Evaluating a pilot community-based self-management program for adults with spinal cord injury

Abstract

Objective: To evaluate outcomes and perceptions of participating in a pilot spinal cord injury (SCI) specific community-based self-management program.

Design: A program evaluation conducted through the review of retrospective data.

Setting: An outpatient vocational rehabilitation service in Singapore.

Participants: Adults with SCI who completed a self-management intervention.

Intervention: A self-management educational program was delivered by healthcare professionals with involvement of peer mentors. Up to six self-selected topics were covered using a multi-modal teaching approach.

Outcome Measures: Retrospective data collected at baseline, post-intervention, and three-month follow-up were analyzed. Outcome measures included the University of Washington Self-Efficacy scale (UW-SES), SCI Secondary Conditions Scale (SCI-SCS), Community Integration Questionnaire (CIQ), and employment. Post-program survey findings were also reviewed.

Results: Data from fifteen participants revealed positive changes over time for the UW-SES (η² = .27), SCI-SCS (η² = .21), and CIQ (η² = .23). Self-efficacy scores increased from baseline to post-intervention with a large effect size (Hedge’s g = 0.89), and from baseline to follow-up with a medium effect size (Hedge’s g = 0.50). Participants reported overall perceived benefit and satisfaction with the program’s design and relevance. They valued access to useful information, effective instructional methods, program customization, and participant empowerment and affirmation. Suggestions for program refinement included: more peer support, psycho-emotional support, and continued program adaptability and accessibility.

Conclusion: A SCI-specific community-based self-management program was associated with short-term improvements in self-efficacy and was well-received. Further research is required to determine its effectiveness, essential program features that promote successful outcomes, and cost-effectiveness of program implementation.

Introduction

Spinal cord injury (SCI) often leads to significant neurological dysfunction, long-term disability, and reduced participation in the community (1). A study published in 1987 estimated the annual incidence of SCI in Singapore to be 27 cases per million (2). Despite the lack of more recently published data, this estimate is comparable to the annual incidence of SCI in other Asia Pacific countries such as Australia, with 21 to32 cases per million (3), and Japan, with 39 cases per million (4). Beyond the immediate impairments that result from their initial injury, SCI survivors are at risk of secondary health complications. A cross-sectional study found that persons with SCI in Singapore reported a higher prevalence of chronic health conditions (e.g. diabetes, hypertension, obesity, high cholesterol) than the general population, secondary health complications, and lower life satisfaction than SCI survivors in other countries (5).

Health complications can be life-threatening, increase health care utilization and costs, and worsen the extent of disability for individuals with SCI (6). They present as barriers to employment (7), and are associated with reduced life satisfaction (8). It is therefore important that rehabilitation following SCI addresses the prevention and management of secondary conditions.

Self-management approaches are promoted to improve health and long-term outcomes in chronic conditions such as SCI (9). Self-management is described as one’s “ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition (pp.177)” (10). Self-management interventions aim to actively engage persons in health maintenance strategies and can potentially address the long-term healthcare needs associated with chronic conditions effectively and efficiently (11). Evidence shows that self-management interventions can increase self-efficacy, physical activity, and self-rated health among individuals with chronic conditions (12). Specifically in the SCI population, they can increase self-efficacy, reduce healthcare utilization (e.g. hospitalizations and doctor visits), promote quality of life, and improve life satisfaction (13–17). These interventions were also found to be valued by persons with SCI (18, 19).

To date, no study has evaluated the effectiveness of SCI specific self-management interventions in Singapore. However, it is important to understand their effectiveness in a culture where Confucian values promote interdependence among family members and learned reliance of individuals with disabilities (20), and where medical paternalism has potentially led to reduced motivation for self-management (21).

In 2019, SPD (a non-profit organization in Singapore) piloted a self-management intervention as a part of regular clinical care provided through its community-based interdisciplinary vocational rehabilitation (VR) program. Citizens and permanent residents with acquired physical disabilities were referred to this program from hospitals (inpatient and outpatient services) and community rehabilitation facilities. Enrolled individuals who were diagnosed with SCI were offered the self-management intervention. The theoretical foundation of this program was predominantly informed by Bandura’s social cognitive theory, which suggests that “people are contributors to their life circumstances” and that personal accomplishments are influenced by interactions between personal factors, behavior, and the environment (22). A key aspect within the social cognitive theory is the concept of self-efficacy, or one’s belief in his/her ability to achieve a desired outcome (23). Perceived self-efficacy has been found to be strongly correlated with patient outcomes among individuals with chronic conditions (11). Therefore, this pilot intervention incorporated strategies to enhance participants’ self-efficacy with the ultimate aim of promoting better health.

The objective of this study is to evaluate the above mentioned pilot community-based self-management intervention, and to understand participants’ perceptions of it. Specifically, it aims to assess changes in self-efficacy and explore the intervention’s potential influence on secondary complications experienced, community integration levels, and employment status. In addition, it aims to determine areas of strength and recommendations for improvement through an analysis of post-intervention feedback from participants, to advise future program enhancement.

Methods

Study design

A program evaluation was conducted through analysis of information previously collected from participants who had completed the intervention. Permission to access the retrospective data was obtained from SPD prior to this study’s commencement and ethics approval was obtained from the University of British Columbia’s Clinical Research Ethics Board.

Participants

Participants were adults (18–60 years old) diagnosed with SCI enrolled in a VR program, and who consented to and completed the self-management intervention. All study participants were without cognitive deficit (i.e. without accompanying brain injury and able to provide informed consent). A sample size calculation was performed a priori at 80% power and an alpha value of .05 using the G*Power software (24). This revealed that a sample size of 15 was required to detect a 7.13 point change (i.e. large effect size) in self-efficacy scores, our primary outcome measure (25, 26).

Pilot intervention

The self-management intervention was designed based on findings from a literature review and survey feedback from healthcare providers and SCI survivors. Findings from this needs assessment revealed that the intervention should facilitate social interaction, involve peer mentors, deliver tailored information through SCI knowledge experts, and utilize internet-based learning materials.

A senior physiotherapist developed the pilot intervention and implemented it with the assistance of two co-facilitators (an occupational therapist and a physiotherapist). Peer mentorship was incorporated through either in-person interaction, or videos of peers offering advice and demonstrating skills. Since the intervention was delivered as part of a VR program, participants also engaged in regular goal setting and received routine support and re-assessments from an interdisciplinary team of occupational therapist, physiotherapist, social worker and employment support specialist.

The social cognitive theory outlines five basic capabilities people possess – cognitive, vicarious, forethought, self-regulatory, and self-reflective capabilities. These enable individuals to accomplish personal goals and navigate challenges (22). Therefore the educational approach adopted in this intervention focused on these capabilities to promote self-management behaviors. Program content and delivery were individualized where feasible and additional resources were offered to participants upon request. Further details of the intervention are provided in Table 1.

Table 1.

Details of self-management education intervention.

Component	Description
Theoretical foundation (educational approach) Mode of delivery	Social Cognitive Theory
	Participants were encouraged to exercise these capabilities: Cognitive capability: through understanding learning objectives, rationales, and potential consequences of behavior Vicarious capability: learning through observation and shared experiences of peers and role models Forethought and self-regulatory capabilities: through goal setting, problem solving, self-directed learning. Self-reflective capability: enhanced self-efficacy through affirmation and experiences of mastery In-person or via video-conferencing platforms
	A combination of groups and one-to-one interaction
Topics	physical activity mobility and assistive technology pain and spasticity management skincare and nutrition bladder and bowel care aging with SCI *topics were self-selected by participants
Delivered by	Main facilitator (physiotherapist with five years of clinical experience in SCI rehabilitation)
	Co-facilitators (physiotherapist and occupational therapist who received competency training in SCI rehabilitation)
	Peer mentor (a more experienced SCI survivor), only when the schedule allowed for it
Frequency Duration Instructional methods Materials	One session in every one to four weeks
	40–80 min per session
	power point presentations, videos, discussions, quizzes/ question and answer sessions, demonstration/ practice, and educational handouts
	(see facilitator resources under Appendix 1)

Overall, 3–8 sessions were delivered to each participant and each session lasted for 40–80 min. The total program duration ranged from three weeks to three months for each individual. Of the 15 participants, 11 took part in at least one group session, four opted for tele-practice sessions, and four interacted with a peer mentor. All participants watched videos of peers with SCI performing specific skills or sharing experiences. These variations in program delivery were largely due to participant preferences and scheduling conflicts. Figure 1 provides an overview of how training resources were utilized and total training duration based on the number of topics selected.

Figure 1.

Overview of how the self-management intervention was delivered across participants.

Descriptive variables

Demographic details such as age, gender, level/ completeness of injury, duration post-injury, education level, marital status, and living situation were collected upon each participant’s admission to the program. These characteristics were used to describe the study sample. Spinal Cord Independence Measure (SCIM-III) scores at baseline were also used to describe participants’ functional levels (27).

Quantitative measures

The primary outcome for this study is self-efficacy. It was measured with the University of Washington Self-Efficacy Scale (UW-SES). The UW-SES has been validated in the SCI population, shows good convergent validity with the Chronic Disease Self-Efficacy 6-item scale, and high internal consistency (28).

Three secondary outcomes were reviewed: the SCI Secondary Condition Scale (SCI-SCS), the Community Integration Questionnaire (CIQ), and employment outcome. The SCI-SCS measures the subjective experience of SCI-related health complications. It has good convergent validity with six items on the SF-12, moderate to high internal consistency, and good test-retest reliability (29). The CIQ is a measure that assesses community integration within the domains of home integration, social integration, and productive activities (30). The CIQ demonstrates good correlation with the Craig Handicap Assessment and Reporting Technique – Short Form and adequate test-retest reliability (31, 32). Employment outcomes were determined based on chart documentation of participants’ reports on their return-to-work status. Employment rates were calculated by expressing the number of participants who returned to work as a proportion of the total number of participants included in this study. No minimal clinically important differences (MCIDs) have been established for the above mentioned outcomes. All outcome measures were scored before the program (baseline), three months after commencement of the program (post-intervention), and 6 months after commencement of the program (follow-up).

Qualitative data

Each participant completed a post-intervention survey, which is used to evaluate new initiatives within the VR program. The survey included eight Likert scale items, and three open-ended questions that explored program strengths and shortcomings, and comments from participants. Survey questions are listed in Table 4. Questionnaires were administered in pen and paper, and collected by a staff member who did not deliver the intervention. These qualitative findings were transferred to a Microsoft Excel document that was subsequently used for retrospective review.

Table 4.

Perceptions of Participants Towards Self-management Intervention (N = 15).

	SD	D	N	A	SA
Likert scale items	n (%)	n (%)	n (%)	n (%)	n (%)
The length of time spent for each session was just right.	0 (0.0)	0 (0.0)	4 (26.7)	6 (40.0)	5 (33.3)
The learning spaces were suitable for me.	0 (0.0)	0 (0.0)	1 (6.7)	10 (66.7)	4 (26.7)
The topics covered were meaningful to me.	0 (0.0)	0 (0.0)	0 (0.0)	10 (66.7)	5 (33.3)
It was hard to understand the information provided.	4 (26.7)	9 (60.0)	2 (13.3)	0 (0.0)	0 (0.0)
I feel more confident in taking care of my health after this programme.	0 (0.0)	0 (0.0)	2 (13.3)	11 (73.3)	2 (13.3)
My heath complications are less of a problem to me after this programme.	0 (0.0)	1 (6.7)	5 (33.3)	6 (40.0)	3 (20.0)
It is not important for people with SCI to take part in programmes like this.	7 (46.7)	6 (400)	1 (6.7)	1 (6.7)	0 (0.0)
Overall, this programme helped me.	0 (0.0)	0 (0.0)	0 (0.0)	12 (80.0)	3 (20.0)
Free text items		Responses n (%)
What did you like most about the program?		12 (80)
What did you dislike (or could have been improved) about the program?		3 (20)
Any other comments about the program?		3 (20)

Note. SD: strongly disagree, D: disagree, N: neutral, A: agree, SA: strongly agree.

Data analysis

We used descriptive statistics to summarize demographical data and Likert scale survey responses, and to describe scores on all outcome measures. Within-subjects repeated measures analysis of variance (RM-ANOVA) was used to compare UW-SES, SCI-SCS and CIQ scores over the three time points. To adjust for multiple comparisons the Fisher’s least significant difference adjustment was applied to p-values (33). Paired t-tests were performed to compare mean scores between two time points. We calculated estimates of effect sizes and reported eta squared values (the degree of association between scores) and Hedge’s g values due to the small study sample (26). Effect sizes were interpreted as small (η² ≥ .01 or g ≥ 0.2), medium (η² ≥ .06 or g ≥ 0.5), or large (η² ≥ .14 or g ≥ 0.8) (25). Parametric tests were adopted for analyses of all continuous variables, as the data met assumptions for normality. A Cochran’s Q test was performed to compare employment status over all time points, and post-hoc McNemar tests were conducted for paired comparisons. Differences were considered statistically significant when p < 0.05. We used descriptive statistics to calculate percentages and frequencies for options on the Likert scale responses of survey forms. All statistical analyses were performed with IBM SPSS Statistics for Windows (Version 27.0. Armonk, NY: IBM Corp).

Free text responses on surveys were analyzed using conventional content analysis (34). Data were read multiple times to gain an overall understanding of responses. We then identified codes from key concepts that emerged from the text, and categorized them into clusters. Each cluster represented a unique theme.

Results

Participant demographics

A total of 15 participants were included in this chart review. One of 16 participants in the database was excluded due to a concurrent diagnosis of traumatic brain injury. Participants were of a median age of 43 years (IQR = 33–57) and had sustained their injury for a median duration of six months (IQR = 4–18). Most had suffered incomplete injuries (93.3%) and presented with paraplegia (73.3%). The mean SCIM-III score was 79 (IQR = 59–82). Further demographic details are provided in Table 2.

Table 2.

Demographic characteristics of participants (N = 15).

	n (%)
Gender
Male	8 (53.3)
Female	7 (46.7)
Injury level
Paraplegia	11 (73.3)
Tetraplegia	4 (26.7)
Injury type
Incomplete	14 (93.3)
Complete	1 (6.7)
Education level
Primary	1 (6.7)
Secondary	5 (33.3)
Pre-university	4 (26.7)
University	5 (33.3)
Marital status
Single	9 (60)
Married	5 (33.3)
Divorced/ Widowed	1 (6.7)
Living situation
Lives with family/friends	14 (93.3)
Lives alone	1 (6.7)
	Median (IQR)	Range
Age (years)	43 (33–57)	29–60
Injury duration (months)	6 (4–18)	2–23
SCIM-III score (total: 100)	79 (59–82)	21–93

Note. IQR: interquartile range, SCIM-III: Spinal Cord Independence Measure.

Primary outcome measure

A within-subjects RM-ANOVA indicated that UW-SES scores were significantly different during at least one time point (p = .011, η² = .27). Post-hoc comparisons revealed that participants’ self-efficacy scores increased significantly from baseline to post-intervention (p = .003), with a large effect size (Hedge’s g = 0.89). The mean self-efficacy score subsequently decreased and the improvement from baseline to follow-up dropped to a medium effect size (Hedge’s g = 0.50).

Secondary outcome measures

Table 3 presents findings for all outcome measures across the three time points. RM-ANOVAs indicated that mean scores were significantly different during at least one time point for both the SCI-SCS (p = .037, η² = .21), and the CIQ (p = .04, η² = .23). Problems related to secondary conditions showed a downward trend over time. Post-hoc tests revealed a significant decrease in SCI-SCS scores from baseline to follow-up (p = .024), with a medium effect size (Hedge’s g = 0.64). Overall, community integration score improved immediately post-intervention then decreased at follow-up. Post-hoc comparisons revealed a significant increase in CIQ scores from baseline to post-intervention (p = .022), with a medium effect size (Hedge’s g = 0.65). Finally, for employment, a significantly greater proportion of individuals were employed at follow-up compared to baseline (p = .025).

Table 3.

Comparison of Outcome Measures at Pre-intervention (T1), Post-intervention (T2), and Follow-up (T3) (N = 15).

	T1	T2	T3			Eta Squared
Outcome measure	mean (SD)	mean (SD)	mean (SD)	F	Sig.	(η²)
UW-SES (range: 15.4–72.6)	43.8 (9.7)	49.4 (8.0)	47.8 (8.6)	5.26	.011*	.27
SCI-SCS (range: 0–48)	12.5 (6.5)	11.5 (5.7)	10.5 (6.6)	3.71	.037*	.21
CIQ (range: 0–29)	11.4 (5.5)	15.5 (5.4)	15.3 (5.4)	4.23	.04*	.23
Outcome measure	Paired time points	Mean difference (SD)	t	Sig.a (2-tailed)	Hedge's g (95% CI)
UW-SES	T1-T2	−5.6 (6.1)	−3.53	.003*	−0.89 (−1.47 to −0.29)
	T2-T3	1.6 (6.6)	0.94	.365	0.24 (−0.27 to 0.73)
	T1-T3	−4.0 (7.8)	−1.98	.067	−0.50 (−1.02 to 0.04)
SCI-SCS	T1-T2	0.9 (2.4)	1.5	0.155	0.38 (−0.14 to .088)
	T2-T3	1.0 (2.9)	1.36	0.196	0.34 (−0.17 to 0.84)
	T1-T3	1.9 (3.0)	2.53	.024*	0.64 (0.08 to 1.17)
CIQ	T1-T2	−4.1 (6.1)	−2.58	.022*	−0.65 (−1.18 to −0.09)
	T2-T3	0.23 (4.1)	0.22	.830	0.06 (−0.44 to 0.55)
	T1-T3	−3.8 (7.5)	−1.98	.068	−0.50 (−1.01 to 0.04)
	T1	T2	T3	T1-T2	T2-T3	T1-T3
Outcome measure	n (%)	n (%)	n (%)	Sig.	Sig.	Sig.
Employment	2 (13.3)	5 (33.3)	7 (46.7)	.083	.317	.025*

Note. SCI-SCS: Spinal Cord Injury Secondary Condition Scale, CIQ: Community Integration Questionnaire, UW-SES: University of Washington Self-Efficacy Scale.

^aFisher's Least Significant Difference adjustment applied.

*p < .05.

Survey responses

All 15 participants completed the post-program survey. Table 4 summarizes their Likert scale responses and the response rates to free-text items.

Likert scale ratings

Majority of participants expressed satisfaction with the intervention in terms of its design and relevance. Most reported greater confidence in health related self-care (86.6%) and that their health complications were less of a problem (60%) after the program. All participants felt they had benefitted.

Perceived strengths of program

Four strengths of the program were identified through analysis of free text survey responses: (1) access to useful information, (2) effective instructional methods, (3) program customization, and (4) participant empowerment and affirmation.

Access to useful information. Many participants appreciated that the content covered during sessions was specific to SCI and relevant to their individual needs. Some perceived the knowledge they gained as crucial for self-care, and one individual stated that the program offered comprehensive information.

All topics in the program are rather relevant for SCI. They are well covered for patients with SCI and help us to manage and understand our situation. [Participant 1]

Effective instructional methods. A number of participants enjoyed learning through demonstration and practice (e.g. performing exercises). The close interaction and ability to review sensitive topics was also perceived as a positive experience. Some reported greater clarity in their understanding of concepts taught and attributed this to receiving one-to-one instructions, the use of examples, and elaboration.

Detailed explanations tailored to my body condition … (I gained) more knowledge and clarity in my current understanding. [Participant 2]

Program customization. Some participants liked that the program catered to their personal needs and medical condition. They appreciated the specific advice and self-management strategies offered during sessions (e.g. pain and spasticity management).

Participant empowerment and affirmation. Participants shared that they felt more empowered to perform self-management behaviors, having gained deeper knowledge and greater awareness of their helath condition. One participant appreciated the facilitator’s affirmation of participants’ abilities.

Recommendations for program refinement

Three areas for program refinement were identified: (1) more peer support, (2) inclusion of psycho-emotional interventions, and (3) continued program adaptability and accessibility.

Peer support. A participant suggested that the program allow for more peer interaction, as such platforms would facilitate useful sharing of personal experiences.

Psycho-emotional interventions. An individual proposed the involvement of other professionals to address mental health issues and emotional coping strategies to help participants cope better with their disability.

Perhaps the program can team up with psychologist/ social worker to provide additional mental health support to overcome the mental “stress” of the acquired disability. [Participant 3]

Program adaptability and accessibility. A participant recommended that the program continue to adapt and evolve to meet the varied needs of its participants. Another commented that the program should remain accessible to all individuals with SCI.

Discussion

Our findings demonstrated that participation in a community-based self-management intervention was associated with increased self-efficacy from baseline to post-intervention. Despite possible cultural barriers to self-management in Singapore, this study demonstrated potential improvements in participant self-efficacy, as has been reported by studies in other countries (15, 35). This positive impact on self-efficacy may be related to the program’s utilization of sources of efficacy information, such as affirmation, showcasing success of peers, and offering opportunities to practice skills and attain mastery. There is evidence to suggest that gains in self-efficacy may lead to greater participation and life satisfaction (36), expanding the potential benefits of such self-management interventions. In our study, the initial large effect of increase in self-efficacy was not maintained at follow-up. A possible explanation is that efficacy expectations vary with task difficulty, circumstances, and experiences (37). With a relatively short median duration of injury of six months, most study participants were likely still adjusting to their disability. Therefore, they may have needed more time to accumulate experiences of mastery and to gain greater generality of self-efficacy.

The positive changes observed in secondary complications and community integration levels require further investigation, as these secondary outcomes are exploratory. In general, participants reported low baseline SCI-SCS scores with a mean of 12.5 out of a total possible score of 48. This could have resulted in a floor effect – a limitation identified from previous evaluations of this measure (29). A floor effect occurs when 15% of participants get the lowest score possible (38). It is also likely that a longer follow-up duration is required to detect larger changes in health complications, such as that observed among participants of a peer mentoring program that incorporated a 12-month follow-up period (14).

Community-based self-management interventions appear to promote reduced activity limitation and increased community integration among persons with SCI (16, 35). This may be attributed to changes in self-efficacy, and the positive association between self-efficacy and participation (39). Although a MCID has not been established for the CIQ, a score of 15 or less is indicative of low integration (40). In this study, individual with CIQ scores above 15 increased from 27% at baseline to 67% at follow-up. This was despite the fact that data had been collected in the midst of nationwide movement restrictions imposed during a global pandemic. Since many items on the CIQ reflect the frequency of engagement in activities outside of the home (30), it is possible that improvements in community integration levels in this study were underestimated.

Employment status is a relatively novel outcome for the evaluation of self-management interventions. It was recognized as meaningful since one’s competence in health management may facilitate successful return-to-work (41). The employment rates we observed at post-intervention (33%) and follow-up (47%) were higher than the pre-intervention rate (13%) and the 13–22% employment rate reported in local studies on the SCI population (1, 5). However, these findings should be interpreted with caution as this study’s participants presented with relatively high levels of functional independence, were receiving VR, and were motivated to return to work. These factors could have increased the likelihood of successful employment (42).

Overall, participants were satisfied with the program’s design. The insights gleaned from their feedback offer useful considerations for future program implementation. Firstly, survey responses reiterated previous qualitative findings that persons with SCI prefer diagnosis-specific self-management interventions (43). This suggests that generic programs involving participants with various medical conditions may not adequately cater to the needs of this population. Next, participant autonomy and program customization appeared to promote participant receptiveness towards the intervention. Facilitators may also consider adopting a variety of instructional methods that match the content being taught, as this can enhance learning outcomes (44). Finally, study participants appreciated how the intervention fostered a sense of empowerment and understanding of self-management concepts. These reports attest to the potential effectiveness of the theoretical approach that was adopted.

Peer support has been recognized as an important component in health education programs and is highly valued by individuals with SCI (45, 46). The benefits of peer-led interventions have been widely established and include positive changes in adjustment, hope, self-efficacy, quality of life, and participation (47). Hence, it was not surprising that limited peer interaction was identified as an area for improvement. Logistical constraints presented as a challenge to increased peer involvement in this study. However, the advantages of peer support allude to the need for creative solutions to overcome these barriers, such as the use of online resources and remote communication platforms. Holistic self-management interventions should also include topics on injury acceptance and emotional coping. With the complexity of the disability that results from spinal injuries, these topics address an integral aspect of living with SCI and are highly relevant to SCI survivors (9, 19).

Limitations

The following limitations should be considered when interpreting the results of this study. First, the lack of a control group prevents causal claims from being made. Changes may have resulted from maturation, co-intervention from concurrent VR, and the overall intensity of rehabilitation received. Subjects were not blinded and our adoption of self-reported measures introduced the risk of reporting bias. Variation in program delivery also had a potential influence on our findings. Study participants were without cognitive impairment, presented with higher levels of functional independence (i.e. high baseline SCIM-III scores), and were largely individuals with incomplete injuries and paraplegia. This selection bias could have affected the results of this study favorably as participants were likely to have better self-care abilities (48). The generalizability of our findings to the larger SCI population was therefore also limited. Finally, the small sample size did not allow us to control for potential confounders.

Conclusions

A pilot community-based SCI-specific self-management intervention was associated with short term improvements in self-efficacy. Participants perceived the intervention as beneficial and valued program features related to information accessibility, effective instruction, program customization, and participant empowerment. Future research is needed to determine the effectiveness of such interventions in the broader SCI population and individuals with a longer duration of injury, identify essential program features that promote successful outcomes, and determine the cost-effectiveness of program implementation. Findings from this study may also be used to advise the development of similar self-management interventions in the future.

Appendix 1.

Spinal Cord Injury (SCI) Self-Management Intervention – Facilitator Resources

	Self-Management Topics & Online Resources	Remarks/ Specific tools
1	Physical Activity
	SCI Action Canada Lab Website: https://sciactioncanada.ok.ubc.ca/ YouTube channel: https://www.youtube.com/user/SCIActionCanada/videos	SCI exercise guidelines Physiotherapist’s guide to promote physical activity Home strength training guide
	National Center on Health, Physical Activity and Disability (NCHPAD) Videos of inclusive workouts: https://www.nchpad.org/Videos Discover Accessible Fitness: https://www.nchpad.org/1247/5931/Discover~Accessible~Fitness	8 min inclusive workout: https://youtu.be/q0ttPm8LSEk A wheelchair user’s guide for using fitness equipment
	Singapore Disability Sports Council https://sdsc.org.sg/sports/	How to get involved in disability sports
	Sports Singapore – ActiveSG Public sports facilities: https://www.myactivesg.com/Facilities Inclusive gyms: https://www.hursolutions.com/findagym	Membership (free for citizens): https://www.myactivesg.com/About-ActiveSG/Membership-FAQs
	Spinal Cord Injury Rehabilitation Evidence (SCIRE) Community Autonomic and cardiovascular health: https://scireproject.com/community/topics/browse-by-area/autonomic-and-cardiovascular-health/ Movement and exercise: https://scireproject.com/community/topics/browse-by-area/movement-and-exercise/	Information on managing autonomic dysreflexia and postural hypotension Supported standing: https://scireproject.com/community/topic/standing/#standing-therapy
2	Mobility & Assistive Technology
	Northwest Regional Spinal Cord Injury System YouTube channel: https://www.youtube.com/user/UWSpinalCordInjury	Wheelchair Skills/ transfers: https://www.youtube.com/playlist?list=PLOCF5umTFDlmWZ7bZzqv0co5rqXWOHkeT
	Christopher & Dana Reeve Foundation Living with Paralysis – resources: https://www.christopherreeve.org/living-with-paralysis	See sections on “wheelchairs” and “home and travel”
	Model Systems Knowledge Translation Center Gait training and SCI: https://msktc.org/sci-topics/gait-training-sci Safe transfer techniques: https://msktc.org/sci-topics/safe-transfer-techniques Wheelchair information: https://msktc.org/sci-topics/wheelchair-information	Maintenance guide for manual and power wheelchairs Fact sheets on manual and power wheelchairs
	SCIRE Community Walking and Mobility: https://scireproject.com/community/topics/browse-by-area/walking-and-mobility/	Information on various interventions and evidence to support
	SPD Tech Able (Assistive Technology Center) Mobility and communication devices https://enablingvillage.sg/assistive-technologies-at-the-enabling-village/	Center that aids with the prescription of assistive technology (for persons with disabilities)
3	Skin Care & Nutrition
	Model Systems Knowledge Translation Center Skin care and pressure sores: https://msktc.org/sci-topics/skin-care-pressure-sores	Fact sheets on skin care and pressure sore management
	SCIRE Community Skin health: https://scireproject.com/community/topics/browse-by-area/skin-health/	Overview of pressure injuries and treatment options
	Spinalis Foundation Food, weight and health for people with SCI https://spinalis.se/food-weight-and-health-for-people-with-spinal-cord-injury-3/?lang=en	Brochure with information on nutrition and weight management
	Health Hub (Ministry of Health) My healthy plate: https://www.healthhub.sg/programmes/55/my-healthy-plate	Fact sheet for easy reference
	Northwest Regional Spinal Cord Injury System SCI Patient Education Pamphlets: https://sci.washington.edu/info/pamphlets/ SCI Forum – Everyday nutrition for individuals with SCI: https://sci.washington.edu/info/forums/reports/nutrition_2011.asp	Maintaining healthy skin pamphlets (Part 1 and 2) Specific information on dietary recommendations for persons with SCI
4	Pain & Spasticity
	SCIRE Community Pain: https://scireproject.com/community/topic/pain/ Spasticity: https://scireproject.com/community/topics/browse-by-area/spasticity/	Fact sheets for participants with evidence summary
	SCIRE YouTube Channel Spasticity: https://www.youtube.com/playlist?list=PLi2Dc1h0G7-sk_cJLtt8DEzoM3j2vcvUB	Videos to explain spasticity and management approaches
	Model Systems Knowledge Translation Center Managing pain after SCI: https://msktc.org/sci-topics/managing-pain-after-sci Spasticity and SCI: https://msktc.org/sci/factsheets/Spasticity	Fact sheets for participants
	Pain Management Network Spin Cord Injury pain: https://www.aci.health.nsw.gov.au/chronic-pain/spinal-cord-injury-pain	See: Quick Steps (SSCI pain management plan – for health professionals)
5	Bladder & Bowel Care
	Model Systems Knowledge Translation Center Bladder management: https://msktc.org/sci-topics/bladder-management Managing bowel function: https://msktc.org/sci-topics/managing-bowel-function Urinary tract infection: https://msktc.org/sci-topics/urinary-tract-infection	Fact sheets for participants
	Shepherd Center Bladder care: https://www.myshepherdconnection.org/sci/bladder-care Bowel care: https://www.myshepherdconnection.org/sci/bowel-care	Specific instructions on how to perform bladder/ bowel management techniques (for transitions in management approach and care giver training)
	Spinal Cord Essentials Handouts: http://www.spinalcordessentials.ca/handouts/	Resources under Self care:  Bladder care  Bowel care
	SCIRE Community Bladder health: https://scireproject.com/community/topics/browse-by-area/bladder-health/ Bowel health: https://scireproject.com/community/topics/browse-by-area/bowel-health/	Fact sheets for participants with evidence summary
	Christopher & Dana Reeve Foundation Bowel maintenance: https://www.youtube.com/watch?v=_ZW1qWqtw4U&list=PL401D8EBAAD253618&index=15 Bladder management: https://www.youtube.com/watch?v=8GrtS2wWJlo&list=PL401D8EBAAD253618&index=18 Catheter options: https://www.youtube.com/watch?v=uj1mJNST9sw&list=PL401D8EBAAD253618&index=19	Short videos to explain bladder and bowel management approaches
6	Aging with Spinal Cord Injury
	Northwest Regional Spinal Cord Injury System YouTube channel: https://www.youtube.com/user/UWSpinalCordInjury	Aging with SCI: https://www.youtube.com/playlist?list=PLOCF5umTFDlnLoYwsrXvQpoyy16kwuspf
	SCIRE Professional https://scireproject.com/clinical-resources/info-sheets/	Fact sheet for participants
	Model Systems Knowledge Translation Center Aging and SCI: https://msktc.org/sci-topics/aging-sci	Fact sheet for participants
	SCI-U Courses: http://sci-u.ca/take-a-course/	Online courses for participants to revisit information covered

Funding Statement

This work was supported by the SPD Research Grant.

Disclosure statement

The lead author (P. Koh) contributed to the development and implementation of the self-management intervention and is an employee of SPD. Every effort was made to manage any potential conflict of interest in this study.