Introduction

Spinal cord injury (SCI) is a devastating neurological condition with many psychological and physical consequences in personal, social, and economic fields. In the past 30 years, its global prevalence has increased from 236 to 1 298 cases per million populations [1]. 
Every year, many people suffer from injuries to the spine and spinal cord due to war, accidents, falls from a height, and diseases of the spine, spinal cord, and neck. Among the consequences of SCI in an individual context, we can mention neurological, pulmonary, digestive, cardiovascular, kidney and urinary tract problems, weight control problems, bedsores, pain, psychological problems, such as depression, anxiety, post-traumatic stress disorder, suicide, sadness, anger, decreased self-confidence, impaired self-concept, and guilt. After that, the social and extra-familial correlation of the person with disabilities is also affected, and economically, it results in a lack of salary, rehabilitation and treatment costs, financial problems, and loss of job. One of the crucial goals is to rehabilitate people. It has SCI, integration in society, and improvement of quality of life [2]. Social integration has three aspects, integration at home, which includes active participation in household chores, integration in society, which includes doing activities outside the home, such as shopping and meeting friends, and integration in productive activities related to employment, job, and educational activities [2]. Social integration of people with disabilities is a key target in all scopes of rehabilitation and is the focus of all healthcare professionals. SCI occurs after a sudden event and usually leads to a change in a person’s performance, such as a decrease in job performance, social integration, and participation in the family environment, leisure time, and school activities, and this decrease in performance is influenced by factors related to the severity and the type of damage and internal factors, such as cognitive, psychological and motor skills, demographic variables such as age, gender and culture, education level, economic status, and social support [3]. In a study, Akyuz et al. reported that social integration of people with SCI was low. Also, they reported that problems related to adapting to the environment and design and access, understanding, and attitude of other healthy people to SCI, as well as health-related problems, especially pain, problems economic and psychological problems, were cited as obstacles to their social integration, respectively [4]. 
 On the other hand, supporting people with SCI and meeting their needs greatly contributes to social integration [5]. A need is a lack that is felt by a person and forces a person to find a way to solve it, for this reason, it is also called motivational demands. Satisfying demands, especially satisfying the highest demands (self-fulfillment and self-fulfillment) makes a person actively try in society. If a person’s demands are not given importance, the person’s compatibility with his surroundings and his participation and productivity will decrease [6]. Although most of the research is related to meeting people’s demands in terms of health and well-being, less attention has been paid to it about people with disabilities and in rehabilitation programs. This study was conducted to determine the correlation between the level of estimated needs and social integration in people with SCI in Saqez City in 2021.

Materials and Methods

The present study was descriptive, analytical, and cross-sectional. The statistical population in the present study was people with SCI in Saqez City in 2021. The statistical sample of the present study was 99 people with SCI in the rehabilitation unit of the Welfare Department and other related departments (aid committee, Martyr Foundation) of Saqez City, who were selected as non-probably and available. After selecting people with SCI who have been injured for at least one year and whose injury is at the trunk and lumbar level and can use their hands, in cooperation with the rehabilitation unit of the Welfare Department (aid committee, Martyr Foundation) of Saqez City and the special worker for people with SCI, the list of these people was taken along with their detailed information, place of life, and phone number, and with the cooperation of the worker and through phone calls with them, coordination was made with the people who wanted to attend the welfare center and complete the questionnaire in person. They attended the welfare office by observing the health protocols of COVID-19 and travel expenses were also covered by the researcher, and they completed the valid questionnaires on Community Integration Questionnaire (CIQ) and Camberwell Assessment of Need for the Elderly (CANE). For people who did not want to attend, or were unable to visit in person due to illness or special disability, did not want the researcher to be present at their place of home, the questionnaire was remotely completed (through the Internet and applications or phone calls), and if the person wanted to be at home, the person’s place of residence or his workplace was referred to, and in the total process, one person visited, and protocols, such as wearing a mask, and preserving safe distance were considered. Before completing the questionnaire, the visitor was given the necessary information on how to complete the questionnaire and how long it would take to complete it, and the answers were done in calm conditions and in sufficient time, with the help of a helper if needed, and in case of inability to read and write, the visitor or researcher reads the questions to the individual. Two questionnaires on social integration and psychological needs were provided to the individual, and the first author was also with the individual to resolve any doubts. Information was also collected by a questionnaire consisting of two demographic sections and a needs assessment questionnaire based on the standard tools of CANE and CIQ.

Camberwell assessment of need for the elderly (CANE) questionnaire 

CANE questionnaire is a comprehensive tool to assess needs that is suitable for different clinical and research environments [7]. Camberwell’s needs assessment questionnaire enables a comprehensive assessment of multi-dimensional needs related to social, psychological, physical health, and environmental demands. This questionnaire is conducted in the form of an interview with the individual, informal caregivers as people who provide informal assistance, and staff of centers providing official services, and provides the possibility of comparing their views and differences. This questionnaire has 24 items, each of which has 24 titles related to the user, two titles A and B related to the caregiver, and four columns for scoring so that one or more users, staff, caregivers, or evaluators can express their opinions. The total score is obtained based on the scores of section 1 of each of the 24 problem areas. The Camberwell tool was recently validated and reliable by Davatgaran et al. in 2016. The intraclass correlation coefficient for the total scores (met and unmet needs) was obtained with a confidence coefficient of 0.78 and 0.87 [8].

Community integration questionnaire (CIQ) 

CIQ is designed to evaluate integration at home, social integration, and productive activity [9]. Wheeler et al. designed and used the first version of this tool for people with brain damage. This tool includes 15 items in three sub-sets of integration at home (1 to 5), integration in the community (6 to 11), and production activities (12 to 15). The scores of the questionnaire items are different and between 0 and 2 in the form of a Likert scale. The Persian version of the CIQ has repeatability (intraclass correlation coefficient [ICC] ≥0.7) and internal consistency (α≥0.7) [10].

Data analysis 

All statistical analyses were performed using SPSS software, version 24.0. at a significance level of 0.5. The Kolmogorov-Smirnov test was used to check whether data were normally distributed. Descriptive statistics indicators included mean±standard deviation (SD). Multiple regression was used to check the correlation between the variables due to the non-normal distribution of the data.

Results 

According to the results of the descriptive statistics in Table 1, among the 99 participants in this study, 72 people (72.73%) were men. The mean and SD of the age of the subjects was 44.67±13.91 and most of the 33 participants (33.33%) had primary education.



Also, Table 2 presents the distribution of integration scores in the home, community, and productive activities of the study of SCI individuals, based on which the mean and SD of the integration score at home was 3.55±3.23, and integration in the community was 97.00±2.83. 6.6 and production activities were 2.33±1.52.



Also, a significant negative correlation was observed between the mean score of unestimated needs and the integration scale at home (P=0.001, r=-0.418). This means that by reducing the score of unestimated needs, the score of integration at home increases. A significant negative correlation (P=0.001, r=-0.541) was observed between the mean score of unestimated needs and the social integration scale. This means that by decreasing the score of unestimated needs, the score of integration in the community will increase. A significant negative correlation was observed between the mean score of unestimated needs and the productivity scale (P=0.001, r= -0.444). This means that by reducing the score of unestimated needs, the productivity score increases (Table 3).



Discussion

This study was conducted to investigate the correlation between the level of estimated needs and the community integration of people with SCI in Saqez City in 2021. The study showed that out of the 24 basic needs raised in the Camberwell questionnaire, 17 basic needs of a person had an effect on his integration and 7 other needs had no effect.
The results of the descriptive statistics showed that most participants in the study were men, which was according to the results of the study conducted by Zhao et al. [11], Tsai et al. [12], Callaway et al. [13]. Also, the mean age of the participants was 44 years, which was according to the study conducted by Kennedy et al. [14] and Zurcher et al. [15]. Therefore, based on previous studies and the results of this study, it seems that SCI often occurs among men and in older age groups, and in the current study, age has a significant inverse correlation with the integration score at home, integration in the community, and the integration score in productive activities. Therefore, the older the person is, the lower their level of integration is, and according to the results of this research, more intervention measures are required to increase integration at home, in the community, and productive activities. Traumas leading to SCI are more common among men than women [16].
The results of inferential statistics showed that one of the vital unestimated needs of people is the need for improved housing, in this regard, Kashif et al. reported that one of the vital unestimated needs of SCI people is the need for improved housing. Failure to estimate the need for improved housing has caused the integration of these people at home to be low and they cannot perform many of their tasks at home [17]. Hosseini et al. [18] reported people with SCI who use a non-automatic (manual) wheelchair as their main tool of mobility, their ability to perform wheelchair manual skills was associated with higher community participation and satisfaction with life. Factors contributing to low success rates should be investigated and interventions needed to improve these rates [18]. Thus, one of the critical steps to increase the integration score of SCI people at home is the provision of improved housing, which has not been met, effective practical measures should be taken in this scope, and more research is needed in this respect, and how to make changes at home. Examining the results of the scale of productive activities indicated a low score of integration of productive activities in SCI people. In this regard, Kee et al. [19] reported in a study that the return to employment activities of SCI people is necessary for social integration. Samuel T. Gontkovsky stated in a report that the independence and social adjustment of SCI people are highly related to their occupational independence [20]. Therefore, the crucial issue to improve integration (directly and indirectly) of people with SCI is to increase the scale score of productive activities and empower them for employment.
Khanjani et al. [21] reported one of the effective factors in a person’s adaptation to a lesion is various social participation, including being active in social work, such as active membership in disabled groups, occupational activities, as well as recreational and sports activities, despite all existing obstacles. It was for the presence of these people in the society. On the other hand, the increase in social participation has made these people visible and finding solutions to remove obstacles [21]. Another study reported that family formation leads to better adaptation to SCI [22]. Tyagi et al. [23] also stated that, during the discharge of people with SCI, all caregivers should be informed about environmental factors, such as barriers or facilitators, capacity, performance, and participation of people so that they can practice their teachable skills at home [23].
Therefore, effective activity and return to the society and daily life of people with SCI is still required, which requires more effective steps. Customized housing according to the conditions of the SCI people is a main demand for these people to integrate at home and social integration and productivity. Unfortunately, it has not been met for a significant part of people with SCI. On the other hand, the need for effective social and friendly activity is one of the unappreciated and common needs of SCI people, which has a significant impact on their quality of life, social integration, and employment.

Conclusion 

The results demonstrated that the unmet needs of people with SCI are related to the level of integration in the three levels of home, social integration, and integration in production activities. So, we suggest the basic needs of people with SCI, especially the need to adapt their place of residence and workplace, should be evaluated and intervened. Rehabilitation managers and disability support organizations should have plans to reduce the unmet needs of people with SCI.

Ethical Considerations
Compliance with ethical guidelines

The Ethics Committee of the University of Social Welfare and Rehabilitation Sciences has approved this study with ethics code 22448. In this study, before the interview and after explaining the purpose and process of the research, written consent was obtained from the participants and they were assured that their information would be kept confidential and the participants were allowed to withdraw from the study at any stage. Also, due to the epidemic of COVID-19 disease, it was essential to observe health tips in all stages of research, especially about the disabled.

Funding

The article was extracted from the master thesis, of Diman Nikooee, Department of Rehabilitation Management, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran. 

Authors' contributions

All authors equally contributed to preparing this article.

Conflict of interest

The authors declared no conflict of interest.

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