Introduction
Spinal cord injury (SCI) is one of the most devastating injuries that severely affects a person’s life [1]. SCI is caused by trauma, disease, or congenital defects and leads to temporary or permanent changes in the functioning of motor, sensory or autonomic systems [2, 3]. The prevalence of SCI worldwide is between 40 and 80 per one million people [4]. It is estimated that more than 70000 people with SCI live in Iran, and 2000 people are added to this figure every year, most of them due to crashes and traffic accidents [5, 6].
These people are exposed to severe psychological stress and suffering because of rapid debilitating changes and multiple challenges [7]. The consequences of SCI can be overwhelming and affect many aspects of a person’s life. Defects in urine and stool function, mobility, and autonomic function, along with secondary complications such as pressure sores and pain, are only part of the consequences that can directly affect a person’s health. People with SCI experience changes related to work, family, economic status, independence, and social attitudes [8, 9]. Among the patients’ other psychological and social problems are the fear of not controlling the situation, fear of death, deformities, social isolation, despair, and worry about the reduction of roles and social participation [9].
Social integration, as the main goal of rehabilitation, refers to the social participation of people with disabilities and their interaction with others [1, 10]. It seeks their re-entry and participation in society after being involved with SCI [11]. In a study titled “environmental barriers and social participation in people with SCI” in America, Tsai et al. showed a negative correlation between environmental barriers and social participation [14]. Aykuz et al., by conducting a study in Turkey, reported that low social integration of people with SCI disabilities were associated with engineering and design problems and accessibility, understanding, and orientation of other healthy people [11]. Also, health-related problems, especially pain, economic problems, and psychological problems, were reported as barriers to their social integration [1, 13].
The review of previous studies reveals the scarcity of qualitative studies to understand the experiences and recognize the barriers and facilitators of social integration of SCI patients. Limited studies have been conducted to identify these factors in different countries with various social and cultural contexts [15-17]. Given that the experience of disability and social integration are two concepts dependent on the context and culture, it seems necessary to know these experiences in various social fields and from the perspective of the people involved in this phenomenon (disabled persons, family caregivers, and service providers). Therefore, this study was conducted to identify these barriers and facilitators in people with SCI in Rofeideh Rehabilitation Hospital, the only government-specialized hospital in the field of rehabilitation in Tehran City, Iran.

Materials and Methods
This study was conducted using the contractual content analysis method with Graneheim and Lundman approach (2004) [18]. The participants included 13 persons with SCI, 4 from family caregivers, and 5 from specialists providing rehabilitation services at Rofeideh Hospital. The latter were purposefully selected based on the inclusion and exclusion criteria. SCI patients were at least 18 years old, 6 months passed since the injury, with mental health, receiving rehabilitation services from the hospital, and willing to participate in the research.
The criteria for family caregivers to enter the study included being the family members or the main caregivers of the patient on the condition of being responsible for taking care of the patient at home and accompanying him in social environments. For the providers of rehabilitation services (physical, psychological, and social) to people with SCI disabilities in Rofeideh Rehabilitation Hospital, having at least two years of relevant work experience was considered an entry criterion. The selection of participants continued until data saturation.
Data collection and analysis
In this research, to collect data, semi-structured and face-to-face interviews were used during the summer and autumn of 2019. The interviews started with general questions suitable for each group and were guided by exploratory questions based on the content and experiences of the participants. Interviews were conducted by the first author and recorded simultaneously with obtaining consent. The duration of the interviews was 30 to 50 minutes on average. By obtaining written consent, the participants were assured that the information would be kept confidential. 
The approach of Graneheim and Lundman (2004) was used for data analysis. First, the text of the interviews was read, and semantic units were identified, coded, and summarized several times. Then, based on the continuous comparison of similarities and differences, the codes that denoted a single topic were placed in a class, the subclasses and classes were categorized, and the core codes were formed. In the next step, the classes were summarized, the central concept of each class was determined, and the main and abstract concepts were extracted.
The data’s validity and strength were also based on the four criteria of credibility, transferability, dependability, and confirmability of Guba and Lincoln [17]. To check the reliability, and long-term conflicts with the data, collecting data from different sources and reviewing the study results were done with the participants. 
For transferability, the participants were selected according to the maximum diversity in terms of age, education, marital status, economic status, place of residence, employment status, injury severity, and conflict duration. To ensure reliability, samples of the conducted interviews and coding were provided to the research team to analyze and review. To comply with the verifiability, the research path was recorded so that other researchers could follow this work if they wished to continue the research in this field.

Results
The average age of SCI patients participating in this research was 40 years. of them, 7 patients were male, and 6 were female. 23% of the participants were living in rural areas, and 77% in urban areas. Also, 30% of the patients were employed, and 70% were unemployed and were housewives. The education of the patients participating in this research ranged from middle school to bachelor’s degree. 
This study included 4 family caregivers and 5 rehabilitation service specialists (social workers, psychologists, nurses, physiotherapists, and occupational therapists). After data analysis and coding, 428 primary codes were extracted, and the facilitators of social integration were placed in three main categories: social support, social participation, and individual beliefs. The barriers to social integration were also placed in three main categories: environmental and structural barriers, physical and moving barriers, and background barriers.
Social support
The participants considered social support as a facilitating factor for social integration. These supports include sympathies and financial and emotional assistance of family members to spending time and maintaining communication with friends and organizational assistance to the disabled person. A 38-year-old disabled lady said:
“…My husband supported me in every decision I made and always told me not to be afraid if I did not have legs; we would be your legs; he was sure that one day I would be even more successful than those with legs.”
Although in some participants, the relationship with healthy friends before the injury was less, those who had a good relationship with previous friends mentioned it as an important source of support. Organizational support and other supports pave the way to return to a relatively normal life for people with SCI.
Social participation
Participants considered membership in SCI associations a factor that made them feel valued by playing roles. They also stated that communication with people like themselves leads to new experiences and learning to solve problems related to the disease and new methods to maintain their interactions with each other and realize their collective goals, ideals, and rights in society. Employment was also an important factor in the self-sufficiency and independence of these people. A 52-year-old disabled person stated in this regard:
“...I was employed in our city’s telecommunication company. With the good mortgage loan I got, I bought a three-wheel motorcycle that belonged to a veteran and used it to go to work. My social activity started from there.”
Personal beliefs
People’s beliefs were placed in two subclasses of spirituality and attitude. The participants believed these are individual beliefs that can guide one life on the path of success and another life on the path of destruction after the injury caused by SCI. An 18-year-old disabled girl said:
“…I believe that disability is not a limitation at all, we indeed have to work harder than healthy people to succeed, but we can achieve our dreams despite this disability if we believe in our abilities.”
The participants also considered having spiritual beliefs an effective factor for coping and adapting to their existing conditions. Spiritual beliefs made them consider this loss of divine wisdom and even try harder to improve their current situations to be proud of the religious test.
Environmental and structural barriers
Environmental and structural barriers include a person’s physical environment and social culture. According to the participants’ experiences, the inappropriateness of urban spaces led to their dependence on others to be present in society. Its long-term consequences were not participating in the social environment and their social isolation. One of the family caregivers said:
“…My daughter uses a wheelchair to go outside the house. It was very difficult to move the wheelchair because of the unevenness of the street. I am worried about how my daughter will go out if I am not there.”
Also, the participants reported that the general beliefs of the people and the society are very negative towards people with SCI and consider them unproductive and without any ability. They were suffering from pitiful looks on themselves, and they said their biggest problem with attending social circles was people’s negative reactions towards them.
Physical and movement barriers
Physical and movement barriers in this research include pain tolerance and physical illness, and problems related to excretion, one of the experts stated:
“…After the injury, SCI patients suffer from bedsores because they cannot move, and the pressure and weight of their body are transferred to one area of the body, and they are involved in this bedsore for a long time. This condition causes these people to lose time for social integration.”
Also, according to the participants’ opinion, due to the difficulty in using the sanitary facilities and the lack of suitable hygienic facilities for these people, as well as the lack of bladder control in some of these people, they are less willing to attend the community.
Background barriers
Background barriers in this research include health knowledge, disease perception, and non-acceptance of change. The participants did not make appropriate decisions about their condition and health without having sufficient understanding and knowledge of their illness and condition. A 30-year-old disabled man said:
“…After being discharged from the hospital, I didn’t know how to take care of myself and what to do to avoid bed sores, and I didn’t know what exercises to do so that my muscles not to get weak.”
In the early stages of SCI, a person expects complete recovery, and it is very difficult for the patient to accept being among the disabled of SCI; as a result, he is not interested in being in the community and being seen in new conditions. Sometimes this acceptance may take a long time, leading to a delay in their social integration.

Discussion
This study was conducted to know the barriers and facilitators of the social integration of SCI patients based on the deep experiences of three groups of SCI patients, the main family caregivers, and rehabilitation service providers to them, in Rofeideh Rehabilitation Hospital as the only university hospital in the field of rehabilitation in Iran.
According to the results, social support is one of the facilitators of the social integration of people with SCI. The participants considered having appropriate permission an important factor in developing their resilience. When they benefited from the support of their spouses, children, parents, and other family members, they could better overcome the consequences and problems after the injury. Consistent with the results of this research, Song’s study showed that family support positively affects the social reintegration of people with SCI [18].
Companionship and continuity of communication with friends were the other experiences of the participants of this study, which helped maintain social relationships and the relatively normal flow of their lives. In line with these results, Khosravi Tapeh et al.’s study also shows a connection between the subscales of social support (support from family, friends, and others) with the quality of life of people with physical and motor disabilities [18]. The support of organizations in charge of the disabled has been helpful in their return to society. Anson et al.’s study also confirm this study’s results about organizational support for people with disabilities [21].
In this study, social participation in various ways, such as membership in SCI associations, re-employment after injury, and communication with other disabled people, has facilitated the social integration of disabled people. Membership in associations enables receiving the services needed for disabled people, and helping other disabled people, has strengthened their sense of usefulness and participation in society.
In line with the results of this study, Dib et al. showed that active membership in related groups and associations causes a feeling of belonging to these groups, performing voluntary activities, and playing an active role in society  [22]. Re-employment has been emphasized by the experts in this study for the social integration of disabled people. According to the results of the present study, the study of Craig et al. shows that employment increases the social participation of people with SCI disabilities [24].
Another facilitator of the social integration of SCI patients in this study is their individual beliefs. Based on the participants’ experience, having positive personal beliefs and recognizing and using the abilities and resources were the strengths of disabled people to adapt to the current situation and search for new solutions to solve their problems. Zhang Hampton’s study in this field shows that belief in self-efficacy in people with SCI increases the quality of life and social participation [29].
Also, in this study, disabled people with strong religious ties and deeper heart beliefs reported that they could take a step from these spiritual beliefs to accept the current unfortunate situation, submit to the divine will and try to enrich their lives with a new position. In this regard, several studies have shown that spiritual beliefs play a facilitating role in adapting and coping with SCI [32, 31].
Recognizing the barriers to the social integration of SCI patients was one of the other issues investigated in this study. Based on the results, all three groups of participants considered an urban disability and physical space limitations in buildings and urban passages to be the main barriers to returning people with disabilities to normal life. In this regard, Tsai et al.’s study shows that the increase in environmental barriers is associated with a decrease in the social participation of people with disabilities [14]. 
In line with these results, the study of Aykouz et al. in Turkey and the study of Hashemi-Parast et al. in Iran show that the understanding and attitude of other people who do not have disabilities are effective in the social integration of people with SCI disabilities [11, 32].
In the present study, physical and movement barriers are other barriers for patients to maintain and continue their normal life. People with SCI suffer from bed sores and infections due to problems in moving, long-term hospitalizations, surgical and physical complications of the injury. Also, they experience chronic pains and muscle spasms. In this regard, Adreaansen et al.’s study shows that skeletal pain, pressure sores, and spasticity are directly related to the quality of life of people with SCI disabilities [35].
The participants also mentioned excretion-related problems (difficulties using toilets and lack of bowel and bladder control) in expressing their other physical problems and considered it an important barrier to attending and participating in their social activities.
Another barrier identified from the items mentioned by the participants of this research is contextual factors. The weakness of self-care skills, lack of awareness and training in these skills led to exacerbating the patient’s physical problems and reduced social interactions. The study of Qadri et al. in this field shows that education plays an undeniable role in proper adaptation, achieving greater independence, and reducing the burden of care for those around the patient [37].
On the other hand, the disabled person’s inability to accept his current condition and the unrealistic hope of complete recovery and freedom from dependence on a wheelchair in the case of patients whose prognosis in this regard was not promising by the treatment team led to their desperation to continue treatment and the process of their reintegration into the society was difficult. Khanjani et al.’s study show that the acceptance of the injury influences the acceptance and adaptation after the injury [31].

Conclusion
The results of this study indicated that an important part of the barriers and inhibitors in the social integration of people with SCI is caused by incorrect planning and policies in this field. Therefore, the planners’ and policymakers’ correct understanding of the experiences of the people involved can provide the basis for different approaches at the micro and macro levels to reduce these barriers.
In this regard, reaching a correct understanding of the facilitators can focus on designing and implementing effective interventions by rehabilitation service providers, especially social workers. Considering the limitations of qualitative studies in generalizing the results of the study, despite the diversity mentioned in the selection of the participants, it is recommended to conduct similar studies in other fields and cultures.

Ethical Considerations

Compliance with ethical guidelines
The University of Social Welfare and Rehabilitation Sciences Ethics Committee has approved this study. In this study, written consent was obtained from the participants before conducting the interview and after explaining the purpose and research process. Also, they were assured that their information would be kept confidential, and the participants were allowed to withdraw from the study at any stage.
This study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.2019.124).

Funding
This article was extracted from the Master’s thesis of Vahid Razaghi, Department of Social Work, the University of Social Welfare and Rehabilitation Sciences.

Authors' contributions
Conceptualization, data analysis, and sources: Vahid Razzaghi and Leila Ostad Hashemi; Validation: Leila Ostad Hashemi, Mohammad Sabzi Khoshnam, and Maliheh Arshi; Research and writing the draft: Vahid Razaghi; Editing and finalization: Leila Ostad Hashemi, Mohammad Sabzi Khoshnam, Maliheh Arshi; Supervision: Maliheh Arashi; Project management: Leila Ostad Hashemi.

Conflict of interest
The authors declared no conflict of interest.

 

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