of 72 participants limited the application of more robust and comparative quantitative analysis in the study.

Secondly, the study had to apply online and phone technologies to recruit participants and conduct the series of interviews. In addition, participants took these interviews in their homes, where they may not necessarily have been comfortable to disclose some aspects of their SRHR. Hence, some aspects such as violence are potential underreported as a result of the method of investigation.

Lastly, the presented study focused on the lived experience and did not engage with the long-term impact and policy change at the time of data collection. However, during the pandemic, the team supported ARRC and young women with disabilities to develop accessible and inclusive information material on HIV, STI, GBV, and COVID-19 [67,68,69]. After the pandemic, the team trained the disability sector representatives on the development of inclusive National Strategic Plans. This translated into an inclusive NSP on HIV, TB, and STI 2023–2028 [2], which is supported by a disability-inclusive Global Fund application in 2024 and the increased integration of disability in national policies and strategies on SRHR in South Africa [70]. The team also developed and piloted a workshop based on service training on GBV and disability for health care workers. This work will have to be published in a separate paper.

5. Conclusions

Young women with and without disabilities experienced challenges when accessing SRHR services during the COVID-19 pandemic. However, women with disabilities experienced additional barriers to accessing services, experienced ‘normalized’ abuse and violence, and struggled to gain the support needed to report violence or seek appropriate care. The provision of SRHR services needs to consider the specific needs of young women with disabilities, including the provision of inclusive and accessible SRHR information and education and service delivery. Inclusive and accessible services need to consider the diversity of people with disabilities and pay specific attention to vulnerable subgroups, such as young women with disabilities, the Deaf, or people with intellectual disabilities. Furthermore, caregiver interventions and service provider trainings and assessments are needed to transform home, work, and service delivery environments into spaces where women with disabilities can enjoy their SRHR on an equal basis with others. This transformation will lay the cornerstone to ensure that young women with disabilities are not left behind during crises.