Advertisement

Influence of Sociodemographic Factors, Health Conditions, and Activity on Participation in People With Spinal Cord Injury in South Korea

Published:August 23, 2022DOI:https://doi.org/10.1016/j.apmr.2022.08.004

      Abstract

      Objective

      To verify the causal relationship between sociodemographic factors, health conditions, and activities that influence the participation of people with spinal cord injury (SCI) using International Spinal Cord Injury (InSCI) Survey data and to investigate the moderation effects of environmental restrictions and health care system concerns.

      Design

      Cross-sectional community survey and structural equation model.

      Setting

      SCI databases of the Korea National Rehabilitation Center and Korea Spinal Cord Injury Association.

      Participants

      Community-dwelling adults (N=890) with SCI.

      Interventions

      Not applicable.

      Main Outcome Measures

      The InSCI questionnaire domains included sociodemographic factors, health conditions, activity, participation, environmental restrictions, and health system concerns. Sociodemographic factors included age, education, and income. Health conditions included bowel dysfunction, respiratory problems, and pain, among others. Activity included “daily routine” and “using hands,” among others. Participation included “interacting with people” and “intimate relationships,” among others. Environmental restrictions included “public places” and “negative attitudes,” among others. Health care system concerns included “nursing care” and “experience of being treated,” among others.

      Results

      The hypothesis that health conditions would have a significant effect on activity was supported because 51% of the total variance in activity factors was explained by health condition factors. The hypothesis that activity would have a significant effect on participation was also supported because 63.4% of total variance in participation factors was explained by activity factors. The moderation effect tests supported the hypotheses that health conditions, activity, and participation would differ depending on the extent of environmental restrictions as well as the extent of health system concerns.

      Conclusions

      When formulating policies and recommendations to promote the participation of people with SCI living in the South Korean community, the influence of environmental restrictions and health systems as well as the causal influence of health conditions and activity should be considered.

      Keywords

      Participation is a critical goal of successful rehabilitation for people with spinal cord injury (SCI). Social participation is an activity involving various social roles that individuals perform.
      • Jette AM
      • Haley SM
      • Kooyoomjian JT.
      Are the ICF activity and participation dimensions distinct?.
      ,
      • Krause JS
      • Crewe NM.
      Chronologic age, time since injury, and time of measurement: effect on adjustment after spinal cord injury.
      However, people with SCI face severe difficulties with physical activity, leading to reduced social relationships.
      • Lee JH
      • Kang B-R.
      Comparison of daily activities and quality of life according to general characteristics of spinal cord injury.
      ,
      • Shin E-K
      • Lee HN
      • Lee I-S.
      Examination of the mediating effect of self-efficacy and perceived social support on the spinal cord injuries’ social participation.
      Because people with SCI in South Korea face difficulties in their ability to perform meaningful roles and participate in outdoor activities, it is necessary to establish rehabilitation strategies to improve their social participation in local communities.
      • Chang FH
      • Liu CH
      • Hung HP.
      An in-depth understanding of the impact of the environment on participation among people with spinal cord injury.
      “Activity” is a state affected by personal attributes such as various behaviors and cognitive and emotional experiences. The social participation of people with SCI may be different from that of other people even at the same activity level due to intervening factors such as environmental characteristics as well as an individual's health status and activities of daily living (ADL).
      As they age, people with SCI experience a decrease in their functional independence. Typically, those who are young and well-educated return to their regular activities after an injury faster than others.
      • Shin H.
      Etiology and epidemiology of spinal cord injury in Korea.
      The activity level and risk of death for people with SCI vary significantly by income and educational level which may help determine the capacity for acquiring self-management activities.
      • Shin H.
      Etiology and epidemiology of spinal cord injury in Korea.
      SCI causes sensory and motor dysfunction, secondary medical conditions, and psychological changes that affect an individual's functioning and may negatively affect their participation and work.
      • Kennedy P
      • Lude P
      • Elfström ML
      • Smithson EF.
      Psychological contributions to functional independence: a longitudinal investigation of spinal cord injury rehabilitation.
      ,

      Bickenbach J, Officer A, Shakespeare T, von Groote P, World Health Organization. International perspectives on spinal cord injury: summary (No. WHO/NMH/VIP/13.03). Geneva: World Health Organization; 2013.

      People with SCI experience various motor impairments and limitations in self-management activities as their health conditions worsen. Serious complications, such as neurogenic pain and spasticity, may accompany SCI. Thus, medical treatment is required to improve their activity.
      • Shin H.
      Etiology and epidemiology of spinal cord injury in Korea.
      ,
      • Ullrich PM
      • Spungen AM
      • Atkinson D
      • et al.
      Activity and participation after spinal cord injury: state-of-the-art report.
      The social model of disability asserts that the oppression and exclusion faced by people with disabilities such as SCI are attributed to societal infrastructure. People with SCI may experience problems with participation because of the environment in which they live. “Misdesigned buildings,” “stairs rather than ramps,” and “no elevators” are realistic and representative examples of the oppression and exclusion faced by people with SCI.
      • Mole H.
      A US model for inclusion of disabled students in higher education settings: the social model of disability and Universal Design.
      (p63, 64, and 66) Appropriate modification of environmental factors can reduce the extent of disability and improve activity and participation levels. Individuals with poor health conditions and inadequate activity experience additional barriers because the environment is not adapted to their needs, which can further lead to restrictions on new activities and participation.
      • Mole H.
      A US model for inclusion of disabled students in higher education settings: the social model of disability and Universal Design.
      ,
      • Van Loo MA
      • Post MWM
      • Bloemen JHA
      • Van Asbeck FWA.
      Care needs of persons with long-term spinal cord injury living at home in the Netherlands.
      The effects of SCI on health conditions, activity level, and participation may vary depending on available health care. Activity level after SCI is a significant factor used to assess health care system quality. People with SCI use health care services frequently, and their social participation level and health care system quality are strongly correlated.
      • Pacheco Barzallo D
      • Gross-Hemmi M
      • Bickenbach J
      • et al.
      Quality of life and the health system: a 22-country comparison of the situation of people with spinal cord injury.
      ,
      • Jette AM
      • Tao W
      • Haley SM.
      Blending activity and participation sub-domains of the ICF.
      Previous studies assessed attributes that distinguished activity from participation according to the International Classification of Functioning, Disability, and Health (ICF)
      • Krause JS
      • Crewe NM.
      Chronologic age, time since injury, and time of measurement: effect on adjustment after spinal cord injury.
      ,
      • Badley EM.
      Enhancing the conceptual clarity of the activity and participation components of the International Classification of Functioning, Disability, and Health.
      and evaluated conceptual clarity.
      • Barclay L
      • McDonald R
      • Lentin P.
      Social and community participation following spinal cord injury: a critical review.
      However, research is lacking on the association between participation and activity in people with SCI. Studies
      • Carpenter C
      • Forwell SJ
      • Jongbloed LE
      • Backman CL.
      Community participation after spinal cord injury.
      ,
      • De Groot S
      • Post MWM
      • Bongers-Janssen HMH
      • Bloemen-Vrencken JH
      • Van der Woude LHV.
      Is manual wheelchair satisfaction related to active lifestyle and participation in people with a spinal cord injury?.
      analyzing factors related to the participation of people with SCI showed that the health care system
      • Jette AM
      • Tao W
      • Haley SM.
      Blending activity and participation sub-domains of the ICF.
      and lifestyle
      • Fekete C
      • Brach M
      • Ehrmann C
      • Post MWM
      • InSCI Stucki G
      Cohort profile of the international spinal cord injury community survey implemented in 22 countries.
      had significant effects on these factors. However, those studies reported varying results on how activity, social participation, and quality of life are affected by disability from SCI; no national large-scale research has been conducted to elucidate direct causal pathways and causal relationships among factors influencing participation in South Korean people with SCI.
      This study aimed to identify factors affecting the participation of people with SCI in South Korea. The causal relationships between sociodemographic factors, health conditions, and activity were assessed, and the effects of environmental restrictions and health care system concerns were evaluated. A hypothetical research model was created to establish the relationship and structure between factors (fig 1).
      Fig 1
      Fig 1The ICF model is a structure wherein all factors, including health conditions, body functions and structures, activity, and participation, interact with one another. In contrast, the conceptual model of this study is a structure wherein sociodemographic factors and health conditions influence activity and activity influences participation. Moderating factors (environmental restrictions and health care system concerns) were not included in the conceptual model of this study.
      The following main hypotheses were proposed: (1) Sociodemographic factors will have significant effects on activity. (2) Health conditions will have significant effects on activity. (3) Activity will have significant effects on participation. (4) Sociodemographic factors, health conditions, activity, and participation will vary according to the extent of environmental restrictions. (5) Sociodemographic factors, health conditions, activity, and participation will vary according to the extent of health care system concerns.

      Methods

      Data collection

      As part of the World Health Organization's Global Disability Initiative, the Learning Health System for Spinal Cord Injuries aims to formulate recommendations and policies regarding data collection on the actual experiences of people with SCI. The International Spinal Cord Injury Survey (InSCI) was introduced under this initiative. The InSCI survey is based on the ICF's core set of SCIs and was developed as an early step to obtain information on the experiences of patients with SCI. It has been conducted since 2017 within 28 countries from 6 World Health Organization regions.
      • Fekete C
      • Brach M
      • Ehrmann C
      • Post MWM
      • InSCI Stucki G
      Cohort profile of the international spinal cord injury community survey implemented in 22 countries.
      • Gross-Hemmi MH
      • Post MWM
      • Ehrmann C
      • et al.
      Study protocol of the International Spinal Cord Injury (InSCI) community survey.
      • Fekete C
      • Post MWM
      • Bickenbach J
      • et al.
      A structured approach to capture the lived experience of spinal cord injury: data model and questionnaire of the International Spinal Cord Injury community survey.
      The InSCI survey was conducted nationwide in South Korea from March to October 2017. Participants with SCI were randomly selected from the total population using the National Rehabilitation Center and the Korea Spinal Cord Injury Association databases following the InSCI research protocol. A total of 6355 individuals with SCI in local communities were invited through text messages, emails, face-to-face interaction, and phone calls.
      A self-administered electronic questionnaire comprising 125 items was made available to participants on the InSCI website. If participants could not access the electronic questionnaire, they completed a paper questionnaire in person or by mail, or they answered the questions by telephone. Email, text message, and telephone reminders were sent to participants. Data were collected from 892 participants. Following the recommendation of the Institutional Review Board, written informed consent was obtained from each participant before they completed the questionnaire (Institutional Review Board no.: NRC-2021-07-057).
      Inclusion criteria were (1) Korean residents older than 19 years with SCI, living in local communities or visiting the outpatient clinic at the National Rehabilitation Center; (2) individuals from local communities currently hospitalized but not hospitalized for the first time for the current disability; (3) those with traumatic or nontraumatic SCI (American Spinal Cord Injury Association Impairment Scale A, B, C, D); and (4) those who understood the purpose of the questionnaires, were able to respond to the items, and agreed to participate. Exclusion criteria were (1) those with SCI with congenital causes; (2) those with neurodegenerative diseases; and (3) those with peripheral nerve injury. According to the power analysis, the minimum sample size required was 200 people per country.
      • Gross-Hemmi MH
      • Post MWM
      • Ehrmann C
      • et al.
      Study protocol of the International Spinal Cord Injury (InSCI) community survey.

      Measurement tool

      The InSCI survey components were structured according to the 5 basic principles of efficiency, feasibility, comparability, truth, and discrimination.
      • Fekete C
      • Post MWM
      • Bickenbach J
      • et al.
      A structured approach to capture the lived experience of spinal cord injury: data model and questionnaire of the International Spinal Cord Injury community survey.
      The construct was evaluated using the Korean version of the InSCI survey, which was translated in a previous study and demonstrated validity and reliability. Verification of the content validity of the Korean version of the InSCI survey was necessary to identify factors affecting the participation of people with SCI in South Korea. Content validity was verified by selecting and classifying the items for each domain in the survey.
      • Fekete C
      • Post MWM
      • Bickenbach J
      • et al.
      A structured approach to capture the lived experience of spinal cord injury: data model and questionnaire of the International Spinal Cord Injury community survey.
      This study used 6 domains (sociodemographic characteristics, health problems, activities of daily living, activity and participation, environmental factors, health care services) of the 11 domains from the Korean version of the survey.
      The InSCI survey is not a standardized questionnaire based on exhaustive theory. Moreover, this study used structural equation model (SEM) analysis to identify factors that affect the participation of people with SCI in South Korea. Therefore, the detailed classification of the items from Fekete's study was preferentially used to verify content validity, but it was modified by the Delphi survey's expert discussion based on Korean SCI characteristics and evaluated for goodness of fit.
      • Fekete C
      • Post MWM
      • Bickenbach J
      • et al.
      A structured approach to capture the lived experience of spinal cord injury: data model and questionnaire of the International Spinal Cord Injury community survey.
      The Delphi survey was conducted by sending individual emails to 100 experts. After deleting personally identifiable information, we conducted the analysis using their responses.
      The survey comprised detailed items that were measured using existing scales for accuracy. Health conditions were evaluated using the Spinal Cord Injury Secondary Health Conditions Scale and the Brief Pain Inventory.
      • Kalpakjian CZ
      • Scelza WM
      • Forchheimer MB
      • Toussaint LL.
      Preliminary reliability and validity of a spinal cord injury secondary conditions scale.
      ,
      • Jette AM
      • Slavin MD
      • Ni P
      • et al.
      Development and initial evaluation of the SCI-FI/AT.
      For the Spinal Cord Injury Secondary Health Conditions Scale, items were scored on a 5-point Likert scale ranging from “no problem” (1) to “extreme problem” (5). The Brief Pain Inventory scale was used to evaluate the variable “pain intensity at its worst,” with 0 points indicating “no pain” and 10 points indicating “pain as bad as you can imagine” (table 1).
      Table 1InSCI questionnaire: item-based final construction concept and measurement
      Latent VariableMeasured VariableMeasurement Questionnaire and ScaleSource of InSCI SurveyCronbach α
      Sociodemographic factorsSociodemographic factor AAge
      Sociodemographic factor BEducation (1-8 points)
      Sociodemographic factor CIncome (1-10 points)
      Health conditionsHealth conditions ABowel dysfunction (1-5 points)SCI-SCS

      and BPI
      0.742
      Urinary tract infections (1-5 points)
      Bladder dysfunction (1-5 points)
      Sexual dysfunction (1-5 points)
      Health conditions BRespiratory problems (1-5 points)0.785
      Circulatory problems (1-5 points)
      Autonomic dysreflexia (1-5 points)
      Postural hypotension (1-5 points)
      Health conditions CPain (1-5 points)0.746
      Pain intensity at its worst (0-10 points)
      ActivityActivity AConducting daily routine (1-5 points)MDS,

      SCI-FI AT,

      SCIM-SR
      0.839
      Getting where you want to go (1-5 points)
      Using public transportation (1-5 points)
      Using private transportation (1-5 points)
      Looking after your health, eating well, exercising, or taking your medicine (1-5 points)
      Shortness of breath during physical exertion (1-5 points)
      Activity BUsing hands and fingers (1-5 points)0.603
      Getting off the floor after lying on one's back (15 points)
      Moving from sitting at the side of the bed to lying down on your back (1-5 points)
      Eating and drinking (1-5 points)
      Washing your upper body and head (1-4 points)
      Washing your lower body (1-4 points)
      Dressing your upper body (1-5 points)
      Dressing your lower body (1-5 points)
      Grooming (1-4 points)
      Using the toilet (1-5 points)
      Moving from the bed to the wheelchair (1-4 points)
      ParticipationParticipation AProviding care or support for others (1-5 points)MDS0.664
      Interacting with people (1-5 points)
      Participation BIntimate relationships (1-5 points)0.784
      Doing things for relaxation or pleasure (1-5 points)
      Environmental restrictionsEnvironmental restriction AMissing or insufficient accessibility of public places (1-4 points)NEFI0.795
      Missing or insufficient accessibility to the homes of friends and relatives (1-4 points)
      Lack of or insufficient adapted assistive technology for moving around over short distances (1-4 points)
      Lack of or inadequate adapted means of transportation for long distances (1-4 points)
      Environmental restriction BNegative attitudes of family and relatives regarding disability (1-4 points)0.868
      Negative attitudes of friends regarding disability (1-4 points)
      Negative attitudes of neighbors, acquaintances, and work colleagues regarding disability (1-4 points)
      Environmental restriction CProblematic financial situation (1-4 points)0.706
      Lack of or insufficient communication devices (1-4 points)
      Lack of or insufficient state services (1-4 points)
      Health care system concernsHealth care system concern ALack of or insufficient nursing care and support services (1-4 points)NEFI,

      MDS
      0.753
      Lack of or insufficient medication and medical aids and supplies (1-4 points)
      Health care system concern BExperience of being treated respectfully (1-5 points)0.841
      Health care providers explained things clearly (1-5 points)
      Experience of being involved in making decisions for treatment (1-5 points)
      NOTE. For health condition, 4 items were excluded from the existing 14 items and grouped into 3 items; for activity, 2 items were excluded from 19 items and grouped into 2 items; for participation, all 4 items were applied, and they were grouped into 2 items; for environmental restrictions, 2 items were excluded from 12 items and grouped into 3 items; for the health care system concerns, one item was excluded from 6 items and grouped into 2 items; for sociodemographic factors, 4 of 7 items were excluded and divided into 3 items in considering the importance of the item contents according to previous studies. Cronbach α exceeded the reliability criterion of 0.6 for all items.
      Abbreviations: BPI, Brief Pain Inventory; NEFI, Nottwil Environmental Factors Inventory; SCI-FI AT, Spinal Cord Injury-Functional Index, Assistive Technologies; SCIM-SR, Spinal Cord Independence Measure Self-report; SCI-SCS, Spinal Cord Injury Secondary Health Conditions Scale.
      The Model Disability Survey (MDS), Spinal Cord Injury-Functional Index Assistive Technologies (SCI-FI AT), and Spinal Cord Independence Measure Self-report were used to evaluate activity.
      • Jette AM
      • Slavin MD
      • Ni P
      • et al.
      Development and initial evaluation of the SCI-FI/AT.
      • Fekete C
      • Eriks-Hoogland I
      • Baumberger M
      • et al.
      Development and validation of a self-report version of the Spinal Cord Independence Measure (SCIM III).

      World Health Organization. Model Disability Survey: survey manual. Geneva: World Health Organization; 2017.

      The MDS was used to evaluate participation
      • Kalpakjian CZ
      • Scelza WM
      • Forchheimer MB
      • Toussaint LL.
      Preliminary reliability and validity of a spinal cord injury secondary conditions scale.
      on a 5-point Likert scale ranging from “no problem” (1) to “extreme problem” (5). The Spinal Cord Injury-Functional Index Assistive Technologies items were evaluated on a 5-point Likert scale ranging from “without any difficulty” (1) to “unable to do” (5). For the Spinal Cord Independence Measure Self-report, items were evaluated on a 4- or 5-point Likert scale from “no independence” (1) to “total independence” (5) and reverse-coded for analysis (see table 1).
      The Nottwil Environmental Factors Inventory was used to evaluate environmental restrictions
      • Ballert CS
      • Post MW
      • Brinkhof MW
      • Reinhardt JD
      SwiSCI Study Group. Psychometric properties of the Nottwil Environmental Factors Inventory Short Form.
      on a 4-point Likert scale, with “not applicable” (1), “no influence” (2), “made my life a little harder” (3), and “made my life a lot harder” (4).
      The Nottwil Environmental Factors Inventory and MDS were used to evaluate health care system concerns.

      World Health Organization. Model Disability Survey: survey manual. Geneva: World Health Organization; 2017.

      ,
      • Ballert CS
      • Post MW
      • Brinkhof MW
      • Reinhardt JD
      SwiSCI Study Group. Psychometric properties of the Nottwil Environmental Factors Inventory Short Form.
      Here, MDS items were assessed using a 5-point Likert scale ranging from “very good” (1) to “very bad” (5) (see table 1).

      Analysis

      Exploratory factor analysis using principal component analysis and item parceling was performed, and the internal consistency within each construct's scales was assessed. Cronbach α of the 6 constructs was analyzed for expected internal consistency, excluding sociodemographic factors (see table 1).
      Confirmatory factor analysis was performed for sociodemographic factors, health conditions, activity, and participation using Amos 24 software.a Key fitness indices such as the normed fit index and Tucker-Lewis Index were assessed through confirmatory factor analysis for the measurement model.
      • Bentler PM
      • Bonett DG.
      Significance tests and goodness of fit in the analysis of covariance structures.
      Construct reliability (CR) and average variance extracted were assessed to validate the factors shown in the measurement model (table 2). Discriminant validity was assessed through the coefficient of determination (table 3).
      Table 2Convergent validity and fit assessment of measurement model
      Latent VariableMeasured VariableStandardized EstimateErrorCRAVEModel Fit

      Indices
      Sociodemographic factorsSociodemographic factors A0.4010.0880.3690.524χ2 (P)=142.762 (<.001)

      df=29

      χ2/df (or CMIN/df)=4.923

      NFI=0.929

      RFI=0.890

      IFI=0.943

      TLI=0.910

      CFI=0.942

      RMSEA=0.082
      Sociodemographic factors B−0.5860.208
      Sociodemographic factors C0.4140.318
      Health conditionsHealth conditions A0.7600.0440.9570.886
      Health conditions B0.6290.047
      Health conditions C0.4830.065
      ActivityActivity A0.5870.0530.9540.879
      Activity B1.0170.047
      ParticipationParticipation A0.8930.0300.9360.830
      Participation B0.8730.043
      NOTE. Convergent validity is secured when the conceptual reliability values of all latent variables are ≥0.7 and the AVE values of all latent variables are ≥0.5. This measurement model secured convergence validity as the conceptual reliability values of the 3 latent variables, excluding sociodemographic factors, were ≥0.7 and the AVE value was ≥0.5. The construct reliability value of the sociodemographic factor was 0.369, which does not secure convergent validity. In the CFA for the measurement model, χ2 (P) was 142.762 (<.001), which did not meet the acceptance criteria; hence, the measurement model was rejected. However, because the significant fitness indices such as NFI and TLI are generally satisfactory compared with the reference value, we can assume there is no problem with the fitness of the measurement model. Therefore, it was verified that the measurement variables of this measurement model have sufficient meaning (criteria for the model fit indices are χ2/df [or CMIN/df]<5.0, CFI>0.9, NFI>0.9, RFI>0.9, TLI>0.9, IFI>0.9, RMSEA<0.1. There is no problem with the model fit because χ2/df [or CMIN/df] slightly exceeds 3; NFI, TLI, IFI, and CFI values are ≥0.9, and the RMSEA value is ≤0.1).
      Abbreviations: AVE, average variance extracted; CFI, comparative fit index; CMIN, chi-square fit statistics; IFI, incremental fit index; NFI, normed fit index; RFI, relative fit index; RMSEA, root mean squared error of approximation; TLI, Tucker-Lewis Index.
      Table 3Correlation coefficient between latent variables
      Latent VariableSociodemographic FactorHealth ConditionActivityParticipation
      Sociodemographic factors1.000 (0.524
      Average variance extracted.
      )
      ---
      Health conditions0.455 (0.207
      Coefficient of determination.
      )
      1.000 (0.886
      Average variance extracted.
      )
      --
      Activity0.277 (0.077
      Coefficient of determination.
      )
      0.679 (0.461
      Coefficient of determination.
      )
      1.000 (0.879
      Average variance extracted.
      )
      -
      Participation0.275 (0.076
      Average variance extracted.
      )
      0.631 (0.398
      Coefficient of determination.
      )
      0.765 (0.585
      Coefficient of determination.
      )
      1.000 (0.830
      Average variance extracted.
      )
      NOTE: If the AVE of each construct is greater than the coefficient of determination, it can be interpreted as having secured discriminant validity. The AVE of each construct is confirmed to be greater than the coefficient of determination between each construct. The coefficient of determination is the square value of the correlation coefficient between the 2 concepts. Therefore, this measurement model can be interpreted as having discriminant validity.
      Abbreviation: AVE, average variance extracted.
      low asterisk Average variance extracted.
      Coefficient of determination.
      Amos 24 and SPSS 21 softwareb were used to conduct an SEM analysis to verify hypotheses 1, 2, and 3, which suggested a significant relationship among the study constructs. Missing data were treated using the full information maximum likelihood method.
      To verify the moderation effects (hypotheses 4 and 5), the participants were divided into 2 groups for each construct (ie, low environmental restrictions vs high environmental restrictions and low health care system concerns vs high health care system concerns). First, cross-validation analysis was performed between the groups using multigroup confirmatory factor analysis for each moderating variable to assess chi-square differences between the unconstructed and constructed models (measurement weights model). When cross-validation was observed, the moderation effects were verified through multigroup structural equation model (MSEM) analysis for each moderating variable. In other words, MSEM analysis was conducted to assess chi-square differences between the unconstructed model and the structural weighted model with constructs.

      Results

      A total of 890 people with SCI were selected, excluding 2 who did not complete the survey. The mean age of the participants was 48 years, with an average duration of disease of 15.6 years (table 4).
      Table 4Demographic and injury characteristics of participants
      CharacteristicFrequency (%)

      or Mean ± SD
      Median (Range)
      Sex
      Male673 (75.9)
      Female214 (24.1)
      Age (y)48.0±11.749.0 (19.00∼82.0)
      Marital status
      Single327 (37.1)
      Married426 (48.4)
      Cohabiting or in a partnership6 (0.7)
      Separated or divorced96 (10.9)
      Widowed26 (3.0)
      Living alone
      Yes251 (28.2)
      No639 (71.8)
      Educational level
      Primary52 (5.9)
      Lower secondary96 (10.9)
      Higher secondary366 (41.4)
      Post secondary24 (2.7)
      Short tertiary150 (17.0)
      Bachelor's or equivalent145 (16.4)
      Master's or equivalent45 (5.1)
      Other5 (0.6)
      Education (y)11.2±5.312.0 (0.0∼33.0)
      Household income position (10,000 won)
      < 96/mo288 (33.8)
      96-190/mo180 (21.2)
      190-257/mo109 (12.8)
      257-313/mo70 (8.2)
      313-368/mo47 (5.5)
      368-424/mo52 (6.1)
      424-558/mo55 (6.5)
      558-660/mo26 (3.1)
      660-995/mo20 (2.4)
      > 995/mo4 (0.5)
      SCI type
      Tetraplegia349 (39.8)
      Paraplegia528 (60.2)
      SCI degree
      Complete509 (57.8)
      Incomplete372 (42.2)
      SCI cause type
      Traumatic815 (92.2)
      Nontraumatic69 (7.8)
      Time since injury15.6±10.115.0 (0.0∼63.0)
      Abbreviations: SCI, spinal cord injury; SD, standard deviation.

      Health conditions, activity, and participation

      SEM analysis showed that health conditions such as bowel function, cardiopulmonary function, and pain had significant causal effects on activities such as mobility and ADL. This indicates that high scores on the health condition scales had a significant causal effect on the high scores on the activity scales. Moreover, 51% of the total variance in activity factors was explained by health condition factors. However, sociodemographic factors, including age, education level, and educational background, did not affect activity. A significant causal effect of activity on participation was confirmed. In addition, a significant indirect effect of health conditions on participation through activity as a mediating variable was confirmed. Consequently, 63.4% of the total variance of participation factors was explained by activity factors (fig 2).
      Fig 2
      Fig 2Standardized path coefficients of estimated SEM with fit indices.

      Environmental restrictions

      To verify the moderation effects of environmental restrictions, MSEM analysis was conducted to assess differences in chi-square between the unconstructed (χ2=198.614) and structural weighted (χ2=379.706) models. Results revealed that Δdf=1981-62, Δχ2=181.091, and P value of Δχ2<.001, indicating statistical significance. Therefore, cross-validation between groups was secured. This suggests that the extent of environmental restrictions has moderation effects on the overall structural relationship.
      MSEM analysis for each environmental restriction level revealed that each path coefficient of the “group with low environmental restriction levels” was more significant than that of the “group with high environmental restriction levels,” except the sociodemographic factor path coefficients. This supported hypothesis 4 (fig 3) and showed the moderation effects of environmental restrictions in the group with high environmental restrictions compared with the group with low restrictions, suggesting that health conditions and activity had fewer effects on activity and participation, respectively.
      Fig 3
      Fig 3MSEM analysis for each environmental restriction level showed that each path coefficient of the “group with low environmental restriction levels” was more significant than that of the “group with high environmental restriction levels,” except the sociodemographic factor path coefficients. This supported hypothesis 4 and showed the moderation effects of environmental restrictions in the group with high environmental restrictions compared with that with low restrictions, suggesting that health conditions and activity had fewer effects on activity and participation, respectively. Activity factors explained 64.8% of the total variance of participation factors in the group with low environmental restriction levels. Activity factors explained 50.1% of the total variance of participation factors in the group with high environmental restriction levels.

      Health care system concerns

      To verify the moderation effects of health care system concerns, MSEM analysis was conducted to assess differences in χ2 between the unconstructed (χ2=208.800) and structural weighted (χ2=292.804) models. Results revealed that Δdf=1981-62, Δχ2=84.004, and P value of Δχ2<.001, indicating statistical significance. Therefore, cross-validation between groups was secured. This suggests that the extent of health care system concerns had moderation effects on the overall structural relationship.
      The MSEM analysis of health care system concerns revealed that each path coefficient of the “group with fewer health care system concerns” was more significant than that of the “group with more health care system concerns,” except the sociodemographic factor path coefficients. This supported hypothesis 5 (fig 4) and showed the moderation effects of health care system concerns in the group with more health care system concerns, suggesting that health conditions and activity had fewer effects on activity and participation, respectively.
      Fig 4
      Fig 4The MSEM analysis for health care system concerns showed that each path coefficient of the “group with fewer health care system concerns” was more significant than that of the “group with more health care system concerns,” except the sociodemographic factor path coefficients. This supported hypothesis 5 and showed the moderation effects of health care system concerns in the group with high health care system concerns, suggesting that health conditions and activity had fewer effects on activity and participation, respectively. Activity factors explained 62.2% of the total variance of participation factors in the group with fewer health care system concerns. Activity factors explained 57.4% of the total variance of participation factors in the group with more health care system concerns.

      Discussion

      With data from the Korean InSCI survey, this study verified the causal relationship between sociodemographic, health condition, and activity factors that affect the participation of people with SCI and investigated the moderation effects of environmental restrictions and the health care system. The results confirmed the hypotheses that health conditions significantly affect activity and activity significantly affects participation in people with SCI. Additionally, health conditions, activity, and participation of people with SCI were significantly different based on the extent of environmental restrictions and health care system concerns.
      The ADL of most people with SCI are negatively affected by secondary physical health conditions such as pain, bladder control, bowel control, and bed ulcers.
      • Piatt JA
      • Nagata S
      • Zahl M
      • Li J
      • Rosenbluth JP.
      Problematic secondary health conditions among adults with spinal cord injury and its impact on social participation and daily life.
      This supports the findings of the present study that health conditions affect activity in people with SCI and replicates the findings of a previous study that indicated health conditions affect independence in ADL.
      • Rivers CS
      • Fallah N
      • Noonan VK
      • et al.
      Health conditions: effect on function, health-related quality of life, and life satisfaction after traumatic spinal cord injury. A prospective observational registry cohort study.
      Moreover, these previous results align with those of another previous study
      • Lundström U
      • Wahman K
      • Seiger Å
      • Gray DB
      • Isaksson G
      • Lilja M.
      Participation in activities and secondary health complications among persons aging with traumatic spinal cord injury.
      that reported an increase in secondary health complications affects activity. Although these studies did not use the InSCI evaluation tools or involve Korean patients, the findings indicate a fundamental influence of such health conditions on the ADL of people with SCI in Korea and other countries.
      The present study found that activity affected participation, which is consistent with the findings of a previous study.
      • Van Leeuwen CM
      • Post MW
      • Westers P
      • et al.
      Relationships between activities, participation, personal factors, mental health, and life satisfaction in persons with spinal cord injury.
      These results are also consistent with previous reports
      • Cobb JE
      • Leblond J
      • Dumont FS
      • Noreau L.
      Perceived influence of intrinsic/extrinsic factors on participation in life activities after spinal cord injury.
      indicating that the effect of activity on participation may vary according to the characteristics of numerous factors. Studies
      • Braaf S
      • Lennox A
      • Nunn A
      • Gabbe B.
      Social activity and relationship changes experienced by people with bowel and bladder dysfunction following spinal cord injury.
      have also shown that health conditions directly affect participation rather than activity. This difference in results may be because the previous study's participants included people with SCI that had only intestinal and bladder dysfunction. Overall, activity factors such as transportation, ADL, and wheelchair use have significant effects on the participation of people with SCI.
      Consistent with the findings of the present study, environmental barriers, especially those such as “access to public places” which had negative effects on participation, were shown to affect participation levels.
      • Braaf S
      • Lennox A
      • Nunn A
      • Gabbe B.
      Social activity and relationship changes experienced by people with bowel and bladder dysfunction following spinal cord injury.
      • Dijkers MPJM
      • Yavuzer G
      • Ergin S
      • Weitzenkamp D
      • Whiteneck GG.
      A tale of two countries: environmental impacts on social participation after spinal cord injury.
      • Tsai IH
      • Graves DE
      • Chan W
      • Darkoh C
      • Lee MS
      • Pompeii LA.
      Environmental barriers and social participation in individuals with spinal cord injury.
      In this study, differences were observed in health conditions, activity, and participation according to the extent of environmental restrictions. In particular, the reduced effects of health conditions on activity and those of activity on participation in the group with higher environmental restrictions are supported by a previous study in which a significant correlation between environmental barriers, activity levels, and physical activity was observed.
      • Hwang EJ
      • Groves MD
      • Sanchez JN
      • Hudson CE
      • Jao RG
      • Kroll ME.
      Barriers to leisure-time physical activities in individuals with spinal cord injury.
      This supports the notion that environmental factors have complex effects on secondary health conditions.
      • Pilusa S
      • Myezwa H
      • Potterton J.
      Environmental factors influencing the prevention of secondary health conditions among people with spinal cord injury, South Africa.
      A study conducted on a sample of the Mongolian population
      • Dorjbal D
      • Prodinger B
      • Zanini C
      • Avirmed B
      • Stucki G
      • Rubinelli S.
      Living with spinal cord injury in Mongolia: a qualitative study on perceived environmental barriers.
      reported that environmental barriers affect physical and mental health and limit activity and participation in almost all areas of life. The study participants were interviewed and did not complete a questionnaire, limiting a direct comparison of results. Overall, these findings suggest that environmental restrictions, such as access to public places, long- and short-distance transportation, and others’ attitudes significantly affect the health conditions, physical activity, and social participation of people with SCI in South Korea.
      The present study revealed differences in health conditions, activity, and participation according to the extent of health care system concerns. Specifically, the reduced effects of health conditions on activity and those of activity on participation in the group with higher health care system concerns are consistent with previous findings.
      • Pelletier CA
      • Latimer-Cheung AE
      • Warburton DE
      • Hicks AL.
      Direct referral and physical activity counselling upon discharge from spinal cord injury rehabilitation.
      These findings reported that the health care system, such as rehabilitation counseling, affects participation and activity levels and that health care system use, including rehabilitation treatment and rehospitalization, is significantly related to health conditions and physical diseases.
      • Jaglal SB
      • Munce SEP
      • Guilcher SJ
      • et al.
      Health system factors associated with rehospitalizations after traumatic spinal cord injury: a population-based study.
      ,
      • Skelton F
      • Hoffman JM
      • Reyes M
      • Burns SP.
      Examining health-care utilization in the first year following spinal cord injury.
      In a previous study,
      • Eastwood EA
      • Hagglund KJ
      • Ragnarsson KT
      • Gordon WA
      • Marino RJ.
      Medical rehabilitation length of stay and outcomes for persons with traumatic spinal cord injury—1990-1997.
      higher activity significantly influenced health care system use, such as rehabilitation services and hospitalization. However, the study involved people with traumatic SCI in the United States, limiting a direct comparison of findings. These findings show that health care system factors such as nursing services, drug support, and rehabilitation services significantly affect the health conditions, physical activity, and social participation of people with SCI in South Korea.
      Appropriate interventions, recommendations, and policy directions that influence participation can positively change the participation of people with SCI in the community. First, it is important to reduce medical complications through intensive rehabilitation at an early stage and to implement the patient's movement and ADL training. In other words, improving overall health and facilitating activities are vital for increasing patient participation. Second, “solving health system problems,” such as nursing care, and increasing access to medical care, are essential. Third, it is important to “remove environmental restrictions,” such as by improving transportation, providing assistive devices, working toward eliminating social prejudice, and addressing economic problems.
      Our findings show that sociodemographic factors do not affect activity. For validity assessment of factors shown in a measurement model, convergent validity is confirmed when the CR of all latent variables is >0.7 and the average variance extracted from all latent variables is >0.5. In this study, the CR of sociodemographic factors was 0.369, and convergent validity could not be secured (see table 2). This may be attributed to the extensive variance estimate (error of the measurement variable) of sociodemographic factors B (education level) and C (income level). Sociodemographic factors included age, education level, and income level. These 3 observation variables do not consistently explain the latent variable, the “sociodemographic factor.” Therefore, this may be a limitation of analyzing 3 sociodemographic variables with various characteristics as 1 latent variable. Analyzing age, educational level, and income level as separate latent variables may suggest that these sociodemographic factors affect activity.

      Study limitations

      Several limitations must be considered in interpreting the study findings. First, although the relationship between the variables was assessed, the assumption of the relationship between the antecedent and outcome variables could not be evaluated. Second, this study examined people with SCI in South Korea; thus, the findings cannot be generalized to all people with SCI. Third, although the structural model of this study provided information through analysis based on the ICF theoretical model, there are limitations to drawing causal conclusions based on the high correlation between concepts. Fourth, this model did not include SCI factors that may affect activity. Fifth, the participants’ response rate to the questionnaire was low, limiting the generalization of the results. Future studies should consider these limitations.

      Conclusions

      The results of this study show that “activities” such as mobility and ADL were critical variables with significant effects on social participation after discharge and that “health condition” factors, including bladder function, bowel function, cardiopulmonary function, and pain, had significant effects on activity in people with SCI in South Korea. Furthermore, differences in “environmental restrictions,” such as transportation, assistive devices, negative attitudes of neighbors and family members toward disabilities, and economic problems, and “health care system concerns,” such as nursing problems and medical access, may cause significant differences in the participation of such people. Therefore, when establishing strategies for rehabilitation and formulating recommendations to promote the social participation of people with SCI dwelling in local communities in South Korea, the influence of environmental restrictions and health systems as well as the causal influence of health conditions and activity should be considered.

      Suppliers

      • a.
        SPSS Amos 24; IBM.
      • b.
        SPSS Statistics 21; IBM.

      References

        • Jette AM
        • Haley SM
        • Kooyoomjian JT.
        Are the ICF activity and participation dimensions distinct?.
        J Rehabil Med. 2003; 35: 145-149
        • Krause JS
        • Crewe NM.
        Chronologic age, time since injury, and time of measurement: effect on adjustment after spinal cord injury.
        Arch Phys Med Rehabil. 1991; 72: 91-100
        • Lee JH
        • Kang B-R.
        Comparison of daily activities and quality of life according to general characteristics of spinal cord injury.
        Korea Soc Cogn Ther Exerc. 2021; 13: 1-8
        • Shin E-K
        • Lee HN
        • Lee I-S.
        Examination of the mediating effect of self-efficacy and perceived social support on the spinal cord injuries’ social participation.
        Korean J Health Psychol. 2008; 13: 625-643
        • Chang FH
        • Liu CH
        • Hung HP.
        An in-depth understanding of the impact of the environment on participation among people with spinal cord injury.
        Disabil Rehabil. 2018; 40: 2192-2199
        • Shin H.
        Etiology and epidemiology of spinal cord injury in Korea.
        J Korean Med Assoc. 2020; 63: 589-595
        • Kennedy P
        • Lude P
        • Elfström ML
        • Smithson EF.
        Psychological contributions to functional independence: a longitudinal investigation of spinal cord injury rehabilitation.
        Arch Phys Med Rehabil. 2011; 92: 597-602
      1. Bickenbach J, Officer A, Shakespeare T, von Groote P, World Health Organization. International perspectives on spinal cord injury: summary (No. WHO/NMH/VIP/13.03). Geneva: World Health Organization; 2013.

        • Ullrich PM
        • Spungen AM
        • Atkinson D
        • et al.
        Activity and participation after spinal cord injury: state-of-the-art report.
        J Rehabil Res Dev. 2012; 49: 155-174
        • Mole H.
        A US model for inclusion of disabled students in higher education settings: the social model of disability and Universal Design.
        Widening participation and lifelong learning. 2013; 14: 62-86
        • Mole H.
        A US model for inclusion of disabled students in higher education settings: the social model of disability and Universal Design.
        Widening Partic Lifelong Learn. 2013; 14: 62-86
        • Van Loo MA
        • Post MWM
        • Bloemen JHA
        • Van Asbeck FWA.
        Care needs of persons with long-term spinal cord injury living at home in the Netherlands.
        Spinal Cord. 2010; 48: 423-428
        • Pacheco Barzallo D
        • Gross-Hemmi M
        • Bickenbach J
        • et al.
        Quality of life and the health system: a 22-country comparison of the situation of people with spinal cord injury.
        Arch Phys Med Rehabil. 2020; 101: 2167-2176
        • Jette AM
        • Tao W
        • Haley SM.
        Blending activity and participation sub-domains of the ICF.
        Disabil Rehabil. 2007; 29: 1742-1750
        • Badley EM.
        Enhancing the conceptual clarity of the activity and participation components of the International Classification of Functioning, Disability, and Health.
        Soc Sci Med. 2008; 66: 2335-2345
        • Barclay L
        • McDonald R
        • Lentin P.
        Social and community participation following spinal cord injury: a critical review.
        Int J Rehabil Res. 2015; 38: 1-19
        • Carpenter C
        • Forwell SJ
        • Jongbloed LE
        • Backman CL.
        Community participation after spinal cord injury.
        Arch Phys Med Rehabil. 2007; 88: 427-433
        • De Groot S
        • Post MWM
        • Bongers-Janssen HMH
        • Bloemen-Vrencken JH
        • Van der Woude LHV.
        Is manual wheelchair satisfaction related to active lifestyle and participation in people with a spinal cord injury?.
        Spinal Cord. 2011; 49: 560-565
        • Fekete C
        • Brach M
        • Ehrmann C
        • Post MWM
        • InSCI Stucki G
        Cohort profile of the international spinal cord injury community survey implemented in 22 countries.
        Arch Phys Med Rehabil. 2020; 101: 2103-2111
        • Gross-Hemmi MH
        • Post MWM
        • Ehrmann C
        • et al.
        Study protocol of the International Spinal Cord Injury (InSCI) community survey.
        Am J Phys Med Rehabil. 2017; 96: S23-S34
        • Fekete C
        • Post MWM
        • Bickenbach J
        • et al.
        A structured approach to capture the lived experience of spinal cord injury: data model and questionnaire of the International Spinal Cord Injury community survey.
        Am J Phys Med Rehabil. 2017; 96: S5-16
        • Kalpakjian CZ
        • Scelza WM
        • Forchheimer MB
        • Toussaint LL.
        Preliminary reliability and validity of a spinal cord injury secondary conditions scale.
        J Spinal Cord Med. 2007; 30: 131-139
        • Jette AM
        • Slavin MD
        • Ni P
        • et al.
        Development and initial evaluation of the SCI-FI/AT.
        J Spinal Cord Med. 2015; 38: 409-418
        • Fekete C
        • Eriks-Hoogland I
        • Baumberger M
        • et al.
        Development and validation of a self-report version of the Spinal Cord Independence Measure (SCIM III).
        Spinal Cord. 2013; 51: 40-47
      2. World Health Organization. Model Disability Survey: survey manual. Geneva: World Health Organization; 2017.

        • Ballert CS
        • Post MW
        • Brinkhof MW
        • Reinhardt JD
        SwiSCI Study Group. Psychometric properties of the Nottwil Environmental Factors Inventory Short Form.
        Arch Phys Med Rehabil. 2015; 96: 233-240
        • Bentler PM
        • Bonett DG.
        Significance tests and goodness of fit in the analysis of covariance structures.
        Psychol Bull. 1980; 88: 588-606
        • Piatt JA
        • Nagata S
        • Zahl M
        • Li J
        • Rosenbluth JP.
        Problematic secondary health conditions among adults with spinal cord injury and its impact on social participation and daily life.
        J Spinal Cord Med. 2016; 39: 693-698
        • Rivers CS
        • Fallah N
        • Noonan VK
        • et al.
        Health conditions: effect on function, health-related quality of life, and life satisfaction after traumatic spinal cord injury. A prospective observational registry cohort study.
        Arch Phys Med Rehabil. 2018; 99: 443-451
        • Lundström U
        • Wahman K
        • Seiger Å
        • Gray DB
        • Isaksson G
        • Lilja M.
        Participation in activities and secondary health complications among persons aging with traumatic spinal cord injury.
        Spinal Cord. 2017; 55: 367-372
        • Van Leeuwen CM
        • Post MW
        • Westers P
        • et al.
        Relationships between activities, participation, personal factors, mental health, and life satisfaction in persons with spinal cord injury.
        Arch Phys Med Rehabil. 2012; 93: 82-89
        • Cobb JE
        • Leblond J
        • Dumont FS
        • Noreau L.
        Perceived influence of intrinsic/extrinsic factors on participation in life activities after spinal cord injury.
        Disabil Health J. 2018; 11: 583-590
        • Braaf S
        • Lennox A
        • Nunn A
        • Gabbe B.
        Social activity and relationship changes experienced by people with bowel and bladder dysfunction following spinal cord injury.
        Spinal Cord. 2017; 55: 679-686
        • Dijkers MPJM
        • Yavuzer G
        • Ergin S
        • Weitzenkamp D
        • Whiteneck GG.
        A tale of two countries: environmental impacts on social participation after spinal cord injury.
        Spinal Cord. 2002; 40: 351-362
        • Tsai IH
        • Graves DE
        • Chan W
        • Darkoh C
        • Lee MS
        • Pompeii LA.
        Environmental barriers and social participation in individuals with spinal cord injury.
        Rehabil Psychol. 2017; 62: 36-44
        • Hwang EJ
        • Groves MD
        • Sanchez JN
        • Hudson CE
        • Jao RG
        • Kroll ME.
        Barriers to leisure-time physical activities in individuals with spinal cord injury.
        Occup Ther Health Care. 2016; 30: 215-230
        • Pilusa S
        • Myezwa H
        • Potterton J.
        Environmental factors influencing the prevention of secondary health conditions among people with spinal cord injury, South Africa.
        PLoS One. 2021; 16e0252280
        • Dorjbal D
        • Prodinger B
        • Zanini C
        • Avirmed B
        • Stucki G
        • Rubinelli S.
        Living with spinal cord injury in Mongolia: a qualitative study on perceived environmental barriers.
        J Spinal Cord Med. 2020; 43: 518-531
        • Pelletier CA
        • Latimer-Cheung AE
        • Warburton DE
        • Hicks AL.
        Direct referral and physical activity counselling upon discharge from spinal cord injury rehabilitation.
        Spinal Cord. 2014; 52: 392-395
        • Jaglal SB
        • Munce SEP
        • Guilcher SJ
        • et al.
        Health system factors associated with rehospitalizations after traumatic spinal cord injury: a population-based study.
        Spinal Cord. 2009; 47: 604-609
        • Skelton F
        • Hoffman JM
        • Reyes M
        • Burns SP.
        Examining health-care utilization in the first year following spinal cord injury.
        J Spinal Cord Med. 2015; 38: 690-695
        • Eastwood EA
        • Hagglund KJ
        • Ragnarsson KT
        • Gordon WA
        • Marino RJ.
        Medical rehabilitation length of stay and outcomes for persons with traumatic spinal cord injury—1990-1997.
        Arch Phys Med Rehabil. 1999; 80: 1457-1463