Introduction

After a spinal cord injury (SCI), the majority of people will require some life adjustments such as adapting to their homes [1], integrating new self-care activities [2], and, potentially, learning new coping strategies (i.e., cognitive mechanisms to reduce stress) to help manage these changes [3]. The way people interpret their injury and the strategies they use to cope with these interpretations have a significant influence on their adjustment [4] and have been shown to reduce the impact of the injury [5], above and beyond moderating factors such as functional independence, sex, age, income, and class [6].

In an effort to identify the coping strategies used by adults with SCI, Elfstrom et al. [7] found that adults tended to find ways of approaching stressors by changing themselves, re-evaluating life values, and looking for ways to diminish the gap between their personal capacities and situational demands, which is a strategy they called “acceptance of injury”. They also found that others tried to challenge the stressors in their lives by increasing their personal control over their life circumstances and their efforts to behave independently (“fighting spirit”). Finally, some adults with SCI attempted to find external controls for their stressors and relied on others to help close the gap between personal capacities and situational demands (“social reliance”). Fighting spirit and acceptance of injury are considered to be positive coping strategies, whereas social reliance is considered to be a negative strategy [8].

These coping strategies have been linked with positive and negative outcomes among adults with SCI. Specifically, acceptance of injury has been positively associated with increased well-being [8, 9], increased psychological adjustment to SCI [10, 11], and reduced anxiety and depression [12]. Similar results were found for fighting spirit, which appears to hold 1-year post-injury [13], as well as across longer time periods [14]. Social reliance, however, has been shown to promote negative outcomes such as increased distress [9, 15], decreased life satisfaction and participation [16], and decreased functional independence [13].

Adults with SCI can learn these coping strategies through cognitive-behavioral training [6] or through the support of their social environment [17], which helps them change their perspective and reframe their appraisals [18]. One additional approach that could help promote the use of coping strategies is peer mentorship. Peer mentorship consists of linking trained peer mentors with fellow adults living with SCI. The premise is that peer mentors are individuals who, through their life experiences with SCI, can provide empathetic understanding, practical advice, and emotional support to their mentees [19, 20]. Peer mentorship programs are often embedded within SCI community organizations, whereby the structure and delivery of these programs can vary from one community organization to another. Emerging research in peer mentoring for adults with SCI suggests that participation in these programs promotes a number of positive outcomes. These outcomes include enhanced wheelchair training skills [21], lower hospitalization rates [22], better self-management skills [23], improved self-efficacy [24], increased life satisfaction[25], and social participation [26, 27]. The role of SCI peer mentorship in assisting with coping has also been suggested in some qualitative studies [20, 28]. Currently, SCI peer mentorship programs have been under-utilized as a potential means for promoting positive coping strategies for adults with SCI.

Present study

The objective of the present study is to determine whether participation in peer mentorship programs is related to an increase in the reported use of positive coping strategies for adults with SCI. Specifically, this study will use a static group comparison design to retrospectively compare adults with SCI who have participated in peer mentorship (mentees) with those who have not (non-mentees) to determine whether there are any differences in their reported coping strategies, while controlling for demographic and SCI characteristics. It is anticipated that participation in peer mentorship will be associated with increased reports of positive  coping strategies (acceptance of injury and fighting spirit) and decreased reports of the social reliance strategy for adults with SCI.

Methods

Participants

A convenience sample of mentees (n = 68) and non-mentees (n = 63) who had an SCI were recruited for the present study from a community-based SCI organization in Canada.Footnote 1 The mentees had to have participated in the organization’s peer mentorship program, which is a non-structured individualized program aimed at enhancing independence and quality of life for adults with SCI. Peer mentors and the directors of the organization found that meaningful interactions typically started on the fourth meeting and previous research has shown that the effects of peer mentorship have been shown to persist for 10 years [27]. As such, the organization identified mentees as those who had received at least 4 peer mentorship sessions in the past 5 years, and non-mentees as individuals who received only 1 short introductory session or no sessions with a peer mentor. Contact lists were generated for both groups and the research team recruited mentees and non-mentees by e-mail and telephone between January and September 2015. In order to participate, they had to be above the age of 18, have an SCI for at least 1 year, and speak either English or French. Participants were excluded if they reported any serious cognitive impairments. Informed consent was provided and participants were offered a $25 gift card for their participation. This study consists of a secondary analysis on this sample of adults with SCI that has already been published [27]. The primary outcome of that study was to examine how participation in peer mentorship was related to motivation, well-being, and participation for adults with SCI.

Materials

Participants completed the following measures through an online and telephone survey.

Demographic profile

Participants reported their age, sex, relationship status, education, ethnicity, years since injury, injury level, mobility device, ASIA classification, adapted vehicle and home, and access to adapted transport. All variables are reported in Table 1. For the purposes of the present analyses, the education and mobility device variables were recorded into dichotomous variables (Education: secondary education or post-secondary education; mobility device: powered wheelchairs or other mobility devices).

Table 1 Participant demographic and spinal cord injury characteristics
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Coping

Participants completed the Spinal Cord Lesion—Coping Strategies Questionnaire (SCL-CS) [7, 8], which assesses three coping strategies for adults with SCI. The first, acceptance of injury (4 items), measures the extent life values have been re-evaluated following injury. Fighting spirit (5 items) measures efforts to behave independently, and finally, social reliance (3 items) measures how adults become dependent on other social beings. Participants respond to each statement using a 4-point Likert scale from 1 (strongly disagree) to 4 (strongly agree). The original validation studies supported that the subscales had acceptable internal reliability (acceptance of injury α = 0.78–0.79; fighting spirit α = 0.61–0.73; social reliance α = 0.68–0.72). Mean scores are calculated to represent each coping domain where higher scores indicate greater affirmation of each type of coping strategy. In this sample, the acceptance of injury and fighting spirit subscales demonstrated strong internal reliability (α = 0.82 and 0.87, respectively), whereas the social reliance subscale did not (α = 0.39). Closer inspection of the social reliance items suggested that the items may assess different constructs. For example, “You have to believe that other people are able to help you out” focused on beliefs about other people, whereas “I would feel completely helpless without support from others” and “My lesion has taught me that we are all dependent upon others” focused on dependence on others. However, removing that item from the social reliance subscale did not substantially improve the reliability (α = 0.47), as such, a composite score was not calculated. Since this subscale could not be used as per the scale guidelines, social reliance was not included in the subsequent study analyses.

Data analysis

First, we examined the normality and checked for univariate outliers for all study variables. Next, group differences (mentee vs. non-mentee) on all demographic (sex, relationship status, education, age, and ethnicity) and SCI (injury level, ASIA classification, mobility device, adapted house, adapted vehicle, adapted transportation, and years since injury) variables were examined using t-tests and chi-square analyses. We also conducted Pearson correlations analyses between the demographic and SCI variables with acceptance of injury and fighting spirit in order to identify any potential covariates.

Because years since injury differs as a function of whether participants received peer mentoring or not (see Results section), moderation analyses were performed to determine whether participation in peer mentorship programs is related to an increase in the reported use of  positive coping strategies for adults with spinal cord injury. Moderation was analyzed using the PROCESS macro for SPSS (Model 1) [29]. To yield standardized coefficients, all variables were converted to z-scores prior to analysis. PROCESS calculates a bias-corrected and accelerated bootstrapped confidence interval (10,000 resamples) for the size of the interaction effect (Peer mentorship*years since injury), with significant moderation indicated by a confidence interval that does not contain zero. Change in R2 indicated the size of the effect where 0.02, 0.13, and 0.26 were indicative of small, medium, and large effects, respectively [30].

Results

Means, standard deviations, and correlations between the demographic and SCI variables are listed in Table 1. Data patterns were examined to identify missing observations and revealed that some variables (i.e., sex, social reliance, injury level) were missing between 1 and 3 observations. Given that this represented less than 2% of overall observations, no modifications were made and a pairwise deletion method was used in the analyses when necessary. Descriptive statistics were calculated for the coping strategies variables (see Table 2). Normality tests showed that acceptance of injury (skewness = −0.32, kurtosis = −0.12) had a normal distribution; but that fighting spirit (skewness = −1.87, kurtosis = 4.34) had a non-normal distribution. Fighting spirit was log transformed to improve normality and satisfy test assumptions (revised skewness = −0.49, kurtosis = 0.50) and, since the variable was reflected during transformation, it was re-reflected to maintain original directionality and interpretation [31]. No univariate outliers were found.

Table 2 Descriptive statistics of coping strategies and correlations with demographic and SCI variables
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Next, as reported in Sweet et al. [27], the results of the correlational analyses with the spinal cord injury/demographic variables with the independent variable showed there was a significant difference between non-mentees (M = 20.10, SD = 12.80) and mentees (M = 14.10, SD = 13.50) for years since injury, t(117) = 2.62, p = 0.010. As such, the main analyses will control for participants’ years since injury via a moderation analysis. Finally, we examined all correlations of the spinal cord injury/demographic variables with acceptance of injury and fighting spirit (Table 2). Since years injury was not included in these analyses as it was already identified as having a relationship with the independent variable [32]. Sex and education (women and those with post-secondary education) were significantly and positively associated with fighting spirit and were controlled for in the respective analyses.

A series of analyses were performed in order to test whether peer mentorship impacts coping for adults with spinal cord injury, as assessed by their acceptance of their injury and their fighting spirit. First, the interaction between peer mentorship and years since injury on acceptance of injury was significant with a small to moderate effect size (F(5127) = 6.86, p < 0.001, r2 = 0.14; see Table 3). To interpret the moderation, years since injury was graphed as low (1 standard deviation below the mean ~6), medium (the mean ~18), and high (1 standard deviation above the mean ~30). There were no reported differences between groups at medium years since injury (~18 years); however, at low years since injury (~6 years), non-mentees reported slightly greater acceptance of injury than mentees and at high years since injury, mentees reported greater acceptance of injury than non-mentees (See Figure 1a and Table 4). Next, the interaction between peer mentorship and years since injury on fighting spirit, while controlling for sex and education, was significant with a small to moderate effect size (F(5123) = 4.96, p < 0.001, r2 = 0.17; Table 3). A similar pattern emerged in the results where there were no differences between groups at medium years since injury. Non-mentees living with their injury for ~6 years, however, reported slightly higher fighting spirit and mentees living with spinal cord injury for ~30 years reported greater fighting spirit (Figure1b and Table 4).

Table 3 Moderation results
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Table 4 Descriptive statistics and mean comparisons for Fig. 1
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Fig. 1
figure 1

Interaction between peer mentorship and years since injury on coping strategies. Please note that the Y-Axis (acceptance of injury or fighting spirit) are in their original units of measurement (1–4) in order to ease interpretability

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Discussion

The objective of the present study was to determine whether participation in peer mentorship programs was related to greater self-reported use of positive  coping strategies for adults with spinal cord injury. Overall, the results found support for this objective and help provide additional evidence for the positive role peer mentorship plays for adults with spinal cord injury.

We found that there was a positive association between peer mentorship and the coping strategies of acceptance of injury and fighting spirit (after controlling for participants’ education and sex), but only for those who have been living with spinal cord injury for longer. However, the inverse was also found for fewer years since injury. These findings may relate to some studies indicating that the types of coping strategies used for adults with spinal cord injury is always evolving [33], but contrast to other longitudinal research hinting that coping strategies remain relatively stable over time [34]. This moderation effect of years since injury was also seen in the primary outcome of this study [27] that found peer mentorship was positively related to life satisfaction and social participation, but only for those who had been injured for a longer time. In line with these findings, the effects of peer mentorship on coping strategies may be stronger for adults who have been injured longer. It is possible that some factors that are covered through mentorship do not become relevant to the mentee until many years following their injury. It is also plausible that non-mentees who are coping well in the earlier years do not seek peer mentorship, which may be detrimental in the long-term if they do not reach out when in need. There are no published data to compare our findings; thus, more research on peer mentorship and coping strategies is needed before strong conclusions can be made.

We did not examine the relationship between peer mentorship and social reliance as we were unable to establish reliability of that subscale. Since social reliance is considered a negative coping strategy that is associated with outcomes such as increased distress [7], decreased life satisfaction [16], and decreased independence [13], we hypothesized that those who participated in peer mentorship would report less social reliance than those who did not. We suspect that the low reliability on this measure was related to the ambiguity of the three items. Specifically, the only item that fully captured the social reliance construct was “I would feel completely helpless without support from others”, whereas the other items focused on beliefs that others have the capacity to help when required and we are all dependant on others. It would be important to further examine this construct using a modified or different measure of this construct.

Although not part of our main objectives, the significant relationships between the covariates and coping strategies do provide additional insights. We found that sex and education were significant covariates for the fighting spirit coping strategies, where women and those with a post-secondary education were more likely to endorse this copy strategy. Although existing spinal cord injury research has found mixed results for differences between males and females [7, 8, 35], research from other fields has consistently found that men and women do vary on the types of coping strategies they use [36]. As for the relationship with education, some coping strategies rely on cognitive skills that are enhanced by education [37] and it is possible that those with more education are better equipped to maintain their fighting spirit.

Limitations

Although this study did provide insight into how participation in peer mentorship programs may be associated with increased use of positive coping strategies for adults with spinal cord injury, the results should be interpreted with caution. To start, this study relied on self-reported data at one single timepoint, thus limiting the comparisons to correlational analyses. Additionally, although the sample consisted of both mentees and non-mentees, this was a community-based static group comparison design with no control or matched comparison group. As such, it is possible that the differences observed between the groups are due to other factors that were not measured as part of this study. Finally, related to the peer mentorship program specifically, we did not collect data related to the frequency of peer mentorship sessions, their satisfaction with these sessions, or whether the sessions occurred individually or in a group format. As a result, the study cannot shed insight into which specific aspects of a peer mentorship program are the most important.

Future directions and practical applications

The results of this study suggest that peer mentorship programs could serve as a means for promoting positive coping strategies for adults with SCI. To better understand the role of peer mentorship in promoting positive coping strategies, future research should continue to examine the outcomes of participating in peer mentorship for adults with SCI. Specifically, these studies should use stronger methodological approaches (i.e., experimental and longitudinal) in order to fully understand the role peer mentorship plays in impacting the types of strategies used. Additionally, research should look beyond the strategies examined in the present study and explore other types of coping (e.g., reappraisal) [6] and their relationship with peer mentorship. Finally, future research should further explore the role of years since injury and understanding why participating in peer mentorship appears to have a greater influence on those who have been injured longer.

Overall, these findings provide additional support for the positive outcomes associated with participating in peer mentorship programs. Since most peer mentorship programs are offered through SCI community-based organizations, these findings may provide additional justification for offering this type of programming and the resources required to run it.