Social Participation of Adults with Spinal Cord Injury During the First Two Waves of the COVID-19 Pandemic in Canada: An Exploratory Longitudinal Study

Abstract

Introduction: The change in environmental and social context during the COVID-19 pandemic affected daily activities of people with spinal cord injury (SCI), their interactions within the community, and, consequently, their social participation during the first wave of the pandemic. However, there is little information about the changes in social participation as the pandemic evolved in Canada. Objective: Our aim was to explore the change in the social participation of adults with SCI after the first two years of the COVID-19 pandemic in Canada. Methods: A follow-up from a previous study exploring the social participation of adults with SCI living during the first wave was conducted eight months later (second wave). Social participation was measured using the Assessment of Life Habits (LIFE-H 4.0) and Measure of Quality of the Environment (MQE) among 18 adults with SCI. Results: Participants reported increases between both waves of COVID-19 in some life habit categories, including mobility, personal care and health, nutrition, and recreation. New environmental factors were identified as facilitators, including the increased availability of businesses in the community. Conclusion: These findings indicate that people with SCI experienced greater realization and satisfaction with certain life habits. Although most barriers and facilitators showed little or no change between the two waves, the reduction in environmental barriers and the increase in facilitators may have contributed to improved social participation as the pandemic progressed.

1. Introduction

In 2022, 8 million Canadians 15 years and older were living with one or more disabilities [1]. According to the World Health Organization, the COVID-19 pandemic and the associated protective and isolation measures have highlighted significant inequities within the population, including those experienced by people with disabilities [2]. In this state of emergency context, the rapid changes (e.g., curfew, changes in the supply of health services, and closure of some businesses) [3] had an impact on physical activity levels, precarious employment, and deteriorating mental health for people with disabilities [4,5,6]. This finding is particularly concerning considering that people with disabilities often have poorer health outcomes than people without disability due to the multiple barriers that limit access to healthcare services, which was reported even before the pandemic [2]. These barriers include, for example, physical environment, logistic related to transportation to the healthcare centers, and a lack of understanding of their healthcare needs [7]. Previous studies have reported that the pandemic increased the social isolation experienced by people with disabilities [8]. Thus, the pandemic has inevitably affected the way people with disabilities carry out their daily activities and how they interact with their community [9]. In turn, people with disabilities experienced changes to their social participation [10], and an overall reduction in their quality of life [11].

According to the World Health Organization, the annual global incidence of spinal cord injury (SCI) is estimated to be approximately 40-to-80 cases per million annually [12], with nearly 31,000 people living with SCI in Canada in 2019 [13]. SCI is a major cause of long-term disability, accounting for over 4.5 million years of life lived with disability worldwide in 2021 [14,15]. Findings from a systematic review reported a various consequences associated with SCI [16], such as loss of motor functions, bowel and bladder dysfunction, and limited mobility [12].

Due to the interaction between individuals and the environment (i.e., obstacles or facilitators), people with SCI are susceptible to face disabling situations, as defined in the Human Development Model-Disability Creation Process (HDM-DCP) [17]. Therefore, the presence of environmental facilitators are important to ensure social participation for people with SCI [16]. For example, people with SCI have specific need to maintain their social participation, such as peer support, adapted transportation, technical aids, and healthcare SCI-related services [18]. In a study conducted among 382 adults with SCI during 2020 and 2021, 59% of participants reported that the COVID-19-related restrictions negatively affected their social participation [19]. More specifically, 51% agreed or strongly agreed that the COVID-19 restrictions drastically reduced their community participation [19]. In addition, a recent scoping review (2024) revealed that the pandemic was detrimental to healthcare utilization, access, and outcomes in individuals with SCI [20]. For example, the frequency of going out, receiving home-visit nursing, and rehabilitation services has decreased during the pandemic period [21]. In Canada, a study reported that protection measures (e.g., foot pump for hand sanitizers) for people with SCI were not adequately adapted during the first wave of the pandemic [9]. However, positive attitudes, support from family and friends, and availability of businesses in the community (e.g., grocery, drug and hardware stores) were reported as facilitators to social participation for people with SCI at the beginning of the pandemic [9].

Social participation has been positively associated with personal fulfillment, and a sense of wellbeing and belongingness [22,23]. These findings are important, given that even before the pandemic, people with disabilities faced obstacles to attaining full social participation, such as discriminatory attitudes [24], problems with transportation [25], lack of facilities, and difficulties with accessibility [26]. As the pandemic progressed in Canada [3], protective and isolation measures were added, modified, and in some cases, removed, leading to a period of uncertainty and adaptation for people with disabilities, such as people with SCI [27]. These changes are potentially influencing, either positively or negatively, the social participation of people with SCI in Canada. Furthermore, social participation may also have evolved for people with SCI since the first wave of the pandemic. The changes in social participation throughout the pandemic are less well documented than social participation at specific times. This information is particularly relevant for exploring how barriers and facilitators have evolved, and how individuals with SCI have adapted in achieving their life habits, thereby informing potential strategies to promote their social participation. In this context, the objective of this study was to explore the change in the social participation of adults with SCI after the first two years of the COVID-19 pandemic in Canada.

2. Materials and Methods

2.1. Design

This exploratory study was conducted in follow up to a previous study exploring the social participation of adults with SCI in Canada during the first wave of the COVID-19 pandemic (abbreviated T1 hereafter) [9]. The present exploratory study (abbreviated T2 hereafter) was conducted during the second wave of the pandemic, approximately eight months after T1. Protective and isolation measures evolved over the period from T1 to T2 in Quebec and British Columbia. A summary of certain protective and isolation measures implemented or modified during T1 and T2 in Quebec and British Colombia is presented in

Table 1. Summary of certain protective and isolation measures implemented or modified during T1 and T2, according to the Canadian Institute for Health Information [3].

First Wave of The COVID-19 Pandemic (T1)	Second Wave of The COVID-19 Pandemic (T2)
Data Collection Between May and July 2020	Data Collection Between December 2020 and April 2021
Protective and Isolation Measures
Quebec
Outdoor recreational activities were permitted	Recreational activities and sports were prohibited in certain regions
The wearing of masks was mandated in indoor public spaces and transport services	Non-essential businesses and personal services were closed
Non-emergency health services were minimized	Private professional and health services were restricted
Outdoor gatherings of 10 people of fewer were permitted in May 2020	Curfew imposed in certain regions in April 2021, and was lifted
Indoor gatherings of 50 in public places were permitted in June 2020	Vaccinations were initiated for some targeted groups, and vaccinations became available for people with disabilities in April 2021
British Columbia
Non-essential businesses reopened in May 2020	Indoor fitness activities and team sports were prohibited
Recommendation to avoid gatherings	Vaccinations was initiated for certain target groups
Elective surgeries resumed in May 2020	The wearing of masks was enforced in indoor public spaces
Visitor access to acute care and long-term care were restricted	Indoor food and drinks services were suspended

. Information regarding all protective and isolation measures are available on the website of the Canadian Institute for Health Information [3].

2.2. Participants

Participants were recruited from a convenience sample in an ongoing longitudinal Canadian multi-site trial (i.e., Quebec City, Montreal, and Vancouver) [28]. The purpose of this randomized controlled trial was to evaluate the efficacy of the Active Living Lifestyles for the manual wheelchair users program for increasing leisure-time physical activity among manual wheelchair users with SCI. Given that the pandemic may have influenced behaviour and participation of this sample, we felt it was pertinent to explore participation more broadly during unprecedented times. As reported by Best et al. [28], to be eligible to participate in this trial, participants had to be 18–65 years older; able to speak English or French; live in the community; have a traumatic or nontraumatic SCI; use a manual wheelchair for at least 1 month; able to self-propel a manual wheelchair for at least 100 m; and do less than the recommended amount of physical activity suggested in the guidelines for adults with SCI. Participants with degenerative conditions were excluded. Participants were recruited through community and clinical partners [28].

This study was approved by the Comité d’éthique de la recherche sectoriel en réadaptation et intégration sociale of the Centre intégré universitaire de santé et de services sociaux (CIUSSS) de la Capitale-Nationale (#MP-13-2018-415, RIS_EMP-2018-590). The Standards for Reporting Observational Studies (STROBE) were followed [29].

2.3. Data Collection

Sociodemographic data (i.e., age, sex, province, employment status, highest education level, annual income, diagnosis, length of time using a wheelchair) were collected at the baseline of the larger ongoing trial. For recruitment in the present study (T2), all participants of the larger ongoing trial were contacted by phone. Considering that the definition of the social participation proposed by the HDM-DCP was used, each participant completed two validated questionnaires based on the HDM-DCP to measure social participation between December 2020 and April 2021, namely the Assessment of Life Habits (LIFE-H 4.0) and Measure of Quality of the Environment (MQE). The questionnaires were completed by phone or videoconference according to the participants’ preferences, and with the assistance of a research professional (C.R.) if the participant expressed the need. The questionnaires completed with the help of the research professional (C.R.) were finished in a single session. Of note, participants completed the same items that were selected from these two questionnaires during T1 to measure changes in social participation [9].

2.4. Assessment of Life Habits (LIFE-H 4.0)

LIFE-H 4.0 was used to measure the quantity and quality of social participation according to the conceptual HDM-DCP [30]. Among the 96 items contains in the full version of LIFE-H 4.0, a group of expert researchers selected 32 items from the questions to assess the realization of twelve life habits. These items have been selected to cover all categories of life habits and select those that are most relevant in the context of the pandemic. These twelve life habits are divided into two broad categories: current activities and social roles habits. The two categories are further divided into six life habits each: (1) communication; (2) mobility; (3) nutrition; (4) physical fitness and psychological well-being; (5) personal care and health; (6) housing; (7) responsibility; (8) interpersonal relationships; (9) community and spiritual life; (10) education; (11) employment; and (12) recreation [30] (Supplemental Table S1). For each item, scoring was applied according to a series of questions, including the realization of the life habits. A total score of the level of social participation was calculated based on responses to 32 items. Total scores were then rescaled over ten points for comparison purposes. A higher score indicates greater independence, less difficulty, and greater satisfaction. Of note, all participants reported that the education life habit category of the LIFE-H was not applicable. Thus, the education life habit category is not presented.

2.5. Measure of Quality of the Environment (MQE)

The MQE was used to assess environmental barriers and facilitators to social participation [31]. The tool was developed on the disability creation model and was content-validated by a group of rehabilitation professionals. While the full version of the MQE contains 119 items, a group of expert researchers pre-selected 45 items to be indicative of a situation or factor that could influence life habits during the pandemic. Participants rated the 45 items according to whether they were a facilitator or an obstacle based on a 7-point Likert scale ranging from −3 (major obstacle) to 3 (major facilitator). Response options “I don’t know” or “Does not apply” were also possible. The reliability test (test-retest) was conducted among young adults with cerebral palsy, indicating that 85% of the items obtained agreement above 60% [32].

2.6. Data Analysis

Descriptive analyses were conducted for sociodemographic data. Given that LIFE-H and MQE are ordinal scales, data were analyzed using a non-parametric rank-based repeated-measure ANOVA (package nparLD 2.1, R software 3.3) [33], which is an extension of the Wilcoxon signed-rank test. It has the advantage treating missing data with no imputation of data or exclusion of the participants required. The nparLD ANOVA generates a Relative Treatment Effect (RTE), an adjusted probability estimates of effect size. An RTE above (or below) 0.5 reflects that scores measured at a specific time are most often higher (or lower) than the median score of the whole data set. To interpret effect sizes, the general boundaries by Vargha and Delaney (2000, see statistic A12 in Table 1 at page 106) were used for large (RTE ≥ 0.71 or RTE ≤ 0.29), medium (RTE ≥ 0.64 or RTE ≤ 0.36), and small (RTE ≥ 0.56 or RTE ≤ 0.44) effects [34]. Ninety-five percent confidence intervals for the RTE were obtained using 1000 bootstrap samples. The nparLD ANOVA is appropriate for clinical data, since participants are often very similar at the initial time of measurement (e.g., a low realization of life habits for all) with an inflated variance at a second time since participation (e.g., unequally improved their capacities during the delay between measurements). Due to its non-parametric nature, the nparLD ANOVA has no assumption about the sphericity of variance nor the stability of a distribution. The p-value significance was assumed at 0.05.

3. Results

Among the 14 participants who participated in the T1 study [9], 13 agreed to participate in T2. Five new participants who were not enrolled in the study at T1 participated in this study for a total of 18. Participants were predominantly male n = 12 (67%), at 48.8 ± 15.1 years of age, and had 15.1 ± 13.3 years of wheelchair (WC) experience (

Table 2. Description of sociodemographic information and participant characteristics ¹.

Characteristic	n (%)
Age, years (mean [SD])	48.8 [15.1]
Sex
Female	6 (33.3)
Male	12 (66.7)
Province
Quebec	14 (77.8)
British Columbia	4 (22.2)
Employment Status 1
Employed	3 (16.7)
Unemployed	9 (50.0)
Retired	5 (27.8)
Highest Education Level
Less than high school	0 (0.0)
High school (started)	6 (33.3)
College/University (started)	2 (11.1)
College/University (completed)	7 (38.9)
Post-graduate studies	2 (11.1)
Annual Household Income, CAD 1
<14,999	0 (0.0)
15,000–29,999	7 (38.9)
30,000–44,999	3 (16.7)
45,000–59,999	3 (16.7)
60,000–74,999	1 (5.5)
>75,000	2 (11.1)
Diagnosis
Paraplegic	15 (83.3)
Tetraplegic	3 (16.7)
Time Using Any wheelchair, years (mean [SD])	15.1 [13.3]

¹ Missing information for one participant.

). Half of the participants were unemployed (50%) and lived in the province of Quebec (77.8%).

3.1. Assessment of Life Habits (LIFE-H 4.0)

Table 2 presents the change of all the life habit categories evaluated by the LIFE-H questionnaire. Between T1 and T2, the social participation score increased for the broad category of social roles (p = 0.0086; small effect size, 0.59;

Table 3. Evolution of the life habit categories measured by the Assessment of Life Habits (LIFE-H) [35].

Life Habit Category	T1-N	Median Score T1 [IQR 1,2]	T2-N	Median Score T2 [IQR]	p-Value	RTE (95% CI) 5
Mobility	14	5.2 [2.1]	18	6.4 [2.4]	0.0285	0.60 (0.51, 0.67)
Associative and spiritual life	9	0.0 [10.0]	10	10.0 [7.5]	0.3303	0.56 (0.44, 0.67)
Housing	14	7.6 [2.3]	17	8.0 [2.0]	0.6734	0.49 (0.41, 0.57)
Nutrition	14	8.7 [1.2]	18	9.2 [0.9]	0.0206	0.58 (0.51, 0.65)
Physical fitness and physiological well-being	14	7.0 [5.6]	18	8.8 [2.6]	0.1301	0.57 (0.48, 0.65)
Employment	8	4.5 [10.0]	11	9.0 [10.0]	0.5854	0.53 (0.45, 0.62)
Recreation	14	3.2 [8.5]	17	10.0 [3.0]	0.0011	0.60 (0.54, 0.66)
Communication	14	10.0 [0.4]	18	10.0 [0.0]	0.4926	0.52 (0.47, 0.58)
Responsibilities	14	9.3 [1.9]	18	9.2 [1.8]	0.4574	0.52 (0.45, 0.59)
Personal care and health	14	6.9 [1.2]	18	8.0 [1.5]	0.0123	0.58 (0.51, 0.66)
Interpersonal relationships	14	10.0 [0.4]	18	10.0 [10.9]	0.4996	0.48 (0.43, 0.53)
Current activities 3	14	7.6 [1.8]	18	8.1 [1.3]	0.0652	0.58 (0.50, 0.64)
Social roles 4	14	6.7 [3.6]	18	9.1 [2.5]	0.0086	0.58 (0.51, 0.64)

¹ The minimum and maximum scores for each life habit category are 0 and 10, respectively. A higher score indicates greater independence, less difficulty, and greater satisfaction. The category education of LIFE-H was not presented in this study, as this category was not applicable for participants. ² IQR, interquartile range. ³ Current activities include six life habit categories (communication, mobility, nutrition, physical fitness and psychological well-being, personal care and health, and housing). ⁴ Social roles include six life habit categories (responsibilities, interpersonal relationships, community and spiritual life, education, employment, and recreation) ⁵ RTE, relative treatment effect, with 95% CI obtained using 1000 bootstrap samples.

). However, the score of current activities did not reach statistical significance (p = 0.0652; small effect size, 0.57). More precisely, the life habit scores increased for categories of mobility (p = 0.0285); personal care and health (p = 0.0123); nutrition (p = 0.0206); and recreation (p = 0.0011). All effect sizes were rated small according to Vargha and Delaney (Table 3) [34]. There was no statistically significant difference between T1 and T2 for the life habit category responsibilities, associative and spiritual life, housing, physical fitness and physiological well-being and health, employment, interpersonal relationships, and communication (Table 3). Supplemental Figure S1 presents individual scores of LIFE-H at T2, and Supplemental Figure S2 presents individual score changes of LIFE-H between T2 and T1.

3.2. Measure of Quality of the Environment (MQE)

Table 4. Change in environmental factors that facilitated or inhibited participants’ accomplishment of the current activities and their social roles according to the Measure of Quality of the Environment (MQE) ¹.

MQE Item	T1-N	Median Score T1 [IQR 1,2]	T2-N	Median Score T2 [IQR]	p-Value	RTE (95% CI)
The availability of businesses in your community (e.g., grocery store, restaurants, hardware store, department stores, shopping malls)	14	−0.5 [1.0]	18	2 [1.6]	0.0013	0.62 (0.55, 0.69)
Public services (fire, police, ambulance, civil protection)	13	0 [1.1]	16	1 [1.2]	0.0904	0.57 (0.48, 0.65)
Electronic communication services (phone, fax, email, Internet)	14	2 [1]	18	3 [1]	0.0626	0.58 (0.50, 0.67)
Technical aid maintenance services	12	0 [1.6]	18	2 [1.3]	0.0187	0.60 (0.51, 0.67)
Rules (e.g., at school, swimming pool, public places)	14	−1 [1.6]	18	0 [1.2]	0.0273	0.61 (0.51, 0.69)

¹ Mean score according to the 7-point Likert scale: −3 (major obstacle), −2 (medium obstacle), −1 (minor obstacle), 0 (neutral score), 1 (minor facilitator), 2 (medium facilitator), and 3 (major facilitator) [31]. ² IQR, interquartile range.

presents relevant changes between T1 and T2 in environmental factors that facilitated or inhibited the accomplishment of daily habits and social roles according to MQE, as determined by the smallest p-values. The complete results for the MQE are presented in Supplemental Table S2. Briefly, compared to T1, the availability of businesses in the community, such as grocery stores, restaurants, and shopping center increased significantly as a facilitator of participants’ social participation (p = 0.0013). Electronic communication services (e.g., phone, internet) were previously identified as a medium facilitator of social participation at T1, but the median score increased toward being a major facilitator (Likert score > 2) at T2 (p = 0.0626; Table 4). However, this change did not reach statistical significance. Maintenance services for technical aids were also identified as a factor that had no effect on the accomplishment of daily activities at T1, but increased toward a medium facilitator at T2 (p = 0.0187). Finally, rules (e.g., at school, swimming pool, public places, etc.) were identified as a minor obstacle at T1 but increased toward as having no effect on the accomplishment of daily activities at T2 (p = 0.0273). All effect sizes were rated small according to Vargha and Delaney (Table 4) [34]. However, most of the barriers and facilitators have not change between T1 and T2 (see Supplemental Table S2 for additional details). The main environmental facilitators and obstacles reported at T2 are presented in Supplemental Figure S3.

4. Discussion

The objective of this study was to explore the change in the social participation of adults with SCI after the first two years of the COVID-19 pandemic in Canada. The study highlighted little change in facilitators and barriers in the environment of people with SCI that have evolved over the course of the pandemic. The findings also showed an increased realization of certain life habits, which, together, positively influenced the social participation of the participants.

4.1. Improvement in the Accomplishment of Certain Life Habits

The achievement of the broad category of social roles increased between T1 and T2. This change may be trending toward statistical significance (p-value: 0.0652) for the broad category of current activities. Specifically, the domains of mobility, personal care and health, recreation, and nutrition improved significantly. An improved realization of life habits was associated with better social participation according to the HDM-DCP [17]. Halvorsen et al. have also reported a strong association between higher levels of participation and the quality of life (i.e., life satisfaction and mental health) for people with SCI [36]. However, another study exploring the social participation of people with SCI over the same time period (i.e., December 2020 and June 2021) found divergent results [37]. Notably, Robinson-Whelen et al. found a decrease in participation in life roles and activities outside of work [37]. In fact, this study evaluated three life domain outcomes at a single time point. The results may, therefore, have been compared to the pre-pandemic period, whereas our results compare two measurement times during the pandemic period [37]. Furthermore, individual characteristics like age, time since injury, and social role history may influence the level of social participation [38]. Future qualitative studies should explore the determinant of social participation and quality of life of people with SCI during and post crisis periods like the pandemic context.

4.2. Improvement of Environmental Factors and Diminution of Barriers to Social Participation

Participants reported little or no change for most of the barriers and facilitators between T1 and T2 of the pandemic. Most of these results did not reach statistical significance. However, new environmental factors were identified as facilitators in the MQE questionnaire as the pandemic continued. The opening of businesses in the community, such as grocery stores, restaurants, and shopping centers, and the availability of electronic communication services and maintenance were rated as facilitators of social participation. Previous studies found similar observations, highlighting that the level of perceived environmental barriers is inversely associated with social participation and employment [39]. Nevertheless, environmental barriers are still present, which would explain a non-significant improvement in life habits related to associative and spiritual life, physical fitness and physiological well-being, and interpersonal relationships. Future qualitative studies could explore how the realization and satisfaction of these life habits interacts with each another, and how this interaction further influences social participation.

Several factors may explain the changes in social roles as the pandemic evolved. First, people with SCI may have used strategies [40] to maintain their social participation during the pandemic. In this regard, a previous study indicated that social support from friends and family was an important coping strategy for people with SCI, especially when faced with events that cause significant changes [40]. This is consistent with findings in the present study, as support from friends and family was identified as an environmental facilitator (Supplemental Material) to perform daily activities as the pandemic continued. Second, the improvement in certain life habit categories, such as mobility, personal care and health, nutrition, and recreation may be explained in part by protective and isolation measures in place at the time of this study. For example, group outdoor sports, and cultural and recreational activities that had been previously cancelled had returned in public places in February in certain regions of the province of Quebec, which may have reduced environmental barriers [41].

Consistent with other studies conducted among people with disabilities during the pandemic, electronic communication services, such as the phone and internet, were consistently reported as facilitators to social participation during the two waves of the pandemic [42,43]. Since this could be an interesting avenue to increase social participation, it would be of interest to determine whether the use of electronic communication services increased due to the pandemic context. Furthermore, future studies could aim to develop telerehabilition and use of mobile technology (apps, tablets and smartphones) to facilitate participation not only during times of crisis, but at all times to help overcome persistent participation barriers for people with SCI. This sample was recruited from an ongoing trial evaluating participation in a peer-led physical activity counselling, it could be interesting to explore how technology and peer mentors may be used to optimize access to PA programs in the future. In addition, the study highlighted that public rules (e.g., at school, swimming pool, public places) were previously a minor obstacle at T1 and had no influence on the realization of life habits during T2 of the pandemic. Interestingly, although participants perceived that the public rules improved between T1 and T2, existing public rules were not considered a facilitator of social participation. Establishing such rules should be considered in consultation with people with SCI to better meet their needs at all times, not only during a crisis. Future studies should consider the development of appropriate measures and programs to better facilitate social participation for people with SCI. The co-creation of such measures and programs could consider participatory approaches that integrate people with SCI throughout all steps of program development or crisis responses [44].

4.3. Limitations and Strengths

First, this study includes a small sample of people with SCI using a manual wheelchair. Due to the small sample size of the participants and the exploratory design of the study, we did not perform a covariate-adjusted analysis. Thus, the presented results could be explained by other factors, beyond the COVID-19 pandemic, that were not explored in this study. The small sample size also limits the statistical power of our analysis, and hence limited our ability to detect changes over time [45]. Second, given that some participants were actively involved in the intervention of the larger study during the data collection, they were in contact with a peer (i.e., person with SCI who used a manual wheelchair) who may have influenced positively their social participation during the pandemic [46]. Consequently, the participants potentially had a higher social participation associated with their involvement in the larger trial, which limits the generalizability of the findings to other individuals with SCI. Third, five participants who did not participate at T1 were added to T2, and one participant who participated in T1 did not participate in T2, which could induce selection bias [9]. In this regard, recall bias may have been introduced for participants who took part in T1, which was not considered in the analysis. Nonetheless, we decided to include all participants who enrolled in the study to avoid further limiting the sample size and gain the broadest perspective possible about social participation during the pandemic. Fourth, protective and isolation measures in place during the interview were variable depending on the participant’s area of residence, which may have influenced social participation [3]. Fifth, the psychometric qualities of the LIFE-H version 3.0 have been evaluated, but version 4.0 has not yet been formally evaluated [47]. In addition, the category education of LIFE-H is not presented in this study, as this category was not applicable for the participants. Finally, the scopes of the LIFE-H and MQE questionnaires are inherently limited, e.g., “increased availability of businesses in the community” provides limited information regarding the extent of business availability.

5. Conclusions

This study reported changes in the accomplishment of certain life habits and the environmental factors of individuals with SCI between T1 and T2 of the COVID-19 pandemic, which, together, may have influenced the social participation of the Canadian participants in this study. The results suggest that certain life habit categories, such as mobility, personal care and health, nutrition, and recreation, have improved during the pandemic. However, no statistically significant changes were observed in several life habits categories (e.g., interpersonal relationships and responsibilities). Although most barriers and facilitators showed little or no change between the two waves, the reduction in environmental barriers and the increase in facilitators may have contributed to improved social participation as the pandemic progressed. For example, the availability of businesses in the community such as grocery stores, restaurants and shopping centers has increased as an environmental facilitator for participants.