Urban–Rural Differences in Quality of Life among Families of Children with Disabilities in Bulgaria
Abstract
Background: Family quality of life (QoL) is a central outcome in disability research, but its distribution across living contexts remains insufficiently defined. Structural differences in service provision between urban and non-urban areas are assumed to influence family outcomes, yet evidence linking service context to family-reported QoL is scarce, particularly in Central and Eastern Europe. In Bulgaria, where specialized services are concentrated in urban areas, this study evaluates urban–rural differences in family QoL.
Methods: Cross-sectional pilot study conducted in 2025 among caregivers of children with autism spectrum disorder (ASD), cerebral palsy (CP), and typically developing controls (n = 36) in Bulgaria, within the NutriLect project. Family QoL was the primary outcome, measured using an adapted Beach Center Family QoL Scale across five domains. Urban versus non-urban residence was the main exposure. Differences in QoL were assessed using Mann–Whitney U and Kruskal–Wallis tests. Associations were estimated using Spearman’s rank correlation coefficients, and effect sizes were calculated.
Results: Urban families reported lower overall QoL than non-urban families (4.31 ± 0.71 vs 4.60 ± 0.41; U = 108.0, p = 0.178; d = 0.48), with consistently lower scores across domains and a significant difference in support and resources (3.65 vs 4.53; U = 78.0, p = 0.047; d = 0.95). QoL was lower in families of children with ASD and CP compared to controls, although differences were not statistically significant (H = 0.64, p = 0.726). QoL was not associated with household income, marital status, or caregiving arrangement; higher maternal education showed a borderline association with QoL (U = 21.5, p = 0.057).
Conclusions: Lower family QoL in urban settings was driven by deficits in support and resources rather than differences in diagnosis or socioeconomic factors. Strengthening coordinated, family-centered support systems may be more effective than increasing service availability alone.
Key messages: • Lower family QoL in urban settings was driven by reduced support and resources rather than differences in diagnosis or socioeconomic characteristics.
• Differences in QoL were not explained by service availability alone, indicating the importance of how support is organized and experienced.
Related
- Family Routines and Parenting Stress in Families of Children With and Without Intellectual Disabilities: A Cross-Sectional Study.
- E-PAtS trial: a protocol for a cluster randomised controlled trial of Early Positive Approaches to Support (E-PAtS) for families of young children with intellectual disabilities
- Quality of Life in a Saudi Arabian Sample of Parents and Caregivers of Children with Disabilities: A Cross-Sectional Analysis.
- Beyond benchmarks: a narrative review of evolving quality of life frameworks for children with neurodevelopmental and learning disabilities and the need for integrated digital twin approaches
- Constructing the Self Data Atlas ontology: a crisp-fuzzy ontology for quality of life representation in children with neurodevelopmental and learning disabilities
BibTeX
@article{chamova2026urbanrural,
title = {{Urban–Rural Differences in Quality of Life among Families of Children with Disabilities in Bulgaria}},
author = {RH Chamova and SP Nikolova and AB Toneva},
journal = {The European Journal of Public Health},
year = {2026},
month = oct,
doi = {10.1093/eurpub/ckag169.1450},
url = {https://doi.org/10.1093/eurpub/ckag169.1450},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Urban–Rural Differences in Quality of Life among Families of Children with Disabilities in Bulgaria
AU - RH Chamova
AU - SP Nikolova
AU - AB Toneva
PY - 2026
DA - 2026/10/01
JO - The European Journal of Public Health
DO - 10.1093/eurpub/ckag169.1450
UR - https://doi.org/10.1093/eurpub/ckag169.1450
AB - Background: Family quality of life (QoL) is a central outcome in disability research, but its distribution across living contexts remains insufficiently defined. Structural differences in service provision between urban and non-urban areas are assumed to influence family outcomes, yet evidence linking service context to family-reported QoL is scarce, particularly in Central and Eastern Europe. In Bulgaria, where specialized services are concentrated in urban areas, this study evaluates urban–rural differences in family QoL. Methods: Cross-sectional pilot study conducted in 2025 among caregivers of children with autism spectrum disorder (ASD), cerebral palsy (CP), and typically developing controls (n = 36) in Bulgaria, within the NutriLect project. Family QoL was the primary outcome, measured using an adapted Beach Center Family QoL Scale across five domains. Urban versus non-urban residence was the main exposure. Differences in QoL were assessed using Mann–Whitney U and Kruskal–Wallis tests. Associations were estimated using Spearman’s rank correlation coefficients, and effect sizes were calculated. Results: Urban families reported lower overall QoL than non-urban families (4.31 ± 0.71 vs 4.60 ± 0.41; U = 108.0, p = 0.178; d = 0.48), with consistently lower scores across domains and a significant difference in support and resources (3.65 vs 4.53; U = 78.0, p = 0.047; d = 0.95). QoL was lower in families of children with ASD and CP compared to controls, although differences were not statistically significant (H = 0.64, p = 0.726). QoL was not associated with household income, marital status, or caregiving arrangement; higher maternal education showed a borderline association with QoL (U = 21.5, p = 0.057). Conclusions: Lower family QoL in urban settings was driven by deficits in support and resources rather than differences in diagnosis or socioeconomic factors. Strengthening coordinated, family-centered support systems may be more effective than increasing service availability alone. Key messages: • Lower family QoL in urban settings was driven by reduced support and resources rather than differences in diagnosis or socioeconomic characteristics. • Differences in QoL were not explained by service availability alone, indicating the importance of how support is organized and experienced.
SN - 1101-1262
SN - 1464-360X
ER -