Abstract
BACKGROUND:
Remunerative employment (RE) is one of the optimal rehabilitation goals for people with spinal cord injury (SCI). However, there has been no study systematically determine the RE status and its related factors in Thais with chronic SCI.
OBJECTIVE:
To cross-sectionally determine RE statuses and their influencing factors in Thais with chronic SCI.
METHODS:
Data from a Thai arm of the International Spinal Cord Injury Community Survey (InSCI) were analyzed. The prevalence of RE and related work status were described.
RESULTS:
Of 223 individuals with chronic SCI whose age was less than 60 years included in this study, 79 (35%) were remunerative employed. Most of them (41, 54%) were self-employed. The most common reason for unemployment was related to health conditions or disabilities. Education year, attending vocational rehabilitation service, and admission≥2 times per year were independent influencing factors of RE with an odds ratio of 1.090, 2.534, and 0.418, respectively.
CONCLUSION:
Since education and vocational rehabilitation were the modifiable positive influencing factor of employment, educational and vocational rehabilitation programs should be formally established and universally applied together with medical rehabilitation to increase the prevalence of RE in people with SCI in Thailand.
Introduction
According to the International Classification of Functioning, Disability, and Health (ICF) framework, remunerative employment (RE) is one of the major life functions and is classified as activities and participation (World Health Organization, 2001). Having opportunities for RE is one of the key goals in rehabilitating people with spinal cord injury (SCI) (Post, 2020). However, results of the International Spinal Cord Injury Community Survey (InSCI) found that the employment rate for people with SCI is still low, ranging from less than 20% in middle-income countries (e.g., Brazil, Greece, Morocco) to more than 50% in high-income countries (e.g., the USA, the Netherland, Switzerland) (Post, 2020), which could partly reflect the efficacy of vocational rehabilitation service of the country. Therefore, evaluating the prevalence of RE in each country is necessary for determining the success of vocational rehabilitation services in that country as well as for comparing it with other countries.
For Thailand, the prevalence of RE described in the global InSCI study in 2017–2018 was 39.5% (Post, 2020). Noteworthy, this study used the cut-off age for retirement of 65 years, which is older than that in Thailand where most people would be retired at the age of 60 years (Kananurak, 2014). Previous studies also demonstrated the prevalence of RE at 47% (Phanharach, 2006; Vongpakorn, 2014). However, both studies were only based on data from a single center, as well as using non-standardized measurement, resulting in incomplete results of RE status and related outcomes.
To increase the prevalence of RE in people with SCI, many studies have identified the influencing factors of RE to indicate which people should be intervened and which intervention could be effective. These factors include socioeconomic factors (Karcz, 2022a; Schwegler, 2021) such as gender, age, marital status, education year, and household income, and SCI-related factors such as the level and severity of SCI (Krause, 1999; Krause, 2012; Kang, 2014). However, both factors were non-modifiable. Therefore, modifiable factors including health-related factors such as secondary health conditions and co-morbidities, psychological factors such as psychological well-being statuses, and environmental factors such as health service and policy (Schwegler, 2021), should be more focused. Since some of these factors were socioeconomically dependent, it is necessary to determine independent influencing factors in a particular country to make these factors suitable to use in real-life settings.
Despite being extensively described in previous studies (Phanharach, 2006; Vongpakorn, 2014), however, there has been no study demonstrating the prevalence of RE and its related information, e.g., work status (employed or self-employed), type of work (sedentary to strenuous), or working hour, and its influencing factors, using specific cut-off age for retirement, as well as applying standard measurement and updated, multicenter data in people with chronic SCI in Thailand. The objectives of this study are 1) to describe the prevalence of RE and work-related statuses, and 2) to determine the independent influencing factors of RE, in people with chronic SCI who were of working age living in Thailand.
Materials and methods
This is a cross-sectional exploratory study. We used data from a Thai arm of the InSCI, a multinational cross-sectional analytical study implemented simultaneously in 22 countries worldwide (Gross-Hemmi, 2017). Ethical approval was obtained from Ethics Committees in all study sites. Written informed consent was obtained from each participant under national regulations.
Inclusion and exclusion criteria
The InSCI study included persons with traumatic or non-traumatic SCI, aged 18 years old or older, living in the community, and being residents of Thailand. Those with congenital etiologies, neurodegenerative disorders, or peripheral nerve damage were excluded from this survey (Gross-Hemmi, 2017). In this study, we included only data from participants who were less than 60 years old, which is the retirement age of Thai citizens. Participants were excluded from this analysis if data indicating their employment status was absent.
Recruitment processes
Convenience sampling was used in all study sites in the Thai InSCI. The four study sites were Maharaj Nakorn Chiang Mai Hospital, Sirindhorn National Rehabilitation Institute, Siriraj Hospital, and Ratchaburi Hospital. Individuals with SCI who had visited at least one of the above-mentioned hospitals/facilities during the study period were face-to-face invited to participate. All participants included in this study were asked to complete the paper-based InSCI questionnaire themselves or by an in-person interview. Data were collected between February 1st, 2017 and August 31st, 2018.
Outcome measurements
The InSCI survey applied a set of questionnaires, containing a 125-item self-report questionnaire covering components of body function and structures, activities and participation, environmental and personal factors, lesion characteristics, and appraisal of health and well-being (Gross-Hemmi, 2017). In the present analysis, questions about demographic personal factors, SCI characteristics, activities and participation, secondary health conditions, health service utilization, energy and drives, personal factors, and work status were used.
Outcome variables
A focused dependent variable (RE) was evaluated using a question in the InSCI questionnaire “Are you currently engaged in paid work?”, which was derived from the SwiSCI Community Survey, Basic Module (Fekete, 2017). It is a binary variable (yes = 1, no = 0).
The work-related statuses included questions regarding 1) working before SCI or not, 2) job title before SCI, 3) attending a vocational rehabilitation program or not, 4) work starting period (e.g., immediately after initial rehabilitation or later), 5) receiving disability pension or not, 6) work situation (e.g., employed by an employer, self-employed), 7) current job title, 8) working hours, 9) desired work status (more, less, or the same), 10) reasons for not working, 11) self-rating of ability to work (unable, 1–11 hours, 12–20 hours, >20 hours). We categorized the physical intensity of the working title, according to the study, into sedentary, light, moderate, heavy, and strenuous (Tomassen, 2000). We assessed the number of participants who changed their work to another degree of physical intensity. We determined the number of participants who maintain working after SCI. All work-related situations were evaluated using the InSCI questionnaire, which was modified from several original questionnaires including the SwiSCI Community Survey, HSR-Module, Study on Health, Ageing and Retirement in Europe (SHARE), Model Disability Survey (MDS), and International Labour Market Integration Assessment in SCI (ILIAS) (Fekete, 2017).
Independent variables
The skeletal-directed acyclic graph was created by identifying the associated factors of pressure injury problems from literature reviews and opinions of all authors. Then, an association between factors were linked using a skeletal-directed acyclic graph by a consensus of all authors. After developing a skeletal directed acyclic graph (Fig. 1), several independent factors were identified, including demographic personal factors (age – years; sex – female = 1 or male = 0; education (combined between pre- and post-SCI) – year; having an assistant – yes = 1, no = 0; working status before SCI – yes = 1, no = 0, SCI characteristics (etiology – traumatic = 1 or non-traumatic = 0; level – paraplegia = 1 or tetraplegia = 0; completeness – complete = 1 or incomplete = 0, time since SCI – more than 10 years = 1 or 10 years or less = 0), activities and participation (independence in mobility = 1 or not = 0; having hand function problems = 1 or not = 0). For secondary health condition variables, urinary tract infection, spasticity, pressure ulcer, and pain problems were included. The original rating of each question, describing as no, mild, moderate, severe, and extreme problem, was re-classified into 2 groups: “0” = no problem; 1 = mild//moderate/severe/extreme problem (Ehrmann, 2020). A health service utilization variable was being admitted as an inpatient in the previous 12 months (less than 3 times = 0; 3 times or more = 1). Psychological factors included energy and drives and personal factors. Energy and drives were assessed by the Short Form 36 (SF-36) vitality and mental health subscale (Fekete, 2017), which would be calculated as continuous variables (Ware, 1992). Personal factors were assessed by a questionnaire specifically developed for the InSCI (Fekete, 2017), which was modified from MDS, the Moorong Self-Efficacy Scale (MSES) (Middleton, 2013), and the General Belongingness Scale (GBS) (Malone, 2012), which all of these were ordinal variables. Since there has been no study demonstrating the effects of energy and drives and personal factors on RE, only factors that were statistically significant on bivariate analyses were included.
A skeletal directed acyclic graph for determining the influencing factors of remunerative employment in people with SCI. SCI, spinal cord injury; black oval = focused outcomes; grey oval = independent factor; grey line = correlation path.
A complete-case analysis was used in all statistical analyses. Data were descriptively analyzed using mean (SD), n (%), or median (interquartile range – IQR), depending on their characteristics and distribution. The prevalence of RE was calculated by the number of participants who were employed or self-employed divided by the number of all participants.
To compare the variables between participants who had RE and those who did not, Fisher’s exact tests, independent t-tests, and Mann-Whitney U tests were used for categorical data, normally distributed continuous data, and non-normally distributed continuous data, respectively. To determine the independent influencing factors of RE, multivariable logistic regression analysis, with an adjustment for all factors available in a skeletal directed acyclic graph, since a direction of the association could not specify due to a cross-sectional design, was applied (Ehrmann, 2019) (Fig. 1).
All statistical analyses were performed using SPSS 26.0 (IBM Corp, Armonk, NY, USA). A p-value of less than 0.05 was considered statistically significant.
Sample size calculation
Although this study analyzed the pre-existing Thai InSCI study data (Gross-Hemmi, 2017), we calculated the sample size to ensure whether the number of preexisting participants was enough for delivering adequate study power. We calculated the sample size according to the general rule suggesting that the sample size should be more than 50 and complied with the number of independent coefficients, i.e., at least 10 people per 1 independent coefficient (Jenkins, 2020; Maxwell, 2000). Since the number of the proposed independent coefficients was 20, a sample size of at least 200 participants was required.
Results
Screened and included participants
Of the total 320 data of individuals with SCI who were included in the Thai InSCI, 223 individuals (70%) were included in this study since their age were between 18–60 years. All 223 individuals had a complete RE status and were included in the analysis.
Demographics, SCI characteristics, and activities and participation of the participants
Table 1 described demographic factors, SCI characteristics, activities and participation, secondary health conditions, health service utilization, and psychological factors that related to the employment of the participants. Most participants were male (163, 73%). The mean (SD) age was 40 (10) years old with a median (25th, 75th percentile) time since SCI of 7 (2.5, 11.5) years. The major cause of SCI was trauma (195, 87%). The majority of the participants had paraplegia (168, 76%) and incomplete SCI (113, 51%). Most of the participants were independent in mobility (187, 84%). The minority of them had hand and arm use problems (72, 33%). Among four secondary health conditions related to employment, spasticity problems were most common (160, 74%), followed by pain, urinary tract infection, and pressure ulcer problems (131 (61%), 111, (52%), and 63 (29%), respectively). Eighty-five participants (38%) have attended vocational rehabilitation services. Ninety-five participants (44%) had two or more hospitalizations in the previous year. The mean (SD) of the SF36-Vitality domain and SF36-Mental health domain score was 75 (14) and 73 (14), respectively. A median of all personal factor scores was between 3 and 4 points, indicating mild to moderate problems.
Demographic data, spinal cord injury characteristics, secondary health conditions, health service utilization, and psychological factors of the participants
Demographic data, spinal cord injury characteristics, secondary health conditions, health service utilization, and psychological factors of the participants
1Mean (SD), 2number (%), 3median (25th, 75th percentile); *significant level at p < 0.05, using independent t-test for mean (SD), Mann-Whitney U test for median (IQR), and Fisher's exact test for number (%), except for severity of SCI and being admitted as inpatient in last 12 months (chi-square test). SCI, spinal cord injury, SCIM, Spinal Cord indepedence Measure; MDS, Model Disability Survey.
In this study, seventy-nine participants were remunerative employed, indicating a prevalence of RE of 35%. Using further questions that could have more than one answer, 35 (46%) worked for wages with an employer and 41 (54%) were self-employed. Nineteen participants (25%) reported that they started working immediately after initial rehabilitation and 60 (75%) reported that they started later. A median (25th, 75th percentile) working hour was 40 (32.5, 47.5) (range 4–56) for employees and 32.5 (20, 45) (range 2–77) for self-employees. Ten participants (13%) needed to work more hours, nine participants (7%) needed to work fewer hours, and 57 participants (78%) needed to work the same as the current amount. According to the physical intensity of the work, 3 (4%) had sedentary work, 38 (52%) had light physical intensity works, 4 (5%) had moderate physical intensity works, 11 (15%) had heavy physical intensity works, whereas no participants were involved in strenuous works. It was noticed that 17 participants (24%) reported non-specific roles, such as employee or officer, which could not be exactly categorized (Table 2).
Work-related statuses of the participants
Work-related statuses of the participants
1Mean (SD), 2number (%), 3median (25th, 75th percentile); SCI, spinal cord injury.
Among those who were not remunerative employed, 1 (1%) worked for wages with an employer, but was currently on sick leave, 10 (6%) worked as an unpaid family worker, 2 (1%) were housewife/househusband, 19 (14%) were students, 89 (64%) were unemployed and did not fall in another status, and 19 (14%) were retired due to the health condition. Noteworthy, a choice of retirement due to age was not present since we include only the participants who were of working age (Table 2). The three most common reasons for unemployment were listed in descending fashion as health conditions or disabilities (103, 36%), do not know how or where to seek work (40, 14%), and could not find suitable work (38, 13%) (Table 3). Focusing on the participant’s thought about the ability to work, which were intended to be answered only by the participants who did not work [15] but were answered by both groups (143 answers), 31 participants (21%) reported that they could work for 1–11 hours a week, 34 (24%) reported that they could work for 12–20 hours a week, and 41 (29%) reported that they could work for more than 20 hours a week. Thirty-seven participants (26%) thought that they could not work at all.
Reasons of unemployment of the non-remunerative employed participants
In addition, one hundred and seventy participants (77%) reported that they had worked before SCI, which most commonly were heavy, moderate, light, sedentary, and strenuous physical intensity works in descending (27%, 21%, 10%, 6%, and 3%, respectively) apart from 53 (33%) whose works could not be exactly specified. Among these 170 participants who worked before SCI, only 58 (34%) people could maintain working. Among those who could maintain working, 28 people (48%) changed their types of work to lower physical intensity levels (Table 2).
Table 1 demonstrates the differences in the characteristics between the working and the non-working group. Participants who were remunerative employed were older and had more education years (p = 0.004 and 0.013, respectively, independent t-test), had a higher percentage of people who lived with SCI ten years or more, had a higher percentage of people who were mobility independent, had a lower percentage of people who were hospitalized 2 times or more in the previous 12 months than those who were not employed (all p < 0.05, Fisher’s exact test). No difference in secondary health conditions, including urinary tract infection, spasticity, pressure ulcer, and pain problems, was found between those with and without RE. According to the energy and drives, participants who were remunerative employed had significantly more SF36-Vitality domain and SF36-Mental health domain scores than those who were not employed (p = 0.006 and 0.014, respectively, independent t-test). Regarding the personal factors, participants who were remunerative employed had significantly more purposes in life scores than those who were not employed (p = 0.016, Mann-Whitney U test). No difference in other personal factors was found between those with and without RE.
Independent influencing factors of RE
Table 4 summarizes the results of an enter method multivariable logistic regression analysis for determining the independent influencing factors of RE. From twenty factors included in the causal diagram, only two independent positive correlating factors and one independent negative correlating factor were identified. The number of education years, combined between pre- and post-SCI was an independent positive correlating factor of RE (all p < 0.05), with an odds ratio of 1.090 (95% CI: 1.011 – 1.176). These results suggest that when all other independent variables are held constant, if the individuals with SCI have an education of one year more, they would have a 9% higher opportunity to be remunerative employed. Attending vocational rehabilitation service was also an independent positive correlating factor of RE (all p < 0.05), with an odds ratio of 2.534 (95% CI: 1.091 – 5.884). These results suggest that when all other independent variables are held constant, if the individuals with SCI attended vocational rehabilitation services, they would have 2.534 times more opportunity to be remunerative employed. On the other hand, hospitalizations ≥ 2 times in the previous 12 months was an independent negative correlating factor of RE (p = 0.026), with an odds ratio of 0.418 (95% CI: 0.194 – 0.900). These results suggest that when all other independent variables are held constant, if the individuals with SCI were admitted ≥2 times in the previous 12 months, they would have a 58% less opportunity to be remunerative employed.
The influencing factors of having remunerative work from an enter method multivariable logistic regression analysis
The influencing factors of having remunerative work from an enter method multivariable logistic regression analysis
B, unstandardized regression coefficient; CI, confident interval; SCI, spinal cord injury; *significant level at p < 0.05, multivariable logistic regression analysis.
This study demonstrated that the prevalence of RE was 35%, which was less than the 39.5% which was reported in the global InSCI study aiming to investigate the prevalence of RE in all participating countries (Post, 2020). This inconsistency might be due to the difference in the inclusion criteria. The study by Post et al. included participants whose ages were lesser than 65 years, which is the retirement age in most of the participating countries. However, this study included only participants whose ages were lesser than 60 years, which is the retirement age specifically for Thailand (Kananurak, 2014). This difference might indicate that people with chronic SCI whose age was between 60–64 years might have a higher prevalence of RE than those whose age was 18–59 years, resulting in a relatively higher prevalence of employment when the participants in this age group were included. Further study, specifically aiming to investigate this issue, is needed. Noteworthy, the prevalence of RE of people with SCI demonstrated in this study is lower than those of the general population (74%) (Kananurak, 2014). A wide gap of RE between people with SCI and the general population indicates a significant problem of Thailand regarding the inclusion of people with SCI for labor market participation.
The prevalence of RE in this study is lower when compared with those in the previous studies in Thailand in 2001 (Phanharach, 2006) and 2012 (Vongpakorn, 2014), which both showed a prevalence of 47%. This inconsistency might be due to the difference in study sites since both previous studies investigated in a university hospital, which potentially has a relatively higher ratio of participants who used the government officer health insurance (Kovindha, 2017; Pattanakuhar, 2022), resulting in more participants who were government officers that were able to maintain their work after SCI than the general population (Vongpakorn, 2014). This study, despite no established sampling method, included several levels of participating hospitals including both university hospitals and general hospitals. Therefore, our results might reflect the actual prevalence of RE in Thailand.
Regarding the types of RE, more than half of the participants who worked were self-employed (54%). This result was different from those in the previous study showing the percentage of self-employed participants was only 11%. Digitalization of the works might be one of the proposed positive influencing factors of the increase in self-employment since digital working could eliminate physical environmental barriers for people with SCI (Karcz, 2022a). However, further studies are still needed to evaluate the effect of digitalization on the works on the physical and mental health of individuals, as well as on the changes in overall labor markets.
Regarding the number of working hours, results from the employed group indicated that their working hours were similar to those of the general population in Thailand, which was 40 hours per week. Another result of this study also indicated that most of the participants in this study would like to work in the same amount as the current one. Both results were compatible with results from the longitudinal study of Karcz, et al., which reported that most of the individuals with SCI who could successfully start their work, could also successfully maintain it in the same amount until the next 5 years (Karcz, 2022b). These results indicate that the most important issue of working after SCI is how to first return to work after SCI since if this process is successful, it is not as difficult to maintain it. It is also supported by several studies from the USA (Sutton, 2020) and Australia (Hilton, 2017), which demonstrated the effectiveness of early vocational rehabilitation programs on the sustainability of working after SCI.
Despite being significantly demonstrated in the previous studies (Tomassen, 2000; Ferdiana, 2014), this study could not show the effects of the physical intensity level of the work before SCI on the employment after SCI. This inconsistency might be due to about one-third of the participants in our could not exactly specify their true job. Only “employee” or “government officer” titles could not be used to appropriately categorize their physical intensity level. In a future study aiming to identify the exact type of work, researchers should inform the participants that they should specify the task they truly perform instead of answering only their employment status.
In this unemployed group, most of the participants reported that if they had an opportunity, they could work with different working hours. For instance, in addition to the reasons related to health conditions or disabilities, which are non-modifiable, the next most common reasons for unemployment did not know how or where to seek work (14%), and could not find suitable work (13%), which could be intervened by a proper job matching program. A previous study in Switzerland demonstrated that a job-matching program could facilitate the job-searching process (Nützi, 2020). However, there has been no established job-matching program currently available in Thailand.
The independent positive influencing factors of RE demonstrated in this study included education years and attending vocational service. In our study, we combined pre- and post-SCI education years, making this factor modifiable. Education years were consistently demonstrated as a positive influencing factor of RE in people with SCI in many studies (Schwegler, 2021; Krause, 2012; Krause, 2006; Calliga, 2019). An increase in education years was related to an increased opportunity to be involved in non-physically dependent work, which could be more suitable in people with SCI who had physical impairments (Tomassen, 2000). If possible, people with SCI should be advised about educational rehabilitation to increase their opportunities to have RE.
Also, attending vocational rehabilitation service was consistently described as a positive influencing factor of RE in people with SCI (Jang, 2005; Byolive, 2021). In Switzerland, where the prevalence of RE was highest, vocational rehabilitation service includes both pre-decision (job matching and decision-making assistance), pre-working (general and task-specific training), and during-working (short-term and long-term follow-up by community-based service) programs (Karcz, 2022b; Nützi, 2020). Another study from the USA also demonstrated that a vocational rehabilitation program was cost-effective in veterans with SCI (Sutton, 2020). However, there has still been no effective and seamless vocational rehabilitation program in Thailand since medical rehabilitation and vocational rehabilitation are steered by different public organizations. After initial medical rehabilitation, most medical rehabilitation facilities which are affiliated with the Ministry of Public Health deliver only some advice to the patient to consult vocational rehabilitation centers, which are separately affiliated with the Ministry of Social Development and Human Security, for non-social security insurance patients and the Ministry of Labor, for social security insurance patients. Due to this non-cooperating management, only some people with SCI in Thailand could attend vocational rehabilitation services, as evident in this study, in which only 38% of participants attended the vocational rehabilitation service.
On the other hand, this study demonstrated that hospitalizations two times or more per year were a negative correlating factor of RE. Since most hospitalizations in people with SCI are related to secondary health conditions (Meade, 2016; Oliveira, 2021), it is important to prevent people with SCI from secondary health conditions which potentially make them admitted to the hospital to increase their employment. Since hospitalization was closely correlated to severe secondary health conditions in people with SCI, it might explain the result of why some secondary conditions, such as pain, which were described as a negative correlating factor of working in previous studies (Schwegler, 2021) were not significantly correlated in this study. In our opinion, hospitalizations three times or more per year would be more practical than individual secondary health conditions.
Strengths and limitations of the study
This is the first study demonstrating the prevalence of RE, its related statuses, as well as its independent influencing factors, using international, standardized tools. The results of this study were analyzed using a pre-specified causal diagram conducted by a skeletal DAG, which is a valid method for controlling confounding factors (Ehrmann, 2019). In addition, the sample size of this study was calculated to confirm that the statistical analyses had enough power.
Our study has some limitations. First, since the prevalence of RE also some related factors of them are socioeconomically dependent, the results from this study should be considered before applying to another socioeconomic context. For example, the prevalence of RE of people with SCI in Thailand where the retirement age is 60 years old could not be directly compared with those of the countries where their retirement age is different, e.g., 65 years old. Second, due to the convenience sampling method, there could have been selection bias as only individuals with SCI who regularly visit a study hospital were invited to participate. Then it could not be claimed that the participants of this study were representative of individuals with SCI in Thailand. Another limitation is associated with the outcome measurements. Since the InSCI survey used self-report questionnaires, there could be a recall bias in nature (Hunger, 2013), as well as some misunderstanding points previously described. However, the objective of the InSCI survey was to determine the individuals’ experience and perspectives of each circumstance, rather than to clinically evaluate it (Kang, 2014). Therefore, the results of this study should be interpreted accordingly.
Applications on clinical and health policy aspects of the study
Immediately after initial rehabilitation, all people with SCI in Thailand should attend educational and vocational rehabilitation services, at least to evaluate and advise on employment issues. Formal educational and vocational rehabilitation services should be urgently established, with seamless integration between all related public agencies, simultaneously with increasing effectiveness of medical rehabilitation programs to reduce hospitalizations to increase the prevalence of RE of people with SCI living in Thailand.
Conclusions
Data from the Thai InSCI demonstrate that the prevalence of RE in people with chronic SCI living in Thailand was 35%. It was also suggested that increasing education years and attending vocational rehabilitation service were the independent positive correlating factors, as well as hospitalizations two times or more per year, was the independent negative correlating factor of RE. These results suggest the importance of having established educational and vocational rehabilitation, simultaneously with effective medical rehabilitation, for increasing the prevalence of RE in Thailand.
Footnotes
Acknowledgments
This study uses some methodological data from the article “The International Spinal Cord Injury Survey: The Way Forward” (Bickenbach J, Batistella L, Gutenbrunner C, Middleton J, Post MW, Stucki G (2020). The International Spinal Cord Injury Survey: The way forward, Arch Phys Med Rehabil, 101, 2227-32.), which is a part of the project “Learning Health System for SCI Initiative (LHS-SCI)”. The LHS-SCI is an effort to implement the recommendations described in the World Health Organization report “International Perspectives on Spinal Cord Injury” (World Health Organization, 2013).
SP would like to acknowledge the Postdoctoral Swiss Government Excellence Scholarship 2022. The other authors have no acknowledgements.
Conflict of interest
The authors declare that there is no conflict of interest.
Ethics statement
The authors certify that the protocol of this analysis was approved by the Research Ethics Committee of all study sites (Maharaj Nakorn Chiang Mai Hospital, Sirindhorn National Rehabilitation Institute, Siriraj Hospital, and Ratchaburi Hospital: Approval number REH-2559-04167).
Funding
The study was supported by the Thai Rehabilitation Medicine Association Research Grant Year 2017 (grant number 01/2560).
Informed consent
Written informed consent was obtained from each participant under national regulations.
Data availability statement
The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Author contributions
SP was responsible for designing the research question, collecting and analyzing the data, drafting the manuscript, and writing the final version of the manuscript. PK, NK, CC, and AK were responsible for designing the research question, collecting the data, and commenting on the final version of the manuscript. US was responsible for designing the research question, analyzing the data, and commenting on the final version of the manuscript.