Introduction

The World Health Organization has defined this condition in three sub-groups which are; impairment, disability, and handicap. According to WHO, impairment is the deficiency and abnormality in psychological, physical and anatomical structures and functions in terms of health. Disability is the constraint and inability to do something normally as a result of a defect. A handicap is the restriction and non-fulfilment of the roles which are expected from the individual, which depends on the age, gender, social and cultural factors, because of a defect or handicap [1]. According to world population estimates, 15% of the world’s population is disabled [2]. 11.7% of population of Germany has a disability. The figure is 12.24% in Canada and 20.0% in New Zealand [3]. When the population of women with disability around the world is examined, it is stated that there are 300 million women with disability and 82% of these women live in developing countries [4]. According to Turkey Statistics Institution data dated 2011, 12.6% of the population of Turkey is disabled. According to a TSI report, 2.0% of these people have a mental handicap, 7.4% of them have an orthopaedic handicap, 1.4% of them are visually handicapped, 1.1% of them are hearing impaired and 0.7% of them have a speech handicap [5]. 18% of the individuals registered on the National People with Disability Data Base have more than one handicap and 58% of these people are men and 41.4% of them are women [6]. Recently the issues related to people with disability have been occupying the agendas of countries worldwide. According to the WHO disability report dated 2011, people with disability have financial difficulties, problems communicating with people and have difficulty in participating in politics and accessing community services [2]. The difficulties of people with disability are many and varied, the most significant ones being related to work, education and health services. In addition to these problems, people with disability are exposed to discrimination and they have serious problems with physical accessibility [7].

In literature, when compared to men with disability, women with disability have been stated to have more difficulty [3, 4, 8]. According to basic indicators of TOA dated 2006, across all disabilities, men with disability have a better chance of treatment and being employed than women with disability [7]. Furthermore, the level of men with disability is higher than women with disability in the research of Problems of People with Disability and Expectations [6]. These results show us that women with disability do not have the same rights as men with disability [8].

The problems that women with disability experience have a negative effect on their reproductive health. Women with disability experience problems mostly in the fields of sexuality, osteoporosis and FP in terms of reproductive health [9,10,11,12,13,14]. Women with disability who cannot access reproductive health services because of physical inaccessibility experience unplanned pregnancy, planned termination, sexually transmitted infections and significant issues that threaten human sexual health [15,16,17,18,19,20]. Mung-nga Li and Kwai Sang Yu have indicated in their study that sexuality is important for women with disability and they should be treated sensitively in terms of health applications for them [21]. In another study which was carried out by Tanebe and his friends, it has been stated that, if women with disability are not married when they are expecting a baby, the situation would not be approved of by others in society [9].

The idea that women with disability are nonsexual negatively affects women with disability making use of the FP service. Beside this, women with disability are not free to choose a FP method and they are forced to choose a FP method that they have not chosen themselves. In fact, women with disability need to be informed about evaluating the most appropriate and safest options relating to FP methods [9, 19, 22]. In research, it has been indicated that sterilisation has been forced on women with disability [9]. Information deficiency of women with disability results from both the medical workers’ discriminatory attitude towards women with disability [15, 23] and the attitude of women with disability [15, 18, 21,22,23,24]. Nurses have the key role in family planning services to be successful and to accomplish the objectives. When nurses whose attitude should be evaluated plan for FP services, they may produce a guide for women with disability which takes into consideration their attitude towards FP services. Thus, the research concerning the attitude of women with disability towards FP should be carried out firstly and these women should also be in their ovulation period. In the literature, there has not been any research including the attitude of women with disability towards FP. With the help of this research, this gap in literature will be filled and the attitude of women with disability towards FP and the factors affecting their attitude will be examined.

Appliance/Material and Methods

The research has been carried out as a definer to examine the factors affecting their attitude. The target population of the study is 120 women with disability who are the members of six associations registered at the Mersin People with Disability Platform. As 12 of 120 women with disability are included to pre-application, the sample of the study is 108 women with disability. Data has been collected by using the half-structured survey and FPAS. The half-structured survey has been prepared with the help of the data obtained from the related literature [10, 16, 25,26,27,28]. After the survey has been prepared it has been pre applied to 12 women with disability who are registered to different associations with different education levels to examine its comprehensibility and usability. After the pre-application, the survey has been put into a final form. FPAS has been used to examine the attitude of women with disability towards FP. This scale was developed by Orsal and Kubilay in 2006. FPAS has 34 items in total and it is used to ensure whether the attitude of women with disability towards FP is positive or not. It is a Likert type scale graded from 1 to 5. The attendee’s answers given on the scale will be evaluated according to the points given to each item. Every expression on the scale is graded from 1 to 5. “I completely agree” is 1 point, “I agree” is 2 points, “I am hesitant” is 3 points, “I disagree” is 4 points, “I completely disagree” is 5 points. On the scale, no expression should be coded inversely. The minimum score that can be taken from the scale is “34”, and the maximum score is “170”. A high score on the scale would indicate that a woman with disability has a positive attitude towards FP and a low score would indicate that a woman with disability has a negative attitude towards FP. On the scale, FP has three sub-divisions; the attitude of society towards FP (15 items), the attitude towards FP methods (11 items), and the attitude towards birth (8 items). In this study, it has been found that, Cronbach Alfa reliability coefficient of the scale is 0.93.

To be able to carry out the study, written permission has been obtained from the subjects, research ethics committee approval dated 24.01.2013 and numbered as 2013/26 has been obtained. Data collecting forms were used with the women with disability participating in the study in the meeting rooms of associations attending to the study from 7 January to 21 June 2013. 23 of the women with disability taking part in the research filled in questionnaires themselves. Those data collecting forms were used in the homes of the 30 women with disability who could not come to the association, and those forms were used with the subjects who were not at home by telephone. The duration of filling out the questionnaires of women who are hearing impaired is 25–30 min, while the duration for the other women with disability is 15 min. Before applying the data collecting tools, informed consent forms of women who are involved in the study were approved. Statistical analysis of data obtained from the research was done by using Medcalc 12.3.0 program. To evaluate the data, average, standard deviation, minimum and maximum values an percentage numbers Oneway Anova test Shapiro–Wilk, Student t test, Levene test, Welch test, Tukey, Games Howell test were used. In the research, socio-demographic features of women with disability constitute independent variables, and FPAS points constitute dependent variables.

Findings

In the research, it has been established that 47.2% of women with disability are 31 years old and above, 37% of them have received a primary education, 37% of them are high school graduates, and 60.2% of them are single. 89.8% of women with disability involved in the research have stated that they have a core family and this is a significant percentage. 70.4% of women with disability do not work, 50% of the income of women with disability is lower than their expenses, and 18.5% of them do not have social insurance. Most of the women with disability involved in the research (85.2%) do not have a systemic/chronic medical history and 11.1% of them are taking regular medication. In the research, it has been found out that 79.1% of spouses of women with disability are 31 or above, 51.2% of them are primary school educated and 30.2% of them do not have a job. 49.1% of women with disability involved in the research have a physical disability, 30.6% of them are hearing impaired, and 20.3% of them are visually impaired. 46.3% of women with disability are disabled from birth and 53.7% of them became disabled as a result of an accident. In the research, it has been established that, 60.4% of women with disability got married between the ages of 20 and 25, 25.6% of them became pregnant for three times or more and 64.7% of them gave birth twice or more. 50% of women with disability who are involved in the research gave birth for the first time between 19 and 25 ages, and 50% of them gave birth for the first time when they were 26 and older. 81% of women with disability have expressed that they want to have 1–2 children, and 19% of them have expressed that they want to have 3 children or more.

24.1% of women with disability involved in the research use FP methods; 36.3% of them use a condom, 33.3% of them use an intra uterine device, 21.2% of them use the oral contraceptive. 50% of women with disability using FP methods use a FP method for 13 months or more and 57.7% of them stopped using FP methods for some reason (for example they wanted to become pregnant). In the research it has also been stated that 16.7% of women with disability get information about FP, 72.2% of women with disability who get information have been informed by a delivery nurse and 11.1% of them have been informed by a doctor.

The Results Related to the Average Scores that Women with Disability Received from FPAS and Its Subgroups

In the research, the total average of women with disability have an FPAS score of 116.72, the minimum FPAS score that they got is “36”, and the maximum score is “167”. The conclusion obtained from this research indicates that women with disability have a positive attitude towards FP (Table 1). In the research the average scores of subgroups have also been stated and according to the results, the average score relating to “society’s attitude towards FP” is 51.68, the average score relating to “attitude towards FP methods” is 36.23, and the average score relating to “attitude towards birth” is 28.80. This result indicates that women with disability have a positive attitude towards the subgroups of FPAS (Table 1).

Table 1 The results relating to the average scores that women with disability received from FPAS and its subgroups
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The Results Related to the Relationship Between the Average Score that Women with Disability Have Received from FPAS and the Factors Supposed to Affect Their Attitude Towards FP

Average FPAS score (112.56) of women with disability who got married between the ages of 19–25 is lower than average FPAS score (124.43) of women with disability who got married after 26. In the statistical evaluation, the difference between average FPAS point according to the marriage age has been found to be significant (p < 0.05) (Table 2).

Table 2 FPAS of women with disability and its subgroups’ distribution of average score according to features relating to their obstetrics stories
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Among women with disability, when the effect of the number of pregnancies on the average score of attitude towards pregnancy is examined, it has been found that the average score of attitude (30.13) of those who get pregnant 1–2 times is higher than the average score of attitude (26.30) of those who get pregnant at least 3 times. In the statistical evaluation, the difference between the number of pregnancies and the average score of the attitude towards pregnancy is significant (p < 0.05) (Table 2).

Discussion

In this research, the attitude of women with disability towards FP has been stated by making use of FPAS. Women with disability have a positive attitude towards FP. There are a great deal of studies which indicate that women have a positive attitude towards FP [29,30,31,32,33,34,35,36,37,38,39,40,41,42,43]. These studies show similarities with our findings. Besides that, even though women with disability have a positive attitude towards FP, they did not get a score close to the maximum score that could have been achieved and therefore the result is significant. This result perhaps is an indicator that women with disability have internalized the traditional gender roles towards women, such as the responsibility for using FP. Therefore, this finding indicates that women with disability need education and advice on FP (Tables 3, 4, 5, 6).

Table 3 FPAS of women with disability and its subgroups’ distribution of average score according to their socio-demographic features
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Table 4 FPAS of women with disability and its subgroups’ distribution of average score according to their spouses’ and parents’ socio-demographic features
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Table 5 FPAS of women with disability and its subgroups’ distribution of average score relating to the features of handicap type
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Table 6 FPAS of women with disability and its subgroups’ distribution of average score relating to the features of FP methods
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In this research, the attitude of women with disability towards FP was examined within three subgroups: society’s attitude towards FP, the attitude towards FP methods and the attitude towards birth. The attitude of women with disability and society’s attitude towards FP, and the attitude towards FP methods and birth were positive. Women with disability who got married at 26 or above have a more positive attitude towards FP when compared to women who get married between 19 and 25. There have been no studies in the literature carried out whether marriage has an impact on attitude towards FP or not. Perhaps it results from the fact that as women with disability get older, their experiences relating to FP also increase.

Women with disability who have 1–2 pregnancies have a more positive attitude towards FP when compared to the women with disability who have 3 or more pregnancies. One of the subgroups of attitude of women with disability towards FP is the attitude towards birth and it has been pointed out that as the number of pregnancies decrease, the attitude towards FP gets more positive. In the study that Aktoprak [43] has carried out, it has been found that, the women who have 1 pregnancy have a more positive attitude towards FP when compared to the women who have more pregnancies. One of the subgroups of attitude towards FP is the attitude towards birth and it has been figured out that the women who have 1–2 pregnancies have a more positive attitude when compared to the women who have 3 pregnancies. On the other hand, when compared to the women who have 3 or more pregnancies, they have a less positive attitude. Çayan [44] has stated in her study that the women who have 1–2 pregnancies have a more positive attitude towards FP when compared to the women who have 3 or more pregnancies. These studies show similarity with our study findings. On the other hand, in the study Apay and her friends have carried out, it has been found that the women who have 3–4 pregnancies have a more positive attitude towards FP when compared to the women who have 1–2 pregnancies. This study does not show similarity with our research findings.

As a result, due to the fact that this research is one of the limited studies in Turkey, it may be a guiding light for Turkish health professionals in the future. Findings from this research will provide a potential guide for women to have a positive attitude towards FP, to identify the factors having a role in affecting their attitude, and it will also be a guide for nurses to plan the consultancy and educational services that will be given to women with disability. Nurses are the ones who have a critical role in guiding women with disability to become familiar with the FP methods by changing the prejudices related to it, and abolishing negative attitudes.

As the results show, based on the research conducted it is suggested that; (1) women who get married between the ages of 19–25 should receive training and consultancy in relation to FP, (2) women with disability who have had at least three pregnancies should be trained about pregnancy and the effect that the number of births have on women’s health, and be helped in the direction of having a positive attitude towards FP, (3) women with disability should gain more knowledge and have raised awareness, and they should have a positive attitude and opinion on FP with the help of the programs related to FP, (4) the consultancy and educational service which will be given to women with disability on FP should involve their spouses, (5) nurses should plan the consultancy and educational services on FP by considering the attitude of women with disability towards FP and the factors affecting their attitude, (6) nurses should receive in-service training about the attitude of women with disability towards FP and the factors affecting their attitude, (7) the attitude of women with disability and ideas related to FP should be identified in a bigger range, the studies should be planned and applied to find out the regional differences, (8) the qualitative studies which investigate the factors affecting the attitude of women with disability towards FP should be carried out and this case should be researched thoroughly.