create the summary of the findings "Methods
Design and participants
A descriptive cross-sectional survey was conducted in 2012. The participants were patients with traumatic SCI who were referred for outpatient rehabilitation to the clinic of the Brain and Spinal Cord Injury Research (BASIR) Center, Tehran University of Medical Sciences. There were 81 (68%) men and 38 (32%) women, with a mean age of 32.4 ± 10.5 years and a median age of 31 years (percentiles of 25–75th were 25–38 years). The mean age at time of SCI was 28.1 ± 10.4 (2–57) years, and the median age was 26 years (percentiles of 25–75th were 21–34 years). Mean duration of SCI was 50.3 ± 55.2 months. There were no significant differences in these variables between the sexes.

The BASIR center is a referral center from all parts of Iran. In this center, there are different rehabilitation facilities such as physiotherapy, occupational therapy, psychological consultations, sexology, and family counseling, and examinations by neurosurgeons, urologists, proctologists, pain and medicine, and rehabilitation specialists.

Materials and measures
A researcher-made structured questionnaire was administered by trained interviewers and the data were collected. To design the questionnaire in the pilot study, first the specialists, nurses, occupational therapists, physiotherapists and medical personnel dealing with the patients with SCI, and also the persons with SCI themselves, were asked to express their ideas about psychosocial problems affecting people with SCI. Then, based on these issues, we designed a questionnaire in which the researcher asked questions about the problems and recorded the answers. All of the participants were asked the same questions based on the questionnaire. The questionnaire had two major parts.

The first part of the questionnaire was about demographic information and the clinical pathology of injury including age, sex, age at the time of injury, the number of family members at home, marital status, the number of children, injury status, complete or incomplete injury, and the reason of injury.

The second part of the questionnaire was about environmental and psychosocial problems and included occupation before and after SCI, education, residence status (personal, leasing, or caring center), having a private room at home, having equipment specific for people with SCI (like a mattress, proper bed and wheelchair, bathroom wheelchair, and toiletries), dependence on others (none/some/a lot), going out alone, having difficulty visiting the physician, having medical equipment and recovery specialists near the home (like physiotherapy and occupational therapy), having difficulty finding accommodation in other cities to use rehabilitation facilities, waiting for a long time to visit the physician, having few recreation and entertainment options, financial problems (therapy, rehabilitation, commuting expenses and so on), having insurance, having difficulty moving about in the home (not having an elevator or ramp) or out of home (inadequate within-the-city commuting paths, improper ramps, few appropriate vehicle for individuals with wheelchairs, no disability-specific parking at hospitals and in the streets), the person who meets the living expenses, having a good relationship with family members (lack of tension between the people with SCI and the family members in spite of dependence on them for doing daily activities), relatives or friends, relationships and a tendency to make connections with other SCI people, sadness, suicidal thoughts, self-confidence, and early outrage after the injury. Most of the questions were answered with yes or no. The ethical approval of this study was obtained from the Tehran University of Medical Sciences. Each subject signed a written informed consent prior to participation.

Education level was categorized as illiterate, primary and middle school (1–8 years of education), high school and diploma (9–12 years of education), and university education (>12 years of education).

The level of a lesion was classified as either paraplegia (injury to the sacral (S1–S5), lumbar (L1–L5), or thoracic (T2–T12) regions of the spine) or tetraplegia (injury to T1 or the cervical spine (C1–C9)). Completeness was classified as either complete (no sensory or motor function preserved in the sacral segments (S4–S5)) or incomplete (sensory but variable motor function preserved below the neurological level of injury).

Academic experts evaluated the validity of the questionnaire. We tried to consider most aspects of psychosocial issues in individuals with SCI. The reliability of the questionnaire (internal consistency) was estimated to be 0.71 by using Cronbach's alpha coefficient. We compared our results with the 2011 National Population and Housing Census in Iran (2011 NPHC in Iran) (http://amar.org.ir/Portals/1/Iran/census-2.pdf), which was at almost the same time as our study.

Statistical analysis
The normality of the data was evaluated using a One-Sample Kolmogorov-Smirnov Test. Continuous variables in two categorical groups were analyzed using a t-test or Mann–Whitney U test as appropriate. Relationships between categorical variables were tested using a χ2 test. Continuous variables were presented as mean ± standard deviation. The significance level was set at P ≤ 0.05.

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Results
Most of the patients (about 94%) replied to the questions (119 of 127). The most prevalent causes of injury were car and motorcycle accidents (66.4%) and falling (12.6%). Fifty-one (42.9%) were single, 59 (49.6%) were married, four (3.4%) were divorced, three (2.5%) were widowed, and two (1.7%) were separated; the latter three occurred after SCI. Sixty patients (50.4%) had an education level of less than 8 years (illiterate or primary–middle school). The demographic and clinical characteristics of participants have been shown in Table 1.

Table 1
Demographic and clinicopathologic characteristics of SCI persons

Sex
Total	P
Men	Women		
N = 81	N = 38	N = 119
Age (years)		31.9 ± 10.9	33.4 ± 9.8	32.4 ± 10.5	0.4
Age at time of SCI (years)		27.7 ± 10.4	28.9 ± 10.6	28.1 ± 10.4	0.5
Duration of SCI (months)		48.6 ± 49.4	53.7 ± 66.4	50.3 ± 55.2	0.6
Level of injury	Paraplegia	51 (63%)	29 (76.3%)	80 (67.2%)	0.1
Tetraplegia	30 (37%)	9 (23.7%)	39 (32.8%)	
Completeness	Incomplete	38 (46.9%)	21 (55.3%)	59 (49.6%)	0.4
Complete	43 (53.1%)	17 (44.7%)	60 (50.4%)	
Marital status	Single	40 (49.4%)	11 (28.9%)	51 (42.9%)	0.04
Married	38 (46.9%)	21 (55.3%)	59 (49.6%)	
Divorced	2 (2.5%)	2 (5.3%)	4 (3.4%)	
Widow	0 (.0%)	3 (7.9%)	3 (2.5%)	
Separated	1 (1.2%)	1 (2.6%)	2 (1.7%)	
Education level	Illiterate	2 (2.5%)	3 (7.9%)	5 (4.2%)	0.2
Primary–middle school	42 (51.9%)	13 (34.2%)	55 (46.2%)	
High school–Diploma	26 (32.1%)	14 (36.8%)	40 (33.6%)	
University Education	11 (13.6%)	8 (21.1%)	19 (16.0%)	
Occupation	Unemployed	60 (74.1%)	25 (65.8%)	85 (71.4%)	0.2
Student	4 (4.9%)	5 (13.2%)	9 (7.6%)	
Employed	17 (21.0%)	8 (21.1%)	25 (21.0%)	
The cause of injury	Crash injury	47 (58.0%)	32 (84.2%)	79 (66.4%)	
Falling	10 (12.3%)	5 (13.2%)	15 (12.6%)	
Sport injuries	5 (6.2%)	0 (0.0%)	5 (4.2%)	
Occupational injuries	9 (11.1%)	0 (0.0%)	9 (7.6%)	
Shot	3 (3.7%)	0 (0.0%)	3 (2.5%)	
Direct Pressure	2 (2.5%)	1 (2.6%)	3 (2.5%)	
Stabbed	3 (3.7%)	0 (0.0%)	3 (2.5%)	
Explosion	1 (1.2%)	0 (0.0%)	1 (0.8%)	
Iatrogenic	1 (1.2%)	0 (0.0%)	1 (0.8%)	
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In married patients, two (3.4%) had no child, 22 (37.3%) had one child, 15 (25.4%) had two children, and 20 (34%) had three to seven children before SCI, and only one woman had a newborn baby after SCI.

Most of the persons with SCI were taken care by their families: 35.3% by their spouse, 37% by parents, 21% by other family members such as a brother or sister, and 5.9% by a nurse; only 0.8% reported self-care. With respect to dependence on others, 31 (26.1%) had little dependence, whereas 70 (58.8%) were highly dependent on others and were unable to perform daily tasks. Most of the individuals with SCI (75.6%) could not leave home alone. Environmental variables and psychosocial outcomes of the participants are listed in Table 2.

Table 2
Environmental variables and psychosocial status of participants with SCI

Sex
Total	P
Men	Women		
N = 81	N = 38	N = 119
Housing problems		42 (52.5%)	14 (38.9%)	56 (48.3%)	0.1
Adequacy of sanitary items	Yes	38 (46.9%)	21 (55.3%)	59 (49.6%)	0.4
Dependence on others	Non	15 (18.5%)	3 (7.9%)	18 (15.1%)	0.1
Somewhat	17 (21.0%)	14 (36.8%)	31 (26.1%)	
A lot	49 (60.5%)	21 (55.3%)	70 (58.8%)	
Going out of home alone	Yes	22 (27.2%)	7 (18.4%)	29 (24.4%)	0.3
Having difficulty visiting the physician	Yes	17 (21.5%)	8 (22.2%)	25 (21.7%)	0.9
Having medical equipment and recovery specialists near the home	Yes	48 (60.0%)	18 (48.6%)	66 (56.4%)	0.2
Having difficulty finding accommodation in other cities to use rehabilitation facilities	Yes	48 (63.2%)	10 (33.3%)	58 (54.7%)	0.005
Waiting for a long time to visit the physician	Yes	59 (72.8%)	23 (60.5%)	82 (68.9%)	0.1
Having recreation and entertainment options	Yes	13 (17.1%)	9 (27.3%)	22 (20.2%)	0.2
Financial problem	Yes	64 (80.0%)	34 (89.5%)	98 (83.1%)	0.2
Having insurance	Yes	73 (90.1%)	34 (89.5%)	107 (89.9%)	0.9
The person who meets the living expenses	Individual with SCI	27 (33.3%)	6 (15.8%)	33 (27.7%)	0.025
Family	49 (60.5%)	32 (84.2%)	81 (68.1%)	
Governments agencies	5 (6.2%)	0 (.0%)	5 (4.2%)	
Having suicidal thoughts	Yes	20 (24.7%)	16 (42.1%)	36 (30.3%)	0.054
Sadness after SCI	Yes	50 (61.7%)	28 (73.7%)	78 (65.5%)	0.2
The need for psychological consulting	Yes	35 (43.2%)	31 (81.6%)	66 (55.5%)	<0.0001
Self-confidence	Bad	12 (14.8%)	9 (23.7%)	21 (17.6%)	0.4
Good	18 (22.2%)	9 (23.7%)	27 (22.7%)	
Excellent	51 (63.0%)	20 (52.6%)	71 (59.7%)	
Early outrage	Yes	55 (67.9%)	27 (71.1%)	82 (68.9%)	0.7
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The majority of the participants (83.1%) had financial problems. Before SCI, only 22 (18.5%) were unemployed, but after SCI, 85 (71.4%) lost their jobs. There was no relationship between level of injury and financial problems (P = 0.3), education level (P = 0.2) or employment (P = 0.9). Only 33 (27.7%) were financially self-sufficient, in most cases, the family made ends meet (81 (68.1%)), with only a few persons (5 (4.2%)) funded by governmental or non-governmental organizations (P = 0.025).

Fifty-six (48.3%) had problems with regard to the house structure, such as lacking a ramp or elevator, or having inadequate space to move a wheelchair. The household population for 95 persons with SCI (79.8%) was between 3 and 7, and in 15 (12.6%) it was 8–10; most of them had no private room. Thirty-seven (31.1%) had a rented house, and one (0.8%) lived in a care center. The mean household population was 5 ± 2, and 50% had a household population of 4–6.

About 90 (75.6%) had transportation problems. By transportation problems, we mean uneven sidewalks, no dedicated public transportation for persons with SCI, non-suitable buses for people using wheelchairs (no ramps), insufficient paramedic transportation, and few disability-specific parking spots.

Sixty (50.4%) had trouble providing sanitary items for example, lacked financial resources, to buy the items or unable to source the specialized items such as diapers, urinary catheters, anti-bed-sore mattresses, and suitable wheelchairs (light, strong, comfortable, anti-sore pillow, removable arms) for toileting and movement.

About 78 (65.5%) were sorrowful, 82 (68.9%) had early outrage, 36 (30.3%) suffered suicidal thoughts, and 21 (17.6%) suffered a lack of self-confidence following SCI (Table 2). There was no difference in sadness, early outrage and self-confidence between the two sexes. Only suicidal thoughts in women were significantly more than in men. Women tended to receive psychological counseling more than men (81.6% vs. 43.2%) (Table 2). There was no relationship between employment and either sadness, suicidal thoughts or self-confidence.

A lack of diagnostic and therapeutic facilities in their home towns made individuals with SCI, 66 (56.4%), travel long distances to reach Tehran or other major cities, leading to accommodation problems for 58 (54.7%), with men facing this problem more than women (Table 2).

Getting physician appointments and enduring long wait times in the doctors’ waiting rooms were problems for 25 (21.7%) and 82 (68.9%) persons with SCI, respectively. Fortunately, about 107 (89.9%) had insurance (Table 2).

The majority of individuals with SCI, 102 (85.7%), had good immediate family relationships, but only 30 (25.4%) had a relationship with other relatives or friends. More than half liked to communicate with other people with SCI (78 (65.5%)). Regarding entertainment facilities, only 22 (20.2%) reported having appropriate sport and recreation facilities."