Accessibility is a broad term encompassing many elements and may include physical, socio-cultural and technological aspects. This case study highlighted issues of environmental accessibility. The degree of environmental accessibility that a person with SCI has is a function of both the physical accessibility of the private and public environments and the degree of functioning and mobility of the individual with and without assistive devices. Under ideal circumstances, there is a collective coordination and optimization of these elements in a patient’s life and community. Some of these are:
- The patient receives proper rehabilitation and is fitted with appropriate assistive devices;
- The private environment (living and/or working) is adapted for optimal accessibility based upon a patient’s specific limitations and needs;
- Government policies establish minimum standards for public accessibility for the disabled;
- Public planning incorporates these policies in the public sphere and in the private sector, building codes must be enforced to ensure access(e.g. wheelchair accessibility).
In Mr. Wun’s case, his acute care focused primarily on stabilizing and treating body functions and structures; his subsequent rehabilitation at home as well as during the follow-up Rehab Cycle worked at treating secondary complications, maintaining health and improving mobility. While the latter Cycle Goal helped increase Mr Wun’s mobility, environmental accessibility – vitally important to his quality of life and community integration – remained unaddressed.
Over the 16 months following his injury, accessibility was addressed on a few levels: the use of his computer has allowed him to maintain a degree of connectivity; the improvement of body structures and functions has increased his mobility; the provision of a wheelchair (although its heavy weight has presented further limitations); and the adaptation of the family home for greater accessibility. Nevertheless, improving access to the outside world continues to present Mr. Wun with a significant challenge in learning to live with SCI. The measures and interventions undertaken by Mr. Wun’s rehabilitation team and family have not been sufficient to provide him with accessibility outside of his home.
Poor road and sidewalks conditions, physical barriers, limited usable public transportation are some of the common external environmental factors that present barriers for him. And beyond limiting physical accessibility, these barriers negatively impact his efforts at reintegrating into the community at large.
Ratification and the subsequent adoption of laws to increase environmental accessibility have demonstrated the government of Thailand's political will.
Aspects of accessibility in public space must often be addressed at a governmental level (see examples in Box 3 below). An absence of interventions by the Thai government for those living with disabilities contributed greatly to his lack of accessibility.While the government signed the UN Convention on the Rights of Persons with Disabilities in 2007 and ratified it in 2008, this has not yet translated into infrastructural changes to improve accessibility.
However, ratification and the subsequent adoption of laws to increase environmental accessibility have demonstrated the government of Thailand’s political will in this area. While these policies and legal amendments offer an important starting point, effective strategies and the necessary resources for translating these frameworks into real increased accessibility for those with SCI and other disabilities is still greatly needed.
Box 3 | Guideline Examples for Two Specific Measures for Improving Access: Walkways and Wheelchairs
A. Design guidelines for footpaths and footways 1
The following guidelines are an example of specific standards established to increase accessibility established by the European Conference of Ministers of Transport in 1999:11
Provision of safe, easy access for everyone walking or using a wheelchair
- a minimum obstacle free footway at least 1800 mm wide – preferably 2000-2500 mm
- width should be greater at bus stops (minimum 3000 mm) and in front of shops (3500 mm or more)
- if possible gradients should be not more than 5 percent (1 in 20) to cater for self-propelled wheelchairs: this should be used as a design limit in new development
- where gradients are unavoidably steeper than this, level areas (preferably 1800mm long) should be incorporated at intervals of 10 meters
- crossfalls, which are needed to make sure rain water drains away quickly, should not be more than 2.5 percent (1 in 40). Anything steeper than this makes it difficult for a wheelchair user to steer in a straight line
- where there is a drop or steep slope at the rear side of a footway (or both sides of a footpath) a 100 mm edging upstand should be provided as a safe guard for wheelchair users and as a tapping rail for long cane users
- surfaces should be non-slip, well-maintained and any joints between paving labs should be closed and flush to avoid catching the small wheels of a wheel chair
- covers and gratings should be non-slip and flush with the pavement surface
- nothing should overhang the footway (signs, tree branches etc.) to a height of less than 2100 mm (preferably 2500 mm)
- where it is not possible to avoid having obstacles in the pavement, such as lamp-posts, traffic signs etc. should have a contrasting band of color 140 mm to 160 mm wide with the lower edge 1.5 to 1.7 meters above ground level. Trees in footway should have a distinctive surface around them (for example grating or pebbled) to warn blind people
- seating should be provided at regular intervals of around 100 meters.
For most persons living with SCI, the wheelchair is a common and indispensible device for increasing mobility. A wheelchair can do much to increase accessibility, independence, participation and social integration. The UN Convention on the Rights of Persons with Disabilities sets an obligation by States to “take effective measures to ensure personal mobility with the greatest possible independence for persons with disabilities.” In other words, persons with disabilities have a right to mobility aiding devices including wheelchairs. Wheelchairs must be appropriate, meaning they:
- Meet the user’s needs and environmental conditions
- Provide a proper fit and postural support
- Are safe and durable
- Are available
- Are affordable and can be maintained in the country
In many cases in low-income settings, persons with disabilities cannot afford wheelchairs and funding sources must be mobilized through government funding, donors and wheelchair funds, for example. Other barriers to wheelchairs include physical barriers of inaccessible surroundings, lack of training and rehabilitation and poor choice in terms of the proper type of wheelchair. It is therefore important that policies for providing wheelchairs address issues of design, production, supply, service delivery, training and financing.
In sum, environmental factors can be a significant contributer to life satisfaction to those with SCI. While rehabilitation can maximize a patient’s access to the environment by optimizing his or her body structures and functions as well as extending a patient’s range of activities and providing assistive devices, healthcare providers’ interventions have limited effects.
Given sufficient resources, the home environment can be adapted or a patient can move to increase accessibility in the private domain. However, for those living with SCI, true environmental accessibility in the public sphere needs to be addressed not only through aspects of the rehabilitative process, but at a broader societal level. In Thailand, ratification of the UN Convention on Disability and legislative efforts were an important beginning. But Mr. Wun’s case illustrates that many challenges remain in making environmental accessibility a reality.