1. Introduction
Most spinal cord injuries (SCI) result in paralysis in the body from damage to the spinal cord due to an unexpected accident. Approximately 80% of individuals with SCI depend on a wheelchair [
1]. SCI may lead to a reduction or cessation in participation in physical activities and is associated with an increased risk of secondary physical problems, such as obesity and bedsores [
2,
3,
4,
5].
According to the standards disclosed by the Korea Ministry of Health and Welfare [
6] and the Korea Institute for Health and Social Affairs [
7], the population of individuals with SCI in Korea was estimated to be 54,000. The Korean Ministry of Health and Welfare reported that for 90.5% of the population with severe disabilities, such as those with SCI, most injuries were due to traffic or industrial accidents [
8]. Similarly, according to the report of the National Center for Spinal Cord Injury Statistics, 91.9% were reported to be caused by traffic accidents, falls, or violence [
9]. Such acquired disabilities can, at times, be accompanied by psychological problems, such as anxiety, because of the sudden and permanent loss of physical functions [
10], as well as depression, anger, hostility, and violent actions [
11]. For example, individuals with SCI may experience recurrent trauma from the accident, which has been shown to be associated with major depressive disorder [
12]. Thus, it is considered important to approach these psychological factors for individuals with SCI.
Recently, research into the effects of sports and rehabilitation program participation among individuals with SCI have expanded from treating mainly the physical disabilities to also considering psychological recovery and improving patients’ quality of life [
13]. Most of the early studies on individuals with SCI focus on the effects of counseling or rehabilitation programs through qualitative research methods, application of tele-counselling [
14], exploring the quality of life [
15,
16], and neuropathic pain [
17]. Although considerable research attention has highlighted the effects of participating in sports activities of individuals with SCI, several authors have noted the lack of quantitative research addressing individuals with SCI [
18,
19]. Moreover, most individuals with SCI have an acquired disability and may have an especially difficult time in accepting their disability compared to those born with a disability [
20]. Therefore, the aspect of psychological approach and disability acceptance are important in research on individuals with SCI.
The literature on the psychological recovery of individuals with disabilities typically emphasizes the goal of increasing life quality or satisfaction through social integration [
21,
22]. Roth, Zittel, Pyfer, and Auxter [
23] revealed that that social integration, through sports or physical activities, is essential to increase the self-esteem of individuals with disabilities. In addition, participation in sports activities may help them overcome pain or sadness [
24] and it can positively influence acceptance of one’s disability [
25]. Disability acceptance is largely subjective [
26,
27] and is associated with positive psychological outcomes, such as life satisfaction [
28,
29], self-esteem [
30], and self-conception [
31]. Reflecting previous studies, in participation through a self-help group, where participants help each other in similar situations, perhaps having a disability becomes less critical [
32,
33]. Lee and Stephen [
34] reported that the social support and disability acceptance of individuals with SCI were improved through participation in sports activities.
For individuals with SCI, participation in sports and physical activities is associated with various positive psychological outcomes, such as social support [
34], self-efficacy and psychological well-being [
35,
36,
37]. Therefore, in this study, we try to approach the situation and perspective of individuals with SCI through self-efficacy that has already been revealed through previous studies. For example, in the SEQRS (Self-efficacy for Quad Rugby Skills) questionnaire [
38], the self-efficacy construct was modified to fit diverse disabilities in the development process and situations related to sports or physical activities. Notably, it is important to consider the environmental factors, as in the current study.
Other factors that can affect quality of life and life satisfaction in individuals with severe physical disabilities are environmental factors such as social support [
39,
40]. In previous studies, peer- or self-help groups have helped to provide emotional support between the different types of received social support [
41] and have enhanced individuals’ self-efficacy beliefs [
42]. The types of received social support (physical, emotional, and informational support) can also diminish the negative effects of stress and mend psychological health [
43]. In fact, the role of self-help group activity is important for individuals with SCI who need help when getting into a swimming pool or when using weight-training devices. Like Villie et al. [
44], we operationalized social support as a “sense of belonging.” Social/psychological effects from such self-help group activities can give participants a “sense of belonging”, which can be defined as a perceived oneness with an organization and the experience of the organization’s successes and failures as one’s own [
45]. Rude and Burham [
46] explained that individuals who lack a sense of belonging can possibly become depressed because of pathological social behaviors such, as excessively dependence on others. Thus, one can predict that a sense of belonging can develop through daily sports and self-help group activities, which can have a positive psychological effect on individuals with SCI and contribute to the goal of psychological recovery.
Therefore, in this study, we examined the importance of disability acceptance among individuals with SCI participating in Sport for All programs through self-help activities with other individuals with SCI. We also examined the positive role of disability acceptance in the relationship between self-efficacy, sense of belonging, and life satisfaction among individuals with SCI participating in Sports for All. This approach will help clarify the psychological effects of sports participation among individuals with SCI rather than focusing on physical activity programs. The conceptual model of our study is shown in
Figure 1. Our specific research questions were as follows:
(1) What affect does disability acceptance have on the relationship between self-efficacy and life satisfaction?
(2) What affect does disability acceptance have on the relationship between sense of belonging and life satisfaction.
Figure 1.
Conceptual model of study.
Figure 1.
Conceptual model of study.
4. Discussion
Lots of research indicates there are psychological benefits to participation in physical rehabilitation and sports [
14,
34,
35]. Although most studies recognize the psychological benefits of physical activities and participation in sports for individuals with SCI, there is only a limited explanation concerning how psychological recovery can occur because of extraneous, mediating, and moderating variables. Thus, based on the results and limitations of preceding studies, we revealed how participation in sports-related self-help groups can aid in the psychological recovery of individuals with SCI. Specifically, we determined that self-efficacy and sense of belonging were positively related to life satisfaction in individuals with SCI participating in Sports for All programs. In addition, we clarified the role of the disability acceptance for individuals with SCI.
Our findings confirmed the mediating effects of disability acceptance in participation self-help group sports activities. Specifically, as in previous studies, the relationships between self-efficacy and life satisfaction, self-efficacy and disability acceptance, belonging and life satisfaction were confirmed. Moreover, we found that higher life satisfaction could be obtained through the mediating variable of disability acceptance for individuals with SCI. The need for efforts to resolve the complexity of these secondary conditions and their inter-relationships has already been suggested [
13], and the mediating effects of disability acceptance explains the key relationships determined in this study. These results support Nicholls et al.’s argument that disability acceptance is a key factor in the recovery of people with spinal cord disorders [
64].
Previous studies related to disability acceptance revealed that perceived disability is the strongest predictor of one’s adaptation and that perception has a greater impact on socio-psychological adjustment than actual impairment does [
65,
66]. Especially, Wright [
67] explained that those with acquired disabilities, such as SCI, experience a sense of loss, and our study supports this notion. The is because most individuals with SCI have many wheelchair-related barriers and obstacles, which can limit their participation in physical activity [
36]. In fact, oftentimes, they require third-party assistance to participate in Sports for All programs, such as assistance with getting into a swimming pool or using weight training device.
These results support the necessity of considering the psychological aspect of disability acceptance along with the physical activities involved in the rehabilitation processes of individuals with SCI. Our results also suggest that participation in self-help groups and group activity programs can increase disability acceptance for individuals with SCI, which can have vast psychological benefits. Through the self-help group sports activities, the acceptance of physical conditions and blocking the negative effects of disabilities can be increased, and ultimately, it will be possible to have a more positive effect on life satisfaction. Such findings have implications for self-help groups and those designing Sports for All programs. In other words, participating in self-help group sports activities that can help and support other individuals with SCI has a positive effect on disability acceptance; receiving social support [
40] can diminish the negative effects of stress and mend psychological health [
43]. This approach is the same as the concept of disability acceptance proposed by Linkowski [
51,
52]. Through the result of this study, it is possible to emphasize the need to increase specialized sport programs and facilities for individuals with a disability.
Although the results of this study are an important initial step to understanding the disability acceptance of individuals with SCI through self-help group participation in Korea, the results should be interpreted considering several limitations. First, this study was conducted without a comparison group and cross-sectional design. Thus, there are limitations in generalizing how sports and physical activity participation may affect the psychological variables collected in this study to a broader population. Although this study found the mediating effect of disability acceptance, it is necessary for future studies to verify whether sports activities are related to the psychological state by a comparative analysis, such as type of group—leisure and rehabilitation, self-help group or not. Moreover, Longitudinal research that observes the changing psychological variables during actual physical activity or sports is needed. Second, in this study, we did not consider the level of participation in Sports for All programs (i.e., time per month, duration, quality of the participation) and conducted research on participants within the Sports for All program. Thus, to allow for results generalization, the moderated mediating model should be verified with variables such as the level of sports participation or engagement. It is necessary to develop an approach that fosters positive psychological states in individuals with SCI through physical activity or sports participation. Future studies might, thereafter, effectively focus not only on finding methods of enhancing individuals, but also on modifying participants’ environments, such as the type of group and disability.