ORIGINAL ARTICLE Relationships Between Activities, Participation, Personal Factors, Mental Health, and Life Satisfaction in Persons With Spinal Cord Injury Christel M. van Leeuwen, MSc, Marcel W. Post, PhD, Paul Westers, PhD, Lucas H. van der Woude, PhD, Sonja de Groot, PhD, Tebbe Sluis, MD, Hans Slootman, MD, Eline Lindeman, PhD ABSTRACT. van Leeuwen CM, Post MW, Westers P, van der Woude LH, de Groot S, Sluis T, Slootman H, Lindeman E. Relationships between activities, participation, personal fac- tors, mental health, and life satisfaction in persons with spinal cord injury. Arch Phys Med Rehabil 2012;93:82-9. Objective: To clarify relationships between activities, partic- ipation, mental health, and life satisfaction in persons with spinal cord injury (SCI) and specify how personal factors (self-efficacy, neuroticism, appraisals) interact with these com- ponents. We hypothesized that (1) activities are related directly to participation, participation is related directly to mental health and life satisfaction, and mental health and life satisfac- tion are 2 interrelated outcome variables; and (2) appraisals are mediators between participation and mental health and life satisfaction, and self-efficacy and neuroticism are related di- rectly to mental health and life satisfaction and indirectly through appraisals. Design: Follow-up measurement of a multicenter prospec- tive cohort study 5 years after discharge from inpatient rehabilitation. Setting: Eight Dutch rehabilitation centers with specialized SCI units. Participants: Persons (N=143) aged 18 to 65 years at the onset of SCI. Interventions: Not applicable. Main Outcome Measures: Mental health was measured by using the Mental Health subscale of the 36-Item Short Form Health Survey and life satisfaction with the sum score of “current life satisfaction” and “current life satisfaction com- pared with life satisfaction before SCI.” Results: Structural equation modeling showed that activities and neuroticism were related to participation and explained 49% of the variance in participation. Self-efficacy, neuroticism, and 2 appraisals were related to mental health and explained 35% of the variance in mental health. Participation, 3 apprais- als, and mental health were related to life satisfaction and together explained 50% of the total variance in life satisfaction. Conclusions: Mental health and life satisfaction can be seen as 2 separate but interrelated outcome variables. Self-efficacy and neuroticism are related directly to mental health and indi- rectly to life satisfaction through the mediating role of appraisals. Key Words: Quality of life; Rehabilitation; Spinal cord injuries; Structural models. © 2012 by the American Congress of Rehabilitation Medicine R EHABILITATION AIMS TO improve participation and ul- timately quality of life (QOL). 1 QOL has been studied extensively in persons with spinal cord injury (SCI). 2-4 Al- though QOL is a difficult construct to define, a distinction can be made between objective and subjective QOL. Within the latter concept, 2 components can be distinguished: (1) the cognitive component that refers to life satisfaction and (2) the emotional component that refers to a person’s affect or mental health. 4 Studies of subjective QOL in persons with SCI showed that QOL recovered after being low immediately after the event. 5-7 In the long run, subjective QOL ratings often were higher than what was expected and were just slightly lower than those of the general population. 2,8 Factors consistently related to higher subjective QOL are higher education, 9-11 increased mobil- ity, 9,10,12 better perceived physical health, 8,10-14 more social support, 9-13,15,16 and better psychological functioning, 7,11,16-20 such as higher levels of self-efficacy 7,16,19 and lower levels of neuroticism. 20 However, less attention has been given to theory- based and statistical modeling of relationships between subjec- tive QOL and personal factors that could affect components of the International Classification of Functioning, Disability, and Health (ICF). 21 The ICF describes the influence of a health condition, such as SCI, on 3 main components of functioning, body functions and structure, activities, and participation, in relation to personal and environmental factors. 21 It is possible From the Rudolf Magnus Institute of Neuroscience and Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and Rehabilitiation Cen- ter De Hoogstraat, Utrecht (van Leeuwen, Post, Lindeman); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (Westers); Center for Human Movement Sciences, University Medical Center Groningen, Uni- versity of Groningen, Groningen (van der Woude, de Groot), Reade Centre for Rehabilitation and Rheumatology, Amsterdam (de Groot); Rijndam Rehabilitation Center, Rotterdam (Sluis); and Heliomare, Wijk aan Zee (Slootman), The Nether- lands; and Swiss Paraplegic Research, Nottwil, Switzerland (van Leeuwen, Post). Supported by the Dutch Health Research and Development Council, ZON-MW Rehabilitation program (grant nos. 1435.0003, 1435.0025). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organi- zation with which the authors are associated. Reprint requests to Marcel W. Post, PhD, Rehabilitation Center De Hoogstr- aat, Rembrandtkade 10, 3583 TM, Utrecht, The Netherlands, e-mail: m.post@ dehoogstraat.nl. 0003-9993/12/9301-00431$36.00/0 doi:10.1016/j.apmr.2011.07.203 List of Abbreviations AIC Akaike’s information criterion EPQ-RSS Eysenk Personality Questionnaire-Revised Short Scale ICF International Classification of Functioning, Disability, and Health ICQ Illness Cognition Questionnaire QOL quality of life SCI spinal cord injury SF-36 36-Item Short Form Health Survey SIP-68 Sickness Impact Profile 68 82 Arch Phys Med Rehabil Vol 93, January 2012