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University of Southern California Dissertations and Theses
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Variables Related To Life Satisfaction In Persons With Spinal Cord Injuries
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Variables Related To Life Satisfaction In Persons With Spinal Cord Injuries
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INFORMATION TO USERS This manuscript has been reproduced from the microfilm master. UMI films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type of computer printer. The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overlaps. Each original is also photographed in one exposure and is included in reduced form at the back of the book. Photographs included in the original manuscript have been reproduced xerographically in this copy. Higher quality 6” x 9” black and white photographic prints are available for any photographs or illustrations appearing in this copy for an additional charge. Contact UMI directly to order. UMI A Bell & Howell Information Company 300 North Zeeb Road, Ann Arbor MI 48106-1346 USA 313/761-4700 800/521-0600 Variables Related to Life Satisfaction in Persons With Spinal Cord Injuries by Hoi-Ling Chou A Thesis Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OF ARTS (Occupational Therapy) May 1996 Copyright 1996 Hoi-Ling Chou UMI Number: 1379576 UMI Microform 1379576 Copyright 1996, by UMI Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. UMI 300 North Zeeb Road Ann Arbor, MI 48103 UNIVERSITY O F SO U TH ER N CALIFORNIA T H E G RAD U A TE SC H O O L U N IV E R SIT Y PARK LO S A N G E L E S . C A L IF O R N IA 9 0 0 0 7 This thesis, written by C h c . L i ............................................... under the direction of h£L.....Thesis Committee, and approved by all its members, has been pre sented to and accepted by the Dean of The Graduate School, in partial fulfillment of the requirements for the degree of Dean Date l / 23./.?6 THESIS COMMI' Chairman Table of Contents List of Tables........................................................................................................................ v A bstract......................................................................................................................................vi C hapter 1. Introduction to the Problem ...............................................................................1 Statement of the Problem....................................................................................................1 Theoretical Framework.......................................................................................................2 Research Approach............................................................................................................. 5 Definition of Terms.....................................................................................................6 Limitations....................................................................................................................8 C hapter 2. Literature Review.................................................................................................9 Overview of Spinal Cord Injury........................................................................................ 9 Neurological Dysfunction After Spinal Cord Injury................................................9 Level of Injury............................................................................................................. 9 Extent of Injury.......................................................................................................... 10 Complete spinal cord injury..............................................................................10 Incomplete spinal cord injury........................................................................... 10 Psychological Reactions to Spinal Cord Injury...................................................... 11 Change of Sexual Function...................................................................................... 14 Vocational and Social Aspects.................................................................................14 Characteristics of the Spinal Cord Injury Population.............................................16 Life Satisfaction.................................................................................................................19 General Review......................................................................................................... 19 Theories..................................................................................................................... 22 Social comparison theory..................................................................................22 Activity theory.....................................................................................................23 Adaptation level theory.....................................................................................24 Factors Related to Life Satisfaction......................................................................... 24 Demographic variables......................................................................................25 Socioeconomic status (SES).............................................................................. 26 Health.................................................................................................................. 27 Social participation............................................................................................ 28 Summary.....................................................................................................................28 Life Satisfaction Among Persons With SCI...................................................................29 Demographic Factors.................................................................................................29 Illness-related Factors................................................................................................31 Personal Factors......................................................................................................... 32 Physical and Social Environmental Factors........................................................... 33 Life Satisfaction and Occupational Therapy..................................................................35 The Role of Occupational Therapy......................................................................... 35 Evaluation...................................................................................................................35 Passive joint range o f motion test.................................................................... 35 Assessment o f motor function............................................................................36 Gross sensory test...............................................................................................36 Functional activities evaluation........................................................................36 Home evaluation.................................................................................................36 Prevocational assessment..................................................................................36 Goal Setting and Planning........................................................................................ 37 Discharge Planning....................................................................................................37 Life Satisfaction and "Occupation"......................................................................... 37 Summary............................................................................................................................ 38 Chapter 3. Methodology........................................................................................................ 40 Design.................................................................................................................................40 iii Subjects...............................................................................................................................40 Instrumentation..................................................................................................................40 Independent Variables...............................................................................................41 Procedure........................................................................................................................... 43 Data Analysis.....................................................................................................................44 Chapter 4. Results...................................................................................................................45 Data Description................................................................................................................45 Hypothesis Test Results....................................................................................................46 Chapter 5. Discussion.............................................................................................................49 References.................................................................................................................................54 iv List of Tables Table 1. Frankel Scale: Functional Classification...................................................................11 Table 2. Etiology of Spinal Cord Injury...................................................................................18 Table 3. Description of Independent Variables...................................................................... 42 Table 4. Social Activity Frequency........................................................................................46 Table 5. Data Description of Non-dichotomous Variables.................................................. 47 Table 6. Results of Independent t-tests for Mean Differences in Life Satisfaction Scores47 Table 7. Correlational Analyses..............................................................................................48 Abstract A questionnaire survey was conducted among 17 persons with at least 2-year history of spinal cord injuries. Respondents include 4 Caucasians from the Los Angeles area and 13 Chinese from Taiwan. Both t test and regressional analysis were applied to determine any statistical significance existing between the score on Satisfaction with Life Scale and a set of independent variables, including demographics, socioeconomic status, subjective health, and social participation. The results indicate that subjective health is the most predictive factor of life satisfaction among the 17 participants. Educational level and social participation also play important roles in expression of life satisfaction. There are no statistically significant relationships between subjective life satisfaction and demographics, occupational status, and yearly income. Further study is indicated by using a larger sample size with various geographical areas. Chapter 1. Introduction to the Problem Statement o f the Problem The number of persons who survive spinal cord injury (SCI) has increased strikingly over the last thirty years. Before World War II, more than 80% of persons sustaining SCI died within two weeks of injury (Frank, Umlauf, Wonderlich, Askanazi, Buckelew, & Ellioll, 1987). Those who survived occasionally had lower cord injuries and lived the rest of their shortened lives without rehabilitation, thus being deprived of their independence. At present, it has been estimated that 10,000 Americans sustain SCI per year (Stover & Fine, 1987). Recently, attention has been directed toward the development of regional traumatic centers in which medical staff provide 24-hour coverage. Trauma death, especially immediate death, is substantially reduced when the patient is treated in a trauma center (Trunkey, 1983). As trauma centers become more common in the United States, it is likely that more persons will survive SCI. The decrease of mortality and prolonged life expectancy from SCI has resulted in more persons entering rehabilitation programs to maximize their independence and to achieve life satisfaction in the community. The current study is based on five interrelated assumptions: (a) that a key role of the occupational therapist is to help people who have survived spinal cord injuries reintegrate into the community; (b) that through reintegration, people with SCI are able to regain their independence and achieve life satisfaction in society; (c) that perceptions of life satisfaction are related to the factors through which individuals structure and organize their daily lives; (d) that these factors can be assessed objectively as well as subjectively; (e) that these factors can be examined through statistical analysis to determine any correlation with a global measure of perceived life satisfaction. 1 As we enter the 1990s, a developing perception is that the ultimate value of health care lies in helping people to function in everyday life. This perception, perhaps, was spurred by the increasing prevalence of chronic disease and disability, such as a spinal cord injury, and by activism for the rights of persons with disability. The increased focus specifically on functional assessment is reflected in public policy which emphasizes regulations for insurance to cover functional retraining and quality of life issues (Ellek, 1990). Quality of life refers to a sense of satisfaction with various aspects of one's life, including activities of daily living and vocation, leisure, social, and role functioning. The degree of life satisfaction experienced by persons with SCI, therefore, has become a major concern in the rehabilitation process. Studies on life satisfaction among people with SCI will enhance our understanding of what constitutes a quality life in this population. Such knowledge may lead to the development of guidelines for clinical practice as occupational therapists help persons with SCI pursue life satisfaction via the therapeutic use of occupation. Furthermore, the findings may further occupational science by revealing how persons with SCI can experience a high quality life in the presence of disability. Theoretical Framework Life satisfaction is defined as a global assessment of one's quality of life according to one's past and present experiences (Diener, Emmons, Larsen, & Griffin, 1985). Although some studies have used the concepts of subjective well-being and happiness interchangeably as indices of life satisfaction in assessment, conceptual distinctions exist among them. The term subjective well-being is typically used to represent an attitude toward one's quality of life, including both a cognitive judgment of life satisfaction and affective reactions that underlie happiness (Schwarz & Clore, 1983). The use of term happiness, in contrast, is used simply to refer to a positive affective state. The three concepts, subjective well-being, life satisfaction, and happiness, overlap. Alternatively, 2 however, one can define the components to be statistically independent of one another, for example, that cognitive components are distinguished from the affective components. Research by Andrews and Mckennell (1980) supported this point of view in that feelings of happiness tended to be lower among older people, but that feelings of satisfaction tended to be higher. The life satisfaction construct has been found to correlate with several other factors. For example, demographic factors such as socioeconomic status as well as objective health have been shown to be significantly related to life satisfaction. Some studies have demonstrated that the total proportion of variance in life satisfaction accounted for by demographic factors is not large (Palmore & Luikart, 1972; Willits & Crider, 1988). A few studies, on the other hand, suggest that perceived health is the most critical influence as one evaluates his or her satisfaction with life (Bull & Aucoin, 1975; Lohr, Essex, & Klein, 1988). However, strong predictors of life satisfaction have not yet been determined. Diener (1984) postulated that perception of life satisfaction is a subjective experience grounded in a general appraisal of one's life. He and his colleagues, Emmons, Larsen, and Griffin (1985), developed the Satisfaction With Life Scale (SWLS) based on the belief that one's level of satisfaction with life is a cognitive judgment dependent upon one's subjective experiences. Results of several studies corroborated that subjective assessments are more predictive of life satisfaction than objective indicators. For instance, housing or employment, although both necessary for a complete picture of the quality of life (Gutek, Allen, Tyler, Lau, & Majchrzak, 1983), in themselves, do not account for life satisfaction. In this pilot study, the SWLS was employed as an operational definition of life satisfaction. In approaching the evaluation of life satisfaction among people with spinal cord injury (SCI), past research has paid much attention to marital maintenance (Crewe & Krause, 1988; DeVivo & Fine, 1985; Urey & Henggeler, 1987) and employment status (DeVivo & Fine, 1982). The general conclusion is that persons with spinal cord injury are less satisfied 3 in these areas than the able bodied. However, what is absent in the literature is persuasive evidence that people with SCI experience less of a global sense of well-being than people without spinal cord injury. Just because one is dissatisfied with one or two aspects of one's life it does not necessarily mean that he or she will express an overall sense of being unhappy or discontent. Do people with SCI experience greater discontent with their life situation than others? Dias and Griffin (1983) demonstrated that the subjects with SCI were generally optimistic over approximately two years after onset. This phenomenon can be explained by adaptation level theories, which maintain that one's attitude toward current situations eventually matches the conditions, no matter the extent to which the events, good or bad, initially result in extreme satisfaction or distress (Appley, 1971). For example, the person who initially typically had experienced great happiness consequent to specific events will eventually adapt such that he or she will experience diminished happiness and employ a higher standard for experiencing happiness in the future. Similarly, accidents, such as SCI, initially bring about intense distress and dissatisfaction; however, the victim typically, with time, accepts its consequences and rearranges his or her life with a considerably improved attitude since he or she will ultimately adapt to this drastic event. It is reasonable, therefore, to expect that people with SCI do not always rate their level of satisfaction with life much lower than those who are able-bodied, even if the injury itself correlates with reduced satisfaction in certain domains of life. Csikszentmihalyi (1988) provides a useful framework for conceptualizing why individuals with spinal cord injury are able to experience a global sense of well-being. In the theory of optimal experince he proposes the optimistic perspective that everyone, including persons with SCI, experiences pleasure in activities, although the pleasurable content may be different depending on one's cumulative experiences and expectations. These optimal experiences contribute to a person's sense of life satisfaction. It may be 4 reasonable to expect that persons with SCI will report life satisfaction because of their own engagement in pleasurable experiences. In consideration of these issues, the purpose of the present pilot study is to examine the correlations between life satisfaction and several demographic factors (i.e., age, marital status, level of injury, and age at onset), socioeconomic status (i.e., education, yearly income, and occupational status), subjective health, and social participation (i.e., formal participation, informal familial participation, and informal nonfamilial participation). The results promise to help uncover the unknown structure of life satisfaction among adults with SCI, and thereby contribute to the enhancement of professional knowledge. Research Approach Statistical analysis was applied in this quantitative research study to examine the association of a broad range of variables on subjective assessment of life satisfaction in spinal cord injured individuals. The use of self-administered questionnaires was adopted in this study. Each respondent was sent an envelope containing a letter describing the purpose of the study, a copy of a consent form for participation, a questionnaire including designed questions regarding various factors, and the Satisfaction With Life Scale along with a self- addressed stamped envelope. The respondents were asked to return the completed information to the researcher. However, only four individuals contacted either by the researcher or through two organizations in the Los Angeles area responded to the questionnaires over a period of one year. Because such a small sample size was obtained after one year of subject recruitment, the content of the questionnaire was translated into Chinese for continuing data collection in the researcher’s home country of Taiwan. The content of translations was cross-examined by an English translator in Taiwan for validity. The sample consequently included two subgroups: four Caucasian adults from the Los Angeles area and thirteen Chinese adults from Taiwan. 5 This study attempted to test the following hypotheses: 1) there exists a relationship between demographic factors (age, duration of disability, level of injury, or marital status) and perceived life satisfaction among adults with SCI. 2) there exists a relationship between socioeconomic status (educational level, yearly income, or occupational status) and perceived life satisfaction among adults with SCI. 3) there exists a positive relationship between subjectively rated health and perceived life satisfaction among adults with SCI. 4) there exists a relationship between the degree of social participation (formal, informal familial, or informal nonfamilial participation) and perceived life satisfaction among adults with SCI. Definition of Terms Spinal cord injury: injury to the spinal cord from physical trauma, which leads to total or partial loss of sensory and/or motor function over the trunk and/or the extremities. Ouadriplegia: an injury occurring to the spinal cord in the cervical region (between the first cervical cord and the first thoracic cord) which results in paralysis in four extremities. Paraplegia: paralysis of the lower extremities, which results from an injury to the spinal cord in the thoracic, lumbar, sacral, or coccygeal areas of the spine. Completeness: a complete transection or compression of the spinal cord, in which there is no sensation, motor function, or reflexes noted below the level of the lesion. Incompleteness: partial transection or contusion of the spinal cord, with some evidence of sensation or motor function below the level of lesion. 6 Life satisfaction: a cognitive judgment made by an individual that consists of a general appraisal of his or her satisfaction with life. Numerical ratings on the Satisfaction with Life Scale (SWLS) were used in this study to operationally define life satisfaction. Socioeconomic status: designed to provide information about the social standing of all individuals in a society in the absence of detailed information about the entire complex of variables involved in overall socioeconomic standing (Powers, 1982). For the subjects in this study this term was operationally defined along three dimensions: (1) education— number of completed years of school; (2) income— measured by the individual’s household annual dollar income; (3) occupation— respondents were asked whether they (a) worked or went to school full-time, part-time, or not at all; (b) did some volunteerism; or (c) were housekeepers. Subjective health: this variable was measured by responses to the scaled question," Would you say your own health in general is (1) excellent, (2) good, (3) fair, or (4) poor." Responses were scored from three to zero, respectively. Social participation: this construct was operationally defined along the following three dimensions: (1) Formal participation— including voting, attending volunteer associations and church-related activities. The respondent was asked (a) whether he had voted since the onset of spinal cord injury and (b) the average number per month of participation in clubs, unions, associations, or religious services during the last twelve months. (2) Informal familial participation— the average number of reported visits or telephone conversations with children and relatives per month during the last twelve months. (3) Informal non familial participation— the average number of reported visits or telephone conversations with close friends and neighbors, as well as attendance at entertainment and sporting events, lectures, concerts, parties, restaurants, etc. during the last twelve months. 7 Limitations The limitations of the study include: 1) because the SWLS needs further validation, the possibility that the SWLS measures life satisfaction inaccurately is a potential limitation of the study. 2) because the subjects were selected from only the Los Angeles area and Taiwan, the results may not be generalized to the entire spinal cord injured population. 3) the sample size is small. The results may not promise to predict significantly the correlation between different variables and life satisfaction in the spinal cord injured population. 4) the validity of the translated scale applied in different societies, i.e., United States of America and Taiwain, might be a potential limitation. 5) the results of correlational analyses indicates the degree of association between the independent variables and perceived life satisfaction, not causal results. 8 Chapter 2. Literature Review Overview o f Spinal Cord Injury Neurological Dysfunction After Spinal Cord Injury The first concern immediately after spinal cord injury is survival. Surgery is always recommended. During the acute phase, individuals must face the problems of loss of voluntary control over their extremities, coping with pain and phantom sensations, alterations in sexual functioning, loss of bladder and bowel control, and the frustrations of immobilization (Hohmann, 1975). Spinal shock follows injury. Spinal shock is the recognition that all reflex activity below the level of lesion is obliterated, giving a picture of flaccid paralysis including sphincter atonia. It may continue with slow recovery, often for as long as two to three months, at which time, the individual is often bothered by spasticity or hyperreflexia during functional performances (Wilson, McKenzie, & Barber, 1974). The most common medical problems associated with spinal cord injury are pressure sores, autonomic dysreflexia, decreased coughing ability and vital capacity, dizziness, and heterotopic ossification (Wilson et al., 1974). Level of Injury Spinal cord injury is described as a phenomenon of impaired sensory and/or motor function over the trunk and/or extremities because of physical trauma to the spinal cord (Hopkins, 1971). The severity of the loss is determined by the level at which the injury occurs. Each level of the spinal cord innervates specific motor and sensory functions. Therefore, the higher the level of lesion, the more profound is the loss of function. Quadriplegia results when an injury occurs to the spinal cord in the cervical region (between the first cervical spine and the first thoracic spine). The term "quadriplegia" refers 9 to paralysis of all four extremities (complete spinal cord injury). Paraplegia refers to paralysis of the lower extremities and results from an injury to the spinal cord in the thoracic, lumbar, sacral, or coccygeal areas of the spine. The terms "quadriparesis" and "paraparesis" refer to weakness, rather than total paralysis, and may be used when an injury is incomplete (Buchanan & Nawoczenski, 1987). Extent of Injury The extent of the injury describes whether the lesion is complete or incomplete. A complete spinal cord injury is one in which all motor and sensory function is lost below the level of the injury. Complete spinal cord injury. At the time of complete injury, all motor power, sensation, and reflexes are lost in those areas of the extremities and trunk that are mediated by the spinal nerves at and below the level of the injured cord. Flaccid paralysis occurs immediately and lasts throughout the initial phase of neurologic shock (also known as spinal shock) (Hopkins, 1971). Spinal shock may occur hours or weeks after the injury. There is a concomitant loss of visceral function, including flaccid paralysis of the bowel and bladder. When spinal shock subsides, the flaccid paralysis is replaced by spasticity when the level of the cord injury is above the level of conus medullaris (Buchanan & Nawoczenski, 1987). Incomplete spinal cord injury. If there is any function intact below the level of injury, the lesion is incomplete by definition (American Spinal Injury Association, 1983). Spasticity is more prevalent than in complete lesions. Some patients with an incomplete cord lesion will have progressive functional recovery, although the return of function may cease at any time. Incomplete 10 spinal cord injuries may also be functionally classified according to the Frankel Scale system (see Table 1). Table 1. Frankel Scale: Functional Classification A. COMPLETE No preservation of motor or sensory function B. INCOMPLETE— PRESERVED Preservation of any sensation below the level of SENSATION ONLY injury, except phantom sensation C. INCOMPLETE— PRESERVED Preserved motor function without useful purpose; MOTOR NONFUNCTIONAL sensory function may or may not be preserved D. INCOMPLETE— PRESERVED Preserved functional voluntary motor function that MOTOR FUNCTION is functionally useful E. COMPLETE RECOVERY Complete return of all motor and sensory function, but may still have abnormal reflexes From "Standards for Neurological Classification O f Spinal Injury Patients", American Spinal Injury Association, November 1983. Psychological Reactions to Spinal Cord Injury The rehabilitation of people with SCI attains its maximal potential around one year after onset, but the psychological and social reactions associated with the catastrophe may extend through the individual's entire life. Past studies (Verkuyl, 1970; Moos 1989) indicate that it usually takes at least 4 years, and sometimes 6 years, to accept psychologically the consequences of an acute spinal cord lesion. According to psychologists’ experience in dealing with the psychological problems associated with spinal cord injury (Vargo, 1975), the more severe the loss in terms of disruption of the total personality functioning, the more intensive and extensive will be the reactions to that loss. The following set of stages of adjustment often follows a spinal cord injury. 11 As the individual realizes his or her loss of body function, an initial stage of denial occurs. It can be observed for a period of about three weeks to two months following injury. Because it is beyond the capability of most people to incorporate such drastic and sudden changes in their self concept, denial is used as a defense mechanism to avoid dealing with the attendant painful realizations. The extensive use of denial begins to disappear only when the individual has had sufficient experiences with his disability so that he can begin to see positive and gratifying experiences in his life (Brickman & Campbell, 1971). The second reaction to spinal cord injury is depression. The first period of the depressive reaction may be characterized by withdrawal and internalized hostility. The individual strongly feels a sense of self-blame for his or her accident, and may think in vague terms of suicide. In general, fifty percent of people with SCI describe suicidal thoughts, but relatively few actually attempt suicide during this period. However, suicide is still a significant cause of death in this population, with approximately one out of ten deaths being related to self-destructive behavior (Macleod, 1988). The patient has little motivation during this period, and there is often a great strain placed on the family. After searching to find a reason for why the injury happened to him or her, the person with SCI then externalizes hostility and blame for his or her loss. He or she is apt to be assaultive physically as well as verbally demanding, intolerant, and impatient. As a means of handling such situations, therapists attempt to channel this hostility and aggression into productive activity. When the individual has gained enough from his or her rehabilitation efforts and training in self-care activities to begin to feel a sense of independence again, he or she is faced with the process of adjustment to his or her disability and has a reaction against dependence. One's attention in this phase is directed toward his or her home, work, or education in an attempt to engender feelings of self-sufficiency (Aadalen & Stroebel-Kahn, 1981). Ideally, it is during this period that the individual should be able to leave the 12 sheltered environment of the institution and resume his or her life in the community with the help of medical professionals (Hohmann, 1975; Vargo, 1978). Historically, researchers have assumed that spinal cord injuries induce a series of psychological stages that occur in predictable and specific phases, as described above. However, little attention has been directed toward understanding psychological differences among persons who sustain SCI as these differences predict eventual psychological adjustment. Recently, psychologists have found that one of the most important factors in successfully helping these people cope with psychological distress is to identify individuals' naturally occurring coping responses to SCI (Frank, Umlauf, Wonderlich, Askanazi, Buckelew, & Elliott, 1987). Empirical results have found that people with SCI with an internal locus of control experience less distress and depression than those with an external locus of control. Spinal cord injury necessitates major adjustment, both physical and psychological. The necessary development of a modified identity is an arduous task involving the gradual integration of the reality of the losses within the person's cognitive, affective, and behavioral functioning, and the mastering of physical and psychological independence. Past studies suggest that psychological adjustment is influenced by many factors, such as age, sex, pre-injury educational and occupational attainments, pre-injury life satisfaction, quality of interpersonal relationships, and personality (Macleod, 1988). If medical practitioners give adequate psychological support and understand the underlying influences on adjustment to disability; and a healthy rehabilitation milieu sets the expectation for being able to lead a meaningful, productive, and gratifying life; it is realistic to expect that the majority of these people will lead a satisfying life in the community. 13 Change o f Sexual Function Perhaps the most threatening concern following a spinal cord injury is the individual's anxiety about the effects of the disability on sexual functioning. After reviewing 33 articles on psychosocial aspects of sexuality following spinal cord injury, Teal and Athelstan (1975) concluded that reduced sexuality can diminish perceptions of self-worth, change one's social role, retard psychological adjustment, and even lead to divorce. It is generally accepted that males have more difficult sexual identity readjustments than females because the situation forces the male into a role reversal featuring passivity, and female genital function is not as severely impaired (Teal & Athelstan, 1975). It is noteworthy that a spontaneous labor can be performed for a female with even a high level of the fifth cervical injury. In one follow-up study (Dias & Griffin, 1983) of 24 females with SCI over a 5-year period, all expressed acceptance of their sex role and had no wish for change as they were interviewed. Research (Siosteen, Lundqvist, Blomstrand, Sullivan, & Sullivan, 1990) has suggested that sexual adjustment after injury is closely and positively correlated to frequency of intercourse, willingness to experiment with alternative sexual expressions, and young age at injury. Studies also have shown that physical and social independence and a high mood level were further positive determinants of sexual adaptation after injury, whereas the neurological level and completeness of injury showed no significant correlation with sexuality. The person who treats individuals with cord lesions should be knowledgeable regarding the effects of cord injury on sexual function in order to assist the injured individual and his or her spouse in resuming a totally healthy life (Teal & Athelstan, 1975). Vocational and Social Aspects One of the more pressing challenges people with spinal cord injury must overcome is resocialization in the community. To succeed, they must preserve a reasonable emotional 14 balance and satisfactory self-image and maintain a sense of competence and mastery in relation to the environment including objects, people, and events. They also have to sustain relationships with their family and friends. Furthermore, they must prepare for an uncertain future and resume a productive worker role (Moos, 1989). A vocational process, including qualified vocational evaluation, training, and eventual employment, can be the best way to achieve full functioning in response to the demands of physical, psychological, and social adaptation (Lassiter, 1977). After reviewing past studies on employment status in people with SCI, DeVivo and Fine (1982) found that the postinjury employment rate remained approximately 50% on the average each year in the United States. One of the critical factors in successful postdisability employment is a high level of education. The extent of disability did not appear to be a significant factor in determining the percentage of the group that was currently employed, but was related to the amount of difficulty in maintaining employment and full-time working (DeVivo & Fine, 1982; Krause, 1990). People with quadriplegia experienced the greatest number of job rejections and averaged fewer hours per week working. However, a person's ability to live productively is not only related to gainful employment but also to that person's other contributions to community and family life. In a study by DeJohn, Branch, and Corcoran (1984), productive activities, apart from gainful employment, based on a person's participation in school or training activities, formal organizations, homemaking, and leisure time activities were also found to importantly predict life satisfaction. These findings are consistent with those found in the normal population. Avocational pursuits are sometimes more strongly related to life satisfaction than are vocational attainments. 15 Characteristics o f the Spinal Cord Injury Population People who suffered spinal cord injuries were not treated successfully until World War II. Presently, an ever increasing number of victims are being cared for more successfully each year. Mortality has decreased and life expectation has been prolonged among people with traumatic spinal cord injuries (Dunnum, 1990). One study (Spack & Istre, 1988) on the epidemiology of spinal cord injury (SCI) reports that the incidence of SCI was between 28.0 and 50.0 new spinal cord injures per million persons at risk every year in the United States in 1987. Stover and Fine (1987) employed the mathematical relationship between incidence and duration to re-estimate the prevalence of SCI, calculating the rate to be approximately 906 per million. Thus, there are presently over 200,000 cases of SCI in the United States. Spinal cord injury is considered a high-cost disability requiring numerous personal life style changes. The costs have an indirect impact on the economy because most injured individuals are in their prime wage earning years and the injuries may prohibit return to the work force (MacKenzie, Shapiro, Smith, Siegel, Moody, & Pitt, 1987). In the United States, SCI occurs most frequently in persons between 15 and 20 years of age. According to the National SCI Database, the mean age at injury is 29.7 years, the median age is 25 years, and the modal age is 19 years. That spinal cord injury often occurs in the working age group is thus recognized. In addition, SCI occurs more frequently among males than among females (4:1 ratio) (Spack & Istre, 1988). Another review of more than 10,000 cases documented in the National SCI database shows that the highest percentage of spinal cord injuries result from motor vehicle accidents (47.7%), followed by falls (20.8%), acts of violence (14.6%), sports (14.2%), and other categories (2.7%) (Table 2). 16 Injuries that result from falls seem to occur more frequently in those over 50 years of age (Dias & Griffin, 1983; Weingarden & Graham, 1989). Among the entire spinal cord injured population, quadriplegics are more common than paraplegics (52% vs. 48%) (Accident Facts, 1983). The cumulative 10-year survival rate of people with SCI is more than 86%. People between 10 and 19 years of age have the highest 10 year survival rate. Not surprisingly, this rate declines after age 29, so that by age 60 to 69, little more than half of these who sustain cord injuries survive 10 years or more. A retrospective study of 5,131 people who sustained their spinal cord injuries between 1977 and 1980 has been completed recently by the National SCI Statistical Center. The leading causes of death were pneumonia, accidents, and suicides. The percentage of deaths due to pneumonia and suicide is significantly higher when compared with that of the normal population (Geisler, Jousse, Wynne-Jones, & Breithaupt, 1983; Macleod, 1988). Accidents, suicides, and cancer were the leading causes of death among paraplegics, whereas pneumonia was the leading cause among quadriplegics. Besides the effect of different diagnostic groups, race and age also influence the causes of death. Pneumonia was the most common cause of death for people over 55 years of age and also among non-white quadriplegics. On the other hand, accidents and suicides were the main causes of death for those less than 55 years of age and among white paraplegics. The duration after onset of injury is also related to the causes of death (Stover & Fine, 1987). During the first month post-injury the most frequent cause of death was illness- related conditions, such as septicemia or pneumonia. In contrast, accidents and suicides were the two most prevalent causes of death more than 6 months post-injury. The above review shows that life expectation among people with SCI has been prolonged by virtue of medical advancement. Thus, the goal of helping these individuals to live better is an important issue challenging rehabilitation professionals. Today, with the 17 rise of deinstitutionalization, the medical professions are devoting increased effort to improving the biopsychosocial status of people with SCI. In the next section, the topic of life satisfaction among the non-disabled population will be reviewed to ascertain the factors that significantly influence it. Table 2. Etiology of Spinal Cord Injury Motor vehicle accidents 47.7% Falls 20.8% Acts of violence 14.6% Sports 14.2% Diving 66.0% Football 6.1% Snow skiing 3.8% Surfing 3.1% Trampoline 2.6% Wrestling 2.3% Gymnastics 2.2% Horseback 2.0% Other sports 11.9% Other 2.7% From Spinal Cord Injury: Facts & Figures, Birmingham, AL, National Spinal Cord Injury Statistical Center, 1986. 18 Life Satisfaction General Review Life satisfaction is conceptualized as an individual's general cognitive appraisal of the quality of his or her life. Two views on the definition of life satisfaction are discussed in the literature (Neugarten, Havighurst, & Tobin, 1961). In the first, life satisfaction is narrowly evaluated by the social environment in terms of social acceptability of individual success or competence. For instance, socioeconomic status might be used as an indicator. In the second focus, the degree of life satisfaction is based upon the individual's internal frame of reference. In this view, the individual is the only judge of his or her well-being. Recently, the trend in the assessment of life satisfaction has moved toward the individual's subjective judgment regarding various aspects of his or her life. Consistent with this perspective are the findings of studies that show general satisfaction with life being related to the aspects chosen by individuals as the most important to them (Shichman & Cooper, 1984). It is generally agreed that a definition of life satisfaction based on the individual's subjective evaluation is more reasonable than one based on external criteria (Cutler, 1979; Diener, 1984). Diener (1984) postulated that the sense of satisfaction resides within the experience of the individual. Although conditions such as objective health, comfort, virtue, or wealth are seen as of potential influence on life satisfaction, they are not necessarily inherent in it. A study conducted by psychologists on the importance of internal referents as determinants of satisfaction also supports this point of view (Gutek, Allen, Tyler, Lau, & Majchrzak, 1983). That is, subjectively assessed life satisfaction is more predictive in the assessment of general life satisfaction than so called objective indicators. Because people live in a subjective world, the objective world is colored by our internal referents. For 19 example, if people perceive conditions as improving, then conditions need not be ideal in order for people to feel satisfied. It has also been suggested that life satisfaction be defined as multifaceted domains of satisfaction (Bortner & Hultsch, 1970; Clemente & Sauer, 1976; Cutler, 1979; Hoyt, Kaiser, Peters, & Babchuk, 1980). Researchers often define life satisfaction as a composite of satisfaction and dissatisfaction experienced across various domains of life. For example, some have assessed satisfaction with life from different role performances, such as worker, parent, spouse, homemaker, citizen, friend, and association member (Neugarten et al., 1961; Clemente & Sauer, 1976; London, Crandall, & Seals, 1977; Glenn, 1975). Researchers not only evaluate the extent of reported activity but also evaluate one's satisfaction with his or her performance in each role. These objective items are basically assessed by one's subjective experience of overall satisfaction. Using partial correlation techniques, Michalos (1980) found support for the notion that substantial levels of covariation were found among the variables used to predict satisfaction with life as a whole from satisfaction with specific domains, for instance, family life and health. Another issue pertaining to the assessment of life satisfaction focuses on whether an affective component is included. Studies reveal that there are definite distinctions between assessment of affective reactions (e.g., happiness) and assessment of life satisfaction defined as a cognitive element (which will be reviewed in depth in following section). Diener, Emmons, Larsen, and Griffin (1985) criticize the inclusion of affective status (for instance zest vs. apathy toward life) as being beyond the scope of the cognitive judgment of life satisfaction. They have developed the Satisfaction with Life Scale (SWLS), focusing on a narrow band definition of life satisfaction, i.e., the evaluation of life satisfaction is a process involving cognitive judgment by globally reviewing one's past and present life. Because this view is broadly accepted in the literature, it is embraced in the present study and the SWLS was used to measure life satisfaction. 20 A number of terms have been used in approaching the measurement of life satisfaction. These terms will be distinguished here. In the literature, subjective well-being is commonly used interchangeably with life satisfaction. However, the scope of subjective well-being is broader than that of life satisfaction. Measures of subjective well-being typically address the integrated judgment of the person's life (Diener, 1984). Their emphasis is on a global assessment of all aspects of a person's life, which includes life satisfaction, positive affect, and happiness. The evaluation of subjective well-being also represents the assessment of quality of life (Schwarz & Clore, 1983). In contrast, happiness, also related to life satisfaction, is distinguished from subjective well-being. Wilson (1967) defined happiness as high mood, fullness of life, receptivity toward the environment, and sociability. The feelings of happiness generally reflect an individual's internal affective state. Happiness is thought as of having both a positive and a negative dimension, which are independent of each other. In contrast to the feeling of happiness from the "heart," an emotional component, satisfaction reflects the outcome of social comparison processes from the "head," a rational aspect (Andrews & Mckennell, 1980). Such comparison may be a conscious, as opposed to nonconscious, feeling of happiness (Diener, 1984; Schwarz & Clore, 1983). In summary, subjective well-being corresponds to how and why people experience their lives in positive way. Measures of subjective well-being are measures of attitudes, and therefore can be expected to reflect cognitive and affective elements. Life satisfaction is related to a cognitive judgment, while happiness reflects an affective reaction. The domains of life satisfaction are multifaceted, evaluated subjectively, and are often based on objective items, for example, health, wealth, or the frequency of social activities each month. 21 In this study, life satisfaction was defined as a cognitive judgment made by an individual that consists of a general appraisal of one's life. Numerical ratings on the Satisfaction With Life Scale were used to operationally define life satisfaction. Theories In this section, three theories (activity theory, social comparison theory, and adaptation level theory) are discussed to explain how persons with SCI experience life satisfaction after injury. These theories were selected for review because they not only serve as useful explanations of life satisfaction but also are intimately linked to clinical applications in occupational therapy practice. However, the review does not cover a number of important theories; the reader is referred to the following reports for more detailed discussion: Schwarz and Clore (1983) on associationistic theories (people may use their momentary affective state as information relevant to making judgments on life satisfaction); Michalos (1980) on goal theories (satisfaction occurs when certain life goals are achieved); and Maslow's (1968) need theories (satisfaction comes from the fulfillment of certain needs). Social comparison theory. In social comparison theory, the main theme is that one uses a selected reference person or group as a standard for comparison of one's degree of satisfaction. Satisfaction or dissatisfaction comes from the perceived discrepancy between one's own status and that of a comparison person or group. In support of this notion, researchers have found that social comparison is the strongest predictor of satisfaction in most domains (Diener, 1984). For example, the relevant source of satisfaction with one's standard of living is having more income than someone else, not just having more income (Duncan, 1975). The most influential comparisons one makes are with the most liked previous experiences one has had or with people perceived as belonging to a similar social class to one's own (Brickman & Campbell, 1971). According to this formulation, it is likely that life 22 satisfaction among people with SCI might be the result of comparison with those who are in a similar situation, that is their spinal cord injured peers. Activity theory. Traditionally, activity theory (Lemon, Bengtson, & Peterson, 1972) has been broadly used in gerontological research. It maintains that one should focus on important activities and goals, and a sense of satisfaction will occur as an unintended by-product. More critically, satisfaction comes from the activity process, not from the result or end product. For instance, some researchers have found a positive association between goal setting and job satisfaction, even if the goals were not achieved (Kim & Hamner, 1976). It is not only the presence of goals that contributes to job satisfaction (whether the goals are achieved or not), but it is participation in the goal setting process that is satisfying. However, it was not clearly understood how activities produce a sense of subjective well-being until the flow theory was proposed by Csikszentmihalyi (1988). In his flow theory, optimal experience or flow arises when the activities have clear goals, generally match one's skills level, provide immediate feedback, and demand intense concentration. People tend to replicate optimal experiences more often relative to other experiences to sustain their lives in harmony. In this way, the experience of flow is intrinsically motivated. The contribution of flow theory to a more complete view of human behavior is similar to the effort that occupational therapy, emphasizing one's ability rather than disability, has made in medicine. Similarly, the challenge in a rehabilitation program demands personal involvement, which stimulates one's potential ability to perform tasks that one could not imagine doing before, in order to earn one's independence along with a sense of achievement. The properties of flow are used to guide the goal-directed activities in occupational therapy to help people with disabilities further their ability to function fully within their total environment (American Occupational Therapy Association, 1988). 23 Through such enjoyable treatment programs guided by occupational therapists, the goal of leading a balanced life style among persons with SCI in the community is promoted. Adaptation level theory. Adaptation level theory (Appley, 1971) suggests that irrespective of how much satisfaction a good event results in, the individual will, over time, eventually adjust evaluatively to the overall level of events. That is, when current events are better than one's standard, derived from his or her past experiences, he or she will be gratified. Nevertheless, if the good conditions continue, adaptation will occur and the individual's standard will elevate so that it at last matches the newer events. He or she will no longer be so happy. Similarly, a corresponding adaptation process occurs for bad events. Empirical data suggest that there is a significant positive relationship between acceptance of disability and duration of the disability, regardless of one's age, as a result of adaptation processes (Woodrich & Patterson, 1983). While the process of learning to live with a spinal cord injury is thought to take many years, Kerr and Thompson (1972) reported that two years was necessary for the person with SCI to feel some degree of stability. Also, it should take at least two years for the individual with SCI to express a sense of satisfaction with life after he or she generally adjusts to the disability. A basic assumption of the current study is that people with SCI are likely to experience, over time (at least two years after onset), satisfaction with their lives (because they eventually adapt to this drastic event); this assumption is theoretically supported by adaptation level theory. Factors Related to Life Satisfaction Individuals' judgments of life satisfaction are influenced by many factors. Such factors can be grouped into four categories: demographic variables, socioeconomic status, health, and social participation. Each of these categories is reviewed below. 24 Demographic variables. Relevant demographic variables include age, gender, and marriage. Some researchers have found that there is no significant correlation between life satisfaction and demographic factors (Palmore & Luikart, 1972; Willits & Crider, 1988). However, Cutler (1979), basing his research on seven age groups ranging from 18 to 90 years old, suggested that age or maturation affects the conceptualization of what constitutes a good life. Results showed not only that life satisfaction is a multidimensional rather than a unidimensional construct, but that the pattern of multidimensionality varies across age groups. Across age groups specific concerns are also differently employed to determine their satisfaction with life. For example, marriage, family, and friends correlate highly with levels of satisfaction for nearly all age groups, whereas satisfaction with one’s employment serves as a more critical factor in the process of judging satisfaction level with life in middle age groups compared to elders. A number of studies indicate that married persons report substantially greater global life satisfaction than unmarried persons (Diener, 1984; Glenn, 1975; Glenn & Weaver, 1981; Wilson, 1967). Glenn (1975) concluded that although married women report greater stress symptoms than unmarried women, they also reported greater satisfaction. Later, Glenn and Weaver (1981) found that marital happiness was far more important than any other kind of satisfaction in contributing to overall life satisfaction, even when education, income, and occupational status were controlled. It is suggested that because the effects for marriage are positive but not always strong (Cutler, 1979; Edwards & Klemmack, 1973), investigators should explore factors that may interact with marriage, such as race (Clemente & Sauer, 1976; Diener, 1984). Little difference in reported satisfaction is found between the sexes (Bortner & Hultsh, 1970; Edwards & Klemmack, 1973; Palmore & Luikart, 1972). Nevertheless, Cutler (1979) suggested that sex differences should be examined within each age group (just mentioned earlier) to see if males and females have different underlying organizational structures that contribute to life satisfaction. 25 Because of the ambiguous results of studies on the demographic factors contributing to life satisfaction in the literature, Clemente and Sauer (1976) recommended that demographic factors be controlled in investigations of life satisfaction. Socioeconomic status (SES). Many studies have shown that SES, which includes education, income, and occupational status, is one of the strongest predictors of life satisfaction (Bull & Aucoin, 1975; Cutler, 1973; Edwards & Klemmack, 1973). Yet, some researchers point out that whether SES has any independent effect on life satisfaction is still an unresolved issue (Bortner & Hultsh,1970; Clemente & Sauer, 1976; Palmore & Luikart, 1972; Willits & Crider, 1988). Cutler (1973) found that people who were socially active were initially more satisfied by their life situation by virtue of, importantly in part, their status characteristics. Bull and Aucoin (1975), who replicated Cutler's work two years later, also suggested that SES was potentially an important variable in evaluating life satisfaction. Edwards and Klemmack (1973) found that income and occupational status were especially critical to the level of satisfaction one experienced. Along this line, Smith and Lipman (1972) found that monthly income is a major factor in evaluations of life satisfaction. Although people who are wealthier tend to be happier, there is no evidence to show that there is a positive relationship between life satisfaction and the overall level of income (Diener, 1984). The relationship between job satisfaction and life satisfaction is estimated to be substantial in the literature. A meta-analysis (Tait, Padgett, Baldwin, 1989) on this topic found that the finding of a larger correlation between job satisfaction and life satisfaction for men than for women disappeared in studies published after 1974. Demographic changes among female workers and changes in the relative importance of work to women's lives are suggested as reasons for this change. Another study (London, Crandall, & Seals, 1977), in 26 examining the relationship between job satisfaction and overall life satisfaction, indicates that job satisfaction contributes relatively little to the life satisfaction of disadvantaged subgroups, as compared with advantaged workers (such as white-color workers, married persons, and those in the high SES group), although it accounts for meaningful variation in perceived satisfaction. It is stated that each of the indicators of SES is positively associated with life satisfaction; however, the contribution of each indicator may vary in different proportions. Indeed, Edwards and Klemmack (1973) found that income and occupational status were more predictive of life satisfaction than was education. Analyses based on data from the General Social Survey of 1982 of the National Opinion Research Center indicate that overall life satisfaction increased with age and education in the U.S. within that year (Mookheijee, 1987). However, the above conclusion resulted in some controversy because this survey did not include an important predictor, personal income, as an independent variable in its analysis. It may be that education is more strongly related to satisfaction among younger middle-aged adults (Palmore & Luikart, 1972). A pervasive finding is that education functions to broaden one's perspective, to increase one's involvement and investment in life, and also to raise one's aspiration level which may have a defeating effect on perceived satisfaction (Diener, 1984; Schichman & Cooper, 1984). Thus, education leads to a greater awareness of both gratification and frustration in various life areas. In fact, several studies have found that there is no significant effect of education on life satisfaction when other factors are controlled (Clemente & Sauer, 1976; Diener, 1984; Willits & Crider, 1988). Health. Subjective assessment of health tends to be more strongly predictive of life satisfaction than objective records made by a physician (Bull & Auoin, 1975; Clemente & Sauer, 1976; Cutler, 1973,1979; Edwards & Klemmack, 1973; Lohr, Essex, & Klein, 1988; Palmore & 27 Luikart, 1972; Smith & Lipman, 1972; Willits & Crider, 1988). Some individuals in poor health and with functional difficulties rate their health as quite good on subjective measures, which suggests that other psychological and social factors are important under such disadvantaged conditions (Lohr, Essex, & Klein, 1988). This result suggests the possibility that people suffering spinal cord injury may rate themselves high in health status on subjective measurements as long as they lead satisfied lives, despite their limited functional status. Social participation. Social participation consists of formal participation, informal familial participation, and informal nonfamilial participation. Past studies (Edwards & Klemmack, 1973; Hoyt, Kaiser, Peters, & Babchuk, 1980; London, Crandall, & Seals, 1977) suggest that higher levels of social activity are associated with higher levels of life satisfaction. Further, they reveal that informal activity is more highly associated with life satisfaction than formal activity, and formal activity more highly associated with life satisfaction than solitary activities. On the other hand, church-related involvement remains positively associated with life satisfaction, even after controlling other variables (Edwards & Klemmack, 1973). It is apparently not activity in general that contributes to life satisfaction, but only particular types of activity that do so. Summary A number of investigators have noted that demographic variables account for only a small proportion of variance in life satisfaction. Research also demonstrates that persons of varying backgrounds are likely to have widely different views as to what constitutes the good life. The preceding review reveals that alternative indicators of life satisfaction do not all exhibit the same pattern. Thus, life satisfaction is probably determined by a number of 28 factors. Further, if researchers intend to investigate what potential variables have an important effect of predicting life satisfaction, appropriate controls for other factors, for example, SES or gender, should be taken into consideration. Then, how much do people with disabilities enjoy their lives? Are they as satisfied as non-disabled people? Cameron, Titus , Kostin, and Kostin (1973) point out that it is a rare person who is not relatively deficient in a number of respects compared to his peers, for example, physical attractiveness, knowledge, or social skills. However, most "non-disabled people" learn to adjust to or cope with their deficits; they manage to enjoy their life in spite of their inevitable drawbacks. Perhaps persons with disability manage to enjoy their life using the same psychological mechanism. Unlike moods, which are relative to a person's usual affective state and which are heavily influenced by immediately prior circumstances, a person's appraisal of his overall quality of existence takes in broader considerations as reviewed earlier. It could be contended that persons who are permanently disadvantaged (e.g. persons with SCI) or permanently advantaged (normals) can be expected to adjust their appraisal of life satisfaction relative to the special set of circumstances associated with their respective statuses. Life Satisfaction Among Persons With SCI The determinants of life satisfaction among persons with SCI can be divided into four categories: personal factors, demographic factors, illness-related factors, and physical and social environmental factors. Each is reviewed, in turn, below. Demographic Factors Research indicates that there are some demographic variables, as well as other factors (which will be discussed later), which may influence the adaptation to spinal cord injury 29 and the experience of life satisfaction. One of these variables is gender; however, limited research has been conducted which addresses disability and its relation to gender. After reviewing the literature, Dailey (1979) discovered that there were few investigations of the problems of disabled women in general, and much less research that was specific to spinal cord injured women. The reason for this deficiency was that males represent about 80% of the population of spinal cord injured people. However, certain research has suggested that spinal cord injured males have more difficulty than females in accepting their disability because of sexual problems related to role reversal (as reviewed earlier). Age is another variable which has been related to life satisfaction in the spinal cord injured population. Kerr and Thompson (1972) followed 181 spinal cord injured people for three years and rated their psychological adjustment. They found that 83% of those between the age of 10 and 20, 60% of those age 20-45, and 41% of those over age 45 made a good or excellent adjustment. When an older individual becomes disabled, changes are required in an already existing self-image (Woodrich & Patterson, 1983). Smith-Hanen (1976) felt that older people must deal with changes in at least three roles; namely, the family role, the occupational role, and the sex role. Dunn (1977) pointed out that older individuals, regardless of type or duration of injury, perceived themselves as having more social discomfort than younger persons, which may have a defeated effect on expressing life satisfaction. The amount of education and attitude toward education may vary according to socioeconomic status and may be significant factors for people with SCI to express life satisfaction. Preinjury level of education has been found to be associated with postinjury employment (Woodrich & Patterson, 1983), to serve as a facilitating factor in the person's attempt to cope with the problems of living (Krause, 1990), and may contribute to an individual's ability to deal with role reversal in marriage to maintain marital satisfaction (Woodrich & Patterson, 1983). All these attempts, i.e., to secure gainful employment and to 30 be active when confronted with problems, are crucial for an individual with SCI to achieve life satisfaction. Illness-related Factors In approaching this issue, a past study (Yerxa & Baum, 1986) found that people with SCI have lower levels of satisfaction than nondisabled controls with respect to their performance of home-management and social/community problem-solving skills. However, in an assessment of overall life satisfaction, the two groups did not significantly differ. This implies that some illness-related factors, such as functional status or psychological stability, can influence the level of satisfaction in specific areas of life, apart from overall satisfaction with life. For example, it is known that marriage has a substantial impact on general satisfaction with life, as reviewed earlier. Unfortunately, it is somewhat difficult for persons with SCI to maintain good relationships with their spouses. Researchers indicate that the short-term negative impact of SCI on marital status is great (Crewe & Krause, 1988; DeVivo & Fine, 1985). Further, fewer marriages and more divorces occur within three years of SCI. However, it is apparent that many couples do adjust favorably and continue to enjoy a positive marital relationship (as suggested earlier). Urey and Henggeler (1987) found that those who were more accepting of their partner's sexual behaviors, made greater use of humor in communications, and engaged in more activities together tended to be more satisfied with their marital relationships. Besides the injury itself, researchers have attempted to find out whether severity of disability is related to life satisfaction among persons with SCI. Krause (1990) has found that injury level was not related to level of productive activity, although participants with quadriplegia in his study averaged fewer hours per week working. However, he indicated that persons with SCI who return to gainful employment have better overall adjustment to 31 the injury and achieve considerable satisfaction with life, followed by persons engaged in unpaid productive activities (school, volunteering, or homemaking), and those who were unemployed. Personal Factors It has been found that personal character crucially influences marital satisfaction among couples with a member with SCI. Empirical evidence shows that those who are married after the onset of SCI express higher levels of satisfaction with their lives, as well as better marital adjustment, than those who are married before the injury (Crewe & Krause, 1988). Researchers have found that people in postinjury marriages have the characteristics of independence and maturity that are necessary to cope with disability and, moreover, to pursue intimate involvement with someone beyond society's stereotypes (Simmons & Ball, 1984). Similarly, self-actualization has been recognized as important in preinjury marriage, if better marital adjustment is expected. People in such situations are more likely to be capable of living in the present moment, neither longing for the past nor overly concerned with the future. Thus, personal factors heavily influence subjective judgments concerning marital satisfaction. Consistent with this notion, Safilios-Rothschild (1970) indicated that one's pre injury value system affects an individual's acceptance of his disability or ability to lead a productive life. More productive persons are characterized by effective social and intellectual functioning, such as pursuing advanced education and avocational activities. Such persons also tend to be more active in the areas of employment, group participation, and family maintenance (Kemp & Vash, 1971). Those characteristics are positively related to life satisfaction, as mentioned earlier. Research by Tickle and Yerxa (1980b) also suggests that persons who are more active in arranging their lives seem more satisfied with their lives. Another study (Carlson, 1979), 32 exploring the conceptual changes of people with SCI, has shown similar results. Those who are more self-oriented, active in goal setting, and flexible in organizing daily activities are more satisfied with their lives after injury. Physical and Social Environmental Factors Past research indicates that both the physical and social environments influence life satisfaction among people with SCI. For example, DeJong and his colleagues (1984), in a series of studies on the life quality of people with spinal cord injury, found that those with unmet occupational therapy needs were more likely to be living in a more restrictive living arrangement and were less satisfied. A restrictive living arrangement implies dependence and a lack of autonomy in one's day-to-day decision making. These researchers also found that the degree of autonomy available within the individual's own home was significantly associated with rated life quality (DeJong & Hughes, 1982). Tickle and Yerxa (1981a), in a study of need satisfaction, suggested that greater satisfaction was associated with a less restrictive enviromnent and living with others in the community. That is, overall life satisfaction correlates with living in a less restrictive environment and with a high degree of autonomy. Maintaining positive relationships with others is an important contributor to life satisfaction. In support of this notion, Rogers and Figone (1979) reported that significant others played an important role in life goal setting among people with quadriplegia. People who express and set more realistic life goals with the help of significant others are more likely to enjoy their lives. The most important significant other in one's life is one's spouse. This is consistent with the finding that marital status was the most important predictor of life satisfaction among people with SCI in DeJong’s survey (1984). From a sociological perspective, social values toward people with physical disability affects their ability to live independently and pursue a high quality of life in the community 33 (Safilio-Rothschild, 1970). It is important for us to believe that everyone has the right to live with dignity and experience a high quality of life. There has been incomplete research addressing the factors which influence the expression of life satisfaction in the spinal cord injured population. Young people appear to adjust better, but individual differences should be recognized. Age at onset and level of severity of the injury are also factors which need to be investigated. Finally, marital status, educational level, and the physical and social environment should be investigated in order to assess their influence on life satisfaction. Thus, the overall purpose of this study was to identify those demographic (i.e., age, duration of disability, and marital status) and disability-related (i.e., severity of disability and duration of disability) variables which influence life satisfaction in persons with spinal cord injuries. Over the last few decades, medical management of SCI has shifted from an emphasis on survival to an emphasis on promoting life quality. This shift parallels both the development of specialized SCI centers and the rise of the independent living movement, which has focused on the quality of life for persons with disabilities. The main objectives in the independent living movement for people with disabilities are l)assuming responsibility for directing one's own life, and 2)participating actively in the day-to-day life of the community. Along with the rise of consumerism, the passive role "patient" has become a more active "agent" in the rehabilitation process. Life goals and needs are defined by the individual himself or herself rather than by the medical team (Cole, 1979). The aim of medical service is to help such persons attain a high quality of life, that is, to enhance satisfaction with their overall lives as members of the community. In this regard, the role of occupational therapy in this movement has been defined by the American Occupational Therapy Association as follows: "the ultimate goal of independent living is for the individual to achieve as full participation in the family/support 34 system and community as possible and achieve a satisfying and meaningful quality of life" (1981). Life Satisfaction and Occupational Therapy The Role o f Occupational Therapy In this portion of the chapter the role of occupational therapists in helping people with SCI is introduced. Rehabilitation of a person with spinal cord injury requires that the occupational therapist, with other rehabilitation team members, help the individual to achieve the highest possible level of independence and integration into the community. Rvaluation Before treatment begins, careful evaluation of all problem areas must be performed. Such an assessment may include the following tests: Passive joint range of motion test. This determines any limitations of full range of joint motion that may be caused by spasticity, muscle imbalance, or improper positioning. 35 Assessment o f motor function. Manual muscle testing reveals areas of muscle weakness and indicates which muscle groups need strengthening. It also helps the therapist to decide whether the individual will require special orthotic equipment. Gross sensory test. This test uncovers anesthetic or impaired areas of tactile sensation, proprioception, and stereognosis, which guides the therapist in training the individual to be aware of sensory loss and to compensate by use of vision. Functional activities evaluation. This measures the person's present level of function and identifies areas requiring special training. Home evaluation. When feasible, the therapist should visit with the person in his or her home to determine if any adjustments or adaptations are needed to allow for more independence. Prevocational assessment. When an occupation is needed the therapist, working with the vocational counselor, may assess the capability and interests of the individual to determine areas for potential job placement and training. 36 Goal Setting and Planning There are common goals that apply to all levels of spinal cord injury. These goals are understood by all rehabilitation team members. They are to prevent skin pressure sores, prevent or correct contractual deformities, increase strength and endurance, develop maximum independence in self-care, and explore vocational or avocational pursuits (Hopkins, 1971; McKenzie, 1970; Wilson et al., 1974). The involvement of the patient in goal setting is important. Good communication between therapists and patients will enhance the attainment of realistic goals more successfully (Taylor, 1974). Discharge Planning The transition from the hospital to the community can be extremely challenging for both the individual and his family. Home adjustment and weekend passes to home are prepared and encouraged. Adequate follow-up and support from rehabilitation team members may be needed to promote adaptation to the unsheltered world (McKenzie, 1970). Every effort should be made by the occupational therapist to help the individual lead a satisfying life in the community. Life Satisfaction and "Occupation1 1 The concept of occupation has long been used in occupational therapy practice. The meaning of "occupation", according to Meyer (1922), is the use of time in helpful and purposeful activities to satisfy oneself. This kind of behavior is intrinsically motivated throughout all stages of development (Florey, 1969; Reilly, 1974). Occupational behavior, as defined by Reilly (1974), is the entire developmental continuum of play and work. The elements of childhood are not only considered important to growth and development, but also prepare for the performance of adult roles (Florey, 1969; Matsutsuyu, 1971; Kielhofner, 1980b). For example, one can observe the urge of the human being to explore and master the environment through play. When growing older, he or she increases in 37 competence and in the degree of capability to meet challenges arising from the environment (Kielhofher, 1980a; Sharrott & Cooper-Fraps, 1986; White, 1971). Within this perspective, there is a dynamic interaction between the human being and the environment. He or she both changes and is changed by the environment. Occupational behavior is a social behavior and is molded and defined by the social environment. It is an active and productive behavior that confers membership in society and satisfies needs for involvement (Kielhofner, 1977; Moorhead, 1969). The concept of occupational behavior is conceptually related to the level of satisfaction in one's daily life. Similarly, people who exhibit productivity, active participation in activities, and balance vocational and avocational pursuits are more satisfied with their lives. That is, the meaning of occupational behavior, the use of time in helpful and purposeful activities, is the origin of satisfaction with everyday life. Dysfunction in occupational behavior may be brought on by physical disability and cause distortions and dissatisfaction because of loss of competence. In the early stages of spinal cord injury, for example, patients may be frustrated as a result of decreased competence in performing occupational behavior. The aim of occupational therapy is to reduce such problems and reestablish the competence to attain the balance between work and play and to achieve life satisfaction. Summary Spinal cord injury is associated with serious physical, psychological, and social problems. This review has centered on the relationship of these problems to life satisfaction, which is a key aim of the rehabilitation process for such individuals. Occupational therapists help persons with SCI cope with problems caused by injury and retain their competence and role performance through active occupational participation. The ultimate 38 therapeutic goal is to facilitate reintegration into the community and enhance the level of life satisfaction of such individuals. In this pilot study, the relationship of demographic factors, socioeconomic status, subjective health, and social participation to life satisfaction in spinal cord injured individuals was examined. The intent was to document which factors best predict life satisfaction in this population. The variables that were examined were those that the literature had suggested as potentially important. 39 Chapter 3. Methodology In this chapter, the research design, subjects, instrumentation, and procedures used in this pilot study are presented. In addition, the employed statistical techniques are described. Design The purpose of this pilot study was to gather preliminary data on whether a relationship existed between each of the factors that had been thought to be associated with life satisfaction and perceived life satisfaction in individuals with SCI. Subjects The criteria for participation in this study are described as follows: (1) an adult, 18 years old or older; (2) a history of a traumatic spinal cord injury at least two years after onset upon participation; (3) living in the community. The subjects consisted of four Caucasian adults who lived in the Los Angeles area and thirteen Chinese adults from Taiwan. All subjects had had at least a 2- year history of spinal cord injury at the time when they responded to the questionnaire and were living in the community. Instrumentation A two-page questionnaire was used in the current study. The first part of the questionnaire explained the purpose of the study. A consent form was included on the other side of the purpose statement. The second part included questions on demographics (including gender, age, age at onset, and marital status), SES (including education, yearly income, and occupational status), subjective assessment of health status in general (ranging from poor, fair, good, to excellent), and average frequency of social participation (formal, informal familial, and informal nonfamilial social activities) per month during the last 40 twelve months. The SCI-related questions were listed after the above described questions. They included diagnosis (the neurological level) and completeness of injury. The third part of the questionnaire consisted of the Satisfaction with Life Scale (SWLS). The SWLS was designed by Diener, Emmons, Larsen, and Griffin in 1983 for the purpose of measuring general life satisfaction among all age groups, from adolescents to adults. It consists of 5 items concerning overall cognitive judgments of one’s life, designed to measure the concept of life satisfaction. Each item is rated on a 1 to 7 scale, so the possible range of scores on the total score is from 5 (low satisfaction) to 35 (high satisfaction). In a study of the scale's reliability and psychometric properties, Diener et al (1985) found the two-month test-retest correlation coefficient to be .82 and coefficient alpha to be .87. Using principal axis factor analysis, a single factor emerged, which accounted for 66% of the variance. They also found a .46 correlation between the SWLS and the Life Satisfaction Index (Neugarten et al., 1961). The item-total correlations for the five SWLS items were: .81, .63, .61, .75, and .66, again showing a good level of internal consistency for the scale. Thus, the scale has adequate psychometric properties. The Chinese version of questionnaire was translated by the researcher initially. The content was then faxed over to the Veteran Health Administration office in Taiwan. It was cross examined and revised mildly by an English translator in the administration office. Independent Variables The independent variables included race, age at study, age at injury, duration of disability, level of injury, completeness of injury, marital status (married or single), education in years (0-11 grades of school, high school graduate, some college, college 41 degree, and graduate school), yearly income in U.S. Dollars, occupational status (full time or unemployed), subjective health rating from excellent, good, fair, to poor (coded as 4 to 1 respectively in statistical analysis), and average monthly frequency of social participation (formal, informal familial, and informal nonfamilial actities) during the last twelve months prior to participation in current study (Table 3). Table 3. Description of Independent Variables Variable Description Demographic 1. Race Caucasian vs. Chinese 2. Gender Male vs. female 3. Age at study Age in years at the time of study 4. Age at onset Age in years at the time of injury 5. Duration of disability Subtract variable 4 from variable 3 6. Level of injury Cervical, thoracic, lumbar, or sacral 7. Completeness of injury Complete vs. incomplete 8. Marital status Single vs. married Socioeconomic status 9. Education Number of completed years of school 10. Income Family's annual dollar income 11. Occupation Full-time vs. unemployed 12. Subjective health Excellent, good, fair, poor Social participation 13. Formal Voting, voluntary association, or church-related activities 14. Informal familial Visit or phone children or relatives 15. Informal nonfamilial Visit neighbors, phone others, entertaining, or hobbies 42 Procedure Three resources were tapped to recruit participants in this study: personal connections, through organizations and hospitals in the Los Angeles area, and from the Veteran Health Administration in Taiwan. Two Caucasian adults with a history of cervical spine injury were first contacted by phone who had been referred by the researcher’s friends. The issue of difficulties in filling out the questionnaire was discussed on the phone. Both potential subjects were encouraged to complete the information either with the help of researcher who could record the answers while on the phone or with the help of their family members or relatives if writing was a problem. Fortunately, both subjects were able to fill out the questionnaire on their own. A set of questionnaires was then sent to each of them by mail following the phone call. The mailing included a letter indicating the purpose of the study, a copy of consent form, a copy of the research questionnaires, and a stamped self-addressed envelope. Both subjects returned the required information to the researcher promptly. Secondly, an attempt was made to recruit subjects who were connected with Rancho Los Amigos Hospital located in Downey, California, by contacting the administrator of that hospital. After an overview of the study was presented and discussed over the phone, a summary of the study along with a set of questionnaires was then sent to its research committee for further review. However, access to the subjects was denied because a similar survey study of their patients had just been conducted. A similar procedure was also attempted at the independent living shelter center at Santa Monica College. The research committee there was willing to help but they requested the questionnaires be sent out through their organization without releasing information on individuals. Two out of ten individuals, both of whom were Caucasian, contacted by the center responded to the questionnaires within two weeks. After one year of effort, only four responses were received from the Los Angeles area. The assistance of the Veteran Health Administration in Taiwan was then solicited. All of 43 the information regarding the current study was translated into Chinese by the researcher for the purpose of subject recruitment. Fifty mailings were sent out. The Health Administration received fourteen responses within one month. The returned questionnaires were then faxed back to the researcher in Los Angeles. Data Analysis T-tests were employed to test the hypothesis that there was a relationship existing between perceived life satisfaction and the dichotomous variables: completeness of injury (incomplete vs. complete), occupational status (employed full-time vs. unemployed) and marital status (married vs. single). Zero-order correlation coefficients were calculated to determine if a relationship existed between perceived life satisfaction and continuous variables: social participation, subjective health, educational level, yearly income, age at injury, age at study, as well as duration of disability. All tests were conducted at the one tailed .05 level of significance (Zar, 1984). 44 Chapter 4. Results Data Description Eighteen persons with SCI participated in this pilot study. Four of them were Caucasian from the Los Angeles area and fourteen were Chinese from Taiwan. However, one questionnaire from the Taiwan group was dropped from the data analysis because it was incomplete. Of the resulting seventeen usable subjects, there were fifteen men and two women, with an average age of 32.6 years. Sixty five percent of the individuals were single and thirty five percent were married. The participants had an average of 12.2 years of education and an average income of about $10,000 US dollars per year. All subjects were either working full-time or unemployed. Over two-thirds of the participants were unemployed and less than one-third of them were working full-time at the time of study. In terms of diagnosis, seventy one percent of the individuals had quadriplegia or quadriparesis and the remaining twenty nine percent had paraplegia or paraparesis. The average duration of disability in this study group was 3.13 years at the time of study. Inspection of subjective health status revealed an impressive degree of disability impact in the study group. Among the respondents, fifty three percent indicated fair health status, twenty nine percent described themselves in poor health, and only eighteen percent said that they were in good health. None of the participants described themselves as in excellent health. Each item under social participation was closely examined through all questionnaires. The most frequently checked items were those informal-nonfamilial activities, such as visiting neighbors, phoning others, and engagement in entertainment or hobbies. Activities in this category accounted for 59.6% of all social activities. On the other hand, individuals with SCI in this study reported that 24.4% of their social activities 45 were devoted to informal-familial activities which consisted of visiting or phoning family or relatives. Volunteering was the least reported activity among the participants. Table 4 summarizes the percentage distribution of each social activity after summing the ratings reported by all respondents. Table 4. Social Activity Frequency Social activity Sum of ratings Percentage Formal social activities 25 16.0% Voting 8 5.1% Volunteering 7 4.5% Church related activities 10 6.4% Informal familial activities 38 24.4% Visiting or phoning family or relatives 38 24.4% Informal nonfamilial activities 93 59.6% Visiting neighbors 22 14.1% Phoning others 36 23.1% Entertainment or hobbies 35 22.4% Hypothesis.Test Results It was found through the t-test that there was no statistically significant difference in the scores on SWLS between the Caucasian group and the Chinese group (t=l .58, .05<p<.l). Therefore, these two groups were combined in all subsequent analysis. The variable gender was eliminated in conducting the analysis because of the very small number of females (2) compared to males (15) in this study. Table 5 reports mean, standard deviation and range of each variable and the score on SWLS. Further results of 46 subsequent independent t-tests revealed that none of the dichotomous independent variables were significantly related to life satisfaction. Table 6 presents the t-test results. Table 5. Data Description of Non-dichotomous Variables Mean Standard Deviation Range Age at Study 32.59 16.33 18-76 Age at Injury 29.2 18.15 15-74 Education (years) 12.24 3.49 6-18 Yearly Income 10,600 8,250 0-25,000 Subjective Health (1— 4) 1.88 .70 1-3 Social Participation (sum 10.88 7.79 0-29 of ratings, 0— 30) Life Satisfaction (7— 35) 16.12 9.68 7-35 Table 6. Results of Independent t-tests for Mean Differences in Life Satisfaction Scores Level of Injury: Completeness of Occupational Status: Marital Paraplegia vs. Injury: Employed full time Status: Quadriplegia Incomplete vs. vs. Unemployed Married vs. Complete Single t value 0.1402 0.353 0.5159 0.0868 p-value >0.25 >0.25 >0.25 >0.25 47 In this portion of analysis, life satisfaction was correlated with duration of disability, socioeconomic factors, social participation, age, and subjective health. Results are shown in Table 7. Table 7. Correlational Analyses Social Participation Subjective Health Age at Injury Age at study Duration of Disability Education Income r 0.48 0.70 0.0012 0.05 0.416 0.64 -0.11 df 15 15 13 15 13 15 15 P <0.05 <0.01 >0.05 >0.05 >0.05 <0.01 >0.05 The results indicated that subjective health was strongly related to life satisfaction in this study group (r=0.7, p<0.01). Individuals who reported a higher score in subjective health tended to be more satisfied with their life. Educational level was also found to be related to life satisfaction (r=0.64, p<0.01). Subjects who were more educated had higher levels of life satisfaction. Along this line, respondents who were more active in social participation were more satisfied with their lives (r=0.48, p<0.05). However, neither age at the time of participation nor age at injury was significantly related to the level of life satisfaction. Annual income was found not to be related to the level of life satisfaction in this study group. 48 Chapter 5. Discussion Eighteen individuals with SCI participated in this pilot study on variables affecting perceived life satisfaction among people with sequela from SCI. The sample that qualified for statistical analysis included four Caucasian adults from the Los Angeles area and thirteen Chinese adults from Taiwan. One subject was dropped from the data analysis because the questionnaire he submitted was incomplete. Since most of subjects were Chinese, the content of the questionnaire was translated into Chinese for administration of the survey in Taiwan. The validity of the content of translations and scales mentioned in the questionnaire, therefore, became a major concern when they were used in different society. In order to assure the accuracy of the content of translations which were initially performed by the researcher, both the original version in English and the translated version in Chinese were faxed to an English translator in the Veteran Health Administration Office in Taiwan for cross-examination and revision. Mild revision in wording was done by the English translator for better understanding. As to the validity of the translated scales used in the questionnaire, there was not much work done to revise the scales but directly translated into Chinese. The only adjustment in the Chinese version of questionnaire was that yearly income was replaced by the monthly income which is more commonly used in Taiwan. Yearly income appearing in the English version of questionnaire was then divided by twelve in order to get the estimated monthly income. However, it is suggested that more corroboration for satisfactory correlation coefficient in validity work regarding the use of translated form should be performed in the future in order to exclude any bias or inaccuracy. There are six key conclusions derived from this pilot quantitative study. First, the small sample size was a major issue in interpreting the statistical results. It may not represent the true phenomenon in the predictions of perceived life satisfaction based upon different objective variables in the spinal cord injured population. Therefore, atypical 49 responses such as extremely satisfied or dissatisfied with their lives can exist in this questionnaire survey. For example, three out of four respondents in. the Caucasian group in this study scored more than 30 on SWLS (35 is the maximum score). It does not necessarily mean that people with SCI from the Los Angeles area tend to express higher levels of life satisfaction by using SWLS. In fact, such small sample size is not sufficiently statistically powerful to estimate the true value of score on SWLS among people with SCI from the Los Angeles area. Another example that may have reflected a small sample size is that both occupational status and yearly income did not significantly relate to life satisfaction in this study, which is not consistent with the results suggested by past studies. In the future, this study should be replicated using a larger sample size and subjects from various rehabilitation programs, also from various geographical regions if the results are considered to apply to the SCI populations. Second, there was no statistically significant relationship between perceived life satisfaction and demographic factors among individuals with SCI in this pilot study. The demographic factors included age at onset, age at study, duration of disability, level of injury (paraplegia/paraparesis vs. quadriplegia/quadriparesis), and marital status. Further study of this issue is recommended using a larger sample size and controlling for certain demographic factors, for example, age and the injury related factors in order to determine the impact of marital status on perceived life satisfaction in people with SCI. Third, the results of the t-test for the nationality factor indicated that there were no statistically significant differences in the mean scores on SWLS between the Caucasian group and the Chinese group. This finding is quite preliminary since there is not much evidence in the literature to suggest what role race or culture plays in perceived life satisfaction among individuals with SCI. It is known that culture has a great influence on an individual’s judgment and what constitutes a satisfactory life. To approach the issue of how race or culture can affect an individual in terms of perceived life satisfaction, a 50 qualitative study may be indicated in the future as perceived life satisfaction is a process of cognitive judgment based upon a person’s past life experiences (Diener, 1984). Fourth, not every socioeconomic factor was found to be significantly associated with perceived life satisfaction among people with SCI in current study. In fact, only level of education had a significantly positive impact on the extent of life satisfaction. This finding is reasonably consistent with what has been suggested in the literature, i.e., the better educated a person is, the more satisfied he or she is with his or her life (Krause, 1990; Woodrich & Patterson, 1983). The possible mechanism behind this finding may be that education serves as a facilitating factor in the person’s attempt to cope with the problems of living and contributes to an individual’s ability to deal with role change (Krause, 1990). As an individual is more intellectually equipped to solve the problems resulting from a spinal cord injury, he or she may have better adaptations to the reality with appropriate level of expectations and get correspondent level of satisfactions. The fifth finding was that subjective health was positively associated with perceived life satisfaction. This finding confirms what has been observed in past studies (Bull & Auoin, 1975; Clemente & Sauer, 1976; Cutler, 1973; Edwards & Klemmack, 1973; Lohr, Essex, & Klien, 1988; Palmore & Luikart, 1972; Smith & Lipman, 1972; Willits & Crider, 1988). In fact, subjective health was the strongest predictor of perceived life satisfaction among all the factors in this study. In other words, how an individual with SCI subjectively judges his or her current health status is highly predictive of his or her perceived life satisfaction. This may suggest that people with SCI who feel capable to lead satisfied lives despite their limited functional status are those who are more open minded with other enjoyable alternatives, for example, self-actualization and social participations. Finally, a positive relationship was found between perceived life satisfaction and the frequency of social participation among the participants in this pilot study. The finding 51 that informal non-familial activities including phoning or visiting friends or neighbors and engagement in hobbies or entertainment were the most predictive of life satisfaction among all social activities is in agreement with past studies (DeJohn, 1984; Edwards & Klemmack, 1973; Hoyt, Kaiser, Peters, & Babchuk, 1980; London, Crandall, & Seals, 1977). The results also corroborate past findings that informal activity is more highly associated with life satisfaction than formal activity. In summary, the most predictive variables of perceived life satisfaction in people with SCI in this pilot study were subjective health, level of education, and frequency of social participation. An individual with at least two-year history of SCI who expressed higher level of life satisfaction in current study was better educated, confident with his or her physical ability, more open-minded and flexible to pursue workable goal in his or her life, and socially active. Statistically significant relationships were not found between perceived life satisfaction and SCI-related factors (level of injury and duration of disability), demographics (age at onset, age at study, and marital status), and employment status. Yearly income level was negatively correlated with life satisfaction in this study. Finally, the results revealed that there was no statistical difference of level of life satisfaction between the Caucasian group and the Chinese group. The goal of rehabilitation for an individual with SCI is to facilitate the potential of recovery, prepare for the anticipated discharge setting, and help reintegrate into the community. The occupational therapist as a rehabilitation team member plays an important role in helping an individual with SCI reach this goal. During the process of recovery, occupational therapists work together with the individual with SCI in recognition of a spinal cord injury, maintaining and strengthening what has been preserved neurologically, and facilitating maximum potential of neurological return. Rehabilitative goals are set both by the individual with SCI along with his or her family and the medical team in order to prepare for the appropriate discharge destination. Therefore, patient and family education becomes a very important task during 52 rehabilitation for the purpose of better carryover of home program and establishment of a constructive therapeutic relationship between patient and medical team. Occupational therapists are able to instill positive attitudes concerning recovery through patient and family education , which is very important in order to support the individual with SCI in the process of reintegration into the community again. 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Creator
Chou, Hoi-Ling
(author)
Core Title
Variables Related To Life Satisfaction In Persons With Spinal Cord Injuries
Degree
Master of Arts
Degree Program
Occupational Therapy
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
health sciences, mental health,health sciences, occupational health and safety,OAI-PMH Harvest
Language
English
Contributor
Digitized by ProQuest
(provenance)
Advisor
Clark, Howie A. (
committee chair
), Carlson, Mike (
committee member
), Zemke, Ruth (
committee member
)
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https://doi.org/10.25549/usctheses-c18-11783
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UC11357623
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1379576-0.pdf
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11783
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Chou, Hoi-Ling
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texts
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University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
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The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...
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Repository Location
USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA
Tags
health sciences, mental health
health sciences, occupational health and safety