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Promoting psychological health in women with SCI: Development of an online self-esteem intervention
Disability and Health Journal xxx (xxxx) xxx
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Brief Report
Promoting psychological health in women with SCI: Development of an online self-esteem intervention Susan Robinson-Whelen a, b, *, Rosemary B. Hughes c, d, Heather B. Taylor a, e, C. Vega a, Thomas M. Nosek f, Margaret A. Nosek b Rachel Markley a, 1, Jose a
Spinal Cord Injury and Disability Research Center, TIRR Memorial Hermann, Houston, TX, USA Center for Research on Women with Disabilities, H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA c The Rural Institute for Inclusive Communities, University of Montana, Missoula, MT, USA d Department of Psychology, University of Montana, Missoula, MT, USA e McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), USA f Department of Physiology and Biophysics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 15 May 2019 Received in revised form 1 October 2019 Accepted 22 October 2019
Background: There are no known interventions addressing self-esteem in women following spinal cord injury (SCI). Objectives: To test the feasibility of an online self-esteem intervention for women with disabilities, as modified for women with SCI. Method: We conducted a randomized, controlled feasibility test of a self-esteem intervention (N ¼ 21). Participants were randomly assigned to the intervention or control group that received intervention materials at the end of the study. Intervention participants met as avatars for 7 weekly real-time group sessions in Second Life (SL), a free online virtual world. Feasibility indicators were study engagement, acceptability of SL and the intervention, and improvements on measures of psychological health promoting behaviors, social support, self-efficacy, self-esteem, and depression. Results: Intervention participants (n ¼ 10) were highly engaged, and most described the SL program as more enjoyable and more convenient than in-person programs. All rated the intervention as “good” (n ¼ 4) or “very good” (n ¼ 6), and all 10 rated themselves has having made positive life changes as a result of the program. Intervention participants experienced significantly greater change than controls on two measures of health-promoting behavior (Health Promoting Lifestyle Profile-II Spiritual Growth/Selfactualization; Interpersonal Relations). Examining change in the intervention group using regression analyses, we found medium-to-large effects of the intervention on these behaviors and measures of depression (CESD-10, PHQ-9). The intervention had small effects on remaining measures. Conclusion: We found preliminary support for the feasibility of this modified self-esteem intervention offered in SL. Such programming may help circumvent barriers to community-based psychological services and may improve psychological health. © 2019 Elsevier Inc. All rights reserved.
Keywords: Spinal cord injury Women Self-esteem Psychosocial intervention Virtual reality
Women constitute approximately 22% of new cases of spinal cord injury (SCI) in the United States,1 yet relatively little research addresses their psychological health.2,3 Women with SCI commonly
* Corresponding author. TIRR Memorial Hermann Spinal Cord Injury and Disability Research Center, 1333 Moursund Houston, Texas, 77030. E-mail address: [email protected] (S. Robinson-Whelen). 1 Although completing the work on the project while at TIRR Memorial Hermann, Rachel Markley is now with the Methodist Hospital in Houston, Texas.
experience profound losses involving body image, identity, and bodily functions.4 Challenges related to sexuality and reproductive health5,6 and secondary health conditions, including chronic pain,7,8 also can impact their psychological health. Additionally, they frequently lack adequate financial resources; accessible transportation; equitable access to employment, community participation, and health care; and personal assistance.4,9,10 Discrimination, erroneous assumptions, microaggressions, and other demeaning factors experienced by people with disabilities11,12 may also compromise the self-esteem of women with SCI.
https://doi.org/10.1016/j.dhjo.2019.100867 1936-6574/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Robinson-Whelen S et al., Promoting psychological health in women with SCI: Development of an online self-esteem intervention, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100867
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SCI is associated with elevated risks for depression,2,13 suicide,14 interpersonal violence,15 post-traumatic stress disorder,16 and psychological stress.17 A systematic review18 of articles on psychological resources in SCI linked positive self-esteem with less depression, stress, and loneliness along with better life satisfaction, sexual adjustment, and social participation. Positive self-esteem can support women in managing disability-related challenges19 and enhancing their psychological health.20,21 We conceptualize self-esteem as the general attitude people place on themselves (global self-esteem) which is linked to psychological health.22 In this article, we describe the adaptation of the Self-esteem in Second Life (SL) Intervention for Women with Disabilities21 to address unique psychological health needs of women with SCI. We report on a test of the feasibility of the modified intervention, referred to as the “Self-Esteem Enhancement Intervention for Women with SCI,” SEE-SCI, which was delivered in the virtual world of Second Life (SL). Methods Overview of study We developed and conducted a feasibility test of SEE-SCI by randomizing a national sample of women with SCI to the intervention or a control group that received program materials at the end of the study. Both groups completed pre- and postintervention questionnaires via telephone interview, and intervention participants provided feedback on their experience via an anonymous online survey. Intervention development SEE-SCI, as in the original Self-esteem in Second Life Intervention for Women with Disabilities, is grounded in social learning theory,23 feminist psychology,24 and the philosophy of independent living.25 Social learning theory incorporates self-efficacy or one’s belief in their ability to take action.23 Feminist psychology24 purports that women’s sense of self is grounded in mutually caring relationships that generate a sense of self-worth and capacity for action. Additionally, women-only groups offer a safe place to share common experiences, develop connections, and address topics difficult to discuss in mixed groups.26 The independent living movement emphasizes consumer empowerment, self-advocacy, and personal autonomy.25 To create SEE-SCI, we started with our previous SL-delivered self-esteem program for women with mobility impairments21 and added SCI-specific examples, scenarios, and images. Women with SCI advised us on program additions, edits, and modifications. Additions included icebreakers and end-of-session activities designed to enhance interaction and build camaraderie. The resulting modified program consists of seven, 2-h, weekly sessions delivered by two female facilitators (a psychologist with a disability and a woman with spinal cord dysfunction who uses a powerchair) who follow a scripted facilitator manual. The program materials include PowerPoint slides and a Participant Activity Booklet. Sessions include didactics, skill building activities, group discussion, weekly action planning, and action planning review. Activities are designed to increase self-efficacy, connectedness, and self-care, which can enhance self-esteem and psychological health. Weekly sessions, which include knowledge and skill-based training cover: 1) Program Overview and Introduction to Goal Setting/Action Planning, 2) Concept of Self-Esteem, 3) Connecting to Self, 4) Caring for Self, 5) Connections, 6) Communication, and 7) Planning for the Future. SEE-SCI was implemented in SL, a free online virtual world (secondlife.com), in which group members participate as avatars in
sessions offered in real-time on our secure parcel of a SL island.21,27 The island offers group meeting areas and locations for relaxation (e.g., a beach, a lily pond).21 Procedures After obtaining IRB approval, we distributed recruitment flyers to local and national organizations inviting women to contact us. To be eligible, women had to be at least 18 years of age; have a traumatic SCI; be at least one year post-injury; and have access to email, a computer, and high-speed Internet connection. Study staff assessed computing resources by inviting potential participants to download SL on their computer. Women were ineligible if they: a) did not understand English well enough to participate in online discussions and complete questionnaires in English; b) were unable to demonstrate understanding of the study; c) self-reported misuse of alcohol/drugs; d) reported active psychosis or plans to hurt/kill themselves; or e) had a visual or hearing impairment that would significantly limit their ability to participate in the online intervention. Eligible participants provided verbal consent by phone, were e/mailed a copy of the consent form, completed the pre-test by phone, and then received their group assignment. Random assignment was determined in advance, using the random selection function of SPSS, but was unknown to study staff until a participant was fully enrolled. Participants assigned to the SEE-SCI group were then scheduled to begin SL training and the intervention sessions. The control group participants did not receive SL training and did not participate in group sessions; they received all study materials at the end of the study. At the end of the program, both intervention and control participants completed the post-test via telephone interview by staff not directly involved in implementation. We sent intervention participants an online survey asking for feedback on the program and the SL platform. Participants in both conditions received a small payment for completing assessments. Intervention participants were not compensated for session attendance but were paid for assessments regardless of the number of sessions attended. Measures The following measures were administered and examined for change over time: Health Promoting Behaviors. We included three subscales (7item Interpersonal Support, 13-item Spiritual Growth/Selfactualization, 7-item Stress Management) from the Health Promoting Lifestyle Profile-II (HPLP-II)28 which reflect behaviors promoted in the intervention. With items rated on a 4-point scale, HPLP-II subscales have been shown to have reasonable internal consistency (Cronbach a ¼ .73-.92) and to be responsive to change in a previous study of women with physical disabilities, including SCI.29 Social Support. We used the Emotional/Informational Support subscale of the Medical Outcomes Study Social Support Survey,30 to measure social support. This subscale, which uses a 4-point rating scale for each of the 8-items, has been shown to have excellent internal consistency (a ¼ 0.94-0.95) in studies of women with disabilities, including SCI.21,31 Self-Efficacy was assessed using the Generalized Self-Efficacy Scale,32 a 10-item measure which uses a 4-point response scale to measure belief in one’s ability to respond to novel or difficult situations. The scale has been shown to have strong internal consistency (a ¼ 0.92)30 and to be amenable to change in previous intervention studies of women with physical disabilities, including SCI.20,21,30
Please cite this article as: Robinson-Whelen S et al., Promoting psychological health in women with SCI: Development of an online self-esteem intervention, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100867
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Self-Esteem was measured using the 10-item Rosenberg SelfEsteem Scale,33 which has been used previously in studies of women with disabilities,19,20 and has been shown to have good internal consistency (a ¼ 0.70-0.88)119,21 and to be responsive to change in previous self-esteem interventions for women with physical disabilities.20,21 Depression was measured using the 10-item (4-point rating scale) Center for Epidemiologic Studies Depression Scale-10 (CESD10)34 and the 9-item (4-point rating scale) Patient Health Questionnaire (PHQ-9),35 both measures of depressive symptomatology that have been used widely and validated with people with SCI, and demonstrated to have excellent internal consistency.36e39 SEE-SCI Program Evaluation. We asked SEE-SCI participants to rate the intervention in general, the extent to which they made changes in response to the intervention, and the extent to which different aspects of the program were helpful. To assess SL as an effective platform, we asked participants to rate the extent to which they felt supported by fellow group members and how enjoyable and stressful it was meeting in SL. We also asked participants to rank order their format preferences (i.e., face-to-face; SL;
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telephone; online, such as WebEx) and to compare face-to-face and SL programs in terms of convenience, enjoyment, and opportunities for social interaction. Finally, we asked participants a) what they liked most, b) what they liked least, and c) the most important thing they learned. Results Sample Of 37 women screened, 23 were eligible, consented, and randomized to the SEE-SCI (n ¼ 12) or control group (n ¼ 11) (Fig. 1). Two women assigned to the intervention dropped mid-way through the intervention (i.e., family medical emergency, new job). Given the small sample, we decided that excluding their data was appropriate for a feasibility/pilot study; thus, data in this paper reflect the 21 remaining participants. Participants were primarily middle-aged, white, and well educated (Table 1) and had been living with their SCI for many years (M ¼ 16.95, SD ¼ 12.95). Although few group differences at
Fig. 1. Consort diagram.
Please cite this article as: Robinson-Whelen S et al., Promoting psychological health in women with SCI: Development of an online self-esteem intervention, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100867
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Table 1 Sample characteristics. Variable
Intervention Group M (SD) or n (%)
Control Group M (SD) or n (%)
N Age Level of Education Less than a high school degree High school and some college College degree Race White Black Asian Ethnicity Non-Hispanic Marital Status Married/Unmarried Couple Occupation Full-time Part-time Unemployed Yearly Personal Incomea
10 50.90 (9.95)
11 44.00 (13.25)
0 (0%) 1 (10%) 9 (90%)
1 (9%) 0 (0%) 10 (91%)
8 (80%) 1 (10%) 1 (10%)
11 (100%) 0 (0%) 0 (0%)
10 (100%)
11 (100%)
7 (70%)
6 (55%)
2 (20%) 3 (30%) 5 (50%) $58,766 ($36,292) Median ¼ $54,000
3 (27%) 3 (27%) 5 (45%) $36,517 ($32,607) Median ¼ $28,600
4 (40%) 6 (60%) 15.36 (18.70) 6 (60%) 7 (70%)
9 (82%) 2 (18%) 11.61 (14.71) 3 (27%) 5 (46%)
Level of Injuryb Paraplegia Tetraplegia Years Post-Injury ADL Help Needed IADL Help Needed a b
Income was reported by 9 intervention and 9 control participants. Groups differed significantly c2(1) ¼ 3.88, p ¼ .049.
pre-test were statistically significant, the two groups differed significantly in level of injury (i.e., more women in the intervention group had tetraplegia), and the intervention group had nearly twice the median household income. The two groups also differed significantly at pre-test in spiritual growth/self-actualization (SEESCI, M ¼ 3.06, SD ¼ 0.37; Control, M ¼ 2.65, SD ¼ 0.42; t ¼ 2.39, df ¼ 19, p ¼ .03; Cohen’s d ¼ 1.05, large effect) and non-significantly in self-esteem (SEE-SCI, M ¼ 23.70, SD ¼ 4.00; Control, M ¼ 20.91, SD ¼ 3.83; t ¼ 1.63, df ¼ 19, p ¼ .12; Cohen’s d ¼ 0.71, medium effect). Because the intervention group had higher scores at pre-test (potentially less opportunity for improvement), we decided to examine changes in the intervention group from pre-to-post in addition to examining group differences in change over time. Engagement Study attrition was 8.7%, suggesting that most successfully engaged in the study. All 10 women who remained in the intervention attended at least half of the sessions (M ¼ 5.7 sessions, SD ¼ 0.95); thus attendance was excellent despite holding evening sessions to accommodate work schedules. Acceptability of Second Life All 10 intervention participants rated SL as “very enjoyable”, and 7 of 10 rated it more enjoyable than face-to-face programs. The majority (n ¼ 9) described SL as more convenient than face-to-face programs. Most indicated that SL was “not very” (n ¼ 1) or “not at all” (n ¼ 6) stressful. All 10 reported feeling “somewhat” (n ¼ 3) or “very” (n ¼ 7) supported by fellow group members. There was a clear split in format preferences, with half (n ¼ 5) selecting SL and 4 selecting face-to-face as their most preferred format.
Open-ended comments similarly reflected these differences, ranging from “I enjoyed having an avatar but it was a little distracting” to “I loved the avatar aspect. What a gas!” Several (n ¼ 3) offered comments indicated a preference for face-to-face programs combined with a realization that was not feasible or realistic. Regarding the convenience of SL, one woman noted “I loved being able to connect from the comfort and convenience of my own home. The fact that we were able to choose an avatar and go to SLwas a fun bonus!” Importantly, several women (n ¼ 3) noted that the anonymity in SL allowed them to “talk more freely” or more easily “open up.” Acceptability of SEE-SCI All 10 women rated the program as “very good” (n ¼ 6) or “good” (n ¼ 4), with all indicating they made either “important” (n ¼ 7) or “minor” (n ¼ 3) positive changes in their lives. All 10 rated action planning, session content, and group discussion as helpful, with most providing the highest (i.e., “very helpful”) rating (n ¼ 7, action planning; n ¼ 6, session content; n ¼ 7, group discussion). The end of session relaxation exercises, which were rushed due to time constraints, received less favorable ratings, with 8 participants rating them as “very” (n ¼ 6) or “somewhat” (n ¼ 2) helpful and 2 rating them as “not at all” helpful. On open-ended questions about what they liked best, all 9 women who responded mentioned meeting, sharing, and connecting with other women with SCI. One stated “I found it interesting how we all have experienced many of the same feelings and problems.” When asked what they liked least, the most frequent response was that the program needed to be longer (n ¼ 4). Finally, when asked for the most important thing learned, 3 of the 9 respondents again mentioned the value of interacting with other women with SCI (e.g., I learned that “I’m not alone”), and 4 mentioned topics related to relationships and communication. Evidence of improvement Two-Group Analysis. We examined group differences in change over time using multiple linear regression analyses to determine if group (SEE-SCI versus control) significantly predicted post-test after controlling for pre-test scores. Analyses were conducted separately on each outcome. The SEE-SCI group demonstrated significantly greater increases in Interpersonal Relations (F ¼ 5.56, df ¼ 1,18, p ¼ .03) and Spiritual Growth/Self-Actualization (F ¼ 4.64, df ¼ 1,18, p ¼ .045) than the control group (Table 2). There was no group effect on the Stress Management subscale or other outcome variables. Single-Group Analysis. Given the pre-existing differences between groups and the developmental nature of the study, we decided to more closely evaluate changes from pre-to post-intervention within the intervention group using paired t-tests. Although significance test results are provided, it is important to consider effect sizes given the small sample size (Table 2). Psychological health-promoting behavior. As shown in Table 2, changes over time were statistically significant and revealed a medium-to-large effect on the Interpersonal Relations (t ¼ 2.27, df ¼ 9, p ¼ .049; Cohen’s d ¼ 0.72) and the Spiritual Growth (t ¼ 2.90, df ¼ 9, p ¼ .017; Cohen’s d ¼ 0.92) subscales. Changes on the Stress Management subscale were minimal and constituted a small effect size (t ¼ 0.76, df ¼ 9, p ¼ .470; Cohen’s d ¼ 0.24). Social support increased slightly from pre-to post-intervention (t ¼ 1.18, df ¼ 9, p ¼ .27), but this change was not statistically significant and represented a small effect size (Cohen’s d ¼ 0.37). Generalized self-efficacy changed very little from pre to posttest (t ¼ 0.25, df ¼ 9, p ¼ .81) reflecting virtually no effect of the
Please cite this article as: Robinson-Whelen S et al., Promoting psychological health in women with SCI: Development of an online self-esteem intervention, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100867
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Table 2 Pre and post-intervention scores on outcome measures for intervention and control groups. Variable
HPLP-IR T1 e Pre T2 e Post HPLP-SG T1 e Pre T2 e Post HPLP-SM T1 e Pre T2 e Post MOSeSSeEI T1 e Pre T2 e Post GSES T1 e Pre T2 e Post RSES T1 e Pre T2 e Post CESD-10 T1 e Pre T2 e Post PHQ-9 T1 e Pre T2 e Post
Intervention Group
Control Group
Group Difference T2 (controlling for T1)
Intervention Group T1 to T2 Change
M (SD)
M (SD)
DR2
F(df)
p
t(df)
p
ES
3.06 (0.34) 3.29 (0.50)
2.96 (0.51) 2.86 (0.49)
.111
5.56 (1,18)
.03
2.27 (9)
.05
.72
3.06 (0.37) 3.41 (0.41)
2.65 (0.42) 2.75 (0.46)
.076
4.64 (1,18)
.04
2.90 (9)
.02
.92
2.52 (0.61) 2.65 (0.55)
2.57 (0.36) 2.72 (0.31)
.003
0.08 (1,18)
.79
0.76 (9)
.47
.24
29.30 (5.85) 31.10 (7.06)
29.36 (7.69) 31.09 (8.15)
.000
0.001 (1,18)
.98
1.18 (9)
.27
.37
34.70 (2.75) 35.00 (3.40)
33.45 (4.37) 32.82 (4.38)
.029
0.92 (1,18)
.35
0.25 (9)
.81
.08
23.70 (4.00) 24.60 (4.22)
20.91 (3.83) 21.00 (5.06)
.009
0.49 (1,18)
.49
1.00 (9)
.34
.32
9.80 (7.64) 6.90 (5.78)
10.36 (6.28) 8.82 (3.87)
.028
2.18 (1,18)
.16
2.40 (9)
.04
.76
6.60 (6.00) 4.90 (5.00)
7.55 (4.39) 6.64 (3.78)
.015
1.19 (1,18)
.29
2.49 (9)
.04
.79
Note: HPLP-IR, Health Promoting Lifestyle Profile Interpersonal Relations; HPLP-SM, Health Promoting Lifestyle Profile Stress Management; HPLP-SG, Health Promoting Lifestyle Spiritual Growth/Self-Actualization; MOSeSSeEI, MOS-Social Support Emotional-Informational Support; GSES, Generalized Self-Efficacy Scale; RSES, Rosenberg SelfEsteem Scale; CESD-10, Center for Epidemiological Studies Depression Scale-10; PHQ-9, Patient Health Questionnaire-9.
intervention on self-efficacy (Cohen’s d ¼ 0.08). Self-esteem scores increased slightly from pre-to post-intervention (t ¼ 1.00, df ¼ 9, p ¼ .34), but the change was not statistically significant and constituted a small effect (Cohen’s d ¼ 0.32). Depression. Changes in depression scores were statistically significant (CESD-10, t ¼ 2.40, df ¼ 19, p ¼ .040, Cohen’s d ¼ 0.76; PHQ-9, t ¼ 2.49, df ¼ 19, p ¼ .035, Cohen’s d ¼ 0.79) with mediumto-large effect sizes. The number of women whose depression scores exceeded the cut-off of 10, indicating risk for clinical depression34,35 decreased from 4 at pre-test to 3 at post-test on the CESD-10 and decreased from 3 at pre-test to 1 at post-test on the PHQ-9. Discussion To assess the feasibility of SEE-SCI, we examined engagement in the study and the intervention, acceptability of SL and the intervention itself, and improvement on measures of psychological health promoting behaviors, social support, self-efficacy, self-esteem, and depression. Evidence suggests that SEE-SCI is feasible and may have the potential to enhance self-esteem and psychological health in women with SCI. The participants responded favorably to the study and the intervention as evidenced by high retention and session attendance. All participants rated SL as enjoyable with the majority describing SL as more enjoyable and more convenient than meeting face-to-face. The use of avatars did not hinder the development of support among group members. In fact, several participants specifically expressed satisfaction with the anonymity afforded by SL. Participants rated SEE-SCI favorably, and most reported they made important positive life changes as a result. In open-ended feedback, the majority commented on the value of connecting with other women with SCI. We found greater improvement in the intervention group
compared to the control group on two health promoting behavior measures (interpersonal relations, spiritual growth/selfactualization). We found no other significant group differences in change over time; however, we must caution that there were some differences between groups at pre-test which may have limited our ability to detect differences in change over time. Examining prepost change in only the intervention group, there were significant improvements over time, reflecting medium-to-large effects, on four outcome measures (interpersonal relations, spiritual growth/ self-actualization, and two measures of depression). We also observed small effects on measures of self-esteem, social support, and stress management behavior. Improvements in stress management were likely limited by the fact that time limitations compromised our ability to consistently and thoroughly cover relaxation exercises. We found minimal improvement over time on our measure of self-efficacy. This was surprising given the considerable time invested in activities designed to enhance self-efficacy; however, baseline self-efficacy scores in the current study (M ¼ 34.70) were notably higher than previous self-esteem enhancement intervention studies with women with physical disabilities (M ¼ 29.79 and 29.78).20,21 With a possible score range of 10e40, the current sample was approaching ceiling at pre-test, allowing less room for significant improvements. It is striking that SEE-SCI resulted in a significant reduction, with a medium-to-large effect, in depressive symptomatology given that we did not specifically recruit women with elevated depression scores. In fact, the current sample had lower baseline depression scores, in addition to higher self-efficacy scores, than those observed in previous self-esteem enhancement studies.20,21 Thus, the intervention seems to hold promise for enhancing psychological health and minimizing depressive symptoms, not just among women who are experiencing clinical depression or significant psychological distress, but also among those with mild or
Please cite this article as: Robinson-Whelen S et al., Promoting psychological health in women with SCI: Development of an online self-esteem intervention, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100867
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subclinical depression. This finding is consistent with findings from the Self-esteem Enhancement Intervention for Women with Physical Disabilities on which the SEE-SCI intervention was based.21 Our results are subject to several limitations. First, conclusions should be tempered by the small sample size. In addition, the disproportionately white, relatively well-educated sample may not be representative of the general SCI population in the U.S., particularly given that having access to a computer and high-speed internet was a requirement for participation. In addition, we examined outcomes separately because of our small sample which increases the likelihood of a Type I error. It is important that future research include a larger, more diverse sample of participants and include a longitudinal follow-up to assure that improvements are maintained. Conclusion Our results suggest that using the cutting-edge technology and rich, immersive environment of SL for intervention delivery can help circumvent barriers that prevent women with SCI from accessing face-to-face programming. We have established the groundwork for refining the design and testing of our intervention model in future studies. While our results are promising, we acknowledge that a more diverse and well-powered sample can strengthen generalizability, document the efficacy of the intervention, and determine the accessibility, affordability, and applicability of this intervention to women with SCI. Declaration of competing interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Submission declaration A portion of study findings were presented at the American Spinal Injury Association Annual Scientific Conference in 2018 and at the 2017 Annual Convention of the Texas Psychological Association. Funding This project was funded by TIRR Memorial Hermann (Houston, Texas). The intervention was implemented and data were collected in the fall of 2016 at TIRR Memorial Hermann. Acknowledgements We acknowledge and thank members of our community advisory board (Mayra Cantu, Julie Collins, and Kemi Yemi-Ese) for advising us on the development of the intervention. We also acknowledge the women with spinal cord injury who participated in the intervention. References 1. National Spinal Cord Injury Statistical Center. Spinal cord injury facts and figures at a glance: 2019 SCI data sheet. Retrieved from https://www.nscisc.uab. edu/Public/Facts%20and%20Figures%202019%20-%20Final.pdf; 2019. 2. Robinson-Whelen S, Taylor HB, Hughes RB, Wensel L, Nosek MA. Depression and depression treatment in women with spinal cord injury. Top Spinal Cord Inj Rehabil. 2014;20(1):23e31. 3. Treischmann RB. Spinal Cord Injuries: Psychological, Social and Vocational Adjustment. New York: Pergamon; 1980. 4. Chau L, Hegedus L, Praamsma M, et al. Women living with a spinal cord injury: perceptions about their changed bodies. Qual Health Res. 2008;18(2):209e221.
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An in-depth understanding of the impact of the environment on participation among people with spinal cord injury. Disabil Rehabil. 2018;40(18):2192e2199. 11. American Psychological Association. Guidelines for assessment of and intervention with persons with disabilities. Am Psychol. 2012;67(1):43e62. 12. Keller RM, Galgay CE. Microaggressive experiences of people with disabilities. In: Sue DW, ed. Microaggressions and Marginality: Manifestation, Dynamics, and Impact. Hoboken, New Jersey: John Wiley & Sons, Inc; 2010:241e267. 13. Hughes RB, Swedlund N, Petersen N, Nosek MA. Depression and women with spinal cord injury. Top Spinal Cord Inj Rehabil. 2001;7(1):16e24. 14. Savic G, DeVivo MJ, Frankel HL, Jamous MA, Soni BM, Charlifue S. Suicide and traumatic spinal cord injury - a cohort study. Spinal Cord. 2018;56(1):2e6. 15. Schmerzler A, Goldstein J, Parkin K. Women, spinal cord injury, and domestic violence: a review. Top Spinal Cord Inj Rehabil. 2001;7(1):37e41. https:// doi.org/10.1310/TAGM-2FNC-4NYU-. 16. Zatzick DF, Rivara FP, Nathens AB, et al. A nationwide US study of posttraumatic stress after hospitalization for physical injury. Psychol Med. 2007;37(10):1469e1480. 17. Rintala DH, Hart KA, Fuhrer MJ. Perceived stress in individuals with spinal cord injury. In: Krotoski DM, Nosek MA, Turk MA, eds. Women with Physical Disabilities: Achieving and Maintaining Health and Well-Being. Baltimore, MD: Paul H. Brookes; 1996:223e242. 18. Peter C, Müller R, Cieza A, Geyh S. Psychological resources in spinal cord injury: a systematic literature review. Spinal Cord. 2012;50(3), 188201. 19. Nosek MA, Hughes RB, Swedlund N, Taylor HB, Swank P. Self-esteem and women with disabilities. Soc Sci Med. 2003;56(8):1737e1747. 20. Hughes RB, Robinson-Whelen S, Taylor HB, Swedlund N, Nosek MA. Enhancing self-esteem in women with physical disabilities. Rehabil Psychol. 2004;49(4): 295e302. 21. Nosek MA, Robinson-Whelen S, Hughes RB, Nosek TM. An Internet-based virtual reality intervention for enhancing self-esteem in women with disabilities: results of a feasibility study. Rehabil Psychol. 2016;61(4):358e370. 22. Rosenberg M, Schooler C, Schoenbach C, Rosenberg F. Global self-esteem and specific self-esteem: different concepts, different outcomes. Am Sociol Rev. 1995;60(1):141e156. 23. Bandura A. Self-efficacy: The Exercise of Control. New York, NY: W. H. Freeman/ Times Books/Henry Holt & Co; 1997. 24. Jordan J. Recent developments in relational-cultural theory. In: Jordan J, ed. The Power of Connection: Recent Developments in Relational-Cultural Theory. New York, NY: Taylor and Francis; 2010:1. 25. Nosek MA, Hughes RB. Navigating the road to independent living. In: Atkinson DR, ed. Counseling Diverse Populations. New York, NY: McGraw-Hill; 2004:172e193. 26. Enns CZ. Self-esteem groups: a synthesis of conscious-raising and assertiveness training. J Couns Dev. 1992;71(1):7e13. 27. Nosek MA, Robinson-Whelen S, Ledoux TA, et al. A Pilot Test of the GoWoman Weight Management Intervention for Women with Mobility Impairments in the Online Virtual World of Second Life.® Disability and Rehabilitation. 2018. https:// doi.org/10.1080/09638288.2018.1473511. Epub ahead of print. 28.. Walker S, Sechrist K, Pender N. The Health-Promoting Lifestyle Profile II. Omaha: University of Nebraska Medical Center, College of Nursing; 1996. 29. Robinson-Whelen S, Hughes RB, Taylor HB, Colvard M, Mastel-Smith B, Nosek MA. Improving the health and health behaviors of women aging with physical disabilities: a peer-led health promotion program. Women’s Health Issues. 2006;16(6):334e345. 30. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32(6):705e714. 31. Robinson-Whelen S, Hughes RB, Gabrielli J, Lund EM, Abramson W, Swank P. A safety awareness program for women with diverse disabilities: a randomized controlled trial. Violence Against Women. 2014;20(7):846e868. 32. Jerusalem M, Schwarzer R. Self-efficacy as a resource factor in stress appraisal processes. In: Schwarzer R, ed. Self- Efficacy: Thought Control of Action. Washington DC: Hemisphere Publishing; 1992:195e213. 33. Rosenberg M. Appendix D: scales and scores. In: Rosenberg M, ed. Society and the Adolescent Self-Image. Princeton, NJ: Princeton University Press; 1965: 305e319. 34. Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depression in well older adults: evaluation of a short form of the CES-D. Am J Prev Med. 1994;10(2):77e84. 35. Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64(2):
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S. Robinson-Whelen et al. / Disability and Health Journal xxx (xxxx) xxx 258e266. 36. Bombardier CH, Kalpakjian CZ, Graves DE, Dyer JR, Tate DG, Fann JR. Validity of the patient health questionnaire-9 in assessing major depressive disorder during inpatient spinal cord injury rehabilitation. Arch Phys Med Rehabil. 2012;93(10):1838e1845. 37. Bombardier CH, Richards JS, Krause J, Tulsky D, Tate D. Symptoms of major depression in people with spinal cord injury: implications for screening. Arch
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Phys Med Rehabil. 2004;85:1749e1756. 38. Sakakibara BM, Miller WC, Orenczuk SG, Wolfe DL, SCIRE Research Team. A systematic review of depression and anxiety measures used with individuals with spinal cord injury. Spinal Cord. 2009;47:841e851. 39. Thakral M, Lacroix AZ, Molton IR. Sex/gender disparities in health outcomes of individuals with long-term disabling conditions. Rehabil Psychol. 2019;64(2): 221e228.
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Contents lists available at ScienceDirect
Disability and Health Journal journal homepage: www.disabilityandhealthjnl.com
Brief Report
Promoting psychological health in women with SCI: Development of an online self-esteem intervention Susan Robinson-Whelen a, b, *, Rosemary B. Hughes c, d, Heather B. Taylor a, e, C. Vega a, Thomas M. Nosek f, Margaret A. Nosek b Rachel Markley a, 1, Jose a
Spinal Cord Injury and Disability Research Center, TIRR Memorial Hermann, Houston, TX, USA Center for Research on Women with Disabilities, H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA c The Rural Institute for Inclusive Communities, University of Montana, Missoula, MT, USA d Department of Psychology, University of Montana, Missoula, MT, USA e McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth), USA f Department of Physiology and Biophysics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 15 May 2019 Received in revised form 1 October 2019 Accepted 22 October 2019
Background: There are no known interventions addressing self-esteem in women following spinal cord injury (SCI). Objectives: To test the feasibility of an online self-esteem intervention for women with disabilities, as modified for women with SCI. Method: We conducted a randomized, controlled feasibility test of a self-esteem intervention (N ¼ 21). Participants were randomly assigned to the intervention or control group that received intervention materials at the end of the study. Intervention participants met as avatars for 7 weekly real-time group sessions in Second Life (SL), a free online virtual world. Feasibility indicators were study engagement, acceptability of SL and the intervention, and improvements on measures of psychological health promoting behaviors, social support, self-efficacy, self-esteem, and depression. Results: Intervention participants (n ¼ 10) were highly engaged, and most described the SL program as more enjoyable and more convenient than in-person programs. All rated the intervention as “good” (n ¼ 4) or “very good” (n ¼ 6), and all 10 rated themselves has having made positive life changes as a result of the program. Intervention participants experienced significantly greater change than controls on two measures of health-promoting behavior (Health Promoting Lifestyle Profile-II Spiritual Growth/Selfactualization; Interpersonal Relations). Examining change in the intervention group using regression analyses, we found medium-to-large effects of the intervention on these behaviors and measures of depression (CESD-10, PHQ-9). The intervention had small effects on remaining measures. Conclusion: We found preliminary support for the feasibility of this modified self-esteem intervention offered in SL. Such programming may help circumvent barriers to community-based psychological services and may improve psychological health. © 2019 Elsevier Inc. All rights reserved.
Keywords: Spinal cord injury Women Self-esteem Psychosocial intervention Virtual reality
Women constitute approximately 22% of new cases of spinal cord injury (SCI) in the United States,1 yet relatively little research addresses their psychological health.2,3 Women with SCI commonly
* Corresponding author. TIRR Memorial Hermann Spinal Cord Injury and Disability Research Center, 1333 Moursund Houston, Texas, 77030. E-mail address: [email protected] (S. Robinson-Whelen). 1 Although completing the work on the project while at TIRR Memorial Hermann, Rachel Markley is now with the Methodist Hospital in Houston, Texas.
experience profound losses involving body image, identity, and bodily functions.4 Challenges related to sexuality and reproductive health5,6 and secondary health conditions, including chronic pain,7,8 also can impact their psychological health. Additionally, they frequently lack adequate financial resources; accessible transportation; equitable access to employment, community participation, and health care; and personal assistance.4,9,10 Discrimination, erroneous assumptions, microaggressions, and other demeaning factors experienced by people with disabilities11,12 may also compromise the self-esteem of women with SCI.
https://doi.org/10.1016/j.dhjo.2019.100867 1936-6574/© 2019 Elsevier Inc. All rights reserved.
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SCI is associated with elevated risks for depression,2,13 suicide,14 interpersonal violence,15 post-traumatic stress disorder,16 and psychological stress.17 A systematic review18 of articles on psychological resources in SCI linked positive self-esteem with less depression, stress, and loneliness along with better life satisfaction, sexual adjustment, and social participation. Positive self-esteem can support women in managing disability-related challenges19 and enhancing their psychological health.20,21 We conceptualize self-esteem as the general attitude people place on themselves (global self-esteem) which is linked to psychological health.22 In this article, we describe the adaptation of the Self-esteem in Second Life (SL) Intervention for Women with Disabilities21 to address unique psychological health needs of women with SCI. We report on a test of the feasibility of the modified intervention, referred to as the “Self-Esteem Enhancement Intervention for Women with SCI,” SEE-SCI, which was delivered in the virtual world of Second Life (SL). Methods Overview of study We developed and conducted a feasibility test of SEE-SCI by randomizing a national sample of women with SCI to the intervention or a control group that received program materials at the end of the study. Both groups completed pre- and postintervention questionnaires via telephone interview, and intervention participants provided feedback on their experience via an anonymous online survey. Intervention development SEE-SCI, as in the original Self-esteem in Second Life Intervention for Women with Disabilities, is grounded in social learning theory,23 feminist psychology,24 and the philosophy of independent living.25 Social learning theory incorporates self-efficacy or one’s belief in their ability to take action.23 Feminist psychology24 purports that women’s sense of self is grounded in mutually caring relationships that generate a sense of self-worth and capacity for action. Additionally, women-only groups offer a safe place to share common experiences, develop connections, and address topics difficult to discuss in mixed groups.26 The independent living movement emphasizes consumer empowerment, self-advocacy, and personal autonomy.25 To create SEE-SCI, we started with our previous SL-delivered self-esteem program for women with mobility impairments21 and added SCI-specific examples, scenarios, and images. Women with SCI advised us on program additions, edits, and modifications. Additions included icebreakers and end-of-session activities designed to enhance interaction and build camaraderie. The resulting modified program consists of seven, 2-h, weekly sessions delivered by two female facilitators (a psychologist with a disability and a woman with spinal cord dysfunction who uses a powerchair) who follow a scripted facilitator manual. The program materials include PowerPoint slides and a Participant Activity Booklet. Sessions include didactics, skill building activities, group discussion, weekly action planning, and action planning review. Activities are designed to increase self-efficacy, connectedness, and self-care, which can enhance self-esteem and psychological health. Weekly sessions, which include knowledge and skill-based training cover: 1) Program Overview and Introduction to Goal Setting/Action Planning, 2) Concept of Self-Esteem, 3) Connecting to Self, 4) Caring for Self, 5) Connections, 6) Communication, and 7) Planning for the Future. SEE-SCI was implemented in SL, a free online virtual world (secondlife.com), in which group members participate as avatars in
sessions offered in real-time on our secure parcel of a SL island.21,27 The island offers group meeting areas and locations for relaxation (e.g., a beach, a lily pond).21 Procedures After obtaining IRB approval, we distributed recruitment flyers to local and national organizations inviting women to contact us. To be eligible, women had to be at least 18 years of age; have a traumatic SCI; be at least one year post-injury; and have access to email, a computer, and high-speed Internet connection. Study staff assessed computing resources by inviting potential participants to download SL on their computer. Women were ineligible if they: a) did not understand English well enough to participate in online discussions and complete questionnaires in English; b) were unable to demonstrate understanding of the study; c) self-reported misuse of alcohol/drugs; d) reported active psychosis or plans to hurt/kill themselves; or e) had a visual or hearing impairment that would significantly limit their ability to participate in the online intervention. Eligible participants provided verbal consent by phone, were e/mailed a copy of the consent form, completed the pre-test by phone, and then received their group assignment. Random assignment was determined in advance, using the random selection function of SPSS, but was unknown to study staff until a participant was fully enrolled. Participants assigned to the SEE-SCI group were then scheduled to begin SL training and the intervention sessions. The control group participants did not receive SL training and did not participate in group sessions; they received all study materials at the end of the study. At the end of the program, both intervention and control participants completed the post-test via telephone interview by staff not directly involved in implementation. We sent intervention participants an online survey asking for feedback on the program and the SL platform. Participants in both conditions received a small payment for completing assessments. Intervention participants were not compensated for session attendance but were paid for assessments regardless of the number of sessions attended. Measures The following measures were administered and examined for change over time: Health Promoting Behaviors. We included three subscales (7item Interpersonal Support, 13-item Spiritual Growth/Selfactualization, 7-item Stress Management) from the Health Promoting Lifestyle Profile-II (HPLP-II)28 which reflect behaviors promoted in the intervention. With items rated on a 4-point scale, HPLP-II subscales have been shown to have reasonable internal consistency (Cronbach a ¼ .73-.92) and to be responsive to change in a previous study of women with physical disabilities, including SCI.29 Social Support. We used the Emotional/Informational Support subscale of the Medical Outcomes Study Social Support Survey,30 to measure social support. This subscale, which uses a 4-point rating scale for each of the 8-items, has been shown to have excellent internal consistency (a ¼ 0.94-0.95) in studies of women with disabilities, including SCI.21,31 Self-Efficacy was assessed using the Generalized Self-Efficacy Scale,32 a 10-item measure which uses a 4-point response scale to measure belief in one’s ability to respond to novel or difficult situations. The scale has been shown to have strong internal consistency (a ¼ 0.92)30 and to be amenable to change in previous intervention studies of women with physical disabilities, including SCI.20,21,30
Please cite this article as: Robinson-Whelen S et al., Promoting psychological health in women with SCI: Development of an online self-esteem intervention, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100867
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Self-Esteem was measured using the 10-item Rosenberg SelfEsteem Scale,33 which has been used previously in studies of women with disabilities,19,20 and has been shown to have good internal consistency (a ¼ 0.70-0.88)119,21 and to be responsive to change in previous self-esteem interventions for women with physical disabilities.20,21 Depression was measured using the 10-item (4-point rating scale) Center for Epidemiologic Studies Depression Scale-10 (CESD10)34 and the 9-item (4-point rating scale) Patient Health Questionnaire (PHQ-9),35 both measures of depressive symptomatology that have been used widely and validated with people with SCI, and demonstrated to have excellent internal consistency.36e39 SEE-SCI Program Evaluation. We asked SEE-SCI participants to rate the intervention in general, the extent to which they made changes in response to the intervention, and the extent to which different aspects of the program were helpful. To assess SL as an effective platform, we asked participants to rate the extent to which they felt supported by fellow group members and how enjoyable and stressful it was meeting in SL. We also asked participants to rank order their format preferences (i.e., face-to-face; SL;
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telephone; online, such as WebEx) and to compare face-to-face and SL programs in terms of convenience, enjoyment, and opportunities for social interaction. Finally, we asked participants a) what they liked most, b) what they liked least, and c) the most important thing they learned. Results Sample Of 37 women screened, 23 were eligible, consented, and randomized to the SEE-SCI (n ¼ 12) or control group (n ¼ 11) (Fig. 1). Two women assigned to the intervention dropped mid-way through the intervention (i.e., family medical emergency, new job). Given the small sample, we decided that excluding their data was appropriate for a feasibility/pilot study; thus, data in this paper reflect the 21 remaining participants. Participants were primarily middle-aged, white, and well educated (Table 1) and had been living with their SCI for many years (M ¼ 16.95, SD ¼ 12.95). Although few group differences at
Fig. 1. Consort diagram.
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Table 1 Sample characteristics. Variable
Intervention Group M (SD) or n (%)
Control Group M (SD) or n (%)
N Age Level of Education Less than a high school degree High school and some college College degree Race White Black Asian Ethnicity Non-Hispanic Marital Status Married/Unmarried Couple Occupation Full-time Part-time Unemployed Yearly Personal Incomea
10 50.90 (9.95)
11 44.00 (13.25)
0 (0%) 1 (10%) 9 (90%)
1 (9%) 0 (0%) 10 (91%)
8 (80%) 1 (10%) 1 (10%)
11 (100%) 0 (0%) 0 (0%)
10 (100%)
11 (100%)
7 (70%)
6 (55%)
2 (20%) 3 (30%) 5 (50%) $58,766 ($36,292) Median ¼ $54,000
3 (27%) 3 (27%) 5 (45%) $36,517 ($32,607) Median ¼ $28,600
4 (40%) 6 (60%) 15.36 (18.70) 6 (60%) 7 (70%)
9 (82%) 2 (18%) 11.61 (14.71) 3 (27%) 5 (46%)
Level of Injuryb Paraplegia Tetraplegia Years Post-Injury ADL Help Needed IADL Help Needed a b
Income was reported by 9 intervention and 9 control participants. Groups differed significantly c2(1) ¼ 3.88, p ¼ .049.
pre-test were statistically significant, the two groups differed significantly in level of injury (i.e., more women in the intervention group had tetraplegia), and the intervention group had nearly twice the median household income. The two groups also differed significantly at pre-test in spiritual growth/self-actualization (SEESCI, M ¼ 3.06, SD ¼ 0.37; Control, M ¼ 2.65, SD ¼ 0.42; t ¼ 2.39, df ¼ 19, p ¼ .03; Cohen’s d ¼ 1.05, large effect) and non-significantly in self-esteem (SEE-SCI, M ¼ 23.70, SD ¼ 4.00; Control, M ¼ 20.91, SD ¼ 3.83; t ¼ 1.63, df ¼ 19, p ¼ .12; Cohen’s d ¼ 0.71, medium effect). Because the intervention group had higher scores at pre-test (potentially less opportunity for improvement), we decided to examine changes in the intervention group from pre-to-post in addition to examining group differences in change over time. Engagement Study attrition was 8.7%, suggesting that most successfully engaged in the study. All 10 women who remained in the intervention attended at least half of the sessions (M ¼ 5.7 sessions, SD ¼ 0.95); thus attendance was excellent despite holding evening sessions to accommodate work schedules. Acceptability of Second Life All 10 intervention participants rated SL as “very enjoyable”, and 7 of 10 rated it more enjoyable than face-to-face programs. The majority (n ¼ 9) described SL as more convenient than face-to-face programs. Most indicated that SL was “not very” (n ¼ 1) or “not at all” (n ¼ 6) stressful. All 10 reported feeling “somewhat” (n ¼ 3) or “very” (n ¼ 7) supported by fellow group members. There was a clear split in format preferences, with half (n ¼ 5) selecting SL and 4 selecting face-to-face as their most preferred format.
Open-ended comments similarly reflected these differences, ranging from “I enjoyed having an avatar but it was a little distracting” to “I loved the avatar aspect. What a gas!” Several (n ¼ 3) offered comments indicated a preference for face-to-face programs combined with a realization that was not feasible or realistic. Regarding the convenience of SL, one woman noted “I loved being able to connect from the comfort and convenience of my own home. The fact that we were able to choose an avatar and go to SLwas a fun bonus!” Importantly, several women (n ¼ 3) noted that the anonymity in SL allowed them to “talk more freely” or more easily “open up.” Acceptability of SEE-SCI All 10 women rated the program as “very good” (n ¼ 6) or “good” (n ¼ 4), with all indicating they made either “important” (n ¼ 7) or “minor” (n ¼ 3) positive changes in their lives. All 10 rated action planning, session content, and group discussion as helpful, with most providing the highest (i.e., “very helpful”) rating (n ¼ 7, action planning; n ¼ 6, session content; n ¼ 7, group discussion). The end of session relaxation exercises, which were rushed due to time constraints, received less favorable ratings, with 8 participants rating them as “very” (n ¼ 6) or “somewhat” (n ¼ 2) helpful and 2 rating them as “not at all” helpful. On open-ended questions about what they liked best, all 9 women who responded mentioned meeting, sharing, and connecting with other women with SCI. One stated “I found it interesting how we all have experienced many of the same feelings and problems.” When asked what they liked least, the most frequent response was that the program needed to be longer (n ¼ 4). Finally, when asked for the most important thing learned, 3 of the 9 respondents again mentioned the value of interacting with other women with SCI (e.g., I learned that “I’m not alone”), and 4 mentioned topics related to relationships and communication. Evidence of improvement Two-Group Analysis. We examined group differences in change over time using multiple linear regression analyses to determine if group (SEE-SCI versus control) significantly predicted post-test after controlling for pre-test scores. Analyses were conducted separately on each outcome. The SEE-SCI group demonstrated significantly greater increases in Interpersonal Relations (F ¼ 5.56, df ¼ 1,18, p ¼ .03) and Spiritual Growth/Self-Actualization (F ¼ 4.64, df ¼ 1,18, p ¼ .045) than the control group (Table 2). There was no group effect on the Stress Management subscale or other outcome variables. Single-Group Analysis. Given the pre-existing differences between groups and the developmental nature of the study, we decided to more closely evaluate changes from pre-to post-intervention within the intervention group using paired t-tests. Although significance test results are provided, it is important to consider effect sizes given the small sample size (Table 2). Psychological health-promoting behavior. As shown in Table 2, changes over time were statistically significant and revealed a medium-to-large effect on the Interpersonal Relations (t ¼ 2.27, df ¼ 9, p ¼ .049; Cohen’s d ¼ 0.72) and the Spiritual Growth (t ¼ 2.90, df ¼ 9, p ¼ .017; Cohen’s d ¼ 0.92) subscales. Changes on the Stress Management subscale were minimal and constituted a small effect size (t ¼ 0.76, df ¼ 9, p ¼ .470; Cohen’s d ¼ 0.24). Social support increased slightly from pre-to post-intervention (t ¼ 1.18, df ¼ 9, p ¼ .27), but this change was not statistically significant and represented a small effect size (Cohen’s d ¼ 0.37). Generalized self-efficacy changed very little from pre to posttest (t ¼ 0.25, df ¼ 9, p ¼ .81) reflecting virtually no effect of the
Please cite this article as: Robinson-Whelen S et al., Promoting psychological health in women with SCI: Development of an online self-esteem intervention, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100867
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Table 2 Pre and post-intervention scores on outcome measures for intervention and control groups. Variable
HPLP-IR T1 e Pre T2 e Post HPLP-SG T1 e Pre T2 e Post HPLP-SM T1 e Pre T2 e Post MOSeSSeEI T1 e Pre T2 e Post GSES T1 e Pre T2 e Post RSES T1 e Pre T2 e Post CESD-10 T1 e Pre T2 e Post PHQ-9 T1 e Pre T2 e Post
Intervention Group
Control Group
Group Difference T2 (controlling for T1)
Intervention Group T1 to T2 Change
M (SD)
M (SD)
DR2
F(df)
p
t(df)
p
ES
3.06 (0.34) 3.29 (0.50)
2.96 (0.51) 2.86 (0.49)
.111
5.56 (1,18)
.03
2.27 (9)
.05
.72
3.06 (0.37) 3.41 (0.41)
2.65 (0.42) 2.75 (0.46)
.076
4.64 (1,18)
.04
2.90 (9)
.02
.92
2.52 (0.61) 2.65 (0.55)
2.57 (0.36) 2.72 (0.31)
.003
0.08 (1,18)
.79
0.76 (9)
.47
.24
29.30 (5.85) 31.10 (7.06)
29.36 (7.69) 31.09 (8.15)
.000
0.001 (1,18)
.98
1.18 (9)
.27
.37
34.70 (2.75) 35.00 (3.40)
33.45 (4.37) 32.82 (4.38)
.029
0.92 (1,18)
.35
0.25 (9)
.81
.08
23.70 (4.00) 24.60 (4.22)
20.91 (3.83) 21.00 (5.06)
.009
0.49 (1,18)
.49
1.00 (9)
.34
.32
9.80 (7.64) 6.90 (5.78)
10.36 (6.28) 8.82 (3.87)
.028
2.18 (1,18)
.16
2.40 (9)
.04
.76
6.60 (6.00) 4.90 (5.00)
7.55 (4.39) 6.64 (3.78)
.015
1.19 (1,18)
.29
2.49 (9)
.04
.79
Note: HPLP-IR, Health Promoting Lifestyle Profile Interpersonal Relations; HPLP-SM, Health Promoting Lifestyle Profile Stress Management; HPLP-SG, Health Promoting Lifestyle Spiritual Growth/Self-Actualization; MOSeSSeEI, MOS-Social Support Emotional-Informational Support; GSES, Generalized Self-Efficacy Scale; RSES, Rosenberg SelfEsteem Scale; CESD-10, Center for Epidemiological Studies Depression Scale-10; PHQ-9, Patient Health Questionnaire-9.
intervention on self-efficacy (Cohen’s d ¼ 0.08). Self-esteem scores increased slightly from pre-to post-intervention (t ¼ 1.00, df ¼ 9, p ¼ .34), but the change was not statistically significant and constituted a small effect (Cohen’s d ¼ 0.32). Depression. Changes in depression scores were statistically significant (CESD-10, t ¼ 2.40, df ¼ 19, p ¼ .040, Cohen’s d ¼ 0.76; PHQ-9, t ¼ 2.49, df ¼ 19, p ¼ .035, Cohen’s d ¼ 0.79) with mediumto-large effect sizes. The number of women whose depression scores exceeded the cut-off of 10, indicating risk for clinical depression34,35 decreased from 4 at pre-test to 3 at post-test on the CESD-10 and decreased from 3 at pre-test to 1 at post-test on the PHQ-9. Discussion To assess the feasibility of SEE-SCI, we examined engagement in the study and the intervention, acceptability of SL and the intervention itself, and improvement on measures of psychological health promoting behaviors, social support, self-efficacy, self-esteem, and depression. Evidence suggests that SEE-SCI is feasible and may have the potential to enhance self-esteem and psychological health in women with SCI. The participants responded favorably to the study and the intervention as evidenced by high retention and session attendance. All participants rated SL as enjoyable with the majority describing SL as more enjoyable and more convenient than meeting face-to-face. The use of avatars did not hinder the development of support among group members. In fact, several participants specifically expressed satisfaction with the anonymity afforded by SL. Participants rated SEE-SCI favorably, and most reported they made important positive life changes as a result. In open-ended feedback, the majority commented on the value of connecting with other women with SCI. We found greater improvement in the intervention group
compared to the control group on two health promoting behavior measures (interpersonal relations, spiritual growth/selfactualization). We found no other significant group differences in change over time; however, we must caution that there were some differences between groups at pre-test which may have limited our ability to detect differences in change over time. Examining prepost change in only the intervention group, there were significant improvements over time, reflecting medium-to-large effects, on four outcome measures (interpersonal relations, spiritual growth/ self-actualization, and two measures of depression). We also observed small effects on measures of self-esteem, social support, and stress management behavior. Improvements in stress management were likely limited by the fact that time limitations compromised our ability to consistently and thoroughly cover relaxation exercises. We found minimal improvement over time on our measure of self-efficacy. This was surprising given the considerable time invested in activities designed to enhance self-efficacy; however, baseline self-efficacy scores in the current study (M ¼ 34.70) were notably higher than previous self-esteem enhancement intervention studies with women with physical disabilities (M ¼ 29.79 and 29.78).20,21 With a possible score range of 10e40, the current sample was approaching ceiling at pre-test, allowing less room for significant improvements. It is striking that SEE-SCI resulted in a significant reduction, with a medium-to-large effect, in depressive symptomatology given that we did not specifically recruit women with elevated depression scores. In fact, the current sample had lower baseline depression scores, in addition to higher self-efficacy scores, than those observed in previous self-esteem enhancement studies.20,21 Thus, the intervention seems to hold promise for enhancing psychological health and minimizing depressive symptoms, not just among women who are experiencing clinical depression or significant psychological distress, but also among those with mild or
Please cite this article as: Robinson-Whelen S et al., Promoting psychological health in women with SCI: Development of an online self-esteem intervention, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100867
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subclinical depression. This finding is consistent with findings from the Self-esteem Enhancement Intervention for Women with Physical Disabilities on which the SEE-SCI intervention was based.21 Our results are subject to several limitations. First, conclusions should be tempered by the small sample size. In addition, the disproportionately white, relatively well-educated sample may not be representative of the general SCI population in the U.S., particularly given that having access to a computer and high-speed internet was a requirement for participation. In addition, we examined outcomes separately because of our small sample which increases the likelihood of a Type I error. It is important that future research include a larger, more diverse sample of participants and include a longitudinal follow-up to assure that improvements are maintained. Conclusion Our results suggest that using the cutting-edge technology and rich, immersive environment of SL for intervention delivery can help circumvent barriers that prevent women with SCI from accessing face-to-face programming. We have established the groundwork for refining the design and testing of our intervention model in future studies. While our results are promising, we acknowledge that a more diverse and well-powered sample can strengthen generalizability, document the efficacy of the intervention, and determine the accessibility, affordability, and applicability of this intervention to women with SCI. Declaration of competing interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Submission declaration A portion of study findings were presented at the American Spinal Injury Association Annual Scientific Conference in 2018 and at the 2017 Annual Convention of the Texas Psychological Association. Funding This project was funded by TIRR Memorial Hermann (Houston, Texas). The intervention was implemented and data were collected in the fall of 2016 at TIRR Memorial Hermann. Acknowledgements We acknowledge and thank members of our community advisory board (Mayra Cantu, Julie Collins, and Kemi Yemi-Ese) for advising us on the development of the intervention. We also acknowledge the women with spinal cord injury who participated in the intervention. References 1. National Spinal Cord Injury Statistical Center. Spinal cord injury facts and figures at a glance: 2019 SCI data sheet. Retrieved from https://www.nscisc.uab. edu/Public/Facts%20and%20Figures%202019%20-%20Final.pdf; 2019. 2. Robinson-Whelen S, Taylor HB, Hughes RB, Wensel L, Nosek MA. Depression and depression treatment in women with spinal cord injury. Top Spinal Cord Inj Rehabil. 2014;20(1):23e31. 3. Treischmann RB. Spinal Cord Injuries: Psychological, Social and Vocational Adjustment. New York: Pergamon; 1980. 4. Chau L, Hegedus L, Praamsma M, et al. Women living with a spinal cord injury: perceptions about their changed bodies. Qual Health Res. 2008;18(2):209e221.
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Please cite this article as: Robinson-Whelen S et al., Promoting psychological health in women with SCI: Development of an online self-esteem intervention, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100867