Environmental factors influencing the prevention of secondary health conditions among people with spinal cord injury, South Africa

Sonti Pilusa; Hellen Myezwa; Joanne Potterton

doi:10.1371/journal.pone.0252280

Peer Review History

Original SubmissionJune 30, 2020
20 Oct 2020 Decision Letter - Juliet Kiguli, Editor PONE-D-20-20175 “My support system has collapsed, that’s why I ended up developing bedsores”: environmental factors and secondary health conditions among people with spinal cord injury. PLOS ONE Dear Dr. Pilusa, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Dec 04 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Juliet Kiguli, MA, PhD Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please include additional information regarding the interview guide used in the study and ensure that you have provided sufficient details that others could replicate the analyses. 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In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. 4. Please amend the manuscript submission data (via Edit Submission) to include author Hellen Myezwa. 5. Please amend your list of authors on the manuscript to ensure that each author is linked to an affiliation. Authors’ affiliations should reflect the institution where the work was done (if authors moved subsequently, you can also list the new affiliation stating “current affiliation:….” as necessary). 6. Please include a separate caption for each figure in your manuscript. Additional Editor Comments: Thank you for your article. Please kindly address the reviewer's comments and also proof read the word to correct any English errors. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for the opportunity to review your manuscript. Your title is engaging and your work investigates an important topic in SCI management. General comments: • When referring to your participants with SCI, please refer to them as “participants”, rather than “patients.” While it is appropriate to use the term “patient” when individuals are in-hospital, or receiving direct medical or rehabilitative care, people with SCI who have enrolled in your study and who are presumably individuals in the community should be referred to as participants to reflect participatory nature of their study participation. Please refer to: Harvey, Lisa A. 2019. “Words Matter. Spinal Cord Asks Authors to Choose Their Words Carefully.” Spinal Cord 57(4):257–257. • Your manuscript states that studies of environmental impacts on SHC prevention are limited in low-middle income countries. There is quite a lot in the literature for higher income countries, and persistent barriers arise regardless of the type of health care system, but for different reasons. That said, what are the underlying causes of your findings that are specific to how rehabilitation / health care is delivered in South Africa? As this is an international journal, your readership may not have a base understanding of your system. Reading your manuscript, I wanted to have a better understanding of the differences between your healthcare system and the one in my country. Please include a concise but informative description of how it works in your country (Private system? Public system? Combination of both? Who typically pays for what and when?). I encourage you to think broadly about the entire welfare regime – in other words – how your nation protects its most vulnerable not only in terms of health care, but also social resources for community living. Then, in the discussion, you can speculate how your results are tied to the structural barriers imposed by the health and welfare system, as appropriate. • You introduce new results / material in the discussion and the conclusion (a figure). Please restructure appropriately. Introduction: • Lines 64-65, surprising that respiratory complications are missing from list of secondary health conditions, unless that is less of a problem in South Africa than in other regions. • You discuss the Guilcher study, and then allude to differences between Canadian and South African health care systems. As I indicated under general comments, a better understanding of the South African system would strengthen your manuscript. While you indicate that South Africa does not have national health insurance, you indicate that 84% are reliant on the public sector, presumably supported by the government. Please clarify how it generally works, including information about the other 16% - are they wealthy and pay privately? • There are persistent links between disability and poverty world-wide, in low income to high income countries. You indicate that a large proportion of the general population in South Africa lives in poverty. Can you comment on the proportion of people with disabilities living in poverty in South Africa? Methods: • Please provide more detail about recruitment, were prospective participants personally invited (if so, by whom), were there flyers, did you go to the therapy gym to recruit therapist participants, did SCI participants identify the caregiver participants, etc. • Describe purposive recruitment relative to your recruitment goals. Did you seek to recruit a wide range of injury levels, etc.? What other characteristics were considered? • Is it possible to include your interview guide as an appendix, or provide examples of questions / topics that were addressed? • Line 109: Did all interviews last 60 minutes? In results, may want to indicate average length and range. • Did you begin coding with a preliminary set of codes from your interview guide? You discussed the ICF in the introduction. Did you use the ICF as a theoretical framework and if so, how did it influence your analysis? Results: • You have a very low number of participants with cervical level SCI. Please provide (in the discussion as relevant) reasoning for this – I wonder if people with higher level injury experience greater barriers returning to the hospital for follow-up and were thus less likely to be recruited. • Line 167: Please de-identify the name of the hospital / rehab center. • Your section on Health care system inefficiencies would benefit, as previously suggested, from a brief but informative overview of how health care and rehabilitation are managed in South Africa. • The latter half of the results section gets a bit thin, with several headings without substantive content or thick description. • In general, I think your results are important, but not surprising to people who work in SCI. Most if not all of the issues you report are experienced by people with SCI, to some extent, even in wealthier countries, but for different reasons. Since you acknowledge that there is a dearth of information in low-middle income countries about environmental factors that influence SHC prevention, you could spend some time in the discussion addressing why the results are the same or different (more below). Discussion: • Your discussion section should lead off with your most important finding(s), then include additional literature as relevant. As currently written, you begin reviewing literature without context to your findings. Indicate how your findings are congruent or incongruent with the studies you reference in the first paragraph. • Lines 261-263 – this is a result, and should be reported under results in order to be addressed in the discussion • It is great that you discuss CRPD and SDGs. Since South Africa has ratified the CRPD, issues experienced by people with SCI can be addressed through UN reporting processes – please discuss how this has the potential to improve rights of people with disabilities. • Since the goal of your manuscript is to investigate SHC prevention in a lower-income region, it seems important for you to address / speculate about the root causes of your findings. What contributes to the shortage of resources (meds, supplies, assistive technology, etc.)? Lack of government investment? Again, it will be helpful for the reader to have a basic understanding of the South African health care system. For example, in the United States, access barriers can arise from insurers’ unwillingness to pay for certain resources, and if a person cannot pay privately, they do without. Are the shortages in South Africa different in that resources are unavailable even if someone was wealthy enough to pay privately? • Similarly, regarding prevention and care – what contributes to your reported non-compliance of health workers to various protocols – are they onerous to follow, lack of knowledge about their existence? What are the institutional influences that contribute? • In general, you could shorten the discussion somewhat by concisely addressing the issues specific to your findings and your overall goal of examining environmental barriers to SHC prevention in a lower-income nation. Conclusion • Conclusion: You introduce new material in the conclusion – Figure 1. This material would be better placed in the discussion, or perhaps even results section. References: • Please correct reference #9 ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. 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Revision 1
15 Jan 2021 Author Response Table 1: Editors comments Corrections - highlighted in grey Editors Comments corrections Section 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Revised Please include additional information regarding the interview guide used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a guide as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. In addition, please include any further details about the development and validation of this tool. Details on the interview guide included in the data collection section Supplementary document added Details on the interview guide included in the data collection section Line 126-131 We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories Added file as supporting information Please amend the manuscript submission data (via Edit Submission) to include author Hellen Myezwa. Amended Please amend your list of authors on the manuscript to ensure that each author is linked to an affiliation. Authors’ affiliations should reflect the institution where the work was done (if authors moved subsequently, you can also list the new affiliation stating “current affiliation:….” as necessary). Corrected Please include a separate caption for each figure in your manuscript. Figure removed Please kindly address the reviewer's comments and also proof read the word to correct any English errors. Revised Table 2: Reviewers comments Reviewers comments Corrections Section General comments When referring to your participants with SCI, please refer to them as “participants”, rather than “patients.” While it is appropriate to use the term “patient” when individuals are in-hospital, or receiving direct medical or rehabilitative care, people with SCI who have enrolled in your study and who are presumably individuals in the community should be referred to as participants to reflect participatory nature of their study participation. Please refer to: Harvey, Lisa A. 2019. “Words Matter. Spinal Cord Asks Authors to Choose Their Words Carefully.” Spinal Cord 57(4):257–257. Corrected throughout the manuscript Patients with SCI replaced with participants or people with SCI Your manuscript states that studies of environmental impacts on SHC prevention are limited in low-middle income countries. There is quite a lot in the literature for higher income countries, and persistent barriers arise regardless of the type of health care system, but for different reasons. That said, what are the underlying causes of your findings that are specific to how rehabilitation / health care is delivered in South Africa? As this is an international journal, your readership may not have a base understanding of your system. Reading your manuscript, I wanted to have a better understanding of the differences between your healthcare system and the one in my country. Please include a concise but informative description of how it works in your country (Private system? Public system? Combination of both? Who typically pays for what and when?). I encourage you to think broadly about the entire welfare regime – in other words – how your nation protects its most vulnerable not only in terms of health care, but also social resources for community living. Then, in the discussion, you can speculate how your results are tied to the structural barriers imposed by the health and welfare system, as appropriate. Revised the introduction and added a section on the South African context and the health care system Line 67-101 • You introduce new results / material in the discussion and the conclusion (a figure). Please restructure appropriately. Removed the figure Introduction • Lines 64-65, surprising that respiratory complications are missing from list of secondary health conditions, unless that is less of a problem in South Africa than in other regions. Revised Line 60-65 You discuss the Guilcher study, and then allude to differences between Canadian and South African health care systems. As I indicated under general comments, a better understanding of the South African system would strengthen your manuscript. While you indicate that South Africa does not have national health insurance, you indicate that 84% are reliant on the public sector, presumably supported by the government. Please clarify how it generally works, including information about the other 16% - are they wealthy and pay privately? • There are persistent links between disability and poverty world-wide, in low income to high income countries. You indicate that a large proportion of the general population in South Africa lives in poverty. Can you comment on the proportion of people with disabilities living in poverty in South Africa? Revised the introduction and added a section on the South African context and the health care system Line 67-101 Methods Please provide more detail about recruitment, were prospective participants personally invited (if so, by whom), were there flyers, did you go to the therapy gym to recruit therapist participants, did SCI participants identify the caregiver participants, etc. Added a section on recruitment Line 126-129 Describe purposive recruitment relative to your recruitment goals. Did you seek to recruit a wide range of injury levels, etc.? What other characteristics were considered? Added in Line 116-122 Is it possible to include your interview guide as an appendix, or provide examples of questions / topics that were addressed? Included topics covered and added the interview guide as a supplementary document Line 126-129 Line 109: Did all interviews last 60 minutes? In results, may want to indicate average length and range. Revised the sentence Line 134 Did you begin coding with a preliminary set of codes from your interview guide? You discussed the ICF in the introduction. Did you use the ICF as a theoretical framework and if so, how did it influence your analysis? Revised 140-144 Results You have a very low number of participants with cervical level SCI. Please provide (in the discussion as relevant) reasoning for this – I wonder if people with higher level injury experience greater barriers returning to the hospital for follow-up and were thus less likely to be recruited. Added a possible reason for low number of participants with cervical level SCI in the paragraph on the study limitations Line 339-348 Line 167: Please de-identify the name of the hospital / rehab center. Revised –removed the name in the quote Line 191 Your section on Health care system inefficiencies would benefit, as previously suggested, from a brief but informative overview of how health care and rehabilitation are managed in South Africa. Overview of the health system outlined in the introduction The latter half of the results section gets a bit thin, with several headings without substantive content or thick description. Revised Line 203-250 Discussion In general, I think your results are important, but not surprising to people who work in SCI. Most if not all of the issues you report are experienced by people with SCI, to some extent, even in wealthier countries, but for different reasons. Since you acknowledge that there is a dearth of information in low-middle income countries about environmental factors that influence SHC prevention, you could spend some time in the discussion addressing why the results are the same or different (more below). Revised the whole discussion section Your discussion section should lead off with your most important finding(s), then include additional literature as relevant. As currently written, you begin reviewing literature without context to your findings. Indicate how your findings are congruent or incongruent with the studies you reference in the first paragraph Revised Line 256-258 Lines 261-263 – this is a result, and should be reported under results in order to be addressed in the discussion Revised Line 263-265 It is great that you discuss CRPD and SDGs. Since South Africa has ratified the CRPD, issues experienced by people with SCI can be addressed through UN reporting processes – please discuss how this has the potential to improve rights of people with disabilities. Added a section on how the issues experienced by people with SCI can be addressed Line 329-337 Since the goal of your manuscript is to investigate SHC prevention in a lower-income region, it seems important for you to address / speculate about the root causes of your findings. Added the reasons for the findings in the discussion section What contributes to the shortage of resources (meds, supplies, assistive technology, etc.)? Lack of government investment? Again, it will be helpful for the reader to have a basic understanding of the South African health care system. For example, in the United States, access barriers can arise from insurers’ unwillingness to pay for certain resources, and if a person cannot pay privately, they do without. Are the shortages in South Africa different in that resources are unavailable even if someone was wealthy enough to pay privately? Added a section on the South African health care in the introduction Similarly, regarding prevention and care – what contributes to your reported non-compliance of health workers to various protocols – are they onerous to follow, lack of knowledge about their existence? What are the institutional influences that contribute? Added the reasons Discussed the reasons 302-305 In general, you could shorten the discussion somewhat by concisely addressing the issues specific to your findings and your overall goal of examining environmental barriers to SHC prevention in a lower-income nation. Revised Conclusion • Conclusion: You introduce new material in the conclusion – Figure 1. This material would be better placed in the discussion, or perhaps even results section Removed the figure References • Please correct reference #9 Revised Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0252280.r002
15 Apr 2021 Decision Letter - Subas Neupane, Editor PONE-D-20-20175R1 “ Environmental factors influencing the prevention of secondary health conditions among people with spinal cord injury, South Africa. PLOS ONE Dear Dr. Pilusa, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== ACADEMIC EDITOR: Please see below for my comments on the manuscript. ============================== Please submit your revised manuscript by May 30 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Subas Neupane Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments (if provided): Please pay attention in the English language used. The English language must be checked by professional language editor. Few examples: Line 52-54, the language should be revised, also the sentence in incomplete. “ We need to explore environmental factors influencing health outcomes, inform the context-based interventions for people with disabilities in South Africa, there. In the methods part line 104 “We used a qualitative method was used to explore the environmental factors influencing the prevention of SHCs in people with SCI”. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Nice addition of South African health care system information in the introduction Methods Line 119 - OPD – outpatient department? Please define Additional information about recruitment is sufficient Good that interview guide was added Sufficient additional detail to data analysis Results Better organized Discussion Restructured discussion section reads very well. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes:** Anne M. Bryden [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0252280.r003
Revision 2
27 Apr 2021 Author Response Corrections - highlighted in yellow in the manuscript Editor Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Corrected Citation (29)- removed this reference and replaced with a more recent article 29. Maart S, Eide AH, Jelsma J, Loeb ME, Toni MK. Environmental barriers experienced by urban and rural disabled people in South Africa. Disabil Soc. 2007;22(4):357–69. Replaced with: Hanass-Hancock J, Nene S, Deghaye N, Pillay S. ‘These are not luxuries, it is essential for access to life’: Disability related out-of-pocket costs as a driver of economic vulnerability in South Africa. African J Disabil [Internet]. 2017 [cited 2017 Nov 1];6(a280):1–10. Available from: https://doi.org/10.4102/ajod. v6i0.280%0A Citation (8) 8. Mashola MK, Mothabeng J, Olorunju S. Readmission dues to secondary health conditions in people with spinal cord injury at a private rehabilitation facility in South Africa.Poster at WCPT congress 2017, Cape Town. 2017;(21):2017. This reference is for a conference poster. Replaced the article with the article by Mashola et al. 2019 ( the same information from the same author) Replaced with: Mashola MK, Olorunju SAS, Mothabeng J. Factors related to hospital readmissions in people with spinal cord injury in South Africa. South African Med J [Internet]. 2019 Jan 31;109(2):107. Available from: https://doi.org/10.7196/samj.2019.v109i2.13344 Line 268 Please pay attention in the English language used. The English language must be checked by professional language editor. Few examples: Line 52-54, the language should be revised, also the sentence in incomplete. “ We need to explore environmental factors influencing health outcomes, inform the context-based interventions for people with disabilities in South Africa, there. In the methods part line 104 “We used a qualitative method was used to explore the environmental factors influencing the prevention of SHCs in people with SCI”. Corrected grammar mistakes throughout the manuscript There is a need to explore environmental factors that influence health outcomes to inform context-based interventions for people with disabilities in South Africa. We used a qualitative design to explore the environmental factors influencing the prevention of SHCs in people with SCI. Line 51-52 Line 103 Reviewer Line 119 - OPD – outpatient department? Please define Changed to outpatient medical clinic Line 119 Attachments Attachment Submitted filename: Response to Reviewers27042021.pdf https://doi.org/10.1371/journal.pone.0252280.r004
14 May 2021 Decision Letter - Subas Neupane, Editor “ Environmental factors influencing the prevention of secondary health conditions among people with spinal cord injury, South Africa. PONE-D-20-20175R2 Dear Dr. Pilusa, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Subas Neupane Guest Editor PLOS ONE Additional Editor Comments (optional): Thank you for the revised manuscript. With this revision, the manuscript is potentially acceptable for publication in PLOS ONE. Reviewers' comments: https://doi.org/10.1371/journal.pone.0252280.r005
Formally Accepted
14 Jun 2021 Acceptance Letter - Subas Neupane, Editor PONE-D-20-20175R2 Environmental factors influencing the prevention of secondary health conditions among people with spinal cord injury, South Africa. Dear Dr. Pilusa: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Subas Neupane Guest Editor PLOS ONE https://doi.org/10.1371/journal.pone.0252280.r006

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