Abstract
Background:
Patients with spinal cord injury (SCI) deal with various restrictive factors regarding their clothing, such as disability and difficulty with access to shopping centers.
Objectives:
We designed a questionnaire to assess attention to clothing and impact of its restrictive factors among Iranian patients with SCI (ACIRF-SCI).
Methods:
The ACIRF-SCI has 5 domains: functional, medical, attitude, aesthetic, and emotional. The first 3 domains reflect the impact of restrictive factors (factors that restrict attention to clothing), and the last 2 domains reflect attention to clothing and fashion. Functional restrictive factors include disability and dependence. Medical restrictive factors include existence of specific medical conditions that interfere with clothing choice. Construct validity was assessed by factorial analysis, and reliability was expressed by Cronbach’s alpha.
Results:
A total of 100 patients (75 men and 25 women) entered this study. Patients with a lower injury level had a higher total score (P < .0001), and similarly, patients with paraplegia had higher scores than those with tetraplegia (P < .0001), which illustrates an admissible discriminant validity. Postinjury duration was positively associated with total scores (r = 0.21, P = .04). Construct validity was 0.97, and Cronbach’s alpha was 0.61.
Conclusion:
Iranian patients with SCI who have greater ability and independence experience a lower impact of restrictive factors related to clothing. The ACIRF-SCI reveals that this assumption is statistically significant, which shows its admissible discriminant validity. The measured construct validity (0.97) and reliability (internal consistency expressed by alpha = 0.61) are acceptable.
Key words: clothing, Iran, spinal cord injury
The incidence of traumatic spinal cord injury (SCI) varies among different nations. The estimated incidence was 87.7 per million in the United States by the end of 2009.1 Iran is one country with a high rate of road accidents2 and SCI. SCI influences many aspects of life, including choice of clothing. Clothing is an important issue for wheelchair users, because it plays an important part in social appearance.
Inattention to fashion can originate from many sources including disability, difficulty in accessing shopping centers, depression, and existence of specific medical conditions such as pressure sores. Until now, no validated questionnaire was available to provide a scale for determining the level of attention to clothing among people with SCI. The score of such a questionnaire can be used for psychological evaluation. We tried to determine the most important factors that may restrict attention to clothing.
Choice of clothing is known to be linked with personality.3 Disability may limit choice of clothing because of restricted ability to don clothing independently as a result of immobility and reduced hand function. Although disability caused by SCI may limit the ability to dress independently, it has been strongly recommended that people with SCI be encouraged to choose their own clothing.4
SCI causes a significant alteration in a person’s self-image because it results in changes in physical abilities, skills, and appearance.5 Before attempts are made to alter and modify clothing for this population, it is essential to have some information about attention to clothing before and after injury. Until now, no standard assessment method to measure level of attention to clothing has been proposed. Howe6 tried an online survey and evaluated some aspects of attention to clothing among people with SCI. The report emphasized the necessity of more consistency between people’s requirements and what is available in the market. We designed a new questionnaire to assess attention to clothing and impact of its restrictive factors among Iranian patients with SCI (ACIRF-SCI). The ACIRF-SCI includes the following 5 domains: functional, medical, attitude, aesthetic, and emotional. The first 3 domains reflect mainly restrictive factors, and the last 2 domains reflect attention to clothing and fashion. Our purpose was to develop a tool to evaluate the level of attention to clothing along with the impact of its restrictive factors (factors that prevent an individual from caring about clothing). In Islamic countries, such as Iran, a significant difference exists among men and women regarding clothing; therefore, in this study, data for men and women are reported separately.
Along with assessment of validity and reliability of this questionnaire, we present preliminary data related to clothing choice and management in Iranian individuals with SCI.
Methods
Study design
This was a cross-sectional study, and we used the ACIRF-SCI to obtain data. Questionnaires were filled out during face-to-face interviews with people who were referred to the Brain and Spinal Cord Injury Research Center between July and October 2013. During interviews, the examiner administered the questionnaire when sitting beside the participant instead of facing him or her to promote first-person perspectives.7 The study was approved by the ethics committee of Tehran University of Medical Sciences.
Participants
People with SCI who did not meet our exclusion criteria entered the study. Adequate information about the study and its confidentiality was provided before enrollment. Exclusion criteria were nontraumatic SCI, age less than 14 years (since clothing is mostly selected by caregivers), and postinjury duration of less than 1 year. Previously, Ullrich et al8 reported that approximately 20% of their subjects with SCI showed both elevated pain and depression during the first year after injury. Pain and depression can interfere with an individual’s social and personal life and can cause inattention to clothing. So it seems reasonable to consider only subjects with postinjury duration of more than 1 year. Moreover, we divided subjects on the basis of gender for analysis. This study was conducted in Iran, where there are differences among men and women based on the Islamic culture.
Demographic features
Age, marital status, postinjury duration, and age at the time of injury were obtained directly during interviews. Type of plegia (paraplegia or tetraplegia) and injury level were assessed initially by physical examination by an experienced neurologist and were confirmed by MRI.
Questionnaire development/validation
No validated questionnaires designed to obtain information about attitude toward or management of clothing in people with SCI have been previously published. The ACIRF-SCI is a 19-item questionnaire that includes 5 domains related to aspects of clothing: functional, medical, attitude, aesthetic, and emotional. Restrictive factors were defined in 3 domains as follows:
Functional restrictive factors: factors including disability and dependence.
Medical restrictive factors: existence of any medical conditions that could not be categorized in the functional (disability) domain such as pressure sores, necessity of regular tracheal suction in people with cervical SCI, or pulmonary infections, which occur mostly in people with cervical injury level. All these medical conditions can be considered restrictive factors that inhibit independent dressing or prevent people from going shopping.
Attitudinal restrictive factors: cultural issues that obligate standards of traditional coverage. Inattention to fashion before injury was also considered an attitudinal restrictive factor.
We assigned a score to each item such that a higher sum would indicate greater attention to clothing and a lesser impact of restrictive factors. A great effort was made to create questions that would be easily understood by the general population and by those with minimal literacy. Table 1 shows each item of the ACIRF-SCI in detail. The domains of functional, medical, and attitude reflect the restrictive factors of attention to clothing and fashion. The functional domain reflects an individual’s disability; the medical domain reflects a medical condition that interferes with clothing; and the attitude domain reflects other restrictive factors such as believing in the necessity of cultural restrictions, lack of education, previous inattention to fashion before injury, and self-esteem as reflected in clothing selection. Along with restrictive factors, which are reflected by the functional and medical domains, attention to clothing is reflected by aesthetic and emotional domains. In the emotional domain, we assumed that people who care more about their clothing (higher attention) tend to complain more about their clothing, become happier when they are satisfied with their clothing, and become sad when they cannot wear clothing they wore previously (Table 1).
Table 1. Domains and items of the ACIRF-SCI.
| Domain | Information collected | Question | Scoring |
| Functional | Disability as a restrictive factor | 1. Do you have personal difficulty with dressing? (F1) | Significant problem: 0 |
| Little problem: 1 | |||
| 2. Do you wear different types of clothing with the same amount of effort? (F2) | No problem: 2 | ||
| No: 0 | |||
| Yes: 1 | |||
| 3. Do you wear different types of clothing after injury? (F3) | Yes: 0 | ||
| No: 1 | |||
| Medical | Medical restrictive factors (existence of medical conditions interfering with clothing such as pressure sores) | 1. Do you have any medical condition that prevents you from wearing whatever you want? (M1) | Yes: 0 |
| No: 1 | |||
| 2. Do you have any medical conditions that stop you from going shopping for clothes? (M2) | Yes: 0 | ||
| No: 1 | |||
| Attitude | Attitude toward clothing | 1. Do you think that type of clothing affects physical health? (A1) | No: 0 |
| Yes: 1 | |||
| Attitude toward necessity of existence of an external restrictive factor regarding clothing | 2. Do you think there should be cultural restrictions for clothing? (A2) | Yes: 0 | |
| No: 1 | |||
| Self-esteem in selection of clothing | 3. Is your opinion important to your caregiver in selecting clothing? (A3) | No: 0 | |
| Yes: 1 | |||
| Education | 4. Do you think wheelchair users should wear shoes? (A4) | No: 0 | |
| Yes: 1 | |||
| Previous inattention to fashion injury? (A5) | 5. How did you judge your clothing before | Bad: 0 | |
| Moderate: 1 | |||
| Good: 2 | |||
| Perfect: 3 | |||
| Attitude toward present clothing options | 6. How do you judge your clothing after injury? (A6) | Bad: 0 | |
| Moderate: 1 | |||
| Good: 2 | |||
| Perfect: 3 | |||
| Attitude toward effects of clothing | 7. How much does clothing affect your mental health? (A7) | Not at all: 0 | |
| Somewhat: 1 | |||
| Very much: 2 | |||
| Aesthetic | Concerns about beauty and attractiveness | 1. Do you wear special clothing for parties and special occasions? (AS1) | No: 0 |
| Yes: 1 | |||
| 2. Do you follow fashion? (AS2) | Never: 0 | ||
| Sometimes: 1 | |||
| Always: 2 | |||
| Concerns about catheter line or bag | 3. Have you ever used blankets to cover your catheter line or bag? (AS3) | No: 0 | |
| Yes: 1 | |||
| Emotional | Mood | 1. Do you complain a lot about your clothing? (E1) | No: 0 |
| Yes: 1 | |||
| 2. How do you feel when you can’t wear clothing you wore before injury? (E2) | Doesn’t matter: 0 | ||
| A little sad: 1 | |||
| Very sad: 2 | |||
| 3. Have you ever been embarrassed by your clothing? (E3) | Never: 0 | ||
| Sometimes: 1 | |||
| Always: 2 | |||
| 4. How happy do you feel when you’re satisfied with your clothing? (E4) | Not at all: 0 | ||
| A little: 1 | |||
| So-so: 2 | |||
| Very much: 3 | |||
| Total score | 0-30 |
Note: ACIRF-SCI = Attention to Clothing and Impact of its Restrictive Factors among Iranian Patients with Spinal Cord Injury.
Validity
Validity refers to the meaningfulness and usefulness of a measure for a specific purpose and whether the measure is appropriate.9 It is considered to be the most important characteristic of a questionnaire.10 Several types of validity have been described previously: content validity, construct validity, and criterion validity.10 Content validity is often determined by the use of experts’ judgments.9 In this study, after the questionnaire was designed by a neurologist with the help of a statistical expert, it was sent to several experts in different fields of general practice, neurology, neurosurgery, and social service to obtain their opinions about whether the questionnaire was able to measure that for which it was designed. According to the method developed by Lawshe,11 each of the subject matter experts (SMEs) on the judging panel responded to the following question for each item: “Is the skill or knowledge measured by this item essential, useful, but not essential, or not necessary?” Content validity was measured using the following formula: CVR: (ne –N/2)/ (N/2) where CVR = content validity ratio, ne = number of SME panelists indicating “essential,” and N = total number of SME panelists.
Construct validity reflects the association of this new measure with other validated measures of the same construct. However, because no validated questionnaire for measuring level of attention to clothing among people with SCI was detected, construct validity was measured by principle component analysis, which represents the extent to which multiple items in a single domain are related.12 Criterion validity represents the usefulness of a measure supported by different studies; but because this is a newly designed questionnaire, criterion validity is not yet applicable for this measure. We tested the scores of the ACIRF-SCI in different defined groups, which were characterized by gender, injury level, and type of plegia (paraplegia or tetraplegia) to determine whether the questionnaire has acceptable discriminant validity and whether it is able to distinguish differences among the defined groups.
Reliability
The term reliability generally refers to the consistency of a measure. Higher error variance means lower reliability. However, the error variance of a measure may change from one population to another, so it is essential to assess the reliability of a measure in a population for which it is to be used.9 We evaluated internal consistency, which is reported as Cronbach’s alpha and can vary from 0.0 to 1.0. A higher Cronbach’s alpha indicates that items on a scale are related and measure the same underlying mechanism.
Interpretation of scores
Lower scores in the functional domain are associated with more disability in dressing. Question 2 addresses difficulty in dressing with specific mechanisms (eg, buttons, zippers); people who experience such difficulty tend to expend different amounts of effort in wearing different types of clothes and thus are considered to be functionally limited. Lower scores in the medical domain represent more severe complications and/ or medical conditions that interfere with clothing selection. Questions in the domain of attitudes toward clothing are designed such that lower scores represent less belief in the effect of clothing on increasing personal mental and physical health, less attention to clothing and fashion, and belief in the necessity of cultural restrictions. Moreover, whether subjects who complete the questionnaire think that wheelchair users should wear shoes reflects their attention to foot health, which is essential in people with disability. Their attitude toward their clothing before injury shows whether they cared about their appearance before the accident. It is noticeable that little attention to appearance before injury is a bias factor, and an individual’s inattention to clothing in the present should be compared with his or her habits before injury to make a proper evaluation. Lower scores in the aesthetic domain reflect less attention to external appearance. People who pay greater attention to clothing tend to wear special clothing for parties and special occasions, and they also try more to hide unpleasant aspects of their disability (eg, by using a blanket to hide a urine bag and catheter). The emotional domain also reflects attention to clothing because it seems that people who care more about their appearance are more likely to be agitated when their clothing options become limited and to complain more about their clothing.
In general, a lower total score on the ACIRF-SCI is associated with less attention to clothing and indicates a higher impact of factors that restrict this level of attention.
The total score of the ACIRF-SCI is between 0 and 30 and is categorized into the following 5 domains: functional (score, 0–4), medical (score, 0–2), attitude (score, 0–12), aesthetic (score, 04), and emotional (score, 08). We understand that the ACIRF-SCI is a preliminary questionnaire and anticipate that further modifications will be necessary.
Statistical analysis
The internal consistency of the responses to the ACIRF-SCI was assessed using Cronbach’s alpha. All these analyses were performed using IBM SPSS software version 21.0 (IBM Corp, Armonk, NY). One-way analysis of variance (ANOVA) was performed to determine whether the total scores of the ACIRF-SCI can distinguish differences among defined groups (based on gender, injury level, and type of plegia). Multiple testing corrections with the Benjamini-Hochberg procedure were performed using R software (version 3.0.2) to correct P values for false-positive results. We used the chi-square test when evaluating the score of each item (as a categorical value) with other categorical variables (gender, plegia type, and injury level).
Results
A total of 100 subjects (75 men and 25 women) entered this study. Mean age of men was 30.19 ± 9.21 years, and mean age of women was 32.21 ± 9.76 years old. Sixty-eight percent of women and 44% of men were married. The percentage of subjects with paraplegia versus tetraplegia was higher in both groups. Table 2 shows the baseline characteristics of these subjects. Mean total score of the ACIRF-SCI was 17.33 ± 3.94 (range, 9–27) for men and 17.84 ± 3.06 (range, 13–23) for women. Scores in each item along with summed scores in each domain are shown in Table 3.
Table 2. Baseline characteristics of men and women with spinal cord injury who completed the ACIRF-SCI.
| Men | Women | ||||
| Mean (SD) | n (%) | Mean (SD) | n (%) | ||
| Age, years | 30.19 (9.21) | — | 32.21 (9.76) | — | |
| Age at time of injury, years | 25.96 (9.11) | — | 28.68 (10.67) | — | |
| Postinjury duration, years | 4.23 (3.45) | — | 4.33 (4.48) | — | |
| Marital status | Single | — | 42 (56%) | — | 8 (32%) |
| Married | — | 33 (44%) | — | 17 (68%) | |
| Divorced | — | 0 (0%) | — | 0 (0%) | |
| Injury level | Cervical | — | 26 (34.7%) | — | 6 (24%) |
| Thoracic | — | 46 (61.3%) | — | 16 (64%) | |
| Lumbar | — | 3 (4%) | — | 3 (12%) | |
| Plegia | Paraplegia | — | 47 (62.7%) | — | 19 (76%) |
| Tetraplegia | — | 28 (37.3%) | — | 6 (24%) | |
Note: ACIRF-SCI = Attention to Clothing and Impact of its Restrictive Factors among Iranian Patients with Spinal Cord Injury.
Table 3. Scores of main domains among men and women with spinal cord injury who completed the ACIRF-SCI.
| Men | Women | ||
| Domain | Mean of total domain score ± SD (range) | (Mean of total domain score ± SD (range) | P* |
| Functional | 1.27 ± 1.10 | 1.16 ± 0.85 | .66 |
| (0–5) | (0–3) | ||
| Medical | 1.67 ± 0.52 | 1.44 ± 0.65 | .08 |
| (0–2) | (0–2) | ||
| Attitude | 8.05 ± 1.83 | 8.40 ± 1.52 | .39 |
| (4–12) | (6–11) | ||
| Aesthetic | 2.03 ± 0.83 | 2.40 ± 0.93 | .06 |
| (1–4) | (1–4) | ||
| Emotional | 5.16 ± 1.35 | 5.44 ± 1.15 | .35 |
| (2–8) | (3–7) | ||
| Total | 18.17 ± 3.23 | 18.84 ± 2.86 | .36 |
| (12–27) | (12–23) |
Note: ACIRF-SCI = Attention to Clothing and Impact of its Restrictive Factors among Iranian Patients with Spinal Cord Injury; SD = standard deviation.
P value stands for one-way analysis of variance (ANOVA) to compare means between men and women.
There was a significant relationship between injury level and total obtained score (P < .0001). Mean total scores for subjects with injury in cervical, thoracic, and lumbar levels were 15.13 ± 3.8, 18.65 ± 3.39, and 18.67 ± 3.38, respectively. The same result was obtained with plegia type, and subjects with paraplegia had significantly higher total scores (P < .0001; mean score 18.65 ± 3.37 and 15.15 ± 3.31 in subjects with paraplegics and subjects with tetraplegia, respectively).
There was no significant association between age and total score. However, in those individuals in which injury occurred at an older age, total score was lower (r = -0.20, P = .04). Postinjury duration was positively associated with higher total scores (r = 0.21, P = .04).
The ACIRF-SCI was reviewed by 4 different experts in the fields of neurology, neurosurgery, general practice, and social services. Construct validity was measured by factor analysis with the extraction method of principle component analysis. Construct validity calculated for each domain is as follows: functional, 0.62; medical, 0.24; attitude, 0.62; aesthetic, 0.66; and emotional, 0.88. Total construct validity was 0.97, which is an acceptable validity in this stage and is also in line with the content validity estimation.
Reliability is expressed by Cronbach’s alpha, and reliability of each domain is as follows: functional, 0.47; medical, 0.05; attitude, 0.31; aesthetic, 0.34; and emotional, 0.20. Total Cronbach’s alpha was 0.61, which is also an acceptable reliability quotient. The lowest Cronbach’s alpha was detected in the medical domain. The total scores of 5 domains are shown in Table 3. There was no significant difference in scores among men and women.
Table 4 shows the association of each item with categorical variables (gender, injury level [cervical, thoracic, or lumbar] and plegia type). This table shows that the ACIRF-SCI has the ability to distinguish between subjects in different groups and has acceptable discriminant validity.
Table 4. Association of measures between injury level, gender, plegia type, and scores of items on the ACIRF-SCI.
| Gender | Injury level | Plegia | |||
| Item | P | P | Corrected Pa | P | Corrected Pa |
| F1 | .351 | <.0001* | .0001 | <.0001 | .0002 |
| F2 | .805 | .253 | .253 | .113 | .1130 |
| F3 | .687 | <.0001* | .0001 | .026** | .0347 |
| Functional total score | .661 | <.0001 | .0001 | <.0001 | .0002 |
| M1 | .194 | .891 | .891 | .95 | .950 |
| M2 | .297 | .028** | .084 | .006* | .018 |
| Medical total score | .083 | .233 | .350 | .032 | .048 |
| A1 | .840 | .496 | .661 | .267 | .411 |
| A2 | .508 | .579 | .662 | .759 | .867 |
| A3 | .627 | .815 | .815 | .972 | .972 |
| A4 | .341 | .002* | .016 | .001* | .008 |
| A5 | .897 | .339 | .542 | .308 | .411 |
| A6 | .066 | .031** | .124 | .173 | .411 |
| A7 | .157 | .108 | .216 | .232 | .411 |
| Attitude total score | .396 | .054 | .144 | .004 | .016 |
| AS1 | .010** | <.0001* | .0002 | <.0001* | .0001 |
| AS2 | .971 | .004** | .0053 | .001* | .0013 |
| AS3 | .409 | .535 | .5350 | .547 | .5470 |
| Aesthetic total score | .062 | <.0001 | .0002 | <.0001 | .0001 |
| E1 | .031** | .747 | .7470 | .812 | .969 |
| E2 | .540 | .636 | .7470 | .581 | .968 |
| E3 | .077 | .042** | .140 | .007* | .035 |
| E4 | .058 | .056 | .140 | .969 | .969 |
| Emotional total score | .357 | .111 | .185 | 0189 | .473 |
| Total score | .362 | <.0001 | <.0001 | <.0001 | <.0001 |
Note: A = attitude domain; ACIRF-SCI = Attention to Clothing and Impact of its Restrictive Factors among Iranian Patients with Spinal Cord Injury; AS = aesthetic domain; F = functional domain; E = emotional domain; M = medical domain.
Correction of P values for multiple testing was performed using the Benjamini-Hochberg procedure.
Significance at level of <.001.
Significance at level of <.05.
Discussion
Suitable clothing can induce a feeling of satisfaction, and its association with mood has been described.13 However, when disability impairs an individual’s ability to choose and wear what he or she desires, depression may occur. Moreover, given various factors that may restrict access to shops or cause a change in emotional status, people with SCI may experience issues related to clothing choice and management and a change in their perception of the importance of clothing. Until now, there was no validated questionnaire to assess attention to clothing and impact of its restrictive factors among individuals with SCI. Howe6 performed an online survey in 2012 and reported that currently available clothing designs are not appropriate for wheelchair users with SCI. Not only may these individuals require specific and modified designs, they may also experience limited access to shops. Therefore, we designed the ACIRF-SCI to include the following 5 domains: functional, medical, attitude, aesthetic, and emotional.
It is assumed that people with greater physical ability (paraplegia and lower injury level) are more able to dress themselves and have a more positive attitude toward clothing. These assumptions have been shown to be statistically significant by using the ACIRF-SCI, which demonstrates an acceptable power to determine these differences. Our results show that people with greater ability (paraplegia rather than tetraplegia, lower injury level) care more about their clothing, experience a lower impact of restrictive factors regarding their clothing, and attain higher total scores (P < .0001) as measured by the ACIRF-SCI. Wirth et al14 observed that people with lower injury level, incomplete lesions, and paraplegia have greater ability and independence as assessed by spinal cord independence measure (SCIM) in comparison with individuals with higher injury level, complete injury, and tetraplegia. Our results show that the power of the ACIRF-SCI is acceptable in distinguishing these differences among people with SCI with different ranges of ability and illustrates that the discriminant validity of the ACIRF-SCI is admissible.
In our study, postinjury duration was positively associated with higher scores on the ACIRF-SCI. It is expected that as time since injury increases, people become more adapted to their situation, and their attention to their clothing increases over time. This assumption was found to be statistically significant as assessed by the ACIRF-SCI.
Investigations of clothing selection among individuals with SCI are limited, and we could not find any direct citations. Many factors, including safety, should be considered6 because suitable designs can help to increase safety during dressing by preventing unnecessary lifting. The role of clothing in preventing accidents that may occur during dressing was first described by Howe.6 Caregivers must often move the body of a disabled individual in the procedure of dressing. When clothes are designed in a way that eliminates unnecessary movements, accidents during dressing can be prevented.
Concerns regarding clothing among people with SCI should be considered and given adequate attention. When specific needs of people with SCI are met, we can expect their self-image and self-esteem to be improved to some extent, which helps them to have an improved mood and perhaps a better quality of life. Before any intervention related to clothing for people with SCI is made, some information about attention to clothing before and after injury is essential. The ACIRF-SCI can be used to measure attention to clothing and impact of its restrictive factors. Comparison of the scores obtained with the ACIRF-SCI before and after any intervention can help us determine whether the intervention has been useful.
There are some concerns about the reliability of responses to the questionnaire, especially regarding cultural issues. In this regard, we assured people of the confidentiality of their responses. Each patient was given a number, and data were indexed without names to assure patients that their responses would cause no difficulty for them. In 2011, Eyal and Eyal15 reported that response bias is a potential source of inflation in questionnaire reliability. They illustrated that respondents to a questionnaire sometimes modify their answers to correspond to previously answered items. This most often happens in long questionnaires in which respondents must answer many questions and occasionally encounter questions with similar concepts. We designed the ACIRF-SCI to be as concise as possible to avoid a reduced response rate.
The assessment of validity and reliability of the first draft of the ACIRF-SCI was performed with 100 people with SCI as a pilot population. Our analysis showed construct validity of 0.97 and an acceptable reliability, which was expressed by Cronbach’s alpha (α = 0.61). The medical domain had the lowest Cronbach’s alpha (0.05). Addition of more detailed questions may invigorate this domain’s reliability; but because long questionnaires are assumed to decrease the response rate, we did not add more detailed questions to this domain.
Study limitations and further investigations
We understand that this is the preliminary design of the ACIRF-SCI, and further modifications and development of new versions can be expected in future studies. Criterion validity remains to be evaluated in future investigations. Although the statistical significance of the ACIRF-SCI is acceptable, the practical significance of this measure may be limited due to use of yes/no questions. Moreover, it should be noted that the use of the ACIRF-SCI should be limited to Iranian and Islamic cultures.
Conclusion
In this study, we designed a questionnaire, the ACIRF-SCI, to assess attention to clothing and impact of its restrictive factors in individuals with SCI. Higher scores were obtained from people with greater physical ability, which shows that the power of the ACIRF-SCI is acceptable to distinguish differences among people with SCI with different ranges of ability, revealing admissible discriminant validity.
Acknowledgments
The authors declare no conflicts of interest.
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