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National Center for Environmental Health. Minus Related Pages. People with SCI may travel up to kilometres to attend their monthly appointments for medication and medical consultation using a hired car because of the lack of wheelchair-accessible public transport.

The first author, assisted by the employee at the rehabilitation hospital, invited patients with SCI who attended the outpatient clinic. Caregivers of people with SCI who consented to the study were invited to participate.

The therapists were recruited in the therapy gym. Therapists were included if they were employed in the rehabilitation hospital and involved in the care of people with SCI. Caregivers of people with SCI, formal or informal, had to be 18 years or older and willing to participate in the study.

Individuals diagnosed with SCI, both non-traumatic and traumatic, accessing outpatient medical clinic at the rehabilitation hospital were invited to participate.

Willing participants with SCI 18 years and above were considered regardless of their gender, level and duration of SCI. An interview guide was developed by the researchers informed by previous studies on SHCs [ 10 ] fig. Part B included questions and probes on the SHCs commonly experienced by people with SCI, prevention and management strategies used, and factors at a personal and environmental level that influenced the prevention of SHCs.

Lastly, questions on barriers and facilitators for the prevention of SHCs were asked. The interview guide was piloted on one therapist in the presence of a researcher experienced in qualitative research to clarify the questions.

Semi-structured interviews were conducted by the principal researcher at a venue that was suitable for the participants. Interviews for all the therapists and some of the participants with SCI were conducted at the rehabilitation hospital.

All the caregivers were interviewed at home. The average length of the interview was 50 min range 45 min—1h30 min.

Interviews were conducted from July October and continued until data saturation was reached when no new information emerged. All the interviews were audio-recorded and transcribed verbatim for data analysis.

MAXQDA The quotes are numbered SC1 1, Therapist 1, Caregiver 1 to ensure anonymity. Analysis was conducted concurrently using content analysis [ 22 ]. The primary investigator read and reread all the transcripts to ensure accurate transcription and get a sense of the content.

One interview transcript was coded inductively by the principal investigator and two other researchers independently. After that, a discussion on the broad codes was conducted, and a preliminary coding framework was developed, informed by the aim and the ICF environmental concept.

An external researcher experienced in qualitative and public health research coded one transcript, and the categories were compared. The differences in the concepts used in the coding framework were discussed. This process helped to refine the categories.

Deductive analysis was conducted on the subsequent transcripts, and similar codes were grouped into sub-categories and categories. A manual display of the categories, sub-categories and codes was conducted by the principal researcher and reviewed by the other researchers.

Throughout the research process, the authors held regular debriefing sessions. The rehabilitation hospital granted permission to use the study site for data collection. All the participants gave written informed consent and permission to record before the interview. This study was approved by the Human Research Ethics Committee of the University M and registered with the South African National Health Research Database reference GP The sample included forty-four participants 21 therapists, six caregivers and 17 participants with SCI.

Four caregivers were female and were formally employed as carers. The therapists interviewed represented diverse professions, and the mean working experience was 8. Tables 1 and 2 outline the demographic profile of the participants.

Categories evident in the qualitative analysis included the impact of social support, inaccessible built structures and transport system, and an inefficient health care system. Social support from family, caregiver and peers aided the prevention of SHCs.

Social support manifested in home adaptation, emotional encouragement, peers sharing experiences, physically assisting with self-care and financial support. If the family member or caregiver lacks knowledge on SHCs, they will not support prevention care. Inaccessible built structures were a barrier to the prevention of SHCs.

Built structures in public facilities such as rough terrain, public toilets not suitable for wheelchair users, and uneven sidewalks proved to be barriers. The participants mentioned how the public transport system was a barrier to the prevention of SHCs.

Stigma against and segregation of people with SCI often characterise the public transport system. Participants reported how taxi drivers did not accommodate people using a wheelchair because it takes time to transfer them into the vehicle.

Another stressor related to transport was the high cost of hiring an alternative private transport system. Participants reported how inefficiencies in the health care system hampered the prevention of SHCs. The sub-categories included a shortage of resources and a lack of knowledge on SHCs among health professionals.

Participants reported a shortage of medication, consumables for bowel and bladder management and assistive devices. Patients expressed that they run out of medication because they are usually not given enough to last them till the next check-up. One kit I get every six months they supply to me.

Unfortunately, lack of necessary bowel and bladder management consumables increased the risk for infection because individuals with SCI ended up reusing consumables. Participants with SCI also expressed how health care workers, including community-based health workers, lacked knowledge on SHCs and prevention.

Where there were hospital standard protocols to prevent pressure sores, health professionals did not comply. Also, care during the in-patient rehabilitation phase was not empowering patients to self-manage post-discharge as described by these therapists:.

The study aimed to explore environmental factors influencing the prevention of SHCs in people with spinal cord injury by interviewing people with SCI, caregivers and therapists. The environmental factors identified were: the impact of social support, the inaccessibility of built structures and the transport system, and an inefficient health care system.

In agreement with previous studies, good social support from a caregiver and peers enhanced the prevention of SHCs [ 23 , 24 ]. Caregivers are part of a trusted social network helping in the prevention and management of SHCs, offering emotional support, assisting with activities of daily living and linking people with SCI with the health care system [ 23 ].

Given the critical role caregivers play, the lack of knowledge on SCI and SHCs is worrying because they will not support prevention care. Peer involvement helps in sharing experiences, expectations, learning and mentoring [ 25 ].

Thus, it can be an adjunct to rehabilitation programmes [ 26 ]. Future research in South Africa can explore the role of caregivers and peer support in delivering rehabilitation service delivery. Despite the United Convention on the Rights of Persons with Disabilities UNCRPD directive on universal access [ 27 ] and the Sustainable Development Goal 11 on the inclusive and accessible environment [ 28 ], environmental barriers for people with disabilities persist.

In this study, inaccessible public transport systems and built structures were barriers to the prevention of SHCs. The main environmental barriers include inaccessible transport and buildings and a negative attitude towards people with disabilities from the community, friends and family [ 15 , 29 ].

Given the social inequities in South Africa, the inaccessible infrastructure and transport system limits participation in the labour market, access to leisure and health-promoting care services and perpetuates exclusion and poverty [ 29 — 31 ].

Possible reasons for barriers in accessing transport and built structures is poor implementation and enforcement of the UNCRPD convention article 9 [ 18 , 32 ]. For the private taxi and bus industry, lack of awareness on universal design and government support to make the vehicles accessible for people with disabilities could be reasons for non-compliance.

There is a need to promote universal design as a public good. Strategies that can be explored include awareness campaigns on universal design at all levels of service delivery for both public and private sectors.

Secondly, lobbying relevant departments to implement and enforce building regulations for all new infrastructure development and changing public transport vehicle specifications to be accessible for wheelchair users. Similar to previous studies, the health system influenced the prevention of SHCs [ 10 , 11 ].

Shortage of medical resources, health professionals lack of knowledge on prevention of SHCs, and a patient care approach that is not holistic and empowering affected the prevention of SHCs. Comparing the study results with previous studies based in high-income countries, countries with better resources and a NHI, participants in this study and the previous ones highlighted how health professionals lacked information on the prevention of SHCs [ 11 , 33 ].

This finding indicates gaps in the training of health professionals on disability issues, comprehensive chronic care management and general public health promotion. What was also worrying was that patient care protocols that required prevention care practice were not adhered to, proving that there is low value placed on preventative and rehabilitation care.

Then again, non-compliance to prevention protocols could be due to the shortage of health professionals to ensure adequate patient care. The SCI care model seems to be more medically oriented.

In this study, patient care was not holistic and not empowering persons with SCI to self-manage. Self-management practice is key to owning personal health and practising health maintenance [ 24 ].

The possible reasons for not empowering people with SCI could be poor integration of public health in health care service delivery, not valuing rehabilitation care in the same manner as curative care, and poor understanding of rehabilitation [ 18 ].

According to the WHO, rehabilitation is a continuous process of enabling an individual with a chronic condition and disability to function and participate in society through therapy, health promotion and disease prevention [ 34 ].

In light of the burden of chronic diseases facing South Africa, there is a need to prioritise rehabilitation care at all levels of care, including health maintenance and prevention of diseases.

Prioritising rehabilitation care can influence planning and resources allocation needed to enhance health for people with disabilities. The shortage of resources such as medicines, bowel and bladder consumables, and assistive devices affects the prevention of SHCs.

The shortage of medication is a national problem due to inadequate procurement processes and suppliers [ 35 ]. Also, not prioritising rehabilitation care affects planning and resource allocation for medication and assistive devices needed by people with disabilities [ 19 , 29 ].

Shortage of assistive devices is a common problem in low and middle-income countries [ 36 , 37 ]. Cited reasons for the shortage of assistive devices include lack of budget allocation, inefficient procurement processes, lack of maintenance and repair services, and supplier backlogs [ 37 ].

Lack of essential medical resources drives patients to buy privately, increasing out-of-pocket costs and increasing financial vulnerability. Access to health for people with disabilities, including SCI, is a human right that must be promoted. Since South Africa has ratified the CRPD, issues experienced by people with SCI can be addressed through UN reporting processes.

Department of Planning, Monitoring and Evaluation. This department can collaborate at different levels with different stakeholders respective government departments, NGOs for people with disabilities, private sector and training institutions to monitor implementation and identify implementation problems.

A coordinated and integrated approach to implementing the convention can influence planning, resource allocation, and service delivery to promote people with disabilities in all spheres. This study has some limitations. We only looked at environmental factors for the participants at one rehabilitation hospital.

The goal is to find new in vitro approaches to understand and treat human diseases caused by the environment. The NIEHS Toxicant Exposures and Responses by Genomic and Epigenomic Regulators of Transcription TaRGET Program seeks to understand how environmental exposures lead to epigenetic changes—that is, modifications to DNA that affect gene expression without altering the underlying genetic code.

Toxic substances such as heavy metals—for example, arsenic and nickel—are associated with epigenetic changes that may lead to cancer, cardiovascular diseases, autoimmune diseases, and neurological disorders. The first phase of TaRGET focused on how environmental exposures affect epigenetic changes that influence the way our cells carry out their physiological functions.

The second phase focuses on characterizing epigenetic changes caused by environmental exposures in different types of cell tissues such as the brain, lung, liver, skin, and blood.

It also focuses on using easier-to-access surrogate tissues to determine if we can observe epigenetic changes in blood that will predict or correlate with epigenetic changes in a particular type of tissue. Findings were done using mouse models, which will be used to inform human studies.

Alternative accessible version pdf. Autoimmunity, which is when the immune system attacks the body instead of protecting it against disease, appears to be rising What happened when genomic researchers targeted more diverse groups of people in their studies?