Spinal cord injury (SCI) is a severe traumatic Disability that occurs suddenly and affects both sensory and Motor functions. According to the National Spinal Cord Injury Statistical Center 1999), there are about 203,000 persons in the U.S. who have sustained a spinal cord injury and approximately 10,000 new injuries occurr each year. Although medical advances have increased the life expectancies of people with SCI, there has been a limited amount of research addressing life satisfaction in people with SCI (Krause, 1992).
Life satisfaction, an individual’s cognitive evaluation of his or her life, is considered an important Rehabilitation goal of people with SCI by many rehabilitation professionals (Boswell, Dawson, & Heininger, 1998; Christopher, 1999; Krause, 1992). Previous studies in the U.S. on life satisfaction have found positive relationships between employment status, age at the onset of disability, marital status, educational attainment, social support, and life satisfaction (Boschen, 1996; Decker & Schulz, 1985; Krause & Dawis, 1992; Mehnert, Krauss, Nadler, & Boyd, 1990). On the other hand, the severity of the injury did not appear to be associated with life satisfaction (Cushman & Hassett, 1992; Schulz & Decker, 1985).
Researchers also point out that individuals’ cognitive evaluation of their lives is influenced by their salient values and that these values are learned through socialization in their culture (Diener & Diener, 1995; Keith, Heal, & Schalock, 1996; Oishi, Diener, Suh, & Lucas, 1999). When studying life satisfaction, one needs to take both culture and value perspectives into consideration (Krause & Dawis, 1992). However, culture is a difficult construct to define (Triandis et al., 1986). The majority of culture-related studies have focused on the individualism- collectivism dimension of cultures (Hofstede, 1980; Schaller, Parker, Garcia, 1998; Thompson, 1997; Triandis et al., 1986). It was found that people in individualistic cultures tend to give priority to the goals of individuals, feel personally responsible for their successes and failures, and experience some separation and distance from their ingroups. In contrast, people in collectivistic cultures tend to give priority to the goals of collectives, share both successes and failures with others, and have close relationships with members of their ingroups (Triandis et al., 1986).
Further, social psychologists found that culturally different nations have demonstrated notable variations in reported life satisfaction (Diener, Sandvik, Seidlitz, & Diener, 1993; Veenhoven, 1991). Poorer countries tend to possess lower life satisfaction than richer ones. For instance, Leelakulthanit and Day (1993) investigated the differences in lite satisfaction between Americans and Thais. They reported that Americans were more satisfied with their lives than Thais. Similarly, Diener, Suh, Smith, and Shao (1995) conducted a survey of life satisfaction among American, Korean, and Chinese college students. They found that Chinese and Korean college students scored much lower than Americans on both life satisfaction and positive feelings after other influential factors (e.g., income and wealth of the countries) were controlled. In a study of the cross-cultural correlates of life satisfaction, Diener and Diener (1995) found that four variables (satisfaction with self, family, friends, and finances) were related to life satisfaction for all participants in 31 nations. However, the size of the correlation between life satisfaction and satisfaction with the self was higher in individualistic countries (e.g., the United States) and lower in collectivistic countries (e.g., Korea). We were not able to locate any cross-cultural study on life satisfaction of people with disabilities in the rehabilitation literature, indicating a need for future investigations in this area.
Diener et al. (1995) suggested that the cultural differences between these countries might be responsible for the differences in reported life satisfaction. In the American culture, individual happiness and satisfaction are considered very important in one’s life and people are socialized to attend to their own needs and satisfaction. In contrast, the Chinese and Korean are socialized to fit into the community and life satisfaction is related to fulfilling one’s responsibilities to his or her family, community, and country (Diener et al., 1995). However, empirical investigations are needed to examine this hypothesis. It should be noted that, in Diener et al.’s study, the participants were college students. If one wants to examine influences of culture and values on life satisfaction of rehabilitation clients cross culturally, one should recruit adults with disabilities in these explorations.
In addition, researchers pointed out that the life satisfaction of women with SCI is a much neglected but critically needed area of research (Krause & Anson, 1997; Trieschmann, 1992). In a national survey of the general public, Gurin, Veroff, and Feld (1960) found that American women had more emotional problems than men. Campbell (1981) reported that American women were more dissatisfied with their lives than men. However, recent studies indicated that American women did not differ from men on most of the general measures of happiness, although they scored much higher on both negative and positive measures of emotions (Fujita, Diener, & Sandvik, 1991). For example, Diener and Diener (1995) reported that the levels of life satisfaction of female college students from 31 countries were similar to the levels of male students and the correlational patterns between life satisfaction and the predictors (satisfaction with self, family, friends, and finances) were similar for men and women across nations.
Further, the few studies which explore the life satisfaction of women with SCI have reported inconsistent findings. Fuhrer, Rintala, Jart, Clearman, and Young (1993) found that women were more likely to have negative feelings and were more at risk for serious Depression than men following SCI. Krause and Anson (1997) indicated that minority women with SCI appeared to experience greater emotional distress than minority men, Caucasian men, and Caucasian women with SCI. On the other hand, minority men with SCI tended to experience less emotional distress than either of the other three groups (Krause & Anson, 1997). These studies contradicted the findings of earlier study by Woodrich and Patterson (1983) which reported that female participants with SCI were more likely to accept their disabilities than male participants.
It appears that gender is an important but less understood factor in life satisfaction of people with SCI. The limited studies on the relationship between gender and life satisfaction, however, do merit further explorations in this area. Moreover, previous investigations indicated that self-efficacy – a person’s beliefs about his or her abilities to cope with life’s exigencies – had an influence on life satisfaction. For instance, Waltz and Bandura (1988) reported that the life satisfaction of cardiac male patients appeared to be influenced by a sense of efficacy, subjective health perceptions, and relatively stable socio-environmental conditions. Arns and Linney (1993) found that a change in vocational status had an impact on self-efficacy which then affected life satisfaction through its influence on self-esteem. In a qualitative study of life satisfaction and psychological well-being in Chinese with SCI, Hampton (1998) reported that self-efficacy was an important predictor of life satisfaction in the Chinese people with SCI. However, more investigations are needed to explore the influence of self-efficacy on life satisfaction in people with SCI.
In summary, although previous research implies that culture and values may have an impact on life satisfaction, no empirical work has directly addressed these issues in people with SCI. Further, the impact of gender and self-efficacy beliefs on life satisfaction of people with SCI is not clear. Accordingly, the purposes of this study were to examine value differences between Americans and Chinese people with SCI, to assess culture and gender effects on life satisfaction, and to explore patterns of correlates of life satisfaction in the two groups.
Continued from page 1. The U. S. and China were chosen for this comparison study because Americans scored particularly high on individualism and Chinese scored particularly low on individualism but high on collectivism when assessed with instruments which measured the individualism-collectivism construct (Triandis et al., 1986). A study of people from these two countries may provide insight about the roles of culture and values in life satisfaction. In addition, as we become more globally linked by travel, communication, and advancing technology, we must learn more about each other in order to communicate effectively and work well together to build a better world in which people with SCI can have a good quality of life.
Method
Participants
Two hundred and sixty-three individuals with SCI participated in the study. Of them, 133 were Americans and 130 were Chinese. The criteria for the participant recruitment included: (a) the person had a traumatic SCI but did not have any cognitive Impairment, (b) the injury duration was at least two years at the time of the study, and (c) the participant was at least 18 years of age at the time of the study. These criteria were consistent with those of previous studies (Hampton, 2000; Krause, 1992) done in the U.S. and China.
In the American group, 64% were males. The majority of the participants were Whites (87%), followed by African Americans (10%) and Hispanic Americans (3%). Of the participants, 37% were single, 40% were married, 19% were divorced or separated, and 4% were cohabitating. Their ages ranged from 20 to 69 years, with a mean age of 43 (SD = 10.92) years. The age at the time of injury ranged from 10 to 64 years, with a mean age of 29 (SD = 11.49) years. The educational levels ranged from 8 to 24 years with a mean of 16 years (SD = 3.05). Ninety-three percent of the participants lived in private non-institutional residences. Among them, 3% lived with friends, 5% lived with an attendant, 22% lived alone, and 62% lived with a spouse or parents. The remaining 7% of the participants lived in nursing homes. Of the participants, 43% were unemployed, 18% held part-time positions, and 39% held full-time positions. The income ranged from below $7,500 to more than $50,000 with a median of $35,001 (SD=I 8,720). The causes and levels of injury are listed in Table 1.
In the Chinese group, 60% were males; 27% were single, 70% were married, 2% were separated, and 1% was widowed. Their ages ranged from 18 to 58 years, with a mean age of 35 (SD = 9.08) years. The age at the time of injury ranged from 13 to 56 years, with a mean age of 31(SD = 8.59) years. The educational levels ranged from 6 to 18 years with a mean of 12 years (SD = 2.98). All participants lived in a non-institutional residence; 3% of them lived alone, 4% lived with their friends, 13% lived with an attendant, and 80% lived with a spouse or parents. Of the participants, 34% were unemployed, 18% held part-time positions, and 48% held full-time positions. Ninety-three percent of the participants were Han (the ethnic majority group in China) and 7% ,of them were descendants of other ethnic groups. The annual income ranged from 2,400 ($300) to 60,000 ($7,500) Chinese yuan with a median of 12,000 yuan ($1,500; SD = 861.88 yuan = $107.74.). The causes of the injury and the severity of the Disability are listed in Table 1.
Table 1
Causes and Severity of Disability In Americans and Chinese with Spinal Cord Injuries
Injury Americans (%) Chinese (%)
Causes
Diving 20 0
Fall 29 10
Gunshot 11 1
Job-related 3 39
Natural disaster 0 4
Vehicle 37 46
Levels
Cervical 59 23
Thoracic 34 51
Lumbar 7 26
Types
Complete 39 58
Incomplete 56 41
Missing 5 1
Instruments
The Life Situation Survey (LSS; Chubon, 1995) was used to assess life satisfaction. The LSS contains 20 items (Chubon, 1995; Clayton & Chubon, 1994). Participants are asked to indicate their agreement on a seven-point Likert scale ranging from “Agree Very Strongly” to “Disagree Very Strongly.’ High scores reflect a higher level of life satisfaction. The LSS has been applied to people with SCI in both the U.S. and China (Clayton & Chubon, 1994; Hampton, 2000). In this study, the Cronbach alpha reliability coefficient of the LSS was .85.
The Individualism-Collectivism scale (Trandis et al., 1986) was used to measure the values of individualism-collectivism. The scale contains 21 items answered on a six-point scale (Extremely Agree to Extremely Disagree). A factor analysis indicated that the scale contained four factors: (a) self-reliance, (b) interdependence, (c) family integrity, and (d) separation from ingroups. Originally, family integrity and interdependence were designed to be the indicators of collectivism; self-reliance and separation from ingroups were indicators of individualism. However, previous studies indicated that (a) collectivism was best described by family integrity but not by interdependence, and (b) individualism was well-described by separation from ingroups but not by self-reliance (Triandis et al., 1993; Triandis, McCusker, & Hui, 1990).
The General Self-Efficacy Scale (GSES) was used to measure an individual’s fundamental beliefs about his or her ability to cope with life’s exigencies (Sherer, Maddux, Mercandante, PrenticeDunn, Jacobs, & Rogers, 1982). It consists of 17 items. Higher scores correspond with higher self-efficacy expectations. The Cronbach reliability of the GSES in this study was .79.
The Self-Rated Health Status scale (SRHS; Lawton, Moss, Fucomer, & Kleban, 1982) was used to measure perceived health. According to Lawton et al. (1982), the Cronbach alpha internal consistency of the scale was .76. The concurrent validity of the scale was supported by a moderate correlation (r = .63) between the scale and clinicians’ rating of health status. The Cronbach reliability of the SRHS in this study was .75.
A demographic: information sheet containing the participants’ age, age at the onset of disability, sex, educational level, marital and employment statuses, income, and injury level was developed. All instruments were translated into Chinese using a back translation method (English-Chinese-English) by a bilingual counseling psychology graduate student and a bilingual counseling psychologist. The Chinese versions of the instruments had been tested in a study of 40 people with SCI in China and the results indicated that the instruments were reliable (Hampton, 1998).
Procedures
The information regarding the study was published in the Newsletters of the National Spinal Cord Injury Association (NSCIA) in the U. S. Thirty local Chapters of the NSCIA across the U. S. were contacted by the phone. Fifteen Chapters agreed to participate in the study. Three hundred and eighty questionnaires in self-stamped envelopes were mailed to the coordinators of the local Chapters. The coordinators then distributed the questionnaires to members who met the recruitment criteria for participants. One hundred and thirty-three questionnaires were returned. The return rate was 35%. Meanwhile, the president and the chief psychologist of a Rehabilitation center for people with spinal cord injuries in Beijing, China were contacted. Because this center was the only rehabilitation facility that specialized in spinal cord injuries in China, its patients came from different geographic areas across China. Two hundred questionnaires were sent to outpatients of the center. One hundred and thirty questionnaires were returned with a return rate of 65%. All participants received $5.00 or 40 Chinese yuan.
Results
A preliminary analysis was conducted to examine variations in values and life satisfaction between majority and minority group members within each country. No significant difference was found. Thus, we decided not to conduct separate analysis for race or ethnicity within each country.
Differences in Values between Americans and Chinese
Continued from page 2. Table 2 reports the means and standard deviations of variables for the groups of Americans and Chinese and for men and women. A multivariate analysis of the variance (MANOVA) was conducted. Four value variables were used as the dependent variables to examine the effect of culture (country affiliation) on individualism-collectivism. There was a significant difference in values between Americans and Chinese; F (4, 249) = 32.86, p [is less than] .0001. Univariate analyses indicated that Americans had significantly higher scores on separation from the ingroup [F(1,252) = 30.07, 12 [is less than] .0001] but significantly lower scores on family integrity [F(1,252) = 66.05, P [is less than] .0001] and self-reliance [F(1,252) = 55.09, 12 [is less than] .0001] than Chinese. The difference in the scores on interdependence was insignificant; F(1,252) = .81,12 [is greater than] .05.
Table 2 Means and Standard Deviations of Perceived Health, Self-Efficacy, Values. and Life Satisfaction
USA
Variable Male Female Total
m SD m SD m SD
Health 9.4 1.8 8.7 1.9 9.1 1.8
Efficacy 135.8 22.9 126.9 27.5 132.6 24.9
Reliance 34.3 11.1 29.6 11.6 32.6 11.5
SFI 11.2 2.2 11.3 2.0 11.2 2.1
FI 6.1 2.9 5.3 2.9 5.8 2.9
ITDPNDT 12.3 2.5 12.0 2.2 12.2 2.4
LSS 99.4 18.5 93.4 20.2 97.2 19.3
China
Variable Male Female Total
m SD m SD m SD
Health 5.5 1.5 6.6 1.6 5.9 1.5
Efficacy 110.1 25.2 114.2 26.2 111.7 25.6
Reliance 43.4 8.3 39.8 8.7 42.0 8.6
SFI 8.7 3.5 10.1 3.0 9.3 3.4
FI 8.6 2.8 8.9 2.8 8.7 2.8
ITDPNDT 12.3 2.4 12.9 2.1 12.5 2.3
LSS 71.0 17.7 75.6 21.2 72.8 19.2
Note. SFI = separation from ingroups; FI = family integrity; ITDPNDT = interdependence;
LSS = life satisfaction.
Culture, Gender and Life Satisfaction
The effects of culture and gender and the interaction effect between these two variables were examined using a univariate analysis of the variance. Values and income were used as covariate variables. The effects of the covariate variables were assessed first. The effect of income was significant; F(1,234) = 5.88, 12 [is greater than] .05. The effect of values, however, was small and insignificant (the F values ranged from .05 to .81,12 [is greater than] .05). Then, the effects of culture and gender were determined after statistically controlling for group difference in values and income. Culture had a strong effect on life satisfaction; F(1,242) = 7.76, 12 [is less than] .001. Americans had much higher life satisfaction than Chinese. However, the effect of gender was not significant; F(1,242) = .17, 12 [is greater than] .05. Males and females with SCI had a similar level of life satisfaction. The interaction effect between culture and gender was significant; F(1,242) = 6.98, 12 [is less than] .01. Chinese males had lower life satisfaction scores (m = 71.0) than Chinese females (m = 75.6) and American males (m = 99.5) and females (m = 94.5).
Correlates of Life Satisfaction in the Two Groups
Multiple linear regression analyses were performed for each of the groups separately. Life satisfaction was used as the dependent variable. Values, gender, and self-efficacy were used as the independent variables. Because the literature indicated that age, age at the time of injury, marital status, educational level, perceived health status, and income were the major contributors to life satisfaction in people with SCI (Krause & Dawis, 1992; Schulz & Decker, 1985); these variables were also included as independent variables. Prior to the regression analyses, gender and marital status were recoded using a dummy coding method. Females and individuals who were divorced, separated, widowed, or single were assigned a value of `0′; males and married individuals were assigned a value of `1.’
Because the entry order of the independent variables could affect results, a stepwise regression procedure was chosen to examine relationships between the independent variables and life satisfaction. It is important to note that, in a stepwise regression procedure, variables enter the equation according to their potency in contributing to the prediction. No hierarchy for inclusion of variables is preestablished; therefore, the results of a stepwise regression procedure reflect the predicative utility of the variables (Pedhazur, 1982).
As can be seen in Table 3, for Americans, perceived health status was the strongest predictor and entered the equation first, followed by self-efficacy, self-reliance, and marital status. The combination of the four predictors accounted for 50% of the variance in life satisfaction, F (4, 121) = 28.79, 12 [is less than] .001. Gender, separation from ingroups, family integrity, interdependence, and other demographic variables did not significantly contribute to life satisfaction when other variables in the model were controlled.
Table 3
Summary of Stepwise Regression Analysis for Gender, Values, Self-Efficacy, and Demographic Variables Predicting Life Satisfaction in Americans with SCI
Variable B SE B [Beta]
Step 1
Health 5.79 .75 .58(***)
Step 2
Health 4.39 .76 .44(***)
Efficacy .26 .06 .34(***)
Step 3
Health 4.39 .73 .44(***)
Efficacy .28 .06 .37(***)
Reliance -.37 .11 -.22(**)
Step 4
Health 4.47 .72 .44(***)
Efficacy .27 .05 .36(***)
Reliance -.38 .11 -.23(**)
Marital status 3.72 1.78 .14(*)
Note. [R.sup.2] = .33 for step 1 (p
