SCI Care: What Really Matters
SCI Care: What Really Matters
Psychosocial support for persons with spinal cord injury in African rural low income settings
Traumatic SCI is a relatively common occurrence in rural areas of low income countries. However, rehabilitation services in these areas are either unavailable or inaccessible by the majority. Psychosocial services are scarce and hardly tailored towards a diagnosis such as traumatic SCI. Left with no option, healthcare professionals such as nurses, medical doctors, surgeons and therapists take responsibility of using their general counselling skills to provide some psychological support to persons with SCI, with variable outcomes. Training psychological aspects to healthcare providers at all levels and formal involvement of local social support groups such as; religious leaders, peer group trainers and family in supporting persons with SCI in the continuum of care in resource constrained areas is crucial. Still, there is a need for a more formal and consistent SCI-specific psychosocial counselling and support for persons with SCI in these setting.
This webinar promotes the Professor Paul Kennedy Legacy Scholarship for Psychology and showcases how the 2024 winner has benefitted from this award. The 2025 Scholarship is currently open – for further information and to request an application form contact bht.nsicpsychology@nhs.net
The opinions of our host and guests are their own; ISCoS does not endorse any individual viewpoints, given products or companies.
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The SCI Care: What Really Matters podcast aims to provide valuable insights and the most up-to-date information for those providing care to people with spinal cord injury (SCI) worldwide. The vision of the International Spinal Cord Society (ISCoS) is to "facilitate healthy and inclusive lives for people with spinal cord injury or dysfunction globally".
Contact us directly with any questions or comments at iscos@associationsltd.co.uk
Okay, welcome everyone to our. It's our first Psychosocial SIG webinar this year, one of two, and I'd just like to acknowledge my name is Leanne Rees and I'm coming from Melbourne and I'd like to acknowledge the Wurundjeri people of the Kulin Nation, the original custodians of the land on which I'm coming from, but also to acknowledge the lands of which everyone is coming and joining us from today. And I'm a physiotherapist, having worked in spinal cord injury for a long time, and I'm a physiotherapist, having worked in spinal cord injury for a long time Now a researcher, but have a real interest in psychosocial care, and it's been an honour to be able to host the webinar today. Just to give you a little bit of a background about who we are. So the Psychosocial Special Interest group are really passionate about acknowledging that psychosocial care for people with people with spinal cord injury is really relevant to everyone who works in spinal cord injury rehabilitation. We acknowledge that there's an interaction between the social and psychological factors of health and well-being in both clinical practice and in research.
Speaker 1:So our special interest group is multidisciplinary and it's for anyone who has an interest in psychosocial care, and this includes people with lived experience, and our aim is to promote psychosocial issues through ISCOS, the International Spinal Cord Association, but also through the spinal cord injury community. Membership to our special interest group is free and you can do that by scanning this QR code and this will put you onto our mailing list. As I said, we hold two webinars each year. We also have a module on eLearn SCI, which is a really comprehensive education tool that covers all the domains that are of importance for people with spinal cord injury. If you are an ISCOSS member, you can also join us via the ISCOSS website. However, to be on the mailing list, please still scan the QR code, and that will ensure that you get information of any activities that we're holding.
Speaker 1:So this is our governing panel. As I said, we are multidisciplinary, but we also come from different areas from around the globe. We've got representation from India, australia, tanzania, canada, america, netherlands and the UK, and we're chaired by Dr Jane Duff, the clinical psychologist in the UK, who's really been a driver in bringing this group together, along with Tyne, I must say, and Kim, some stalwarts of the group.
Speaker 2:Many, many people. Yeah, but thank you.
Speaker 1:I'd like to just give a bit of a promotion to the Professor Paul Kennedy Legacy Scholarship for Psychology. This is in memory of Paul, who did a lot of work in contributing to psychosocial issues and did a lot of research and clinical work for people with spinal cord injury. The award is currently open. Applications are due on the 16th of June, so just next month. Information about the scholarship is available in different languages Chinese, english, french, spanish and if you wanted any information, there is an email address at the bottom of the slide here. This scholarship will provide funds to either attend an ISCOS conference or to attend a skills-based training workshop activity or course, and then what we would like is that then you present your learning outcomes of your project, which is what we're going to be hearing about today from Hallelujah. And even though it is, I wouldn't say it's primarily to support early career psychologists, but really it's for anyone who works with anything in the area of psychosocial issues in spinal cord injury, particularly those from low-income countries. These are previous award winners, so again, quite good representation from around the globe. We have had in 2021, we had Dr Dean from Chicago and we had a representative from Bangladesh in 22. And then we had Nadia from Ukraine in 2023. And last year's award winner who will be presenting today? We have hallelujah from tanzania.
Speaker 1:So just some housekeeping for the webinar today. Um, if, please let us know where you've come from, so in the chat, we'd love to know who you are, what country you're based in and what spinal service you might be working in. We'd love to keep your on. It's so nice to be able to see people on the other side of the screen. It's comforting to know that you're not just talking into thin air. Please post questions to everyone. We will save the questions to the end of the presentation, though Closed captions are enabled for anyone who has hearing impairment. We do have Pete from the ISCOSS events company available online, so if there are any IT issues, please message him directly. This presentation is recorded and the recording will be sent to you via email on a link, and we would love your feedback at the end. So if you want to get in early, you can scan this QR code now. Otherwise we will have the QR code at the end of the presentation again.
Speaker 1:Okay, so for our guest speaker today, we have Dr Hallelujah Moshi. Hallelujah is a senior physiotherapist and head of the Kilimanjaro Christian Medical Centre and Physiotherapy Department and University. His research interests are in rehabilitations of people with spinal cord injury, especially in resource-constrained areas. At the present, hallelujah is working on establishing a traumatic spinal cord injury database based on the ISCOS international data set. He's dedicated clinical time to diagnostic, prognostic and life counselling to people with spinal cord injury and he's learned a great deal about spinal cord injury psychology from various resources. But I do love that he's highlighted that most importantly, it's from the people themselves and I said Hallelujah was the 2024 Professor Paul Kennedy Legacy Scholarship for Psychology and I met Hallelujah a couple of years ago when ISCOS was in Edinburgh and it was so lovely at the Psychosocial SIG workshop that we had pre-conference workshop and I was excited to see another physiotherapist in the room. So I'll hand over to you now hallelujah and I'm controlling the slide. So hallelujah is going to be telling me when to move, jane sorry, um leah, leah, hallelujah.
Speaker 2:I just want to check with everybody in terms of posting in the chat, because there doesn't seem to be an everybody um feature. There is a host and panelists, so can other people see the message messages people are posting, um from tazewa in zambia, for example, ernst in in south africa, or whether it's just the hosts and panelists that can see that?
Speaker 3:I can see them.
Speaker 2:Yeah, but we're on a. There should be an everyone option and there isn't. Doesn't seem to be. Oh great, ernst. You can see just the host visible. Can you see the Ernst? Can you see the the chat from other people?
Speaker 3:I can see no Ernst can't, yeah, I, I can see no.
Speaker 2:Ernest can't. Yeah, I think we can see hallelujah, but I don't think everybody else can see everybody else's messages. No, jane Stambridge can't see the chat. Thank you, jane, good to see you. And Kim can't see the chat. Pete, sorry, is it possible to make an everyone option available? Pete, sorry, is it possible to make an everyone option available? I can see what I can do, but I've got everyone available on my chat, so let me just see what I can sort out. Thank you. So for all of those that have posted to hosts and panellists, thank you very much. Might be a tall order for me to gather them up and repost them, but I will endeavor to do that during hallelujah, because it's great. We've seen a whole variety of people attending um. As and when we get the everyone chat function up, I'll let you know, and please put any questions in there, just so we can connect people. Hallelujah, I'm really sorry for the kind of disturbing your start and we can kind of go from there. So I'll keep you posted everybody. Thank you very much.
Speaker 1:Thanks, Jane. I'll hand over to you now. Hallelujah.
Speaker 3:Thank you very much for having me on this webinar and I'm very delighted to speak to various persons around the world who are working with persons with spinal cord injury. On the area of psychosocial support. I want to highlight what we are going to cover today because I've been introduced, as you heard earlier, but in our presentation we are going to look at important facts that are there about psychology and psychosocial support and how they relate with environment and so on, and then we'll look at the review of resource. When we talk of rural resource constraint areas, what do we mean and how does that connect with psychosocial life? And we will look also a little bit on hospitalization in these areas. Also, community integration when they go back to the community, what to expect and then we'll look at helpful ideas that I've seen working from our side which one can use really to help to support these people psychologically when they go back to their community or when they're in the hospitals. And then we'll have a discussion at the end when it comes to breaking the bad news and so on. So can we go to the first slide please? Yeah, so this is one of the articles that I was looking at and where it is clearly indicated that the psychological outcomes most frequently quantified are depression, and I see, maybe it's because we have many tools to assess depression and so there's so much research about depression as compared to other elements, and also self-esteem and anxiety, among other things. Qualitative evidence suggests that we could have interventions that can help to improve life, enjoyment, relaxation and source of positive destruction. So there are means that can be used, but when we come to look at the resource constraint areas, you will find that those new technologies and so on, they might not be there.
Speaker 3:Can we go to the next one, please? And then you have another important fact a set of psychological and social support factors is strongly related to subjective well-being of anybody. So we have to know that there is this set of psychological and social supportive factors which we have to consider during rehabilitation for our persons with spinal cord injury to have that subjective well-being. And in poor rural settings, these challenges we have various challenges which may be amplified due to limited access to mental health care and support services. So today we are talking of areas where you don't have psychologists, and even if you have one or two psychologists, they're not really equipped with what it takes to cancel someone with a spinal cord injury specifically.
Speaker 3:Can I go to the next one, please? Specifically, can I go to the next one, please? And then physical barriers. Now, when you talk of rural areas, it's a special group because there's challenges with physical barriers, lack of access to transportation. So even if you want to go out and sit out there and have a drink and have a relaxation, it's a challenge when it comes to transportation. And then we have stigma. So stigma is more pronounced in rural areas as compared to urban areas or townships, and unemployment also, or underemployment, and then we have limited opportunities and lack of social support systems in these areas as compared to those who are more in the townships.
Speaker 3:Can I read the next one? I'm going quickly because this is not the most important part of the presentation really, but we know that there is an array of challenges that these people face and because I'm talking to most of you maybe are psychologists or you are doing something to psychosocial aspects, then these are things that sometimes they go unnoticed. For instance, cognitive impairment. It is a big challenge because we realize that people do not even perform the way they used to perform before, and we find also some challenges when people try to return to work and there are some issues like they are not doing the way they used to be, even though they might be physically not that affected. So cognitive impairment is well documented, the consequence of spinal cord injury affecting approximately 60 percent. Documented. The consequence of spinal cord injury affecting approximately 60 percent. And around 17 percent of spinal cord injury. Patients are diagnosed with psychiatric disorders. So we find that we send them back to the communities.
Speaker 3:But families and their co-workers tell us they don't behave as they used to behave before.
Speaker 2:I remember when I was doing my interviews with clients in the rural areas.
Speaker 3:The families complained that they have noticed that they have increased anger and that was not there before the injury. And these are the things that we have to know. They need some psychological support to be able to live the way they used to be before or even to be better Next, able to live the way they used to be before or even to be better Next. Yeah, this slide is just there just to mention a list of the commonness that are reported in mental health challenges like depression, anxiety disorder and adjustment disorder, but also post-traumatic stress disorder, chronic, but these ones we have some factors which are not exhaustive, but when the injury is severe, like complete injuries, can be different from incomplete, but I've seen also people who have incomplete injuries because of the pain that they experience. It can be even they can have more mental issues compared to people who have complete injuries. So pain is a big thing when it comes to whether someone is going to be mentally okay or not, and also support systems and I will talk a lot about that as we continue, because at least in these rural areas we have supportive system that could be used if they knew what to do. So having people around is not a problem, but do people know what is it and how they can help? So access to rehabilitation and counselling services, and employment and financial stabilities these are factors that can contribute to a poor mental health.
Speaker 3:Next, for those who attended the talk in 2023, it's very important for us to remind each other that it's a multifactorial model that we need to really to address and when you come to the final part of this webinar, I'll talk about who we can involve. When it comes to the rural areas, there are very key people that if they know what to do and if they know about spinal cord injury, they can be very helpful. So I echo that lecture that was given that it is really multifactorial model and we need to integrate psychosocial guidelines and person-centered approach into spinal cord rehabilitation to achieve treatment goals. Why do I put that bolded? It's because that's something that is really missing. We do a lot, we're trying to do a lot in these settings, but the psychosocial element is forgotten so much. I've seen in hospitals where they have psychologists but they only counsel people pre and post HIV, aids and the cancer patients, but we have not seen that as a part and parcel of rehabilitation for person with spinal cord injury, so I thought that's something to stress also.
Speaker 3:Next, yeah, let's look at what we mean by rural resource constraint area. I put it there because not everyone has worked in those settings, so it's good to have an highlight of which areas we're talking about Next, please. So in Africa, it's indicated that 55 to 70% Africans live in the rural area, and I know in Tanzania it's 73% people live in these areas, which we are talking about today. So we are talking about the biggest area, I mean the biggest population, where they are living. That's where we are trying to focus on today, but also, because of urbanization, it is changing a little bit. Maybe in some areas it's 50-50, but there's a lot of urbanization taking place and very fast growth of these rural areas in some areas.
Speaker 3:And the majority are small scale peasant farmers. Now this is very important because we are trying to think how do we get them back there, because one of the most important psychosocial element is whether they can go back to work and whether they can end something for themselves. And some of them are informal entrepreneurs, which meaning that they cannot have compensation. They don't have a contract, that is clear. So once you get the injury, that's the end of the contract, kind of, because they send their contract maybe on weekly basis, or they only get a payday, maybe on weekly basis, or they only get a payday. And some average age that we see is when you talk of trauma in these areas is 35. Of course, it is 17 years to 45. On average, the majority are in their 35. And we have to consider that we are talking of young parents. They have young kids who need school fees and so on. They're trying to build their families at that time. So all this has a very big impact when it comes to psychosocial life and relatively limited access to information.
Speaker 3:These rural areas are not people who can easily go online and find some tips of how to navigate on what can be helpful for their health. It's different from those who are coming from more town or cities and most dedicated people. They might have a little bit of more support from what they see online, compared to these ones who may not be able to see anything Because even the phones that they use maybe it's not a smartphone or they don't even have a phone. Yeah, so these are some of the pictures which can tell you the occurrence. You can see the motor. We call them bodagodas in Tanzania. Motorcycles and cars these are the main. We call them border borders in Tanzania. Motorcycles and cars these are the main way in which people travel in these areas.
Speaker 3:So there's a lot of accidents, but also climbing trees especially in my area where I come from, the leading cause is falling from the trees because of the activities that are concentrated around Mount Kilimanjaro. But you have to look at this not only as a cause, but when you look at the last picture there, right, it's also the challenge of living there with a wheelchair. So all this contributes to challenge the mental health of anybody who goes back to wheelchair. Next slide, to challenge the mental health of anybody who goes back down. We'll check next one. And these are the activities.
Speaker 3:The picture on your left side actually, there's a guy in the tree for those who can see clearly, and this is how he falls from a tree and that is what he used to do, maybe to pick fruit from the trees, because the trees, for instance in Klimajaro, they can be 20 meters high because of the climate, and so if you have to pick mangoes or something, then you have to find someone who is good at doing that climb the trees. Now, if he falls from the tree, that means his job to climb the tree is gone, yeah, but also, because of that height, means that the injury can be very bad and they can have also other fractures, not only the spinal cord injury. So you have a lady most of our ladies. They get injuries because they fall with something on their head. So head loading is very common in rural Africa and when you slip and fall with something a bucket of water- or something on your head.
Speaker 3:So head loading is very common in rural Africa and when you slip and fall with something a bucket of water or something on your head, then going back again to do the same activity, it's completely impossible. And also we have many other causes. When you talk of someone who was hit by a car or a house collapsed on them, it's very common because of the infrastructure and the type of houses that we have. The next one yeah, the next slide should be about these are the activities. So you can imagine the guy who is carrying that big bag. Now those would be potatoes, so it's not something light. And if they fall with that one and they get injured, you can be sure that they are not going to go back to there. You cannot say returning to work. There is nothing like returning to work. They have to think of completely a new life and that can be mentally very challenging. But I also have spoken about ladies and head loading and so on. The next one yeah, this is two articles that we have tried to show that when you talk of road traffic accident and falls as the leading cause when it comes to rural areas, we have many other causes. For instance, this young man who was hunting a bird and he hit a bird in the tree and the arrow came back to him to hit his neck and he had cervical spinal cord injury, something that you cannot explain. You know, it's very strange. But also we have seen a number of people get ox cut accidents, yeah, and they get some injuries. So we have to think of these rural areas as precipitate, precipitant of more injuries because of these other causes. Can we go to next one, please? Of more injuries because of these other causes? Can we go to next one, please? Yeah, now in the host symptom.
Speaker 3:Actually, when they get injuries I will talk of Tanzania, which reflects most of African countries or Sub-Saharan Africa they end up with the primary health care first before they come to the specialized or advanced or how do you call it, tertiary host symptoms, and sometimes they stay there for days and during the transfer from the accident scene to the car, from the car to the primary health care, sometimes they get more injuries and most of these they get conservative treatment and non-surgical, because in most areas where you in the rural areas, they don't have this technology or they don't have this expertise or theatres that can do surgery, so staying in the hospital for three months or for six months because of conservative management is common and you know that can have a very big impact when it comes to mental health because they're away from home for a very long time and also in our hospital.
Speaker 3:For instance, where I work is one of the biggest hospitals in the country and now we have a spinal fixation surgery. It's one of the biggest forces in the country and now we have a spinal fixation surgery spinal surgery but only for those who can afford, and you can see, we can see that more than half of the patients cannot afford and they still have to take the conservative management.
Speaker 3:Next one, please, of course, when I was talking of conservative management, then you have to consider also the complications like pressure sores, which also can have a very big impact on mental health. Maybe let's move to the next piece. I think I'm spending too much time on these articles and overall the results shows poor community integration and it's because environment scores very poorly when it comes to aspects of quality of life. They made score very good on social, a little bit good on on physical and and so and and and on the social, on cycle, but when it comes to environment throughout, throughout, when I read articles, I can see it's caused very poor when it comes to wheelchair users.
Speaker 3:And we feel that is what makes it going back to the community very difficult. Next one, please? Yeah, you see, that's one of the paper that I worked on and it shows the single digit score is only on the environment, even though they have some very good scores when it comes to psychological and social, even though it's not that good. But when you look at the environment, we believe that if something is done on the environment, we can improve a lot on the other domains also. Yeah, the next one, please. Yeah, this was an article that was done here in my hospital but also which shows depression is very high 35% when they're in the hospital. But it was a cross section and we may not be able to discuss that so much because maybe it depends on what was going on on that week. Let's go to another one Now. This is where we really want to talk more about, because I have done interviews in the communities twice when I was doing my master's and when I was doing my PhD and it comes very clearly that there are some things that can be reinforced to improve their quality of life, but also to improve their mental well-being.
Speaker 3:The most important thing that I've seen throughout, and even when I read in articles, is having a supportive family. Now that is not about the community, so to speak, because they always say the community can change the community. I see, when we have patients in the hospital, in the first week they get so many people visiting them. In the second week maybe a little bit less, but with time you can see that it's only the wife or only the daughter who is coming to see this man, because at the end it's the family that can support you and you cannot depend so much on the other people in the community.
Speaker 3:So when we looked at what really makes life possible and what can those people who are successfully living with spinal cord injury in these communities, they say you have to have a social skill, you have to have some kind of faith, I must say. But in my area they speak straight away and say it's about believing in God and that God is behind this. Some they can get angry that God let behind this. Some they can get angry that God let this happen to me. But many of them use that as because the doctor has failed to make me walk again, then I depend on God and God knows what to do. But also they want to be supported, to know about health risk. I know most of them. They say if you know what to do not to get pressure.
Speaker 3:So if you know what to do not to get urinary they say, if you know what to do not to get pressure sore, if you know what to do not to get urinary tract infection, or if you know what to do when you get sick, that is very important for you to survive. But you have to be creative because they're going to a very environment that is very difficult and they have to have a problem solving skill. But above from after having this family that is supportive, then you have to have the community, because what we see also here, especially during rainy season, is that you cannot go out because of the mud, but people can push your wheelchair. People can even carry your wheelchair with you on the wheelchair if you need that help. So that support from the community is very important, but they say it's not reliable. The only reliable support is actually that of a family. But also it really matters what did you have before the injury? And if you used to have a job and you used to have a property or a premise, a house or something, it helps the logical pick from there and move on with your life. But also having a wheelchair, the next one, yeah, now, because I did a grounded theory I came to realize that most of those who did not come to terms with the injury Now I want everyone to understand I'm not talking about being passive here.
Speaker 3:I'm not saying that you have to. You don't have to do your stem cell and thing and try to find solution and just accept this is how it is. But people who did not accept that, coming to terms with the fact that maybe I may not walk again, they ended up using a lot of whatever resource they had in the family to go for prayers, to go for, you know, stem cell therapy, to go for any therapy that they could hear, not with the intention to be more functional, but with intention to work again. And when that failed they fall into depression because they've spent so much money on something that did not work. So we came to realize that when we look, accepting your condition is very important, or coming to terms with the fact that this is not something that can change and try to work from there. Was that, what was? That was the bridge to move into, into being possible to cope with the situation. But also you have to be accepted. So it's accepting and being accepted. And when you talk of being accepted by environment. It means accessibility, but also being accepted by the. It means accessibility, but also being accepted by the people. It means that social connection being connected to your family, to your friends, to the community again, when they accept you the way you are and they're willing to support you. So acceptance came up as a very strong thing that we want to work on. It's very important that we bring this forward because it also come to the last part of this webinar where we want to say about breaking the bad news yes, the next one, please.
Speaker 3:Yeah, so we are talking of inaccessible environment, but if you look at, we cannot, I cannot zoom. But if you look at, we cannot, I cannot zoom. But if you look at the man who is sitting on a wheelchair on the top but the top one is putting on a greenish T-shirt on a wheelchair Actually there is a son behind him, which we cannot see because I cannot zoom, but also the wife is standing there, but there is a father. For those who have good eyes, there is a black dot. I don't know if we could zoom, but I wanted to make sure that you can see that the family is very important for this man. There is a son behind him which you cannot see. There's a wife standing there, but there is also a father. You cannot see my arrow. Can you see my arrow? No, because I'm not the one who is sharing the screen. But what I wanted to show you in that picture is that the family is the whole thing behind this person and if we manage to work with the family carefully, then all these psychosocial issues also could be. Now this is the guy who had been out of the hospital for six years and he had never been out of his house environment because of how the road that leads to that house that even walking is difficult for us who are able to walk. But also these other pictures show you that even though we have inaccessible environment, we have people who are willing to help and it's still something that can be done in within their home environment to make a life a little bit bearable as compared to how it is. Yeah, maybe when we are coming to discussion, I may be able to share the screen and also expand that area. I really wanted to show you that behind that monday's that power of the family, the next one, please. I think it takes time to go to the next slide, because it's a heavy document also. Yeah, so if you can look now, maybe you can see his father. He looks very black and he has a gray hair, but he's hiding behind. He's not close to the family, but he's standing on your left side in between the tree and the banana tree. There is a man standing there Actually that is the father. And behind this man, behind the wheelchair, there's a young man who is hiding there with a white T-shirt and the wife, maybe. Next, these three guys that you see there were my supervisors during my PhD who came to visit from Sweden. So I went to show them where I'm doing my data collection and I like this picture because it seems like there's a boundary between us and that man, and the boundary is the environment. You can see the stones and so on. So he cannot come down on a wheelchair to come to meet us, so we have to reach out for him.
Speaker 3:Next one Now I'll tell you this man who died last three years. He has been on a wheelchair for more than 32 years and he has a cervical spinal cord injury, a C5 complete. He has had pressure sores and things. He has gone through a lot for all this time. But he told me he had a supportive family. That was the biggest thing he had. He had something before he got injured because he was employed, so he had a house, he had a farm and so on. So these are the things that they have to sit with the family and see how they can use those ones he had. His wife actually was a nurse, but he stopped working so that he can look after the husband and his son went to take physiotherapy so that he could also help his father with some exercises. And also he was very accepted, a very important person in the family and the priests the leader of the community would come and visit almost every week. So he had this social skill of having people come in to ask him for some help to support them, because he was the longest living person with that level of injury in our community. But these are the things that he said. But he said I still have hope and faith in God, otherwise I would have killed myself. But I believe God knows why I'm in this condition and he's the one who knows when I should die. So these are some elements of things that really, really matters for these people and if you can work on those ones, they can help them to survive and these ones help them also to add to their mental health, and these ones help them also to add to their mental health. Yeah, so now we have a supportive community.
Speaker 3:I've spoken about the supportive family, but the community really is very supportive. The only thing is that you cannot expect for them to be there tomorrow. They can be very supportive today, but there's no guarantee that tomorrow they'll give you the same support. But the family can be trusted. Now here is a man who has a spinal cord injury. Possibly they will carry him. Anyhow, they will try to get him to hospital, because it takes you maybe two kilometers from where you fall from the tree to get to where you can get into the car, because the road or the path that leads to the families it's very far from where you can pick the car. And they are helping. But do they know what they're caused? Maybe they're making the injury more complete, but deep inside they're helping and we see so many people children pushing people on their wheelchairs and you don't even ask them to do that. They see that you are struggling and they will come quickly and push you out of the mud. So the community is really supportive and if the community knew, or they know, what to do, I think it would be a very important area to strengthen for social support of these people. Yes, next one. Now this is where we are.
Speaker 3:I will tell you the story of where I work and when I left for South Africa in 2010 to do my masters at the University of Western Cape, I decided to do my master's thesis on quality of life, or what does life look like when you get spinal cord injury.
Speaker 3:So I went to interview 16 people in the rural community, but I was very shocked to see that all 16 people had gone to find an alternative to walk again after discharge from the hospital.
Speaker 3:So some had gone for prayers, others had gone for witchcraft I don't know how you call them. We call it alternative medicine here. Others have used herbs, a lot of other things that they had tried to try to find out why they are not able to walk. But also, most of them said they were not told clearly that they will never walk again Until they were discharged from the hospital in 2012,. Most of the patients were not told. They were told to work hard with exercises. They were told you have to exercise more, but nobody was there to tell them that you will never walk again. So I realized that most of the complications that they had it was lack of information, and also why they went for alternative medicine looking for ability, chances of walking again or being able to erect again was because this information was missing or it was not properly given. So when I came back I told my hostito or there was a professor who was working in this department and he said well, it's true that most of the people don't get that information very clearly.
Speaker 3:But that requires some counseling and we don't have a place where these people are properly counseled about the diagnosis and prognosis. So he assigned me, after I had finished my master's, to do that. He asked me can you do that? Can you tell them about what is spinal cord, how does it work and so on, and try to tell them at the end that they may not be able to walk again as they go home? So I started doing that. It was very challenging. Sometimes they will not understand. Sometimes they fall into depression because I didn't know really how to do it, because I'm not a psychologist. But with time I learned from a lot of errors that I made and from that time to date I'm the one who does that. But who should be doing that and when should that be done? Should they do that before surgery, for instance, or after surgery, or should we wait for six weeks? Sometimes we wait for six weeks. Let them settle, let them be stable, and that's why I want to put that one as an open discussion for all of us to see how does it work at your area.
Speaker 3:I was talking to Jane. Maybe there's going to be a webinar in the future where we can also dive more into that, but maybe today we can also talk about that, but the consequences that we see here. I will also finish before we start opening the discussion, because I spoke to the spinal surgeon here and he said when he tried to tell people that we are going to do spinal surgery, but this is not going to make you walk, but it's going to get you out of bed as early as possible and you're not going to get pressure ulcers. So they refuse to pay. They say I just want a surgery that will make me walk and not surgery that will put me on a wheelchair. So they would tell them we need to do surgery and see what will happen. So they leave them with a question mark and they will pay for surgery which is very expensive.
Speaker 3:Looking at the social, economic status of the people. They might need to sell a piece of land somewhere to pay for surgery here. So they might sell something very valuable for their life to pay for surgery. And they wouldn't pay if they knew that they are not going to walk again. So you have to leave them in dilemma, not knowing that they will not walk again or not for them to pay and have surgery done. Now, these questions are going to fall to the physiotherapist during sessions. These questions are going to fall to the nurse during dressing. Like now it is two weeks, am I going to walk again? So the challenge that I see here in my setting is that if you open before surgery, the challenge is that they would not mobilize funds for the surgery and they will end up with conservative treatment. So, yeah, can we open that for discussion If you want to talk or you want to put that on a chat so that we can learn from your experience.
Speaker 2:Hallelujah, thank you so much. We've we've got one question in the chat so far, so just while we're waiting for others regarding people's responses to that, kim, who's an OT, has asked where do the wheelchairs come from? Are they donated? Do people ever have to share wheelchairs? Are most people in manual wheelchairs or is there an option for powered wheelchairs?
Speaker 3:Yeah, thank you very much. That's a very good question. Yes, we have our own local factories, or we call them workshops for wheelchair production and we follow the WHO basic wheelchair provision protocol to have those produced that fit our environment. Actually, here the three wheelers works better, but most of people I must say 80% of our patients cannot afford one, so we have to depend on donated wheelchairs which are less expensive. They may have to contribute something for clearing the container, because when the containers come for donation we have to clear it from the pot, and that is they have to contribute. It's a cost shared thing.
Speaker 3:Those who don't have wheelchairs completely if we have donated wheelchairs, we still have to give them one, but most of these wheelchairs may not be that appropriate for the environment where they are going, but at least when we have them we do give them.
Speaker 3:Especially, like now. We don't have any donated wheelchair, so some patients are going home without one and those who are going, and sometimes we look at the backyard of the hospital and find any type of wheelchair which can be more harmful than not having a wheelchair, also If it doesn't have a cushion, and it can cause a lot of more complications compared to people who are maybe lying on the bed. So it's true that we have a big challenge and we don't have any option of a wheelchair. Only very rich people who happen to have this can order it from abroad. But here we don't have them. But we cannot even tell that option to our patients because they feel so bad that they cannot afford it. But if we see that they can afford it we give them a chance to order those ones from outside the country. But I must say we get some local support like Lions Club and Rotary Club in in in our town. They can buy two or three wheelchairs when there's a very dire need or when they have something to offer yeah, thank you, hallelujah.
Speaker 2:We've got another question which I will post um and which I will mention um pete. I don't know, while while we're doing that, if it's possible to kind of have a gallery option or kind of audio option for people, um, so I'll leave that one um that technical stuff with pete. But we've got um a question from wilkester, who says um which I think was just posted to the panelists, um, but the from the rehabilitation perspective, ot, physio and orthopedic um, wilkester suggests the community should be sensitized on matters of physical disabilities and need ownership which will prompt to make the pathways wide enough for passage of wheelchairs and maneuvering people using crutches and white canes. So about a kind of environmental and societal response that can help with a psychological response Wilkes-Barre was suggesting.
Speaker 3:Yeah, and I think that's very key because most of these people they say, well, even if I'm feeling down, I want to go out there and maybe watch football or something, but when there's inaccessibility I cannot come out of the house or I cannot leave my home environment to meet other guys out there and have a drink or so. Then that adds more to the how do you call it? Now, I'm not a psychologist, that's not a depression, that's mood where you are not happy, so you cannot go out. But if you could go out you could ease your mind, you could meet a friend on the way and talk a little bit. But actually, if we make accessibility possible, I'm sure that is more helpful and it can change a lot of other aspects of mental health. I saw someone also who asked about peer group trainers. Did we? I had a slide on that, lynn did we have that slide?
Speaker 1:There's still three slides left in your slide deck. Oh yeah, sorry. No, that's okay.
Speaker 3:Yeah, let me go to that because it's very important as we continue the discussion, I think. So this is a picture of a lady, if you want to follow her. She gave me permission to use this picture. She is called Wakonta. For those who can write down, she's one of our stars, wakonta Kapunda. I can write it on the chat. She's called Wakonta Kapunda.
Speaker 3:She uses her tongue to write movie scripts because she's a C5 complete injury. She has issues with sympathetic dysfunction, but she has moved beyond that and she's known throughout the country. She attended very big events because she can use her time to type on there. But I put her there because these are the times when people ask you when will I walk again, when you put them on a tilting table for 40 minutes and you have a lot to talk about. As a physio, I find that they use that as an opportunity to ask you about sexuality, about marriage, about having children. So you have a lot of time. And occupational therapists for goodness sake, they have even more hard time because they can take one hour or two hours with one client and they have to answer all these questions. That's why we feel that let's go to the next slide now. Yeah, we feel that training others you know peer group trainers we use them a lot in our hospital, all these ones that I've posted here they come to our hospital to talk to our clients before discharge, to encourage them and to show them there's a possibility to live again their questions based on their experience. That is very important, because I don't have a spinal cord injury, but someone has it and can talk from their own perspective. Let's go, and we use that a lot. The next one, please. So this is what we think, even though I suggest that we train physios, we train nurses, we train autists especially people who spend most of their time with personal spinal cord injury to have a little bit of aspects of psychosocial support and to know how do I deal with someone who is depressed and be able to answer some of their questions. That is important. And then you have your peer supporters and then you have to consider important others.
Speaker 3:Now family. I think they want to help, but they don't know much about Spano-Kodijari. So that education to the family is very important, especially this person who is going to live with the person with Spano-Kodijari for the rest of their lives. It could be a wife, it could be a caretaker. But here in Africa or in my area, really religious leaders, when nobody visits a pastor, will pop in and say hi and maybe make a prayer or something. So if they don't know prognosis and this diagnosis, they can give them false promises like miracles and so on. So if they know these things and they go there with the knowledge, they can be of a help in counseling.
Speaker 3:But we have seen people who still go to traditional medicine even though they come from a very big hospital. And even when they're informed, we still have some few people who still feel like, well, the doctor failed, but maybe someone who can speak to the spirits somewhere can make me walk again. So when they put them, maybe on a bed that does not have a proper mattress for one week, you're not trying to treat them. They come back with pressure sores. So these are people that we cannot avoid, because people still follow them. So you can train the person not to go there, but if they still go there, we need these people to know also if these people will lie down for too long, they'll get this and that. So those are some areas that I haven't covered and that's why I saw a question about peer groups.
Speaker 2:Hallelujah, thank you thank you very much. There's just another question coming from retination. I will just copy that um. If people would um want to raise their hands, pete can see that so he could then invite people to um to um say their questions. But we've got a couple of comments that have come in. Ernst has said the breaking of news the most important part of rehab varies from patient to patient depending on many factors age, cognition, family dynamics. Insight into awareness of recovery differs very much from one person to another. Time to be more certain of prognosis is usually by six weeks. What do people agree? That's a great question.
Speaker 3:I really would like to hear from other people. Yeah, what do you think people about breaking the bad news?
Speaker 2:Sorry, I missed that. Sorry I missed that question.
Speaker 1:I missed your comment.
Speaker 2:Was that a question to everybody? Hallelujah, sorry, hello yeah, sorry. Sorry, your comment I missed, I couldn't hear it. Yeah, I just want everyone to speak about that breaking the bad news.
Speaker 2:if someone wants to share their experience, so there's lots of people putting things in the chat. I'm not sure that everybody can speak, unfortunately, and also from Leanne she can only see us two. She can't see, we can't all see each other. So I will try and convey some of the comments from the chat which might convey what people are thinking on this. So Teish says I think we should be honest with the patient and should inform them about their wellbeing and health condition because it's their right to know. So this, so this responsible doctor should tell the patients that they will not be able to walk for sure. At the beginning it would be hard for the person to accept the reality, but in the long time it will help them understand their situation and they will find a way to cope with the condition and to improve their condition. No false promises should be given. I think one of the questions was about the timing, whether six weeks feels. Leanne, I can see your hands up.
Speaker 1:Oh, I just had a question for Hallelujah, but I'll let you finish. Oh, okay.
Speaker 2:What do you think about the timing? Hallelujah.
Speaker 3:Yeah, the timing is very tricky. I think what I find more useful is to understand the psychological adjustment, like at which level is this person like when they're very angry and they're blaming everything? Maybe you cannot do that and also, as someone said already, it depends on their background. There are some people who can receive that information in the first two days and there are some people who may take longer time. So I think one has to know are they still angry, are they still on denial? So I think it's a very challenging situation.
Speaker 3:Why I'm saying that is because we have had a case where someone was told he would never walk again and he ran into depressions, refused to eat anything for some number of days, he almost died.
Speaker 3:And what was so strange, we even called in a psychologist and failed, and a counselor and failed. But when the priest came in, he, he was open and he started eating. So it was very strange for us because we thought now we have to be able to think beyond. You know our professions and you know so I think the earlier the better, because I want to pay for surgery, knowing exactly what are the outcomes and why. Of course, if it's for surgery, you have to tell me benefits so that I can pay, even though I'm not going to work again.
Speaker 3:But some patients, when you tell them that maybe you cannot do the surgery on the same day because they might need some time to come to terms with that time to come to terms with that, so I think the earlier the better. But again, sometimes I take longer time, especially for patients who have so much ambition and they were promised so much before I met them and everyone told them positive thing about the diagnosis. Nobody gave them any negative thing. So they might long, a little bit long time to accept what I'm telling them.
Speaker 2:so, yeah, it's, it's not a straightforward answer, so to speak thank you, hallelujah, just to continue this theme, and then um wilkinson's put his hand up so we can probably go to the audio. But there's two other comments along, um, along the kind of prognosis information and I know, leanne, you had a question um. So, jane, um stanbridge from the uk said telling them from the beginning is important, but whether someone listens or takes it on board is the issue, especially if someone's incomplete. And ram has said um, from, also from the uk medical consultant, there is no right time that suits all. It has to be looked at on an individual basis, delivered in a compassionate manner and in an environment that is safe and appropriate.
Speaker 2:Most people know the answer but may not be ready to hear it and until they've spent some time in the rehab centre. And Wilkes-Wales just said it's not the right of the patient or the client to know the prognosis. How it is relayed is the matter? Then leave it to be said later. And, wilkes-wales, I know you had your hand up. Are we able to go to? Um? You're muted. Oh, hi, wilkes-. Hi, how are you Good? Thank you. Great, we can hear you.
Speaker 4:Yes, I'm grateful and I'm happy to participate in this webinar. I wanted to conclude as a person who has a disability and who is supporting persons with disabilities, as an occupational therapist and and as a cancer psychologist. Most of the time, especially in the rural areas where the pathways are very difficult to maneuver, I found it very necessary to work with the family and also the community, through the community leadership, to give them information on types of disabilities and how they are acquired, because there are those that are genetic and there are those that are acquired because of motorbike accidents or road accidents, and they're those that are required because of either motorbike accidents or road accidents. So I always tell the community that today it might be this person, the other day it might be you and it might be your relative. So the best thing to do is how can we make this environment become a condition for all of us?
Speaker 4:Because I believe in inclusivity. This person might be having an injury and a physical disability, but they might support us as a community, because some of the people of this accident are key decision makers and they can participate in community affairs committees and making decisions and supporting the community to grow as a whole. And so when you talk to the leadership, the elders and the church leaders and the people, everyone, they start getting information and getting the awareness that reduces the stigma and everyone starts getting involved and understanding that it's about us, it's not about that very person. Then they can now make the pathways a little bit accessible, because so and so's child is learning here and that's why I always advocate for even inclusive education, so people or children with disabilities can learn within their environment. Why is that very necessary? If we remove children from their environment and we take them to special schools, special colleges, they become foreigners in their own community.
Speaker 2:Now the community doesn't have the responsibility. They know that's the responsibility of the government.
Speaker 4:Actually, sometimes back in the day we used to be told that child is for the government and so the community doesn't have the responsibility. But in the environment it makes it easier that the children within the community get to understand that this is our colleague. The parent does not necessarily have to escort them. They can have a peer colleague to cover for them. We used to call them Pals, my Pals. So the first day, if that is a child with a visual impairment, they can be taken to school the first week with the parent or the sibling. But the next day I've made friends. Friends now it's the friends who come for that child from home time for school with someone with a wheelchair. They push and you see, now the whole community gets involved and that's that's. That's the best way, that's sustainable and also community-owned responsibility.
Speaker 2:Thanks so much thank you very much. Is there anything you'd want to respond? We've got another question in the chat and I know Leanne had her hand up as well.
Speaker 3:Yeah, I think what she brought up is very, very important when the community interprets it as their issue. And sometimes, you see, we also find that there are some issues whereby people with disability or with spinal cord injury, they're actually maltreated by their own family or by their own husband. Someone is maltreated by the husband or by the wife, and if the community is well aware that this is our responsibility, they become more protective even to the person, because they are also how do you say they are marginalized, so to speak. So the issue of infrastructure is very important, a political or policy issue, and we cannot take it at individual level or at individual family level. It's a community thing. And, as she said, in the rural area you have to think not only about the politics. But the religious leaders have a very big voice. It can be announced in the church that next Monday we are going to work on the road, so they can come and try to do something on the road.
Speaker 2:Remember, we are not talking of tarmac roads.
Speaker 3:We are talking of roads that you can use, your, your, your the things that you use in your farm to make it better for someone, maybe with a challenge, and if that is done, then also it comes to the school, it comes to the church itself, it comes to areas where this person with a disability can visit, and you know, the more they go out the more they engage, the better their mental health and that is what I think that is very, very important, what she brought up, and that is how we should go.
Speaker 3:The challenge that I see in Tanzania for now it's because of many parties, political parties. So if the ruling party gives them this order that we should do this, or that people from the opposition party, the response is not as the time when you had one party during the Malini era time. So if there was an announcement that we are going to work on the road, in that time there was no objection. But nowadays people will come and say, no, we are not going to work on the roads because we pay tax and the tax should do that. You know, those are the people from the non-ruling party. So the politics has a lot to do with accessibility and if politics is not good, we may not expect much really, and we cannot run away from politics because it makes all these things happen. So it's true that community involvement is a key to get accessibility better.
Speaker 2:Thank you, and there's a question from Dirk in the chat of is there long-term follow-up after rehab? Is that possible and organized, particularly because of people having secondary health conditions, as we know, after spinal cord injury?
Speaker 3:from the tanzanian context and I think it's from most of the rural areas. Unfortunately no, and that's the biggest thing that we we are worried about that we had. Maybe they pay a lot of money and we are doing a lot to get them, you know, to train them to be active and this and that, but once they are discharged we don't have that service where we can do a follow-up At least. I give them my phone number, they can call me when they have an issue, I can advise them on the phone at least. And that is on a personal basis. It's not a possible arrangement. And I and that is on personal basis, it's not a possible arrangement and I feel that is something that should be possible to be arranged by a hospital whereby they should be able to call because, um, again, going there they're so scattered, it can be expensive and who's going to bear the cost?
Speaker 3:So again it goes back to the politics. What's the policy of the country when it comes to fall up? Who is going to pay that? Who is going to give you the transport? Who is going to pay for that cost? So it's not there yet, I must confess, but it's a very important element that is missing in our city. I don't know about other rural cities.
Speaker 2:Thank you, and Leanne has very, very patiently waited for your question. Leanne, my apologies, I was just kind of covering others, please go ahead.
Speaker 1:No, totally fine. I feel cheeky that I get to ask a question actually, hallelujah, you mentioned you learnt from many mistakes when you were first given the task of breaking the news. Were first given the task of breaking the news, do you mind sharing a mistake that's helped you be able to communicate better today, if you're feeling comfortable to? Because, yeah, interesting.
Speaker 3:Yes, I think one of the biggest mistakes was I once concerned a patient and told him he will never walk again without telling him. You know, now I learned that I have to take them through the anatomy, through the function of the brain, you know, at their level, to understand how these things work. So I told him that you will never walk again without telling him the pathology or the anatomy a little bit to understand how these things connect. And then he went to home and then he was told he was asked about his sexual function and he said I think I wasn't told about that. So they tried to go somewhere else to try to get some solution for this, for erection. So when I met him next time he blamed me a lot because he said you told me that I'll not walk again, but you did not tell me about sexual function and that I'll never erect again. So I've spent this much. He has spent a lot of money on trying to recover that it's because my counselling was incomplete.
Speaker 3:I was supposed to cover a lot of other elements and so now when I do this counselling, I also ask them do you know also about your erection, if they're spastic and they're not spastic, and what are the possibilities of getting involved in sexual life again and so on. And also he did not ask me about that during the counseling and I didn't have it in mind. I came to realize later that this matters more to Muslims than walking again sometimes. So if you don't cover that area, they may walk out of that room because maybe you look younger than them and they wouldn't ask you that. And if you don't cover that area, they still go in the same direction of those who are going to spend a lot of money trying to walk again, but these ones are going to spend a lot of money trying to erect again.
Speaker 3:So I think that was one one area that I learned, that it has to be more comprehensive than walking. And that's just to cover a lot of other aspects, like complications, like you know, the sexual life and so on. But also I had counseled someone who I asked him whether he wanted the counseling with the wife, and then he said no. But then he came with the wife, but he said no. But then he came with the wife, but he had said no. So that was a very challenging environment for me. Should I continue with the counseling?
Speaker 3:but he said now my wife is here, you can start cancelling and I realized that maybe you need to cancel this person individually first, before the wife come in, because I ended up speaking some things that he didn't want the wife to hear at that particular time. So maybe you have to have one-on-one first me and the person and ask him if he would like the wife to come in next time also, or he would like to talk to the wife himself. So those are the things that I learned along the way, so yeah, thank you.
Speaker 1:It's when we can learn the best, when we figure out what we shouldn't be doing.
Speaker 2:Um, jane, had it up, thank you yeah, I it um your, your response um Halu was was really thoughtful and um, I was thinking um about an interesting question, not to be able to be answered now but but to the group, if we were to do a workshop is whose responsibility is it to provide that kind of information? And I think what often happens in rehab is everybody thinks it's everybody else's and or somebody else has done it. And that's where people fall between not having information because um each, each professional group thinks perhaps it's being covered in a different setting. Um, and I don't know if you have any experience of I mean, I I think probably it's everybody's, but whether there's somebody who's has a more primary responsibility would be an interesting, um interesting discussion. Um, but also you know your, your experience that you said about um doing it with the individual and then the family, I think is really is really valuable, because then you can kind of broaden it, broaden it out, but do you does it sit with anybody in your service who should do that discussion?
Speaker 3:yeah, I've given my experience. I don't know from others because from my experience it wasn't done by the doctor because there was not that session. It was like, if it is a guideline, there is nothing. Like you know, prognostic counseling, for instance, it was completely skipped. So anyone who find out that they have more time with the patient, remember here after surgery, the doctor, the surgeon, would only pass through the ward round and through the ward round and through the ward round.
Speaker 3:All these students around you have, you know, a patient next bed. You cannot give that information to anybody at that ward round. So it's during therapy that they ask all these questions and I think the person, everyone, should be able to do this counselling. But you have to have enough information. Also, because you don't want to. They'll ask you also about spasticity and they'll ask you about sexuality. They'll ask you about their bladder and barrel. So if you don't have much information specific to spinal cord injury, they may not trust you so much because they feel like he doesn't know about this, he doesn't know about that. Who is he to tell me about walking again, for instance? So I think I am on your side to think it's everyone who works with a patient with spinal cord injury that we need to make sure that everyone who is doing that has some certain you know. For instance, you cannot avoid talking about sexuality.
Speaker 2:You cannot avoid that even though they may accept that they are not going to work again.
Speaker 3:They'll ask you about erection. They'll ask you about having children. They'll ask you about getting married. You know, yeah, maybe you hear from others.
Speaker 2:Thank you, hallelujah um. Just from the chat. Peer support is vital, definitely. Um is one of the comments as it gives lived experience. However, they need to have the right peer supporters, need to have the right training um, because they can be giving just their experience and not best practice or not understand the differences in level of injury um, and then wiltshire has said um, this has helped to make um a follow-up on discharge from hospitals and those who have just been identified and are yet to have been seen by rehabilitation um and the and the importance of early intervention and immediately after birth from people who've given following childbirth, I think. So that was yeah, that's speaking from the community-based rehabilitation workers in Kenya that have been involved in training and they've been given basic skills on identification of personal disabilities, use of locally available resources to support and basic exercises, what can be done in the home program. We get loads of good information. Thank you very everybody for sharing.
Speaker 2:I'm going to hand back hand back to leananne um because I think we're probably just coming up. It's a bit limited and maybe this is a learning for us. Leanne um for our, because we've simply set the function as a webinar um that doesn't allow people to be a gallery view, um, so maybe, um, we can have a chat with you afterwards in terms of what might be the better settings to enable people to see each other and kind of participate a bit more. But from my perspective as chair and before I hand back to Leanne, thank you very much for everybody's contributions We've had. Even though the chat the actual audio chat has been very limited, the written chat, the chat in the chat, has been amazing and really rich and has given us some good ideas for a potential webinar that we could do as a psychosocial SIG. On this and, leanne, I'll tag to you, thank you.
Speaker 1:Thank you, jane, and thank you, hallelujah, for your presentation and for answering the questions. It's really fantastic to hear the practices and experiences in other countries. I've just got a few slides to wrap this session up. Just in regards to our special interest group activity, for those of you who aren't aware, we have the ISCOS annual scientific meeting in Gothenburg in October, which is very exciting, and we will be having a meeting on that program. We haven't confirmed the day or time, but if you're on the mailing list, that will be one way that we will be able to communicate to you when that is and, for those who are attending ISCOS, you'll be able to see it come up on the program. This meeting will be for people who are attending ISCOS. It's not something that will be online, so it'll be a lovely in-person meeting, which will be nice.
Speaker 1:There's also another masterclass coming up and if you scan this QR code, you'll be able to get some more information. It's on sexuality relationships and rehabilitation, being conducted in May June. It looks like three half days. Yeah, well, there it is. It says three half day online workshop, which will be really exciting. So please scan that qr code. Um, if you're interested, I'll just give you a little bit of time to pull your phones out, uh, and then, for future events, please scan the first qr code to join our mailing list.
Speaker 1:If you haven't done already, it's free to join our special interest group and, as I said, we have two webinars each year, so the next one will be on the 6th of November. We have Dr Emily Bray, who's based in Queensland, here in Australia, and she's going to be talking on some reflections on a five-year post, on five years of an Engage program which is looking at engagement of people with spinal cord injury, which will be a really fantastic presentation for sure. So if you're on our mailing list, you'll get more details about that, where you can register and then get a link to the session. And then, finally, we'd love your feedback on this webinar that we've given. So the second QR code there on the left of screen. We'd really love to hear your thoughts on the format. As Jane's highlighted, we've used this webinar format, which unfortunately means we can't see everyone, but we'll have a chat and and figure out if there's a different way and then that's it. Um, but I do believe we don't have twitter anymore, jane. Is that right or not?
Speaker 2:x, I should say um, I have yet to post to say we're going to get off it, but we are planning definitely to to exit it. So, um, so I would encourage exit x. So I'd encourage people if you're not linked up with us via linkedin that um to do so, because that will be the best way to get media information, and to join our mailing list, because then you'll get specific information sent to your email box fantastic, so thank you very much everyone.
Speaker 1:Thank you again. Hallelujah really appreciate it and we look forward to hopefully seeing you for the november webinar.