Urban-Rural Disparities in Community Participation after Spinal Cord Injury in Ontario

Abstract

Background: Personal, social, and environmental factors may influence self-efficacy and social reintegration among people living with spinal cord injury or disease (SCI/D) in urban and rural areas. Novel data collection methods have the potential to characterize community participation (CP) in diverse settings.

Objectives: The objectives were (1) to describe and compare self-reported community participation (Reintegration to Normal Living Index (RNLI) and Moorong Self-Efficacy Scale (MSES)) levels of individuals with SCI/D living in urban or rural Ontario, Canada; and (2) to determine the accuracy of an artificial intelligence (AI) optical mark recognition tool for extracting data from CP surveys conducted among participants after transitioning from inpatient rehabilitation to home and residing in the community.

Methods: We partnered with SCI Ontario staff to collect MSES and RNLI survey data from adults with motor complete (e.g., AIS A-B) and incomplete (AIS C-D) SCI/D living in urban or rural Ontario, Canada, between January and October 2022. The Rurality Index of Ontario (RIO) from the postal code determined urban or rural residency. Optical mark recognition (OMR) software was used for survey data extraction. A Research Associate validated the extracted survey responses. Descriptive statistics, correlation analysis, and non-parametric statistics were used to describe the participants, their impairments, and their reported CP levels across urban and rural settings.

Results: Eighty-five individuals with SCI/D (mean age 53.7 years, 36.5% female) completed the survey. Most of the participants resided in major urban areas (69.4%) and had traumatic injuries (64.7%). The mean total MSES score for Ontarians with SCI/D was 87.96 (95% confidence interval [CI]: 84.45, 91.47), while the mean total RNLI score for the same individuals was 75.61 (95% CI: 71.85, 79.37). Among the MSES domains, the lowest score was observed in response to sexual satisfaction (mean: 4.012, 95% CI: 3.527, 4.497), while the lowest RNLI domain item score was associated with the ability to travel out of town (mean: 5.965, 95% CI: 5.252, 6.678). Individuals with incomplete injuries in rural areas reported lower MSES and RNLI scores than those with complete motor injuries, whereas no significant differences were found in MSES and RNLI scores among urban residents based on impairment. These findings suggest that, depending on the environmental context (e.g., rural vs. urban areas), AIS categories may influence the perception of CP among people living with SCI/D. The OMR tool had 97.4% accuracy in extracting data from the surveys.

Conclusions: The CP (MSES and RNLI) scores reported by individuals with SCI/D differ based on their living setting. In rural Ontario, individuals with greater functional ability reported lower CP than their counterparts living in urban settings. Although CP remains a challenge, the needs of individuals with motor incomplete SCI/D and heterogeneous levels of mobility residing in rural areas require exploration and targeted interventions. The OMR tool facilitates accurate data extraction from surveys across settings.

Keywords: Moorong Self-Efficacy Scale (MSES); Reintegration to Normal Living Index (RNLI); artificial intelligence; community participation; optical mark recognition (OMR); spinal cord injury or disease (SCI/D).

Figure 1

(a) MSES total score by impairment level for CP survey respondents; (b) RNLI total score by impairment level for CP survey respondents.

Figure 2

(a) MSES total score by impairment level in major urban CP survey respondents; (b) RNLI total score by impairment level in major urban CP survey respondents; (c) MSES total score by impairment level in rural or non-major urban CP survey respondents; (d) RNLI total score by impairment level in rural or non-major urban CP survey respondents.

Figure 2

(a) MSES total score by impairment level in major urban CP survey respondents; (b) RNLI total score by impairment level in major urban CP survey respondents; (c) MSES total score by impairment level in rural or non-major urban CP survey respondents; (d) RNLI total score by impairment level in rural or non-major urban CP survey respondents.