## Introduction

#### Education

Perhaps the most important ingredient for the prevention and management of PUs is education. The goal of improving education applies not only to the patient but also to the patient’s physician, nurse, therapist, family and community. In order to live successfully with SCI, individuals need to understand the possible complications of their condition, a knowledge base that often begins in rehabilitation centers. Unfortunately, in many developing nations, specialized rehabilitation centers with trained rehabilitation personnel are very rare.2, 41 After the 2005 Earthquake in Pakistan, Rathore et al.8 noted fewer complications such as PUs among those with SCI when specifically treated by rehabilitation specialists, a finding that has been well-established in the developed world.71 Even without dedicated rehabilitation centers, all medical personnel who interact with SCI patients should have at least a basic understanding of SCI management, ideally learned in medical and nursing school.

Improving SCI education in the developing world is no simple task however. First, in regions of the world plagued by rampant infectious disease, poverty and/or civil unrest, care of the disabled simply falls beyond the capacity of limited healthcare resources. Second, the multitude of languages and dialects, a poor understanding of human anatomy and physiology, and devastatingly low literacy rates in many developing nations makes dissemination of knowledge challenging.8 Finally, care providers, and especially international aid organizations, need to understand and operate within the context of their patients’ lives. In a comparative analysis of people living with SCI in 14 countries representing all WHO world regions (Thailand, India, Vietnam, Malaysia, Denmark, Germany, Switzerland, New Zealand, Australia, Israel, USA, Canada, Brazil and South Africa), Reinhardt et al.72 noted, ‘health professionals know only little about the environment of their patient,’ a situation likely to breed unrealistic expectations of how one is to care for oneself once living at home. Indeed, even if ‘first-world’ care is provided to a patient in the hospital, these efforts will go to waste if the necessary care cannot be continued after discharge.13 In other words, hospital and rehabilitation treatment strategies must be tailored to a patient’s outpatient world.

Finally, the notion of education is also paramount as it applies to public awareness and dissolution of social stigmas. Community reintegration and peer support are pivotal components of success after SCI and are known to be associated with decreased rates of PUs and other SCI-related complications in the developed and developing world alike.28, 40 Unfortunately, both environmental and psychosocial barriers impede community participation. In Iran, individuals with SCI report social isolation and feelings of being pitied.9 In Pakistan, disabled persons are often concealed in the home because disability is believed to bring guilt and shame upon a family.41, 42 Such situations may foster depression and limit motivation towards self-care. Indeed, psychological comorbidities such as depression and anxiety themselves may foster PU development.40 In the end, more than ramps and wheelchair-accessible buildings are necessary to decrease complications associated with poor community accessibility; community integration will also require improved societal understanding of SCI.

## Conclusions and future directions

The preceding discussion supports the hypothesis that PUs are more difficult to prevent and treat in developing nations where the risk factors for PUs such as poverty, low education, limited activity level and malnutrition, are more prevalent. That said, this discussion also suggests that PU rates in the developing world can be decreased with improved acute care, adequate nursing, improved support surfaces and education.

In order to decrease the incidence of PUs in developing countries, we first need to understand the actual weight of the burden. There is currently little data on the true prevalence or cost of PUs in many regions of the developing world, regions where we expect the burden to be particularly high. Fortunately, organizations such as the International Spinal Cord Society have established data sets that could be used to standardize international data collection on PUs.73 Even with these data collection templates, however, harvesting information will be a challenge in hospitals and clinics with vast catchment areas connected by poor roads, lack of electronic records and few if any rehabilitation specialists.

Irrespective of the true statistics, there are clear targets for improving PU prevention and management and for SCI care more generally. Perhaps the most obvious deficiency highlighted here is that of dedicated rehabilitation centers and trained rehabilitation providers. Although there has been some progress in bringing rehabilitation strategies to the developing world, there is still a lack of rehabilitation medicine in many remote or impoverished regions. Tackling this deficit will be challenging. A first step towards the naissance of dedicated rehabilitation centers and providers is education. To this aim, a recent initiative by the International Spinal Cord Injury Society and other collaborating partners has developed a wide range of electronic learning modules for SCI available at no charge over the Internet (http://www.elearnsci.org). In addition, there are a variety of other useful online resources such as the Spinal Cord Injury Rehabilitation Evidence project (scireproject.com) and the Paralyzed Veterans of America Consortium for Spinal Cord Injury Clinical Practice Guidelines (http://www.pva.org), to name only a few.

Although affordable and durable medical devices for PU management do exist, further research in this area is needed. Importantly, these devices must fit within the context of the patient’s environment, and patient and caregiver training with such devices is essential. Finally, public awareness campaigns are needed to minimize risk factors for PUs, to promote community integration, and to empower people with disabilities.

In many ways, management of SCI in developing countries is a unique opportunity to improve SCI care throughout the world. It is an opportunity to build on years of experience in developed nations whereas also breaking new ground. Who knows what might be discovered when a system of care is rebuilt in a different clime, with fresh insight.

Finally, though uncomfortable, it is necessary to ask the difficult question—is it worth it? In world regions where healthcare resources are slim and public health issues like infectious disease, malnutrition and fetal and maternal health have a much larger societal impact, should communities invest in improving SCI outcomes? The authors would like to suggest that the answer to this question is indisputably yes. For those who are willing to reach out beyond the borders of the developed world, there are many patients, families, providers and communities eager to learn, to heal and to thrive.

## Data archiving

There were no data to deposit.