Barriers and facilitators in accessing sexual health services among disabled middle-aged and older adults in England: A qualitative study

Barriers and facilitators in accessing sexual health services among disabled middle-aged and older adults in England: A qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and facilitators in accessing sexual health services among disabled middle-aged and older adults in England: A qualitative study Sophie Bowen, Eneyi Kpokiri, Yoshiko Sakuma, Joseph D Tucker, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7052728/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Middle-aged and older adults are more likely to have disabilities that impact sexual health. However, there is limited research exploring experiences of disabled middle-aged and older adults accessing sexual health services. This qualitative study explored the barriers and facilitators in accessing sexual health services among middle-aged and older disabled adults in England. Objective The objective of this manuscript is to identify the barriers and facilitators of accessing sexual health services among disabled middle-aged and older adults in England. Methods We conducted interviews with nine disabled middle-aged and older adults (aged 45 and above) in England. Participants were recruited through a disability community organisation by online invitation. Interviews were audio-recorded after obtaining verbal consent and transcribed verbatim. We used thematic analysis. The Levesque framework that identifies five dimensions of accessibility was adapted to guide data analysis and interpretation of findings. Results Participant disability types included mobility impairment, visual impairment, hearing impairment, or another long-term condition (a condition that cannot be cured). They faced widespread barriers to accessing sexual health services, some of which included physical inaccessibility, limited inclusivity, and inadequate addressal of sexual health needs. Some reported facilitators were maintaining existing processes, creating a more welcome environment and tailoring services. Conclusions The findings suggest that available sexual health services are not adequately tailored to meet needs of disabled middle-aged and older adults in England. There is an urgent need to adapt existing sexual health services to make them more appropriate for middle-aged and older disabled adults. Sexual health services disabled adults barriers facilitators access Figures Figure 1 Figure 2 1. Background An estimated 1.3 billion people are estimated to experience disability worldwide ( 1 ). and According to the UK Equality Act 2010, 14.6 million disabled people live in the United Kingdom (UK) ( 2 , 3 ). Disabled people are entitled to basic human rights equal to non-disabled people, including their sexuality and sexual health (sexual health), fulfilled ( 4 , 5 ). Disabled people may have greater sexual health needs compared to non-disabled people because of their increased vulnerability to abuse ( 6 ). Sexual health services among disabled people have been neglected ( 7 ) because of the pervasive societal belief that disabled people are asexual ( 8 ) or sexually inactive ( 9 ). Furthermore, the sexual health needs of disabled people are not adequately addressed by disability research and services in the UK ( 6 ). Middle-aged and older adults are more likely to have a disability that directly impacts sexual health ( 10 ). A global study with middle-aged and older adults (aged 40–80) in 29 countries found that sexual desire and activity persist into old age ( 11 ). Despite the intersectionality of sexuality and health in an ageing society, UK research, policy and programmes have consistently paid little to their needs ( 12 ). Campaigns for sexual health literacy and interventions are often targeted towards younger populations considered ‘at-risk’ cohorts, largely ignoring adults over 60 ( 13 ). Furthermore, the lived experiences of middle-aged and older adults are often neglected. Older people's expression of sexuality is overlooked in healthcare settings ( 14 ). Healthcare professionals ignore sexuality among older people ( 15 ) ( 14 ), and general practitioners in the UK do not proactively address their sexual health needs ( 16 ). Voices from disabled middle-aged and older adults about sexual health are missing. There is a need for research regarding disabled people’s barriers and facilitators to accessing sexual health services in the UK. A UK disability advocacy organisation reported that a lack of privacy, cultural prejudice, and lack of opportunity made accessing sexual health services more difficult for disabled people in the UK ( 17 ). However, few UK sexual health studies focus specifically on middle-aged and older adults and/or include middle-aged and older adults. For example, the NATSAL does not include middle-aged and older adults ( 7 ). 2. Methods 2.1. Study design We conducted a qualitative study using semi-structured interviews. Qualitative research designs allow an in-depth understanding of participants’ life experiences by exploring their thoughts, attitudes and perceptions ( 18 ). Furthermore, qualitative methods can collect open-ended data, which allows the potential exploration of personal and sensitive issues ( 19 ). Purposive sampling was chosen over probability sampling given its less resource-intensive nature ( 20 ) and also considering its use in qualitative research for the identification and selection of participants related to the subject of interest ( 21 ). Interviews can be advantageous when working with vulnerable populations, including disabled people; it can allow participants to convey their thoughts and opinions, increase self-awareness, and provide self-acknowledgement and validation ( 22 ). 2.2. Participant recruitment Participants were recruited through in-person clinics, social media announcements, and email lists. We partnered with an organisation focused on serving disabled people called ‘Independent Living Alternatives’, which invited the disabled community using email lists. We also recruited participants via local clinics, social media platforms and other community networks. Six people dropped out of the study. Drop-outs were people who were initially responsive to our recruitment (including who registered) but then dropped out whilst arranging the interview or during the interview process itself. Social media platforms included Twitter and ‘Nextdoor’ app. EK also made direct messages and posts on WhatsApp groups. Consent to participate and an information sheet were provided to participants (Appendix A). We recruited participants from 7th October 2021 until 7th March 2022. Inclusion criteria was adults aged 45 and above who considered themselves disabled, were English-speaking and resided in the UK for at least six months. 2.3. Data collection and management We developed a semi-structured interview guide (Appendix B). The guide included sections on demographics, experiences, and preferences for sexual health services. The draft questions were reviewed by the study team and piloted with three participants before being finalised. An experienced qualitative researcher and a junior researcher conducted four interviews, both at home and the workplace. No repeat interviews were conducted. Field notes were made during and after the interview. No-one was present in the interviews aside from the researchers and participants. There was no relationship established with participants prior to study commencement. The only information known to participants about the interviewers was the (interviewer’s) reasons for doing the research and their role at LSHTM. Due to COVID risks and individual preferences, all interviews were conducted by phone or video conference. No characteristics were reported to participants about the interviewers. Informed consent was obtained from each participant either written or verbally before the interview commencement. All nine interviews were audio-recorded, and recordings were stored on the cloud with password-protected files. Transcripts were anonymised, and identifiable information was redacted from each transcript. Transcripts were not shared with participants’ but some participants joined a later community advisory board and designathon where the findings were shared. The interviews lasted 55 minutes on average and generated approximately 500 minutes of audio recordings, which were transcribed using a transcription software called ‘Rev’. Data stored on Rev’s platform is encrypted via industry best-practice standards. All data was encrypted. We had detailed discussions with nine participants and reached data saturation with no new themes emerging after the 7th interview conducted. 2.4. Data analysis approach Thematic analysis was employed to analyse interview data and provide interpretations of participants' viewpoints ( 23 ), considering its ability to identify data patterns and organise them into meaningful themes ( 24 ). Interviews were coded by a mixture of deductive ( 25 ) and inductive analysis ( 26 ). Interviews were deductively coded based on interview topic guide questions; these helped to conceptualise relevant barriers and facilitators. Subsequently, an inductive approach was used to identify potential themes and subthemes. A deductive lens was then adopted to re-analyse the themes and understand how these could be appropriately viewed within the Levesque framework ( 27 ). Levesque’s framework suggests a multidimensional view of healthcare access, combining health systems (approachability, acceptability, availability and accommodation, affordability and appropriateness) and the population’s socioeconomic determinants (ability to perceive, seek, reach, pay and engage) ( 28 ). In Appendix C, the full rationale for choosing the Levesque framework is given. The six steps recommended by Braun and Clarke to conduct the thematic analysis were followed ( 29 ). These steps were data familiarisation (reading and re-reading of the data), generating codes, searching for themes, reviewing potential themes, defining and naming themes, and reporting. This also helped to create a thematic map, allowing the links between codes to be visualised ( 29 ). Finally, each piece of data was re-analysed to ensure it was relevant to each theme. We coded the data using NVIVO12. There was a high level of consensus regarding these, with only minor adjustments made with regards to how to structure the key findings. The research team’s background as abled-bodied and not being middle-aged or older adults was an important consideration, as it is possible that we may have overlooked some nuanced perspectives of disabled middle-aged and older adults. To try and address this during interviewing, we regularly sought clarification and encouraged full interviewee explanations for contextual insight. Participants did not provide feedback on the findings. 2.5. Ethical considerations We obtained ethical approval from the ethics committee of the London School of Hygiene and Tropical Medicine (ref number: 26134-01 and Ref: 26725). 3. Results Demographic backgrounds of our participants are shown in Table 1. Participant ages ranged between 52 and 68, and participants were mainly situated in London boroughs, except for two participants; for a breakdown of demographic information by each participant, see Appendix D. We identified two themes under facilitators and four under barriers, and these were mapped onto distinct parts of the Levesque framework (Fig. 1 ). Appendix E outlines a more detailed coding tree including subthemes. In Appendix F, themes which mapped onto more than one component of the Levesque framework are discussed. 3.1. Barrier: Inadequate operation of services (‘Approachability’ and ‘Appropriateness’) Several participants discussed limited signposting to sexual health services and described this as being a service promotion issue: “I don't think they [sexual health services] are openly promoted” (Participant 7, male, age 65–70). A participant also mentioned that no healthcare providers suggested using sexual health services for addressing their sexual health needs (APPENDIX G, quote 1). A lack of knowledge about choices and options could mean individuals may not access sexual health services: “If I'm not certain what the choices are, I might not access the service” (Participant 8, male, age 65–70). There was also limited sexual health information; a participant contrasted the lack of sexual health information to other health-related areas (APPENDIX G, quote 2). Most participants referred to their limited inclusivity, defined here as a lack of representation of disabled middle-aged and older adults in sexual health services. A participant mentioned that sexual health services focused upon young people more and that sexual health services may not be suited to addressing older people’s sexual health needs (APPENDIX G, quote 3). Furthermore, almost half of the participants highlighted how sexual health services were not inclusive of disabled people: “They're [sexual health services] taboo and they're not well known. And they don't celebrate an inclusion of disabled people in sexual practice” (Participant 8, male, age 65–70). “I can't remember seeing any images of disabled people in sexual health clinics and any recognition that people have access needs” (Participant 9, male, age 55–60). 3.2. Barrier: Physical inaccessibility (‘Availability and accommodation’) Most participants reported the physical inaccessibility of sexual health services. This can be viewed in three stages (Fig. 2 ). Experiencing physical inaccessibility can cause negative emotions (APPENDIX G, quote 4) and even make individuals “turn round and leave” (participant 9). Furthermore, inaccessibility can break the continuity of trust between an individual and a service – the lift was broken for 6 months and they were not directly notified about this (APPENDIX G, quote 5). Several participants mentioned barriers before entering sexual health services, such as a lack of suitable parking facilities onsite (APPENDIX G, quote 6) and sexual health services facilities with a small entrance and inaccessible doorbell (participant 7). Other physical aspects were requirements for: level access, ramp access or lift access to enter the building (participant 4). Several participants commented upon barriers inside sexual health services buildings, such as multiple floors (participant 7) and a lack of operational lift (participant 9). Participant 4 also expressed the importance of having sufficient waiting-room space and an accessible ‘changing places toilet’. A few participants stated barriers during appointments, such as waiting for rooms with adjustable beds (APPENDIX G, quote 7). Sometimes adjustable beds could not be lowered to the same height as the wheelchair. Consequently, participant 5 had to forfeit treatment because they could not get onto the examination bed. Another physical barrier mentioned by a few participants was the lack of hoists available at general practices: “ So I asked, could I take my portable hoist […]? They said, no, I was not allowed to bring my portable hoist to transfer me on the bed and they don't have one. So they referred me to the hospital” (Participant 4, female, age 50–54). This quote highlights the physical inaccessibility and the lack of flexibility with individuals using their hoist. A few participants commented on the lack of machine adaptability towards disabled people (APPENDIX G, quote 8). This can cause not only a delay (due to rescheduling another scan) but also a potentially less optimal screening method (performing a CT scan instead of the mammogram). 3.3. Barrier: Inadequate addressal of sexual health needs (‘Appropriateness’) A participant expressed concern with the way their sexual health needs were considered, where disabled people and older adults had limited opportunities, such as a lack of home visits: “Most GPs don't do house calls […] when my GP retires […] I don't know what I will do about having a smear test. And that's real worry […] [This situation] makes you feel like you are expendable as a person” (Participant 5, female, age 61–65). Dismissive healthcare professionals’ attitudes were mentioned by one participant when asking whether they could have oral sex after taking certain medications (APPENDIX G, quote 9). The healthcare professionals’ dismissive response in shutting down the question greatly impacted the participants' mental and physical well-being (APPENDIX G, quote 10). A few participants commented on healthcare professionals’ inadequate knowledge of understanding disabled people’s physical requirements: “What becomes necessary is if things are a bit not straightforward and staff don't know what they're doing exactly. Well, that in itself is a barrier for me because there's more attention placed on me because, ‘Well, we don't know if we can fit in this room, I don't think we can transfer to the hoist, so maybe we won't do this test today’ " (Participant 9, male, 55–60). Another situation outlining healthcare professionals’ inadequate knowledge regarding disabled people’s requirements was inviting an assistant into the examination room without the participant's consent (APPENDIX G, quote 11), or not proactively asking if they required privacy (APPENDIX G, quote 12). 3.4. Barrier: Unsuitable structure of services (‘Appropriateness’) One participant mentioned a lack of effectively co-ordinated care, which was due to the increased fragmentation of healthcare services: “When I started off, it was a sort of a one stop service. So my HIV consultant could do everything for me. She could refer me on to other specialists. She could prescribe medication that wasn’t necessarily directly related to the HIV […] what I now get from sexual health services is much more limited, much more specific” (Participant 3, male, age 66–70). This highlights how current sexual health services are less capable of addressing sexual health in a broad manner, unlike previously. Another concern about coordinated care was limited continuity and communication between different services, where the participant was responsible for transmitting information between specialists and expressed concern with not being an expert (APPENDIX G, quote 13). Although various sexual health services in England are open to everyone (termed ‘non-differentiated’ services hereafter), some are dedicated solely to disabled people. A few participants unfavourably commented on these dedicated services: “Personally, I'd rather access a general service that provided my needs as well as everyone else's” (Participant 8, male, age 65–70). “I think it’s outrageous to send disabled people to different places” (Participant 9, male, age 55–60). Participant 9 expressed their perception that dedicated services were unnecessary and worked against the values of the Equality Act. They expressed that instead of dedicated services, non-differentiated services should be upscaled for disabled people to access. Facilitators to accessing sexual health services are shown in Fig. 1 . These were maintaining and improving daily management of services and changing the implementation of sexual health services. 3.5. Facilitator: Maintaining and improving service management (‘Approachability’ and ‘Appropriateness’) For this research, ‘daily management’ involves managing departments, functions, and processes. Most participants referred to this theme. A facilitator maintained effective existing processes; several participants described sexual health services as well-supported in certain areas. A participant said: “ I feel as an older person living with HIV that I am well supported” (Participant 3, male, age 66–70). When considering STI testing, a participant expressed a positive experience with postal services: “I think the last time it all worked well” , but also raised the point that the adequacy of sexual health services “Depends on the disabilities” (Participant 1, male, age 61–65). Existing effective processes were also outlined where healthcare professionals took a proactive approach with STI-testing (APPENDIX G, quote 14). This was particularly important considering the participant expressed they did not feel comfortable raising STI testing as a topic (APPENDIX G, quote 15). A participant highlighted the importance of healthcare professionals being well-versed in understanding the legal obligations in equal service provision for all people (APPENDIX G, quote 16). They also raised the importance of making NHS information standards more visible (APPENDIX G, quote 17). Several participants raised the importance of a positive sexual health services environment which foster trust and address their sexual health needs: “Making more welcoming services. Building trust. And more disabled people being able to get the support they need around their sexual health” (Participant 9, male, age 55–60). Other participants emphasised how a facilitator was a healthcare worker with having open-minded attitude (Appendix G, quote 18) and the provision of standardised staff training (Appendix G, quote 19). Participant 5 felt services should offer basic amenities, such as easily accessible water and the option to buy food for people with diabetes. 3.6. Facilitator: Modifying implementation of services (‘Appropriateness’) Most participants emphasised that it is important to design services together with disabled people and/or in keeping their needs in mind. Co-production of sexual health services was mentioned by a participant several times: “[…] working with disabled people to co-produce. Because if you, for example, take statutory requirements and just kind of work towards minimum standards, let's say, but you have no input from disabled people, what's written down in regulations, that doesn't mean it's going to work in practice.” (Participant 9, male, age 55–60). For this research, ‘tailored services’ refers to services designed for a particular person or group. Some participants mentioned tailoring sexual health services to disabled people, which could involve considering the visual and physical nature of the services, such as using leaflets and posters representative of disabled people (APPENDIX G, quote 20), as well as adequate space for wheelchair users and assistants (APPENDIX G, quote 21). A few participants also suggested encompassing a social model approach (discussed below). 4. Discussion The objective of this study was to identify barriers and facilitators facing disabled people in accessing sexual health services in the UK. Our data suggest that physical accessibility barriers and lack of care coordination limited access to sexual health services for older disabled people in the UK. Differentiated services and building onto existing services were noted as facilitators of accessing sexual health services in this group. There are limited research studies in the UK assessing disabled peoples’ barriers and facilitators in accessing sexual health services, but this study provides valuable insight, especially for the English sexual healthcare system. This research fills a much-needed gap in UK literature. This study’s focus population has sexual and reproductive health needs which have historically been neglected. One of the most frequently reported barriers in the study was physical inaccessibility. The same facets of physical inaccessibility found in this study were also noted in existing literature which found an unsuitable ramp access or lack of lift ( 30 ), ( 31 ), ( 32 ) more than one floor without an operational lift ( 33 ) and beds which do not lower down to wheelchair height ( 30 ). However, one study in Ghana mentioned how this physical inaccessibility can be overcome if they receive appropriate aid ( 34 ). In contrast, physical inaccessibility issues were not overcome in this study. Moreover, not all disabled people have caregivers available to accompany them to every appointment, highlighting the importance of adapting the physical structure of sexual health services. Another frequently reported barrier was the inadequate operation of sexual health services, which comprised of two subthemes: 1) limited signposting and information 2) a lack of representation within sexual health services. The former is mentioned in existing literature (46) ( 31 ) ( 32 ). If people are not adequately signposted and are unaware of when they should utilise sexual health services, this could have large implications regarding how and if these services are accessed. A lack of representation of disabled middle-aged and older adults within sexual health services was not found in other literature and was a unique finding of this study. Participants spoke particularly negatively towards the unsuitable structure of sexual health services. One participant perception highlighted that current sexual health services are contrary to the Equality Act 2010 ( 35 ), which commits sexual health services to provide services for all, including disabled people. If non-differentiated sexual health services providers believe disabled people’s needs can be met through dedicated services (services for disabled people only), this might be one of the reasons that non-differentiated sexual health services do not currently cater for disabled people’s needs adequately. One of the most frequently reported facilitators was maintaining existing processes. One participant expressed gratitude that their healthcare professionals proactively mentioned STI testing because they felt uncomfortable raising it. A literature review supported this finding ( 36 ), which found a hesitancy of disabled people to mention sexual health, highlighting the importance of health care professionals continuing to proactively raise sexual health topics. Another frequently reported facilitator was tailoring services. Using a social model of disability was suggested by participants as an important factor to consider when tailoring services. The social model views disability through interactions with disabled people and a barrier-filled environment ( 37 ). Consequently, encompassing a social model approach would describe inaccessible sexual health services as the result of a poorly adapted environment and would likely aim to overcome these barriers. Our study has important implications and recommendations for policies, practices and research. To improve physical accessibility, policies could state a mandatory inclusion of disability-friendly facilities within sexual health services, such as ramps, adjustable beds, hoists and changing places toilets. Improving physical accessibility is endorsed under a United Nations framework of five actions to achieve full inclusion of the sexual and reproductive health of disabled people ( 38 ). Policies and sexual health services practice could also be updated to outline that all staff must receive training on catering to disabled people’s requirements. Not only did participants highlight inadequate staff training, but most impediments to providing good-quality services are related to providers’ attitudes and limited knowledge about disabilities ( 38 ). Co-production of sexual health services with disabled middle-aged and older could help make sexual health services more accessible by tying together statutory systems with the expertise of service users (53) (54). Study participants expressed unfavourable views about dedicated sexual health services and how they felt non-differentiated services should cater for everyone’s needs instead. One way this could be achieved is through integrated care, which focuses on the needs of individuals, their families, and communities ( 6 ). However, changing service structures may take time and require long-term follow-up to monitor outcomes, and the effects may not be immediate. Further research is needed to determine whether our findings are consistent across other sexual health services in the UK and to inform how sexual health services can be tailored towards disabled middle-aged and older adults. Future research should include people with varied disabilities because people with different disabilities may have different needs and require different support types ( 33 ). Our study has several limitations. Barriers and facilitators to accessing sexual health services can vary with disability types ( 33 ); however, in this study, most of our participants reported a physical disability and representation of other types of disabilities is lacking. Therefore, these results may not represent the experiences and views of disabled middle-aged and older adults across England or the UK, nor be entirely applicable to different contexts. Furthermore, there may have been bias about which participants enrolled onto this study, as we employed purposive sampling methods through a single disability organisation in London. Individuals with more critical views of existing sexual health services may have been more likely to participate. The implications of this may be that some positive perceptions about sexual health services may be missed. Furthermore, this study had a small sample size of nine participants. Nevertheless, despite the small numbers, we reached data saturation. 5. Conclusion The study findings highlight that health systems should play a role in making sexual health services accessible for disabled middle-aged and older adults. Minimising barriers and incorporating facilitators to access sexual health services could help address the issues this subpopulation faces in accessing sexual health services. However, the paucity of literature in this field warrants future research not limited to other disability types, geographical locations, and intersecting factors to comprehensively inform policies and practices. Declarations Clinical trial number: not applicable. Ethics approval and consent to participate We obtained ethical approval from the ethics committee of the London School of Hygiene and Tropical Medicine (ref number: 26134-01, and Ref: 26725). Informed consent was obtained from each participant either written or verbally before the interview commencement. Consent to participate and an information sheet were provided to participants (Appendix A). Ethics Committee: London School of Hygiene and Tropical Medicine Research Ethics Committee, and London School of Hygiene and Tropical Medicine MSc Research Ethics Committee. Consent for publication The information sheet that goes alongside the consent form contains information that informs participants that their data will be published. “What will happen to the results of this study? The study results will be published in a scientific journal so that other researchers can learn from them”. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was jointly supported by the Economic and Social Research Council, UK Research and Innovation (UKRI) (grant number: ES/T014547/1), the National Natural Science Foundation of China (72061137001), the Natural Science Foundation of China Excellent Young Scientists Fund (82022064), the Natural Science Foundation of China Young Scientist Fund (81703278) and the Special Support Plan for High-Level Talents of Guangdong Province (2019TQ05Y230). Authors' contributions Sophie Bowen wrote the main manuscript text and prepared figures and tables. Dan Wu, Joseph D Tucker and Huachun Zou obtained funding support. Dan Wu conceived the idea, oversaw the study progress, provided supervisory inputs to and edited this manuscript. Eneyi Kpokiri and Yoshiko reviewed the manuscript extensively multiple times to provide feedback and changes. Acknowledgements We would like to acknowledge Hannah Kuper, Thomas Shakespeare and Shaffa Hameed for contributing their thoughts to this paper, especially for providing information and ensuring that the language used was disability friendly. Conflicts of interest There were no conflicts of interest. References WorldHealthOrganization. Disability 2023 [Available from: https://www.who.int/news-room/fact-sheets/detail/disability-and-health#:~:text=Key%20facts,1%20in%206%20of%20us. SCOPE. Disability facts and figures [Available from: https://www.scope.org.uk/media/disability-facts-figures/. GOV.UK. Definition of disability under the Equality Act 2010 [Available from: https://www.gov.uk/definition-of-disability-under-equality-act-2010#:~:text=You%27re%20disabled%20under%20the,t%20apply%20to%20Northern%20Ireland. . WorldHealthOrganisation. Sexual health [Available from: https://www.who.int/health-topics/sexual-health#tab=tab_2. GOV.UK. Sexual and reproductive health and HIV: applying All Our Health 2022 [Available from: https://www.gov.uk/government/publications/sexual-and-reproductive-health-and-hiv-applying-all-our-health/sexual-and-reproductive-health-and-hiv-applying-all-our-health. WorldHealthOrganisation. Promoting sexual and reproductive health for persons with disabilities. 2009. Holdsworth E, Trifonova V, Tanton C, Kuper H, Datta J, MacDowall W, et al. Sexual behaviours and sexual health outcomes among young adults with limiting disabilities: Findings from third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3). BMJ open. 2018;8(7) (no pagination). Shah S. “Disabled People Are Sexual Citizens Too”: Supporting Sexual Identity, Well-being, and Safety for Disabled Young People. Frontiers in Education. 2017;2:46. UNISON. 2018 National Disabled Members' Conference. UNISON PRELIMINARY AGENDA 2018 [Available from: https://www.unison.org.uk/content/uploads/2018/07/2018-National-Disabled-Members-Conference_Preliminary_Agenda_Report_20180716.pdf Barlow FK, Walker N. Disability and Ageing. In: Pachana NA, editor. Encyclopedia of Geropsychology. Singapore: Springer Singapore; 2017. p. 674-80. Nicolosi A, Laumann EO, Glasser DB, Moreira ED, Jr., Paik A, Gingell C. Sexual behavior and sexual dysfunctions after age 40: the global study of sexual attitudes and behaviors. Urology. 2004;64(5):991-7. Knox J. United Nations Office of the High Commissioner on Human Rights,‘. Mapping Report. Nash P, Willis P, Tales A, Cryer T. Sexual health and sexual activity in later life. Reviews in Clinical Gerontology. 2015;25(1):22-30. Doherty S, Byrne M, Murphy AW, McGee HM. Cardiac Rehabilitation Staff Views about Discussing Sexual Issues with Coronary Heart Disease Patients: A National Survey in Ireland. European Journal of Cardiovascular Nursing. 2011;10(2):101-7. Balami JS. Are geriatricians guilty of failure to take a sexual history? Journal of Clinical Gerontology and Geriatrics. 2011;2(1):17-20. Gott M, Hinchliff S, Galena E. General practitioner attitudes to discussing sexual health issues with older people. Social science & medicine. 2004;58(11):2093-103. DisabilitySheffield. Disability Sheffield Information Service: Sexual Health Factsheet 2018 [Available from: https://www.disabilitysheffield.org.uk/admin/resources/sexual-healthupdate2017-1.pdf. Ohman A. Qualitative methodology for rehabilitation research. J Rehabil Med. 2005;37(5):273-80. DeJonckheere M, Vaughn LM. Semistructured interviewing in primary care research: a balance of relationship and rigour. Fam Med Community Health. 2019;7(2):e000057. Valerio MA, Rodriguez N, Winkler P, Lopez J, Dennison M, Liang Y, et al. Comparing two sampling methods to engage hard-to-reach communities in research priority setting. BMC Med Res Methodol. 2016;16(1):146. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health. 2015;42(5):533-44. Hutchinson SA. The Development of Qualitative Health Research: Taking Stock. Qualitative Health Research. 2001;11(4):505-21. Crowe M, Inder M, Porter R. Conducting qualitative research in mental health: Thematic and content analyses. Australian & New Zealand Journal of Psychiatry. 2015;49(7):616-23. Thompson J. A Guide to Abductive Thematic Analysis. The Qualitative Report. 2022;27. Bonner C, Tuckerman J, Kaufman J, Costa D, Durrheim DN, Trevena L, et al. Comparing inductive and deductive analysis techniques to understand health service implementation problems: a case study of childhood vaccination barriers. Implement Sci Commun. 2021;2(1):100. Chapman AL, Hadfield M, Chapman CJ. Qualitative research in healthcare: an introduction to grounded theory using thematic analysis. J R Coll Physicians Edinb. 2015;45(3):201-5. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. International journal for equity in health. 2013;12:18. Cu A, Meister S, Lefebvre B, Ridde V. Assessing healthcare access using the Levesque’s conceptual framework– a scoping review. International journal for equity in health. 2021;20(1):116. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101. Ahumuza SE, Matovu JKB, Ddamulira JB, Muhanguzi FK. Challenges in accessing sexual and reproductive health services by people with physical disabilities in Kampala, Uganda. Reproductive Health. 2014;11(1):59. Tun W, Okal J, Schenk K, Esantsi S, Mutale F, Kyeremaa RK, et al. Limited accessibility to HIV services for persons with disabilities living with HIV in Ghana, Uganda and Zambia. J Int AIDS Soc. 2016;19(5 Suppl 4):20829. Rugoho T, Maphosa F. Challenges faced by women with disabilities in accessing sexual and reproductive health in Zimbabwe: The case of Chitungwiza town. Afr J Disabil. 2017;6:252. Mavuso SS, Maharaj P. Access to sexual and reproductive health services: Experiences and perspectives of persons with disabilities in Durban, South Africa. Agenda. 2015;29(2):79-88. Badu E, Gyamfi N, Opoku MP, Mprah WK, Edusei AK. Enablers and barriers in accessing sexual and reproductive health services among visually impaired women in the Ashanti and Brong Ahafo Regions of Ghana. Reproductive health matters. 2018;26(54):51-60. GOV.UK. Equality Act 2010 2010 [Available from: https://www.legislation.gov.uk/ukpga/2010/15/contents. Greenwood NW, Wilkinson J. Sexual and reproductive health care for women with intellectual disabilities: a primary care perspective. Int J Family Med. 2013;2013:642472. PeopleWithDisabilityAustralia. Social model of disability [Available from: https://pwd.org.au/resources/models-of-disability/. WorldHealthOrganization. Promoting sexual and reproductive health for persons with disabilities 2009 [Available from: https://www.unfpa.org/sites/default/files/pub-pdf/srh_for_disabilities.pdf. Carrillo JE, Carrillo VA, Perez HR, Salas-Lopez D, Natale-Pereira A, Byron AT. Defining and targeting health care access barriers. J Health Care Poor Underserved. 2011;22(2):562-75. Table 1 Table 1 . Sociodemographic participant characteristics. Characteristics Frequency (n=9) Percentage (%) Gender Male 6 67% Female 3 33% Age group (years) 50-54 2 22% 55-60 1 11% 61-65 3 33% 66-70 3 33% Sexual orientation Heterosexual/straight 4 44% Gay 4 44% Bisexual 1 11% Relationship status Single 4 44% Married/civil relationship 2 22% Long-term relationship 1 11% Widowed 2 22% Disability type Mobility impairment 2 22% Mobility impairment + medical condition 4 44% Visual impairment 1 11% Hearing impairment 1 11% Long-term condition 1 11% Geographic distribution Inside London 7 78% Outside London 2 22% Additional Declarations No competing interests reported. Supplementary Files APPENDIXAInformedconsentformandinformationinvitationsheet.docx APPENDIXGParticipantquotes.docx APPENDIXFRationaleforwhythemescouldbevisualisedinmorethanonecomponentoftheLevesqueframework.docx APPENDIXBInterviewtopicguide.docx APPENDIXCReasonsforchoosingtheLevesqueframework.docx APPENDIXEThemesandsubthemesfromqualitativedataanalysis.docx APPENDIXDSociodemographicparticipantcharacteristics.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 Sep, 2025 Reviewers agreed at journal 26 Aug, 2025 Reviewers invited by journal 25 Aug, 2025 Editor invited by journal 20 Aug, 2025 Editor assigned by journal 28 Jul, 2025 Submission checks completed at journal 26 Jul, 2025 First submitted to journal 26 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7052728","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":515731138,"identity":"6eeffa0f-b06b-45f6-9db3-a4a6e8e89bc6","order_by":0,"name":"Sophie Bowen","email":"","orcid":"","institution":"MSc Public Health","correspondingAuthor":false,"prefix":"","firstName":"Sophie","middleName":"","lastName":"Bowen","suffix":""},{"id":515731139,"identity":"cdc3566c-d3c7-453e-b776-048e010251a7","order_by":1,"name":"Eneyi Kpokiri","email":"","orcid":"","institution":"London School of Hygiene and Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Eneyi","middleName":"","lastName":"Kpokiri","suffix":""},{"id":515731140,"identity":"a2297e59-7283-439b-9110-4c2e56ff442c","order_by":2,"name":"Yoshiko Sakuma","email":"","orcid":"","institution":"London School of Hygiene and Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yoshiko","middleName":"","lastName":"Sakuma","suffix":""},{"id":515731141,"identity":"320acd56-99d2-47ca-90e3-da84fa09f22a","order_by":3,"name":"Joseph D Tucker","email":"","orcid":"","institution":"London School of Hygiene and Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"D","lastName":"Tucker","suffix":""},{"id":515731142,"identity":"e6f56f9d-20d5-4359-8709-f6bce6e58821","order_by":4,"name":"Huachun Zou","email":"","orcid":"","institution":"Sun Yat-Sen University","correspondingAuthor":false,"prefix":"","firstName":"Huachun","middleName":"","lastName":"Zou","suffix":""},{"id":515731143,"identity":"93131d57-a988-42fa-b7b1-1a7360783b07","order_by":5,"name":"Dan Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYDCCAyCigoEZzOEhXssZkrUwtkE5RGnhO372mDTvvDvsujMSGB+8bWOQNyekRfJMXpo077ZnzGY3EpgN57YxGO5sIKDF4ECO2W3ebYdBWtikedsYEgwOENJy/g1QyxywFvbfxGm5AbKlAWILM1FaJG+8Mf855xhQy5mHzZJzzkkYbiCkhe98jrHBm5rDyWbHkw9+eFNmI0/QFhhIBsZOA5CWIFI9ENgRr3QUjIJRMApGHAAAa7NBJvWKRTIAAAAASUVORK5CYII=","orcid":"","institution":"Nanjing Medical University","correspondingAuthor":true,"prefix":"","firstName":"Dan","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2025-07-05 11:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7052728/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7052728/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93537615,"identity":"3201bfb7-bdb2-452a-9a3f-1eeff719de38","added_by":"auto","created_at":"2025-10-15 02:06:56","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":167710,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/27e4389567b270f98530dde3.docx"},{"id":93537617,"identity":"84b16336-e995-49ec-8707-fd91f94b2e4d","added_by":"auto","created_at":"2025-10-15 02:06:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":130122,"visible":true,"origin":"","legend":"","description":"","filename":"25072025ManuscriptClean.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/890fa2be7bda8dc61695ced2.docx"},{"id":93537631,"identity":"9bdbe68d-ab63-4315-bc13-1be4b9474acb","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":42520,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/8e512b7eafc23cb3566e3324.docx"},{"id":93537620,"identity":"8e8c3859-3cdd-4c68-b376-e6e24bfe2171","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":18670,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/0a6a86681dd7cdc84b0d6488.docx"},{"id":93537619,"identity":"a934a5cf-99ee-4651-bfc9-b8139d2a313a","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"json","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8148,"visible":true,"origin":"","legend":"","description":"","filename":"0ed4011bdc0744a797ccb3b923306229.json","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/e83e46c3f5b163ac262aa47e.json"},{"id":93537623,"identity":"d186cb6d-4bad-48f3-ab9e-309e6af576a3","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":19507,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXAInformedconsentformandinformationinvitationsheet.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/ae7de680d65d66396021198b.docx"},{"id":93537629,"identity":"2efe7ea7-ca68-4fc6-804f-d16079f9c0f3","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":18641,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXBInterviewtopicguide.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/0bed3755d711bc47af0e5309.docx"},{"id":93537624,"identity":"fb2426dd-908c-4966-af2d-e362f721bcec","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":16166,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXCReasonsforchoosingtheLevesqueframework.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/937fc8d3bfbe7f14b374b773.docx"},{"id":93537625,"identity":"075f6ac4-148c-4918-a2da-7fd5f257a9fe","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":23266,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXDSociodemographicparticipantcharacteristics.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/9c6bc5608bf2bfc327da064e.docx"},{"id":93537634,"identity":"d0cb45db-9479-48d3-9464-8491e0e5d301","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":44078,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXEThemesandsubthemesfromqualitativedataanalysis.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/e6b886c7b092d1e81634f251.docx"},{"id":93537639,"identity":"3d41b88c-3ac4-41bb-bb15-4d11fe7ca16a","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":16250,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXFRationaleforwhythemescouldbevisualisedinmorethanonecomponentoftheLevesqueframework.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/3b4f242c9b525e0d9a466552.docx"},{"id":93537626,"identity":"910c1872-81a8-473e-bcfc-9a838cd664e8","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":23587,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXGParticipantquotes.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/6fed1ad8adf5f21f3f19a75e.docx"},{"id":93539268,"identity":"1e8e2c26-30dd-4d6c-9c6f-0120dc120196","added_by":"auto","created_at":"2025-10-15 02:14:57","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101460,"visible":true,"origin":"","legend":"","description":"","filename":"0ed4011bdc0744a797ccb3b9233062291enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/49e9ed2d22cf415188b7a276.xml"},{"id":93539271,"identity":"1501f9c7-5fa9-432e-a54e-3e5ebaf6cf2c","added_by":"auto","created_at":"2025-10-15 02:14:57","extension":"jpeg","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":476412,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/80d941c09249960ac600d5aa.jpeg"},{"id":93539269,"identity":"8457a396-5dd8-44b6-a3b6-1d1bd8862d0e","added_by":"auto","created_at":"2025-10-15 02:14:57","extension":"jpeg","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":547806,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/693f4b9a0dd7065aec1fe470.jpeg"},{"id":93539957,"identity":"7efaa8ee-b4d6-4a2a-bf98-f958577bfeb0","added_by":"auto","created_at":"2025-10-15 02:22:57","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":116368,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/b759c80ae2cc599e73e7d58f.png"},{"id":93537635,"identity":"175e185f-fa01-4f50-89f6-fad1e87754b8","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":149593,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/eff4cb54671d07d23511a933.png"},{"id":93537640,"identity":"9625e627-c43f-4e2f-a86f-98d32af718da","added_by":"auto","created_at":"2025-10-15 02:06:58","extension":"xml","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97914,"visible":true,"origin":"","legend":"","description":"","filename":"0ed4011bdc0744a797ccb3b9233062291structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/9c309ccb5496abdeb563f34b.xml"},{"id":93537636,"identity":"e6c95184-607d-46f1-9cac-c0b85a31b582","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":113035,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/54c8c9b1db5493ca4b16c1e7.html"},{"id":93539265,"identity":"e455cb48-b3b9-4cc8-b66d-cefa9ae21b97","added_by":"auto","created_at":"2025-10-15 02:14:56","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":117822,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAdapted Levesque framework: barriers and facilitators to accessing sexual health services\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e (45). The data generated by qualitative interview responses was mapped onto relevant factors in Levesque’s conceptual framework of access to health care. The barriers are in red boxes and the facilitators are in green boxes.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/e2091b09b32801d7f52b7596.jpg"},{"id":93537614,"identity":"d7bbcae0-9f2e-48ef-821b-4e8160657ed5","added_by":"auto","created_at":"2025-10-15 02:06:56","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":103513,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePhysical barriers to sexual health services. \u003c/strong\u003e\u003c/em\u003e\u003cem\u003ePhysical barriers are broken down into three main stages: prior to entering the sexual health service building, within the sexual health service waiting area and within the sexual health service appointment.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/2259f1765ec8de87f91e0c90.jpg"},{"id":93539958,"identity":"4e9ab3c0-352f-4121-97ad-2127c4e2170c","added_by":"auto","created_at":"2025-10-15 02:23:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1186987,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/eb372494-552d-49ce-b9f3-04aa9f9e2b1f.pdf"},{"id":93539266,"identity":"604c70fb-fbc5-4864-81de-7d0b92e80db3","added_by":"auto","created_at":"2025-10-15 02:14:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19507,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXAInformedconsentformandinformationinvitationsheet.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/f9ec4272f8f9f63d59c658a5.docx"},{"id":93537627,"identity":"6adb2ab3-6804-4325-bbd4-2fa018277095","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":23587,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXGParticipantquotes.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/642886c3cc8b0a0828b4bbe2.docx"},{"id":93539267,"identity":"9ccd7d7b-c0b1-4eb1-8aa8-e5ff647f0797","added_by":"auto","created_at":"2025-10-15 02:14:57","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":16250,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXFRationaleforwhythemescouldbevisualisedinmorethanonecomponentoftheLevesqueframework.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/ca646bf877d6293a4173e8bc.docx"},{"id":93539956,"identity":"f3f64c2d-98a9-4677-b0d4-91f6676279c6","added_by":"auto","created_at":"2025-10-15 02:22:57","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":18641,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXBInterviewtopicguide.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/f1752b473d83e36074ca1516.docx"},{"id":93537628,"identity":"4176c800-515b-4889-83c1-097991e0e30f","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":16166,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXCReasonsforchoosingtheLevesqueframework.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/1ed4145ff7254a7845db558c.docx"},{"id":93539272,"identity":"118c7296-74d3-4187-9152-787475f1e01c","added_by":"auto","created_at":"2025-10-15 02:14:57","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":44078,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXEThemesandsubthemesfromqualitativedataanalysis.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/49031baff9d8631207d5f82a.docx"},{"id":93537632,"identity":"15e6b683-8b79-476a-bbab-799c1f200ed2","added_by":"auto","created_at":"2025-10-15 02:06:57","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":23266,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXDSociodemographicparticipantcharacteristics.docx","url":"https://assets-eu.researchsquare.com/files/rs-7052728/v1/95ff748ca6489225a28c8962.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and facilitators in accessing sexual health services among disabled middle-aged and older adults in England: A qualitative study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eAn estimated 1.3\u0026nbsp;billion people are estimated to experience disability worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). and According to the UK Equality Act 2010, 14.6\u0026nbsp;million disabled people live in the United Kingdom (UK) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Disabled people are entitled to basic human rights equal to non-disabled people, including their sexuality and sexual health (sexual health), fulfilled (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Disabled people may have greater sexual health needs compared to non-disabled people because of their increased vulnerability to abuse (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Sexual health services among disabled people have been neglected (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) because of the pervasive societal belief that disabled people are asexual (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) or sexually inactive (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Furthermore, the sexual health needs of disabled people are not adequately addressed by disability research and services in the UK (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMiddle-aged and older adults are more likely to have a disability that directly impacts sexual health (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). A global study with middle-aged and older adults (aged 40\u0026ndash;80) in 29 countries found that sexual desire and activity persist into old age (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Despite the intersectionality of sexuality and health in an ageing society, UK research, policy and programmes have consistently paid little to their needs (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Campaigns for sexual health literacy and interventions are often targeted towards younger populations considered \u0026lsquo;at-risk\u0026rsquo; cohorts, largely ignoring adults over 60 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Furthermore, the lived experiences of middle-aged and older adults are often neglected. Older people's expression of sexuality is overlooked in healthcare settings (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Healthcare professionals ignore sexuality among older people (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), and general practitioners in the UK do not proactively address their sexual health needs (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Voices from disabled middle-aged and older adults about sexual health are missing.\u003c/p\u003e\u003cp\u003eThere is a need for research regarding disabled people\u0026rsquo;s barriers and facilitators to accessing sexual health services in the UK. A UK disability advocacy organisation reported that a lack of privacy, cultural prejudice, and lack of opportunity made accessing sexual health services more difficult for disabled people in the UK (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). However, few UK sexual health studies focus specifically on middle-aged and older adults and/or include middle-aged and older adults. For example, the NATSAL does not include middle-aged and older adults (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study design\u003c/h2\u003e\u003cp\u003eWe conducted a qualitative study using semi-structured interviews. Qualitative research designs allow an in-depth understanding of participants\u0026rsquo; life experiences by exploring their thoughts, attitudes and perceptions (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Furthermore, qualitative methods can collect open-ended data, which allows the potential exploration of personal and sensitive issues (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Purposive sampling was chosen over probability sampling given its less resource-intensive nature (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and also considering its use in qualitative research for the identification and selection of participants related to the subject of interest (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Interviews can be advantageous when working with vulnerable populations, including disabled people; it can allow participants to convey their thoughts and opinions, increase self-awareness, and provide self-acknowledgement and validation (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Participant recruitment\u003c/h2\u003e\u003cp\u003eParticipants were recruited through in-person clinics, social media announcements, and email lists. We partnered with an organisation focused on serving disabled people called \u0026lsquo;Independent Living Alternatives\u0026rsquo;, which invited the disabled community using email lists. We also recruited participants via local clinics, social media platforms and other community networks. Six people dropped out of the study. Drop-outs were people who were initially responsive to our recruitment (including who registered) but then dropped out whilst arranging the interview or during the interview process itself. Social media platforms included Twitter and \u0026lsquo;Nextdoor\u0026rsquo; app.\u003c/p\u003e\u003cp\u003eEK also made direct messages and posts on WhatsApp groups. Consent to participate and an information sheet were provided to participants (Appendix A).\u003c/p\u003e\u003cp\u003e We recruited participants from 7th October 2021 until 7th March 2022. Inclusion criteria was adults aged 45 and above who considered themselves disabled, were English-speaking and resided in the UK for at least six months.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Data collection and management\u003c/h2\u003e\u003cp\u003eWe developed a semi-structured interview guide (Appendix B). The guide included sections on demographics, experiences, and preferences for sexual health services. The draft questions were reviewed by the study team and piloted with three participants before being finalised. An experienced qualitative researcher and a junior researcher conducted four interviews, both at home and the workplace. No repeat interviews were conducted. Field notes were made during and after the interview. No-one was present in the interviews aside from the researchers and participants. There was no relationship established with participants prior to study commencement. The only information known to participants about the interviewers was the (interviewer\u0026rsquo;s) reasons for doing the research and their role at LSHTM. Due to COVID risks and individual preferences, all interviews were conducted by phone or video conference. No characteristics were reported to participants about the interviewers. Informed consent was obtained from each participant either written or verbally before the interview commencement. All nine interviews were audio-recorded, and recordings were stored on the cloud with password-protected files. Transcripts were anonymised, and identifiable information was redacted from each transcript. Transcripts were not shared with participants\u0026rsquo; but some participants joined a later community advisory board and designathon where the findings were shared. The interviews lasted 55 minutes on average and generated approximately 500 minutes of audio recordings, which were transcribed using a transcription software called \u0026lsquo;Rev\u0026rsquo;. Data stored on Rev\u0026rsquo;s platform is encrypted via industry best-practice standards. All data was encrypted. We had detailed discussions with nine participants and reached data saturation with no new themes emerging after the 7th interview conducted.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Data analysis approach\u003c/h2\u003e\u003cp\u003eThematic analysis was employed to analyse interview data and provide interpretations of participants' viewpoints (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), considering its ability to identify data patterns and organise them into meaningful themes (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Interviews were coded by a mixture of deductive (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and inductive analysis (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Interviews were deductively coded based on interview topic guide questions; these helped to conceptualise relevant barriers and facilitators. Subsequently, an inductive approach was used to identify potential themes and subthemes. A deductive lens was then adopted to re-analyse the themes and understand how these could be appropriately viewed within the Levesque framework (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLevesque\u0026rsquo;s framework suggests a multidimensional view of healthcare access, combining health systems (approachability, acceptability, availability and accommodation, affordability and appropriateness) and the population\u0026rsquo;s socioeconomic determinants (ability to perceive, seek, reach, pay and engage) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In Appendix C, the full rationale for choosing the Levesque framework is given.\u003c/p\u003e\u003cp\u003eThe six steps recommended by Braun and Clarke to conduct the thematic analysis were followed (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). These steps were data familiarisation (reading and re-reading of the data), generating codes, searching for themes, reviewing potential themes, defining and naming themes, and reporting. This also helped to create a thematic map, allowing the links between codes to be visualised (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Finally, each piece of data was re-analysed to ensure it was relevant to each theme.\u003c/p\u003e\u003cp\u003eWe coded the data using NVIVO12. There was a high level of consensus regarding these, with only minor adjustments made with regards to how to structure the key findings. The research team\u0026rsquo;s background as abled-bodied and not being middle-aged or older adults was an important consideration, as it is possible that we may have overlooked some nuanced perspectives of disabled middle-aged and older adults. To try and address this during interviewing, we regularly sought clarification and encouraged full interviewee explanations for contextual insight. Participants did not provide feedback on the findings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5. Ethical considerations\u003c/h2\u003e\u003cp\u003eWe obtained ethical approval from the ethics committee of the London School of Hygiene and Tropical Medicine (ref number: 26134-01 and Ref: 26725).\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eDemographic backgrounds of our participants are shown in Table\u0026nbsp;1. Participant ages ranged between 52 and 68, and participants were mainly situated in London boroughs, except for two participants; for a breakdown of demographic information by each participant, see Appendix D.\u003c/p\u003e\u003cp\u003eWe identified two themes under facilitators and four under barriers, and these were mapped onto distinct parts of the Levesque framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Appendix E outlines a more detailed coding tree including subthemes. In Appendix F, themes which mapped onto more than one component of the Levesque framework are discussed.\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.1. Barrier: Inadequate operation of services (\u0026lsquo;Approachability\u0026rsquo; and \u0026lsquo;Appropriateness\u0026rsquo;)\u003c/h2\u003e\u003cp\u003eSeveral participants discussed limited signposting to sexual health services and described this as being a service promotion issue:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don't think they [sexual health services] are openly promoted\u0026rdquo; (Participant 7, male, age 65\u0026ndash;70).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA participant also mentioned that no healthcare providers suggested using sexual health services for addressing their sexual health needs (APPENDIX G, quote 1). A lack of knowledge about choices and options could mean individuals may not access sexual health services:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If I'm not certain what the choices are, I might not access the service\u0026rdquo; (Participant 8, male, age 65\u0026ndash;70).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThere was also limited sexual health information; a participant contrasted the lack of sexual health information to other health-related areas (APPENDIX G, quote 2).\u003c/p\u003e\u003cp\u003eMost participants referred to their limited inclusivity, defined here as a lack of representation of disabled middle-aged and older adults in sexual health services. A participant mentioned that sexual health services focused upon young people more and that sexual health services may not be suited to addressing older people\u0026rsquo;s sexual health needs (APPENDIX G, quote 3). Furthermore, almost half of the participants highlighted how sexual health services were not inclusive of disabled people:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They're [sexual health services] taboo and they're not well known. And they don't celebrate an inclusion of disabled people in sexual practice\u0026rdquo; (Participant 8, male, age 65\u0026ndash;70).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I can't remember seeing any images of disabled people in sexual health clinics and any recognition that people have access needs\u0026rdquo; (Participant 9, male, age 55\u0026ndash;60).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.2. Barrier: Physical inaccessibility (\u0026lsquo;Availability and accommodation\u0026rsquo;)\u003c/h2\u003e\u003cp\u003eMost participants reported the physical inaccessibility of sexual health services. This can be viewed in three stages (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Experiencing physical inaccessibility can cause negative emotions (APPENDIX G, quote 4) and even make individuals \u0026ldquo;turn round and leave\u0026rdquo; (participant 9). Furthermore, inaccessibility can break the continuity of trust between an individual and a service \u0026ndash; the lift was broken for 6 months and they were not directly notified about this (APPENDIX G, quote 5).\u003c/p\u003e\u003cp\u003eSeveral participants mentioned barriers before entering sexual health services, such as a lack of suitable parking facilities onsite (APPENDIX G, quote 6) and sexual health services facilities with a small entrance and inaccessible doorbell (participant 7). Other physical aspects were requirements for: level access, ramp access or lift access to enter the building (participant 4).\u003c/p\u003e\u003cp\u003eSeveral participants commented upon barriers inside sexual health services buildings, such as multiple floors (participant 7) and a lack of operational lift (participant 9). Participant 4 also expressed the importance of having sufficient waiting-room space and an accessible \u0026lsquo;changing places toilet\u0026rsquo;.\u003c/p\u003e\u003cp\u003eA few participants stated barriers during appointments, such as waiting for rooms with adjustable beds (APPENDIX G, quote 7). Sometimes adjustable beds could not be lowered to the same height as the wheelchair. Consequently, participant 5 had to forfeit treatment because they could not get onto the examination bed.\u003c/p\u003e\u003cp\u003eAnother physical barrier mentioned by a few participants was the lack of hoists available at general practices:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eSo I asked, could I take my portable hoist [\u0026hellip;]? They said, no, I was not allowed to bring my portable hoist to transfer me on the bed and they don't have one. So they referred me to the hospital\u0026rdquo; (Participant 4, female, age 50\u0026ndash;54).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis quote highlights the physical inaccessibility and the lack of flexibility with individuals using their hoist.\u003c/p\u003e\u003cp\u003eA few participants commented on the lack of machine adaptability towards disabled people (APPENDIX G, quote 8). This can cause not only a delay (due to rescheduling another scan) but also a potentially less optimal screening method (performing a CT scan instead of the mammogram).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.3. Barrier: Inadequate addressal of sexual health needs (\u0026lsquo;Appropriateness\u0026rsquo;)\u003c/h2\u003e\u003cp\u003eA participant expressed concern with the way their sexual health needs were considered, where disabled people and older adults had limited opportunities, such as a lack of home visits:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Most GPs don't do house calls [\u0026hellip;] when my GP retires [\u0026hellip;] I don't know what I will do about having a smear test. And that's real worry [\u0026hellip;] [This situation] makes you feel like you are expendable as a person\u0026rdquo; (Participant 5, female, age 61\u0026ndash;65).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e Dismissive healthcare professionals\u0026rsquo; attitudes were mentioned by one participant when asking whether they could have oral sex after taking certain medications (APPENDIX G, quote 9). The healthcare professionals\u0026rsquo; dismissive response in shutting down the question greatly impacted the participants' mental and physical well-being (APPENDIX G, quote 10).\u003c/p\u003e\u003cp\u003eA few participants commented on healthcare professionals\u0026rsquo; inadequate knowledge of understanding disabled people\u0026rsquo;s physical requirements:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;What becomes necessary is if things are a bit not straightforward and staff don't know what they're doing exactly. Well, that in itself is a barrier for me because there's more attention placed on me because, \u0026lsquo;Well, we don't know if we can fit in this room, I don't think we can transfer to the hoist, so maybe we won't do this test today\u0026rsquo; \" (Participant 9, male, 55\u0026ndash;60).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother situation outlining healthcare professionals\u0026rsquo; inadequate knowledge regarding disabled people\u0026rsquo;s requirements was inviting an assistant into the examination room without the participant's consent (APPENDIX G, quote 11), or not proactively asking if they required privacy (APPENDIX G, quote 12).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.4. Barrier: Unsuitable structure of services (\u0026lsquo;Appropriateness\u0026rsquo;)\u003c/h2\u003e\u003cp\u003eOne participant mentioned a lack of effectively co-ordinated care, which was due to the increased fragmentation of healthcare services:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When I started off, it was a sort of a one stop service. So my HIV consultant could do everything for me. She could refer me on to other specialists. She could prescribe medication that wasn\u0026rsquo;t necessarily directly related to the HIV [\u0026hellip;] what I now get from sexual health services is much more limited, much more specific\u0026rdquo; (Participant 3, male, age 66\u0026ndash;70).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis highlights how current sexual health services are less capable of addressing sexual health in a broad manner, unlike previously. Another concern about coordinated care was limited continuity and communication between different services, where the participant was responsible for transmitting information between specialists and expressed concern with not being an expert (APPENDIX G, quote 13).\u003c/p\u003e\u003cp\u003eAlthough various sexual health services in England are open to everyone (termed \u0026lsquo;non-differentiated\u0026rsquo; services hereafter), some are dedicated solely to disabled people. A few participants unfavourably commented on these dedicated services:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Personally, I'd rather access a general service that provided my needs as well as everyone else's\u0026rdquo; (Participant 8, male, age 65\u0026ndash;70).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it\u0026rsquo;s outrageous to send disabled people to different places\u0026rdquo; (Participant 9, male, age 55\u0026ndash;60).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipant 9 expressed their perception that dedicated services were unnecessary and worked against the values of the Equality Act. They expressed that instead of dedicated services, non-differentiated services should be upscaled for disabled people to access.\u003c/p\u003e\u003cp\u003eFacilitators to accessing sexual health services are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. These were maintaining and improving daily management of services and changing the implementation of sexual health services.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.5. Facilitator: Maintaining and improving service management (\u0026lsquo;Approachability\u0026rsquo; and \u0026lsquo;Appropriateness\u0026rsquo;)\u003c/h2\u003e\u003cp\u003eFor this research, \u0026lsquo;daily management\u0026rsquo; involves managing departments, functions, and processes. Most participants referred to this theme.\u003c/p\u003e\u003cp\u003e A facilitator maintained effective existing processes; several participants described sexual health services as well-supported in certain areas. A participant said:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI feel as an older person living with HIV that I am well supported\u0026rdquo; (Participant 3, male, age 66\u0026ndash;70).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhen considering STI testing, a participant expressed a positive experience with postal services:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think the last time it all worked well\u0026rdquo;\u003c/em\u003e, but also raised the point that the adequacy of sexual health services \u003cem\u003e\u0026ldquo;Depends on the disabilities\u0026rdquo; (Participant 1, male, age 61\u0026ndash;65).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eExisting effective processes were also outlined where healthcare professionals took a proactive approach with STI-testing (APPENDIX G, quote 14). This was particularly important considering the participant expressed they did not feel comfortable raising STI testing as a topic (APPENDIX G, quote 15).\u003c/p\u003e\u003cp\u003eA participant highlighted the importance of healthcare professionals being well-versed in understanding the legal obligations in equal service provision for all people (APPENDIX G, quote 16). They also raised the importance of making NHS information standards more visible (APPENDIX G, quote 17).\u003c/p\u003e\u003cp\u003e Several participants raised the importance of a positive sexual health services environment which foster trust and address their sexual health needs:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Making more welcoming services. Building trust. And more disabled people being able to get the support they need around their sexual health\u0026rdquo; (Participant 9, male, age 55\u0026ndash;60).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOther participants emphasised how a facilitator was a healthcare worker with having open-minded attitude (Appendix G, quote 18) and the provision of standardised staff training (Appendix G, quote 19). Participant 5 felt services should offer basic amenities, such as easily accessible water and the option to buy food for people with diabetes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.6. Facilitator: Modifying implementation of services (\u0026lsquo;Appropriateness\u0026rsquo;)\u003c/h2\u003e\u003cp\u003eMost participants emphasised that it is important to design services together with disabled people and/or in keeping their needs in mind.\u003c/p\u003e\u003cp\u003e Co-production of sexual health services was mentioned by a participant several times:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[\u0026hellip;] working with disabled people to co-produce. Because if you, for example, take statutory requirements and just kind of work towards minimum standards, let's say, but you have no input from disabled people, what's written down in regulations, that doesn't mean it's going to work in practice.\u0026rdquo; (Participant 9, male, age 55\u0026ndash;60).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFor this research, \u0026lsquo;tailored services\u0026rsquo; refers to services designed for a particular person or group. Some participants mentioned tailoring sexual health services to disabled people, which could involve considering the visual and physical nature of the services, such as using leaflets and posters representative of disabled people (APPENDIX G, quote 20), as well as adequate space for wheelchair users and assistants (APPENDIX G, quote 21). A few participants also suggested encompassing a social model approach (discussed below).\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe objective of this study was to identify barriers and facilitators facing disabled people in accessing sexual health services in the UK. Our data suggest that physical accessibility barriers and lack of care coordination limited access to sexual health services for older disabled people in the UK. Differentiated services and building onto existing services were noted as facilitators of accessing sexual health services in this group. There are limited research studies in the UK assessing disabled peoples\u0026rsquo; barriers and facilitators in accessing sexual health services, but this study provides valuable insight, especially for the English sexual healthcare system. This research fills a much-needed gap in UK literature. This study\u0026rsquo;s focus population has sexual and reproductive health needs which have historically been neglected.\u003c/p\u003e\u003cp\u003eOne of the most frequently reported barriers in the study was physical inaccessibility. The same facets of physical inaccessibility found in this study were also noted in existing literature which found an unsuitable ramp access or lack of lift (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) more than one floor without an operational lift (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and beds which do not lower down to wheelchair height (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). However, one study in Ghana mentioned how this physical inaccessibility can be overcome if they receive appropriate aid (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). In contrast, physical inaccessibility issues were not overcome in this study. Moreover, not all disabled people have caregivers available to accompany them to every appointment, highlighting the importance of adapting the physical structure of sexual health services.\u003c/p\u003e\u003cp\u003eAnother frequently reported barrier was the inadequate operation of sexual health services, which comprised of two subthemes: 1) limited signposting and information 2) a lack of representation within sexual health services. The former is mentioned in existing literature (46) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). If people are not adequately signposted and are unaware of when they should utilise sexual health services, this could have large implications regarding how and if these services are accessed. A lack of representation of disabled middle-aged and older adults within sexual health services was not found in other literature and was a unique finding of this study.\u003c/p\u003e\u003cp\u003eParticipants spoke particularly negatively towards the unsuitable structure of sexual health services. One participant perception highlighted that current sexual health services are contrary to the Equality Act 2010 (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), which commits sexual health services to provide services for all, including disabled people. If non-differentiated sexual health services providers believe disabled people\u0026rsquo;s needs can be met through dedicated services (services for disabled people only), this might be one of the reasons that non-differentiated sexual health services do not currently cater for disabled people\u0026rsquo;s needs adequately.\u003c/p\u003e\u003cp\u003eOne of the most frequently reported facilitators was maintaining existing processes. One participant expressed gratitude that their healthcare professionals proactively mentioned STI testing because they felt uncomfortable raising it. A literature review supported this finding (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), which found a hesitancy of disabled people to mention sexual health, highlighting the importance of health care professionals continuing to proactively raise sexual health topics. Another frequently reported facilitator was tailoring services. Using a social model of disability was suggested by participants as an important factor to consider when tailoring services. The social model views disability through interactions with disabled people and a barrier-filled environment (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Consequently, encompassing a social model approach would describe inaccessible sexual health services as the result of a poorly adapted environment and would likely aim to overcome these barriers.\u003c/p\u003e\u003cp\u003eOur study has important implications and recommendations for policies, practices and research. To improve physical accessibility, policies could state a mandatory inclusion of disability-friendly facilities within sexual health services, such as ramps, adjustable beds, hoists and changing places toilets. Improving physical accessibility is endorsed under a United Nations framework of five actions to achieve full inclusion of the sexual and reproductive health of disabled people (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Policies and sexual health services practice could also be updated to outline that all staff must receive training on catering to disabled people\u0026rsquo;s requirements. Not only did participants highlight inadequate staff training, but most impediments to providing good-quality services are related to providers\u0026rsquo; attitudes and limited knowledge about disabilities (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Co-production of sexual health services with disabled middle-aged and older could help make sexual health services more accessible by tying together statutory systems with the expertise of service users (53) (54). Study participants expressed unfavourable views about dedicated sexual health services and how they felt non-differentiated services should cater for everyone\u0026rsquo;s needs instead. One way this could be achieved is through integrated care, which focuses on the needs of individuals, their families, and communities (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). However, changing service structures may take time and require long-term follow-up to monitor outcomes, and the effects may not be immediate. Further research is needed to determine whether our findings are consistent across other sexual health services in the UK and to inform how sexual health services can be tailored towards disabled middle-aged and older adults. Future research should include people with varied disabilities because people with different disabilities may have different needs and require different support types (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur study has several limitations. Barriers and facilitators to accessing sexual health services can vary with disability types (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e); however, in this study, most of our participants reported a physical disability and representation of other types of disabilities is lacking. Therefore, these results may not represent the experiences and views of disabled middle-aged and older adults across England or the UK, nor be entirely applicable to different contexts. Furthermore, there may have been bias about which participants enrolled onto this study, as we employed purposive sampling methods through a single disability organisation in London. Individuals with more critical views of existing sexual health services may have been more likely to participate. The implications of this may be that some positive perceptions about sexual health services may be missed. Furthermore, this study had a small sample size of nine participants. Nevertheless, despite the small numbers, we reached data saturation.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe study findings highlight that health systems should play a role in making sexual health services accessible for disabled middle-aged and older adults. Minimising barriers and incorporating facilitators to access sexual health services could help address the issues this subpopulation faces in accessing sexual health services. However, the paucity of literature in this field warrants future research not limited to other disability types, geographical locations, and intersecting factors to comprehensively inform policies and practices.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eClinical trial number: not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe obtained ethical approval from the ethics committee of the London School of Hygiene and Tropical Medicine (ref number: 26134-01, and Ref: 26725). Informed consent was obtained from each participant either written or verbally before the interview commencement. Consent to participate and an information sheet were provided to participants (Appendix A).\u003c/p\u003e\n\u003cp\u003eEthics Committee: London School of Hygiene and Tropical Medicine Research Ethics Committee, and London School of Hygiene and Tropical Medicine MSc Research Ethics Committee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe information sheet that goes alongside the consent form contains information that informs participants that their data will be published. \u0026ldquo;What will happen to the results of this study? The study results will be published in a scientific journal so that other researchers can learn from them\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was jointly supported by the Economic and Social Research Council, UK Research and Innovation (UKRI) (grant number: ES/T014547/1), the National Natural Science Foundation of China (72061137001), the Natural Science Foundation of China Excellent Young Scientists Fund (82022064), the Natural Science Foundation of China Young Scientist Fund (81703278) and the Special Support Plan for High-Level Talents of Guangdong Province (2019TQ05Y230).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSophie Bowen wrote the main manuscript text and prepared figures and tables.\u003c/p\u003e\n\u003cp\u003eDan Wu, Joseph D Tucker and Huachun Zou obtained funding support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDan Wu conceived the idea, oversaw the study progress, provided supervisory inputs to and edited this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEneyi Kpokiri and Yoshiko reviewed the manuscript extensively multiple times to provide feedback and changes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge Hannah Kuper, Thomas Shakespeare and Shaffa Hameed for contributing their thoughts to this paper, especially for providing information and ensuring that the language used was disability friendly.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were no conflicts of interest. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorldHealthOrganization. Disability 2023 [Available from: https://www.who.int/news-room/fact-sheets/detail/disability-and-health#:~:text=Key%20facts,1%20in%206%20of%20us.\u003c/li\u003e\n\u003cli\u003eSCOPE. Disability facts and figures [Available from: https://www.scope.org.uk/media/disability-facts-figures/.\u003c/li\u003e\n\u003cli\u003eGOV.UK. Definition of disability under the Equality Act 2010 [Available from: https://www.gov.uk/definition-of-disability-under-equality-act-2010#:~:text=You%27re%20disabled%20under%20the,t%20apply%20to%20Northern%20Ireland. .\u003c/li\u003e\n\u003cli\u003eWorldHealthOrganisation. Sexual health [Available from: https://www.who.int/health-topics/sexual-health#tab=tab_2.\u003c/li\u003e\n\u003cli\u003eGOV.UK. Sexual and reproductive health and HIV: applying All Our Health 2022 [Available from: https://www.gov.uk/government/publications/sexual-and-reproductive-health-and-hiv-applying-all-our-health/sexual-and-reproductive-health-and-hiv-applying-all-our-health.\u003c/li\u003e\n\u003cli\u003eWorldHealthOrganisation. Promoting sexual and reproductive health for persons with disabilities. 2009.\u003c/li\u003e\n\u003cli\u003eHoldsworth E, Trifonova V, Tanton C, Kuper H, Datta J, MacDowall W, et al. Sexual behaviours and sexual health outcomes among young adults with limiting disabilities: Findings from third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3). BMJ open. 2018;8(7) (no pagination).\u003c/li\u003e\n\u003cli\u003eShah S. \u0026ldquo;Disabled People Are Sexual Citizens Too\u0026rdquo;: Supporting Sexual Identity, Well-being, and Safety for Disabled Young People. Frontiers in Education. 2017;2:46.\u003c/li\u003e\n\u003cli\u003eUNISON. 2018 National Disabled Members\u0026apos; Conference. UNISON PRELIMINARY AGENDA 2018 [Available from: https://www.unison.org.uk/content/uploads/2018/07/2018-National-Disabled-Members-Conference_Preliminary_Agenda_Report_20180716.pdf \u003c/li\u003e\n\u003cli\u003eBarlow FK, Walker N. Disability and Ageing. In: Pachana NA, editor. Encyclopedia of Geropsychology. Singapore: Springer Singapore; 2017. p. 674-80.\u003c/li\u003e\n\u003cli\u003eNicolosi A, Laumann EO, Glasser DB, Moreira ED, Jr., Paik A, Gingell C. Sexual behavior and sexual dysfunctions after age 40: the global study of sexual attitudes and behaviors. Urology. 2004;64(5):991-7.\u003c/li\u003e\n\u003cli\u003eKnox J. United Nations Office of the High Commissioner on Human Rights,\u0026lsquo;. Mapping Report.\u003c/li\u003e\n\u003cli\u003eNash P, Willis P, Tales A, Cryer T. Sexual health and sexual activity in later life. Reviews in Clinical Gerontology. 2015;25(1):22-30.\u003c/li\u003e\n\u003cli\u003eDoherty S, Byrne M, Murphy AW, McGee HM. Cardiac Rehabilitation Staff Views about Discussing Sexual Issues with Coronary Heart Disease Patients: A National Survey in Ireland. European Journal of Cardiovascular Nursing. 2011;10(2):101-7.\u003c/li\u003e\n\u003cli\u003eBalami JS. Are geriatricians guilty of failure to take a sexual history? Journal of Clinical Gerontology and Geriatrics. 2011;2(1):17-20.\u003c/li\u003e\n\u003cli\u003eGott M, Hinchliff S, Galena E. General practitioner attitudes to discussing sexual health issues with older people. Social science \u0026amp; medicine. 2004;58(11):2093-103.\u003c/li\u003e\n\u003cli\u003eDisabilitySheffield. Disability Sheffield Information Service: Sexual Health Factsheet 2018 [Available from: https://www.disabilitysheffield.org.uk/admin/resources/sexual-healthupdate2017-1.pdf.\u003c/li\u003e\n\u003cli\u003eOhman A. Qualitative methodology for rehabilitation research. J Rehabil Med. 2005;37(5):273-80.\u003c/li\u003e\n\u003cli\u003eDeJonckheere M, Vaughn LM. Semistructured interviewing in primary care research: a balance of relationship and rigour. Fam Med Community Health. 2019;7(2):e000057.\u003c/li\u003e\n\u003cli\u003eValerio MA, Rodriguez N, Winkler P, Lopez J, Dennison M, Liang Y, et al. Comparing two sampling methods to engage hard-to-reach communities in research priority setting. BMC Med Res Methodol. 2016;16(1):146.\u003c/li\u003e\n\u003cli\u003ePalinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health. 2015;42(5):533-44.\u003c/li\u003e\n\u003cli\u003eHutchinson SA. The Development of Qualitative Health Research: Taking Stock. Qualitative Health Research. 2001;11(4):505-21.\u003c/li\u003e\n\u003cli\u003eCrowe M, Inder M, Porter R. Conducting qualitative research in mental health: Thematic and content analyses. Australian \u0026amp; New Zealand Journal of Psychiatry. 2015;49(7):616-23.\u003c/li\u003e\n\u003cli\u003eThompson J. A Guide to Abductive Thematic Analysis. The Qualitative Report. 2022;27.\u003c/li\u003e\n\u003cli\u003eBonner C, Tuckerman J, Kaufman J, Costa D, Durrheim DN, Trevena L, et al. Comparing inductive and deductive analysis techniques to understand health service implementation problems: a case study of childhood vaccination barriers. Implement Sci Commun. 2021;2(1):100.\u003c/li\u003e\n\u003cli\u003eChapman AL, Hadfield M, Chapman CJ. Qualitative research in healthcare: an introduction to grounded theory using thematic analysis. J R Coll Physicians Edinb. 2015;45(3):201-5.\u003c/li\u003e\n\u003cli\u003eLevesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. International journal for equity in health. 2013;12:18.\u003c/li\u003e\n\u003cli\u003eCu A, Meister S, Lefebvre B, Ridde V. Assessing healthcare access using the Levesque\u0026rsquo;s conceptual framework\u0026ndash; a scoping review. International journal for equity in health. 2021;20(1):116.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101.\u003c/li\u003e\n\u003cli\u003eAhumuza SE, Matovu JKB, Ddamulira JB, Muhanguzi FK. Challenges in accessing sexual and reproductive health services by people with physical disabilities in Kampala, Uganda. Reproductive Health. 2014;11(1):59.\u003c/li\u003e\n\u003cli\u003eTun W, Okal J, Schenk K, Esantsi S, Mutale F, Kyeremaa RK, et al. Limited accessibility to HIV services for persons with disabilities living with HIV in Ghana, Uganda and Zambia. J Int AIDS Soc. 2016;19(5 Suppl 4):20829.\u003c/li\u003e\n\u003cli\u003eRugoho T, Maphosa F. Challenges faced by women with disabilities in accessing sexual and reproductive health in Zimbabwe: The case of Chitungwiza town. Afr J Disabil. 2017;6:252.\u003c/li\u003e\n\u003cli\u003eMavuso SS, Maharaj P. Access to sexual and reproductive health services: Experiences and perspectives of persons with disabilities in Durban, South Africa. Agenda. 2015;29(2):79-88.\u003c/li\u003e\n\u003cli\u003eBadu E, Gyamfi N, Opoku MP, Mprah WK, Edusei AK. Enablers and barriers in accessing sexual and reproductive health services among visually impaired women in the Ashanti and Brong Ahafo Regions of Ghana. Reproductive health matters. 2018;26(54):51-60.\u003c/li\u003e\n\u003cli\u003eGOV.UK. Equality Act 2010 2010 [Available from: https://www.legislation.gov.uk/ukpga/2010/15/contents.\u003c/li\u003e\n\u003cli\u003eGreenwood NW, Wilkinson J. Sexual and reproductive health care for women with intellectual disabilities: a primary care perspective. Int J Family Med. 2013;2013:642472.\u003c/li\u003e\n\u003cli\u003ePeopleWithDisabilityAustralia. Social model of disability [Available from: https://pwd.org.au/resources/models-of-disability/.\u003c/li\u003e\n\u003cli\u003eWorldHealthOrganization. Promoting sexual and reproductive health for persons with disabilities 2009 [Available from: https://www.unfpa.org/sites/default/files/pub-pdf/srh_for_disabilities.pdf.\u003c/li\u003e\n\u003cli\u003eCarrillo JE, Carrillo VA, Perez HR, Salas-Lopez D, Natale-Pereira A, Byron AT. Defining and targeting health care access barriers. J Health Care Poor Underserved. 2011;22(2):562-75.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e. Sociodemographic participant characteristics.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n=9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eMale\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e67%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003e50-54\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e22%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003e55-60\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003e61-65\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003e66-70\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual orientation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eHeterosexual/straight\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e44%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eGay\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e44%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eBisexual\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eSingle\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e44%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eMarried/civil relationship\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e22%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eLong-term relationship\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eWidowed\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e22%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisability type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eMobility impairment\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e22%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eMobility impairment + medical condition\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e44%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eVisual impairment\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eHearing impairment\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eLong-term condition\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeographic distribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eInside London\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e78%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 51%;\"\u003e\n \u003cp\u003e\u003cem\u003eOutside London\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.6%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.4%;\"\u003e\n \u003cp\u003e22%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sexual health services, disabled adults, barriers, facilitators, access","lastPublishedDoi":"10.21203/rs.3.rs-7052728/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7052728/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMiddle-aged and older adults are more likely to have disabilities that impact sexual health. However, there is limited research exploring experiences of disabled middle-aged and older adults accessing sexual health services. This qualitative study explored the barriers and facilitators in accessing sexual health services among middle-aged and older disabled adults in England.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eThe objective of this manuscript is to identify the barriers and facilitators of accessing sexual health services among disabled middle-aged and older adults in England.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted interviews with nine disabled middle-aged and older adults (aged 45 and above) in England. Participants were recruited through a disability community organisation by online invitation. Interviews were audio-recorded after obtaining verbal consent and transcribed verbatim. We used thematic analysis. The Levesque framework that identifies five dimensions of accessibility was adapted to guide data analysis and interpretation of findings.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eParticipant disability types included mobility impairment, visual impairment, hearing impairment, or another long-term condition (a condition that cannot be cured). They faced widespread barriers to accessing sexual health services, some of which included physical inaccessibility, limited inclusivity, and inadequate addressal of sexual health needs. Some reported facilitators were maintaining existing processes, creating a more welcome environment and tailoring services.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe findings suggest that available sexual health services are not adequately tailored to meet needs of disabled middle-aged and older adults in England. There is an urgent need to adapt existing sexual health services to make them more appropriate for middle-aged and older disabled adults.\u003c/p\u003e","manuscriptTitle":"Barriers and facilitators in accessing sexual health services among disabled middle-aged and older adults in England: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 02:06:51","doi":"10.21203/rs.3.rs-7052728/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-16T06:51:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"77621532405805851791073686027789620720","date":"2025-08-26T13:50:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-26T03:16:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-20T04:14:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-28T05:29:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-26T23:58:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-07-26T22:54:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e8d98b5a-5f12-47be-a9ee-625a1480ed4f","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-15T02:06:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-15 02:06:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7052728","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7052728","identity":"rs-7052728","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}