O

IYJT

PoA

ssogv

(ld

a

nmgpScreasodt

sdpb

M

Fm

U

sz

aR

1371

RIGINAL ARTICLE

nfluence of Race/Ethnicity on Divorce/Separation 1, 2, and 5ears Post Spinal Cord Injury

uan Carlos Arango-Lasprilla, PhD, Jessica M. Ketchum, PhD, Kathryn Francis, BS, Paola Premuda, PhD,

aryn Stejskal, PhD, Jeffrey Kreutzer, PhD

Svmctp

eibitactid

ciwaseiuNi

wdbsaciCowasd

ABSTRACT. Arango-Lasprilla JC, Ketchum JM, Francis K,remuda P, Stejskal T, Kreutzer J. Influence of race/ethnicityn divorce/separation 1, 2, and 5 years post spinal cord injury.rch Phys Med Rehabil 2009;90:1371-8.

Objectives: (1) To compare the proportions of divorce/eparation between races/ethnicities at 1, 2, and 5 years postpinal cord injury (SCI); (2) to examine changes in proportionsf divorce/separation over time within each race/ethnicityroup; and (3) to compare the changes in proportions of di-orce/separation over time between races/ethnicities.Design: Retrospective study.Setting: Model Spinal Cord Injury Systems.Participants: A sample of participants married preinjury

N�1528; 1108 whites, 258 blacks, 162 Hispanics) was se-ected from the National Spinal Cord Injury Statistical Centeratabase from 1988 to 1998.Interventions: Not applicable.Main Outcome Measures: Proportion of separation/divorce

t 1, 2, and 5 years postinjury for each race/ethnic group.Results: At all postinjury years (1, 2, 5y), blacks had sig-

ificantly greater odds of divorce/separation versus stayingarried than Hispanics. In addition, whites had significantly

reater odds of divorce/separation versus staying married com-ared with Hispanics at 1 and 2 years postinjury. People withCI of all races/ethnicities showed significantly greater in-reases in the odds of divorce/separation versus staying mar-ied over time (1–2, 2–5, 1–5y postinjury). Although there wasvidence that the races/ethnicities were significantly differentt each postinjury year, and that each race/ethnicity showedignificant increases in the proportion of divorce/separationver time, there was no indication that the increases in theivorce/separation over time were significantly different amonghe race/ethnic groups.

Conclusions: Family therapists and rehabilitation profes-ionals should work together to reduce the separation andivorce rates in all subjects with SCI, with special attentionaid to meeting the specific needs of those with minorityackgrounds.Key Words: Divorce; Rehabilitation; Spinal cord injuries.© 2009 by the American Congress of Rehabilitationedicine

From the Departments of Physical Medicine and Rehabilitation (Arango-Lasprilla,rancis, Premuda, Stejskal, Kreutzer), and Biostatistics (Ketchum), Virginia Com-onwealth University, Richmond, VA.Supported by the National Institute on Disability and Rehabilitation Research,

nited States Department of Education (grant no. H133A060039).No commercial party having a direct financial interest in the results of the research

upporting this article has or will confer a benefit on the authors or on any organi-ation with which the authors are associated.

Reprint requests to Juan Carlos Arango-Lasprilla, PhD, Dept of Physical Medicinend Rehabilitation, Virginia Commonwealth University, 730 E Broad St, 4th Fl,oom 4230a, Richmond, VA 23219, e-mail: jcarangolasp@vcu.edu.

0003-9993/09/9008-00837$36.00/0doi:10.1016/j.apmr.2009.02.006

PINAL CORD INJURY is usually the result of an acutetraumatic event, such as a motor vehicle collision, fall, or

iolent incident, which may result in partial or complete loss ofobility and sensation, depending on the level of injury and the

ompleteness of the spinal cord lesion.1,2 In the United States,he incidence of SCI is estimated at nearly 12,000 new caseser year, and it currently affects 227,080 to 300,938 people.3

An SCI results in physical, emotional, psychosocial, andconomic changes that affect subjects with SCI and their fam-lies.4-7 Examples of physical changes can include bladder andowel dysfunction, problems with sexual function, respiratorympairment, spasticity, pain, and pressure ulcers.8,9 The emo-ional impact of SCI can include depression,10-12 anxiety,8,13

nd substance abuse with possible dependency.14-16 The psy-hosocial consequences often include increased social isola-ion17 and lower QOL.18 Finally, economic changes mightnclude medical and home modification costs,5,19 as well asecreased employment and associated income.20

Experiencing an SCI often results in a lack of autonomy thatauses the person with SCI to require some degree of caregiv-ng. Family members are likely to assume the role of caregiver,hich involves assisting the person with SCI in a variety of

ctivities of daily living.21,22 The physical, emotional, psycho-ocial, and economic changes experienced after SCI can bespecially difficult for these caregivers.5,23 Furthermore, fam-ly-member caregivers are often informal caregivers who arentrained and largely unprepared to assume the caregiving role.ot surprisingly, taking on these new responsibilities with

nadequate resources can provoke stress in them.5,23

Being a caregiver for a person with SCI has been associatedith a wide range of negative effects, including the following:ecreased QOL,24 less choice and control over life,22 increasedurden,22 increased financial instability,22 anxiety/depres-ion,25 and psychologic morbidity.26 In most cases, the spousessumes the role of primary caregiver.27 Research on spousalaregivers of subjects with SCI shows increased emotionalmpact and more health problems, particularly for wives.28

aregiver spouses of people with SCI reported more symptomsf burnout, fatigue, anger, and resentment than spouses whoere not caregivers.29 Schulz et al30 reported that the daily

mount of time spouses (who were also primary caregivers)pent aiding the person with SCI was strongly correlated withepression in the spouse, even after controlling for health and

List of Abbreviations

AIS American Spinal Injury AssociationImpairment Scale

ANOVA analysis of varianceCI confidence intervalNSCISC National Spinal Cord Injury Statistical CenterOR odds ratioQOL quality of life

SCI spinal cord injury

Arch Phys Med Rehabil Vol 90, August 2009

iot

aavders9paspwwl

attrsa

spftcosttdnpp(Agtdydoor

itbeSiccsoflf

rp

(jrshs(icvaenf

P

ptfgtmsdhc(

NypaSowdnctclsrt

uiill

M

d

ajja

w

1372 ETHNICITY AND MARITAL STATUS IN SPINAL CORD INJURY, Arango-Lasprilla

A

ncome measures. In addition, this study found that the degreef perceived burden was inversely related to life satisfaction inhe caregiver.

The negative consequences that SCI causes on the personnd his/her spousal caregiver may lead to relationship problemsnd possibly separation/divorce. Thus, it is not surprising thatarious studies have found that subjects with SCI have higherivorce rates compared with the general population.31,32 Forxample, DeVivo and Fine31 studied 143 single and 133 mar-ied subjects with SCI over 3 years postinjury to determine thehort-term impact of SCI on marital status. Approximately0% of those single subjects with SCI remained single, com-ared with an expected 80% in the general population. Also,pproximately 19% of married subjects with SCI divorced/eparated, compared with an expected 6% according to USopulation divorce/separation rates. A decade later, divorceas still more common in subjects with SCI. People with SCIere 1.7 times more likely to divorce than the general popu-

ation.32

Although there is a prevalent belief that remaining singlend/or being separated/divorced is more common after SCIhan remaining married, the actual rates reported in the litera-ure are quite variable.23 Divorce rates for subjects with SCIange from 17% to 48%.31-35 The reported marriage rate foringle SCI patients is nearly 3 times smaller than that of theirble-bodied peers.15

Several factors have been identified that influence maritaltatus after SCI, including age, sex, education, discharge dis-osition, employment status, having children (or not), level ofunctional ability, previous divorce,31-33 and cultural tradi-ions.36 Because of the relationship between race/ethnicity andultural traditions, this variable may be an important moderatorf marital status after SCI. Unfortunately, only 2 SCI researchtudies examining marital status have included race/ethnicity inheir analyses. Among subjects with SCI who were married athe time of injury (n�133), discriminant analysis of postinjuryivorce and separation rates found that being black was sig-ificantly related to obtaining a divorce within the first 3 yearsostinjury compared with whites.31 DeVivo et al32 studied 622ersons from the model Spinal Cord Injury Systems of Care502 whites, 80 blacks, and 40 subjects of Native American,sian, or Hispanic descent) who were single before injury andot married after SCI and were followed 1 and 15 years afterheir marriage. Although race was not a significant predictor ofivorce in the multivariate regression model, univariate anal-sis showed that 23 out of the 80 blacks in their sampleivorced. This rate was 1.6 times higher than the divorce ratef whites and the highest of the 3 race groups. The divorce ratef the other racial/ethnic group was not significantly differentelative to whites.

There are various limitations of the previous studies exam-ning race/ethnicity and marital status after SCI. For instance,he minority groups were small in number, consisting mainly oflacks.31,32 Consequently, the analyses may not have hadnough power to detect true differences in marital status afterCI, and/or the effects may have been confounded by combin-

ng subjects from various ethnicities into a single racial/ethnicategory (ie, other). One study did not control for potentialonfounders and used a cross-sectional analysis of maritaltatus in couples married after the injury for varying amountsf time.32 This latter study did not take into considerationuctuations in marital status that may occur over time uniquelyor each race/ethnicity.

To our knowledge, this is the first study to examine theelationship between race and divorce/separation 1 to 5 years

ost-SCI in a large longitudinal sample of diverse subjects c

rch Phys Med Rehabil Vol 90, August 2009

whites, blacks, and Hispanics) who were married before in-ury. The purpose of the present study was to examine theelationship between race/ethnicity and subsequent divorce/eparation at 1, 2, and 5 years post-SCI. Specifically, the studyad 3 aims: (1) to compare the odds of divorce/separation versustaying married between races/ethnicities at each follow-up year;2) to examine changes in odds of divorce/separation versus stay-ng married over time within each race/ethnicity group; and (3) toompare the changes over time in odds of divorce/separationersus staying married between races/ethnicities. Demographicnd injury characteristics that differ significantly among race/thnicities, significantly affect divorce/separation, and/or sig-ificantly affect divorce/separation over time were controlledor the final analysis.

METHODS

articipantsAll participants were Model Spinal Cord Injury System

atients enrolled in the NSCISC database. The database storeshe records of patient rehabilitation and follow-up informationrom 25 designated model systems nationwide. Although eli-ibility criteria have been revised several times since the da-abase’s creation in 1975,37 as of January 2005, all participantsust (1) receive system inpatient care, (2) be treated at a model

ystem within 1 year of injury, (3) have a clinically discernibleegree of neurologic impairment after a traumatic event, (4)ave provided informed consent, (5) reside in the geographicatchment area of the model system at the time of injury, and6) be a citizen of the United States.

A sample of 1664 participants was initially selected from theSCISC database on the basis of the following criteria: (1) 18ears or older at injury, (2) subjects classified as either His-anic, non-Hispanic white, or non-Hispanic black, (3) marriedt injury, (4) injury occurred between September 30, 1988, andeptember 30, 1998, and (5) subjects not classified as widowedr other at any of the follow-up visits. In addition, 1 subjectas excluded from the analysis data set who was classified atischarge as normal on the AIS and had a normal category ofeuro impairment. The initial date of September 30, 1988, washosen because this was the date the measure FIM was addedo the database. The end date of September 30, 1998, washosen because participants’ second-year follow-up was noonger required 2 years after this (October 1, 2000). For theake of brevity, we will use the terms “black” and “white” toefer to non-Hispanic blacks and non-Hispanic whites, respec-ively.

To assess marital status 1 to 5 years postinjury, the subjectssed in this analysis must have at least 1 year of follow-upnformation. A total of 136 (8.17%) subjects could not bencluded in this analysis because marital status at all 3 fol-ow-up visits (1, 2, 5y) was unknown. Thus, 1528 subjects wereeft for analysis.

easuresThe measures and modeling types for the independent and

ependent variables used in this study are summarized below.Dependent variable. The dependent variable used for this

nalysis was a categorical variable indicating whether the sub-ect was married or divorced/separated at the specified postin-ury year. This measure was collected from participants at 1, 2,nd 5 years postinjury.

Independent variables. The primary independent variableas a categorical variable indicating whether the subject was

lassified as Hispanic, white, or black. Subjects who were

cb

asws(ts(s

cicmfawmrcw(iCao

S

aTimwav

uwncF

gaeididsts

ibasiitst

cPafetfAtli

D

1T77t((a

I

mpenPs.natcevv

D

1eP.A2Pa

EM

s((clmo

1373ETHNICITY AND MARITAL STATUS IN SPINAL CORD INJURY, Arango-Lasprilla

lassified as non-Hispanic, not white or non-Hispanic, and notlack were not considered in this study.Other demographic variables available for analyses included

ge at injury, sex, level of education at injury, and employmenttatus at injury. Highest formal level of education completedas categorized into less than high school (grades 1–11), high

chool/general equivalency diploma, or more than high schoolassociate’s degree, bachelor’s degree, master’s degree, doc-oral degree). Primary occupational, educational, or trainingtatus was categorized as employed, unemployed, or otherhomemaker, on-the-job training, sheltered workshop, retired,tudent, other/unclassified).

Measures of injury characteristics available for analysis in-luded cause of injury, FIM total motor score at discharge fromnpatient rehabilitation, category of neuroimpairment at dis-harge, and AIS at discharge. Cause of injury was dichoto-ized into not violent (vehicular, sports related, falls, flying/

alling objects, medical/surgical complications, pedestrianccidents, other) and violent (ie, gunshot wounds, penetratingounds, person-to-person contact, explosions). The FIM is theost widely accepted measure of functional assessment in the

ehabilitation community. The FIM total motor score at dis-harge is a 13-item measure collected by raters at dischargeith scores for each item ranging from 1 (total assist) to 7

complete independence) with the exceptions of the transfertems (tub and shower), which have minimum values of 0.ategory of neuroimpairment at discharge was dichotomizeds paraplegia or tetraplegia, and AIS at discharge was dichot-mized as incomplete or complete.

tatistical AnalysesAll statistical analyses were conducted by SAS (version 9.1),a

nd graphics were produced by SigmaPlot (version 11.0).a

here were a total of 136 subjects who could have beenncluded in the analysis if their marital status had not been

issing at all 3 follow-up years. These subjects were comparedith the 1528 included subjects with respect to demographic

nd injury characteristics by chi-square analyses for categoricalariables and t tests for continuous variables.Preliminary analyses that used ANOVA models for contin-

ous variables and chi-square tests for categorical variablesere conducted to identify differences between the race/eth-icity groups with respect to age at injury, sex, level of edu-ation at injury, employment status at injury, cause of injury,IM at discharge, neuroimpairment, and AIS impairment.To test the hypotheses of interest, a repeated-measures lo-

istic regression model was fit using the framework of gener-lized linear mixed-effects models.38 The model includedffects for follow-up year, race/ethnicity, and the 2-waynteraction between race/ethnicity and year. To correctly un-erstand the effects of ethnicity on marital status and changesn marital status over time, the model should adjust for theemographic and injury characteristics (covariates) that areignificantly different among the races/ethnicities as well ashose that may affect marital status and changes in maritaltatus over time.

Because there were a variety of potential covariates andnteraction effects that could be added to this model, model-uilding strategies similar to those used for logistic regressions outlined by Hosmer and Lemeshow39 were used. Briefly, theteps are as follows: (1) Models for each covariate were fit,ncluding main effects for follow-up year and the covariate ofnterest. Any covariate with P less than .25 was considered forhe adjusted model. (2) Models for each covariate identified intep 1 were fit and included main effects for follow-up year and

he covariate of interest, as well as the follow-up year by p

ovariate 2-way interaction effect. Any interaction effect withless than .10 was considered for the adjusted model. (3) The

djusted model was initially fit with effects for race/ethnicity,ollow-up year, the race/ethnicity by follow-up year interactionffect, and all potential covariates and interaction effects ob-ained from steps 1 and 2 as well any additional covariatesound to differ significantly among the races/ethnicities. (4)ny covariate (if it was not included in a significant interac-

ion) or covariate by follow-up year interaction effect that noonger contributed to the fit of the model (P�.05) was removedn a backward selection manner.

RESULTS

escription of the SampleThe demographic and injury characteristics of the sample of

528 are summarized irrespective of race/ethnicity in table 1.he mean age � SD at injury of subjects was 43.9�14.5 years,2.5% were white, 16.9% were black, 10.6% were Hispanic,9.8% were men, and 74.0% had at least a high school educa-ion. There was some missing data for level of educationn�86), employment at admission (n�5), cause of injuryn�1), FIM at discharge (n�80), neuroimpairment (n�15),nd AIS impairment (n�22).

ncluded Versus ExcludedThe 136 subjects who were excluded because of missingarital status information at all 3 follow-up visits were com-

ared with the 1528 subjects used for analyses. There was novidence that the included and excluded subjects differed sig-ificantly with respect to age at injury (t�.57, df�1662,�.571), FIM total at discharge (t�.49, df�1569, P�.625),ex (�2�2.40, df�1, P�.122), education at admission (�2�40, df�2, P�.820), AIS (�2�.55, df�1, P�.457), andeurologic impairment (�2�2.93, df�1, P�.087). Includednd excluded subjects were significantly different with respecto employment at admission (�2�12.18, df�2, P�.002) andause of injury (�2�6.23, df�1, P�.013). Specifically, thexcluded subjects had lower proportions of employment (63.2%s 75.5%) and greater proportions of violent injuries (17.65%s 10.61%) than the included subjects.

ifferences in Covariates Among the Races/EthnicitiesThe demographic and injury characteristics of the sample of

528 are summarized by race/ethnicity in table 1. The 3 races/thnicities were different with respect to sex (�2�13.27, df�2,�.001), employment at admission (�2�61.21, df�4, P�

001), education at admission (�2�185.66, df�4, P�.001),IS (�2�8.51, df�2, P�.014), neurologic impairment (�2�9.94, df�2, P�.001), cause of injury (�2�130.99, df�2,�.001), age at injury (F2,1525�25.40, P�.001), and FIM totalt discharge (F2,1445�9.49, P�.001).

ffects of Demographic and Injury Characteristics onarital Status and Changes in Marital Status Over TimeNeurologic impairment and FIM total at discharge were not

ignificant univariate predictors of marital status postinjuryP�.25), whereas sex (P�.158), education at admissionP�.052), employment at admission (P�.001), AIS (P�.001),ause of injury (P�.001), and age at injury (P�.001) were ateast marginal predictors (ie, P�.25). Sex, neurologic impair-ent, education at admission, employment at admission, cause

f injury, and age at injury were not significant univariate

redictors of changes in marital status over time (P�.10),

Arch Phys Med Rehabil Vol 90, August 2009

ww

A

sa

ebeiddmpacitAmmdt.aai

(cttmpabs

y

NA hool.

1374 ETHNICITY AND MARITAL STATUS IN SPINAL CORD INJURY, Arango-Lasprilla

A

hereas AIS (P�.001) and FIM total at discharge (P�.018)ere at least marginal predictors (ie, P�.10).

djusted ModelThe distribution of marital status for each follow-up year is

ummarized in table 2. These unadjusted data do not reflectdjustment for relevant demographic and injury characteristics.

Table 2: Observed Marital Status 1, 2, and 5 Years Postinjury byRace/Ethnicity

Characteristics

1-YearFollow-up

2-YearFollow-up

5-YearFollow-up

n % n % n %

WhiteMarried 995 93.8 790 90.7 528 81.7Not married 66 6.2 81 9.3 118 18.3Divorced 37 3.5 58 6.7 101 15.6Separated 29 2.7 23 2.6 17 2.6

BlackMarried 222 89.2 156 81.2 90 71.4Not married 27 10.8 36 18.8 36 28.6Divorced 11 4.4 14 7.3 24 19.1Separated 16 6.4 22 11.5 12 9.5

HispanicMarried 149 93.7 117 91.4 61 75.3Not married 10 6.3 11 8.6 20 24.7Divorced 4 2.5 8 6.3 16 19.8Separated 6 3.8 3 2.3 4 4.9

OverallMarried 1366 93.0 1063 89.3 679 79.6Not married 103 7.0 128 10.7 174 20.4Divorced 52 3.5 80 6.7 141 16.5

Table 1: Demographic and

CharacteristicsWhite

(n�1108)

Age at injury (N�1528) 44.6�14.2Discharge FIM (n�1448) 57.0�22.8Sex (N�1528)

Male 859 (77.5)Female 249 (22.5)

Employment (n�1523)Employed 856 (77.5)Unemployed 40 (3.6)Other 208 (18.8)

Education (n�1442)Less than HS 186 (17.8)HS/GED 612 (58.6)More than HS 246 (23.6)

AIS (n�1506)Incomplete 622 (57.0)Complete 469 (43.0)

Neurologic impairment (n�1513)Paraplegia 554 (50.5)Tetraplegia 542 (49.5)

Cause of injury (n�1527)Not violent 1050 (94.9)Violent 57 (5.1)

OTE. Values are mean � SD or n (%).bbreviations: GED, General Educational Development; HS, high sc

CSeparated 51 3.5 48 4.0 33 3.9

rch Phys Med Rehabil Vol 90, August 2009

A repeated-measures logistic regression model was fit withffects for follow-up year, race/ethnicity, and 2-way interactionetween race/ethnicity and year. To correctly understand theffects of race/ethnicity on marital status and changes in mar-tal status over time, the model should also adjust for theemographic and injury characteristics that are significantlyifferent among the races as well as those that may affectarital status and changes in marital status over time. As

reviously reported, ANOVA and chi-square tests indicate thatll of the demographic and injury characteristics are signifi-antly different among the races/ethnicities (P�.014). Univar-ate repeated-measures logistic regression models indicatedhat sex, education at admission, employment at admission,IS, cause of injury, and age at injury significantly affectarital status postinjury (P�.052). The univariate repeated-easures models further showed that AIS and FIM total at

ischarge significantly affect changes in marital status overime (P�018). Therefore, additional effects for each of the demographicnd injury characteristics, as well as interactions between yearnd AIS and between year and FIM total at discharge, werenitially included in the model.

The main effects for sex (P�.124), education at admissionP�.120), neurologic impairment (P�.113), FIM total at dis-harge (P�.999), and the interaction effect for year by FIMotal at discharge (P�.052) did not significantly contribute tohe fit of the adjusted model and were removed. The finalodel then included main effects for year, race/ethnicity, em-

loyment at admission, AIS, cause of injury, and age at injury,s well as interaction effects for year by race/ethnicity and yeary AIS. The effect tests for the final adjusted model areummarized in table 3.

Comparison between races/ethnicities at each follow-upear (aim 1). At 1 year postinjury, blacks (OR�3.11; 95%

Characteristics of Sample

Black(n�258)

Hispanic(n�162)

Overall(N�1528)

45.6�15.4 36.5�12.2 43.9�14.551.7�23.7 61.6�22.3 56.6�23.0

218 (84.5) 142 (87.7) 1219 (79.8)40 (15.5) 20 (12.3) 309 (20.2)

165 (64.2) 129 (79.6) 1150 (75.5)35 (13.6) 20 (12.4) 95 (6.2)57 (22.2) 13 (8.0) 278 (18.3)

92 (37.4) 97 (63.8) 375 (26.0)134 (54.5) 50 (32.9) 796 (55.2)20 (8.1) 5 (3.3) 271 (18.8)

152 (59.8) 74 (46.0) 848 (56.3)102 (40.2) 87 (54.0) 658 (43.7)

85 (33.2) 91 (56.5) 730 (48.2)171 (66.8) 70 (43.5) 783 (51.8)

200 (77.5) 115 (71.0) 1365 (89.4)58 (22.5) 47 (29.0) 162 (10.6)

Injury

I, 1.36–7.11) and whites (OR�2.17; 95% CI, 1.01–4.69) had

sHe

1ipo

o9oa

(stg11

wpp21

my57np

ei1dycn

EMO

sst

stCosee

til

(ot(

tpcapriAwpp4(og11dc

eershmgpdcp

stmmcafaHGa

D

Aa

1375ETHNICITY AND MARITAL STATUS IN SPINAL CORD INJURY, Arango-Lasprilla

ignificantly greater odds of divorce/separation compared withispanics. Blacks and whites did not have significantly differ-

nt odds of divorce/separation at 1 year postinjury.At 2 years postinjury, blacks (OR�4.60; 95% CI, 2.06–

0.27) and whites (OR�2.96; 95% CI, 1.40–6.27) had signif-cantly greater odds of divorce/separation compared with His-anics. Blacks and whites did not have significantly differentdds of divorce/separation at 2 years postinjury.At 5 years postinjury, blacks had significantly greater odds

f divorce/separation compared with Hispanics (OR�2.21;5% CI, 1.11–4.38). Whites did not have significantly differentdds of divorce/separation compared with blacks or Hispanicst 5 years postinjury.

Changes in marital status over time for each race/ethnicityaim 2). For whites, the odds of divorce/separation versustaying married were 1.64 times greater at 2 years postinjuryhan at 1 year postinjury (95% CI, 1.29–2.09), 1.94 timesreater at 5 years postinjury than at 2 years postinjury (95% CI,.55–2.42), and 3.18 times greater at 5 years postinjury than atyear postinjury (95% CI, 2.49–4.07).For blacks, the odds of divorce/separation vs staying married

ere 1.78 times greater at 2 years postinjury than at 1 yearostinjury (95% CI, 1.17–2.72), 1.57 times greater at 5 yearsostinjury than at 2 years postinjury (95% CI, 1.03–2.40), and.80 times greater at 5 years postinjury than at 1 year postinjury(95% CI, 1.79–4.40).For Hispanics, the odds of divorce/separation versus stayingarried were 3.27 times greater at 5 years postinjury than at 2

ears postinjury (95% CI, 1.72–6.23) and 3.95 times greater atyears postinjury than at 1 year postinjury (95% CI, 2.06–

.57); however, the odds of divorce/separation were not sig-ificantly different for 2 years postinjury compared with 1 yearostinjury.Comparison of changes in marital status between races/

thnicities (aim 3). There was no evidence of a significantnteraction effect between race/ethnicity and year (F4,1979�.14, P�.336). Thus, the differences in the proportion ofivorce/separation between the race/ethnicity groups at eachear postinjury do not change significantly over time, and thehanges over time in the proportion of divorce/separation areot significantly different among the race/ethnicity groups.

ffects of Demographic and Injury Characteristics onarital Status Postinjury and Changes in Marital Statusver TimeThe final adjusted model further indicated that employment

tatus at admission, cause of injury, and age at injury also hadignificant effects on marital status postinjury, and furthermore,

Table 3: Effect Tests for Adjusted Model

Effects F NDF, DDF P

Year 35.93 2, 1953 �.001Race/ethnicity 6.41 2,1493 .002Year�race/ethnicity 0.88 4,1953 .474Employment at admission 5.57 2,1493 .004AIS 2.02 1,1493 .155Year�AIS 7.27 2,1953 .001Cause of injury 6.38 1,1493 .012Age at injury 68.04 1,1493 �.001

bbreviations: DDF, denominator degrees of freedom; NDF, numer-tor degrees of freedom.

hat AIS has an effect on changes in marital status over time. d

For employment status at admission, the odds of divorce/eparation vs staying married were significantly greater forhose who were unemployed versus employed (OR�2.47; 95%I, 1.44–4.25) and for those who were unemployed versusther (OR�2.68; 95% CI, 1.28–5.61). The odds of divorce/eparation versus staying married were not significantly differ-nt for those classified as other compared with those who weremployed.

With respect to cause of injury, the odds of divorce/separa-ion versus staying married were 1.77 times greater for partic-pants with violent injuries compared with those with nonvio-ent injuries (95% CI, 1.14–2.77).

For age at injury, comparisons were made between the 25th32y) and 75th (55y) percentiles of the distribution of age. Thedds of divorce/separation versus staying married were 4.57imes greater (95% CI, 3.19–6.56) for younger participants32y) compared with older participants (55y).

Finally, with respect to AIS, there was a significant interac-ion between year and AIS. Thus, the differences in the pro-ortions of divorce/separation between the incomplete andomplete groups change over time, and the changes over timere different for the complete and incomplete groups. Therobability of divorce/separation increase over time at a greaterate for those with complete AIS compared with those withncomplete AIS. More specifically, for those with completeIS, the odds of divorce/separation versus staying marriedere 1.80 times greater at 2 years postinjury than at 1 yearostinjury (95% CI, 1.29–2.50), 2.70 times greater at 5 yearsostinjury than at 2 years postinjury (95% CI, 1.99–3.67), and.87 times greater at 5 years postinjury than at 1 year postinjury95% CI, 3.49–6.79). For those with incomplete AIS, the oddsf divorce/separation versus staying married were 1.71 timesreater at 5 years postinjury than at 2 years postinjury (95% CI,.20–2.44), and 2.21 times greater at 5 years postinjury than atyear postinjury (95% CI, 1.54–3.17). However, the odds of

ivorce/separation versus staying married were not signifi-antly different for 2 years postinjury versus 1 year postinjury.

DISCUSSIONThe first aim of the present study was to assess the differ-

nces in the proportion of divorce/separation between races/thnicities at 1, 2, and 5 years postinjury, after adjusting forelevant demographic and injury characteristics. The presenttudy found that at all postinjury years (1, 2, and 5y), blacksad significantly greater odds of divorce/separation vs stayingarried than Hispanics. In addition, whites had significantly

reater odds of divorce/separation versus staying married com-ared with Hispanics at 1 and 2 years postinjury. The odds ofivorce/separation versus staying married were not signifi-antly different for blacks versus whites at 1, 2, and 5 yearsostinjury or for whites versus Hispanics at 5 years postinjury.One explanation why Hispanics had lower odds of divorce/

eparation than blacks or whites postinjury could be the similarraditional values and customs that unite them, including fa-ilism, a sense of responsibility for the welfare of other familyembers, and religious beliefs.40 In general, Hispanics have a

ommon respect for elders and people with disabilities as wells a sense of obligation for their care.41 Familism, or valuingamily over individual and/or community needs, is a strong,lmost universal value in Hispanic subjects. Additionally, forispanic spouses, SCI and other disabilities may be viewed asod’s will, and coping with difficult life circumstances may beway of demonstrating worthiness.42

The results of the present study differ from those reported byeVivo et al,32 who found that there were no significant

ifferences in the divorce rates between different race/ethnic

Arch Phys Med Rehabil Vol 90, August 2009

gtdddsymilsagsHhsp

FdddsvtssbNwpctrpia

perppsCtilraqc

opdpdaorpmif

5wCo

ucpoaAcprsewoi

bbmeqpsn(rw

S

bimasmsdi1pbomgtSssptalU

tscplT

1376 ETHNICITY AND MARITAL STATUS IN SPINAL CORD INJURY, Arango-Lasprilla

A

roups. However, 3 important methodologic differences be-ween the 2 studies may account for this discrepancy. First,ifferent definitions are used for marital status. DeVivo et al32

efines termination of marriage as any change from married toivorced/widowed on successive annual evaluations, but thistudy defines it as subjects divorced/separated at 1, 2, and 5ears postinjury. Second, the time when participants werearried and follow-up evaluations differ. Although the partic-

pants in the present study were married pre-SCI with fol-ow-up 1 to 5 years post-SCI, participants in the DeVivo32

tudy got married post-SCI and were followed 1 to 15 yearsfter marriage. Finally, different sample sizes and minorityroup representations were used. DeVivo32 studied 622 per-ons (502 whites, 80 blacks, 12 Native Americans, 5 Asians, 23ispanics) and clumped the latter 3 races/ethnicities into oneeterogeneous minority group. Conversely, the present studyampled 1528 participants (1108 whites, 258 blacks, 162 His-anics) and compared each racial/ethnicity group separately.The present study’s findings also contrast with DeVivo and

ine’s conclusion31 that blacks are more likely than whites toivorce within 3 years postinjury. Again, several methodologicifferences may explain this divergence. The first importantistinction involves inclusion criteria, with DeVivo31 only con-idering divorces and the present study considering both di-orces and separations. Second, sample sizes and data collec-ion methods differ greatly. DeVivo’s31 small sample used 130ubjects from an Alabama center, whereas this study’s largerample uses 1528 subjects from a national, multicenter data-ase. Third, minority representation and reporting also differ.amely, DeVivo31 included only blacks and whites in his studyithout reporting the number of minority subjects, whereas theresent study includes blacks, whites, and Hispanics, with alear description of racial/ethnic group sizes. Finally, distinc-ions in time of data collection may contribute to differentesults. The data reported in this study were collected fromatients whose SCI occurred between 1988 and 1998, whereasn DeVivo’s31 study, the injuries had occurred between 1973nd 1980.

The second aim of this study was to examine changes inroportions of divorce/separation over time within each race/thnicity group. The results of the present study found that allaces/ethnicities showed significantly greater increases in theroportion of divorce/separation over time (1–2, 2–5, 1–5yostinjury). One possible explanation for these results maytem from the challenges that occur over time postinjury.hronic stress and caregiving may accrue considerably over

ime such that challenges get worse instead of better, leading toncreased proportions of separation/divorce rates at 5 years oronger. Because partners of someone with a SCI begin toealize that the physical, behavioral/emotional, psychosocial,nd economic problems are going to be long-term conse-uences, the probability of separation or divorce often in-reases.

The third aim was to assess the differences in the changesver time (1–5y postinjury) between races/ethnicities in theroportion of divorce/separation, after adjusting for relevantemographic and injury characteristics. The results of theresent study found no evidence that the increases in theivorce/separation rates over time were significantly differentmong the race/ethnicity groups. In other words, the likelihoodf divorces and separations increased over time regardless oface/ethnicity. This coincides with previous findings that theercentage of divorces among people with SCI who werearried at the time of injury increased in the first 3 years after

njury.31,43 However, unlike their findings, in this sample, we

ound that divorces and separations continued to increase up to a

rch Phys Med Rehabil Vol 90, August 2009

years postinjury for all of 3 racial/ethnic groups. Thirty years’orth of follow-up data from the Model Spinal Cord Injuryare Systems also confirm a rise in divorces and separationver time.44

Other interesting findings of the present study are that beingnemployed, younger, and having SCI as a result of a violentause increases the odds of divorce/separation. In addition, foreople with complete AIS (more severe injury), the proportionf divorce/separation across the 5 follow-up years increased atsignificantly greater degree than for those with incompleteIS. In the general population, being married has been asso-

iated with being healthier45 and having lower levels of de-ression.46 For people with SCI, being married has shown to beelated to less depression, higher self-reported QOL, and lowerelf-reported handicap (especially in social integration andconomic self-sufficiency areas).27,47 It seems that for peopleith SCI, being married is related to positive psychosocialutcomes, such as life satisfaction, return to productive activ-ties, and independent living.23,47-49

The findings of the present study have clinical relevanceecause they indicate a potential area of intervention for reha-ilitation professionals in order to avoid separation/divorce inarriages of people with SCI. Rehabilitation professionals can

asily screen for signs of stress in the marriage by includinguestions on the present functioning of the marriage in theireriodic follow-up visits, and can help the family problem-olve and implement more effective coping strategies ifeeded. Counseling, as well as referral to community resourceseg, personal care attendants, home care services, vocationalehabilitation agencies), should be made available to personsith SCI and their families by rehabilitation professionals.

tudy LimitationsThe results of this study must be interpreted with caution

ecause of the following limitations: (1) Confounding factors,ncluding social support, acculturation level, income, length ofarriage, length of preinjury relationship, religious preference

nd spiritual beliefs held by the couple, and neurobehavioralequela exhibited by the person with SCI were not extensivelyeasured and therefore could not be controlled. (2) All SCI

urvivors in the present study were recruited from the NSCISCatabase regardless of ethnicity and received inpatient rehabil-tation/treatment from these standardized centers from 1988 to998; thus, the results may not generalize to the at-large U.S.opulation of SCI survivors. It is possible that the averagelack and Hispanic SCI survivor does not receive such state-f-the-art rehabilitation or top-quality care; therefore, oneight expect additional differences in outcomes for these

roups compared with whites when examining marital status inhe population of SCI as a whole. (3) Hispanics and blacks withCI were the only minority groups considered in this study; asuch, these findings cannot be extended to other minorityubgroups, such as Native Americans and Asians. (4) Theresent study includes Hispanics with SCI in the United Stateshat are registered as aliens or citizens, but may not representll of the Hispanics with SCI in the United States, given thearge undocumented population of this group living in thenited States.The current study provides insight into how divorce/separa-

ion is changing over time within white, Hispanic, and blackubjects with SCI. However, this study does not lend itself toomparisons to the general population. To assess how the SCIopulation differs with respect to non-SCI populations, a futureongitudinal study involving both groups would be necessary.oday, the U.S. general population divorce/separation rate is

pproximately 11% to 13%.50,51 Although divorce/separation

r(i

bsdjs11sdtnedidatsw

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3

3

3

1377ETHNICITY AND MARITAL STATUS IN SPINAL CORD INJURY, Arango-Lasprilla

ates for subjects with SCI were lower for follow-up years 17.01%) and 2 (10.75%) in our study, divorce/separation ratesncreased at follow-up year 5 (20.40%).

CONCLUSIONSThe present study found that at all postinjury years (1, 2, 5y),

lacks had significantly greater odds of divorce/separation ver-us staying married than Hispanics, after adjusting for relevantemographic and injury characteristics. In addition, after ad-ustment, whites had significantly greater odds of divorce/eparation versus staying married compared with Hispanics atand 2 years postinjury. With the exception of Hispanics fromto 2 years postinjury, people with SCI of all races/ethnicities

howed significantly greater increases in the proportion ofivorce/separation over time (1–2, 2–5, 1–5y postinjury). Al-hough there was evidence that the races/ethnicities were sig-ificantly different at each postinjury year and that each race/thnicity showed significant increases in the proportion ofivorce/separation over time, there was no indication that thencreases in divorce/separation over time were significantlyifferent among the race/ethnicity groups. Family therapistsnd rehabilitation professionals should work together to reducehe separation and divorce rates in all subjects with SCI, withpecial attention given to meeting the specific needs of thoseith minority backgrounds.

References1. Falvo D. Medical and psychosocial aspects of chronic illness and

disability. 3rd ed. Salisbury: Jones & Bartlett; 2005.2. Senelick RC, Dougherty K. The spinal cord injury handbook: for

patients and their families. 2nd ed. Birmingham: HealthSouth Pr;1998.

3. National Spinal Cord Injury Statistical Center. Spinal cord injury:facts and figures at a glance. Birgmingham: National Spinal CordInjury Statistical Center; 2008.

4. Bamford E, Grundy D, Russell J. Social needs of the patient andhis family. BMJ 1986;292:546-8.

5. Chan RC, Lee PW, Lieh-Mak F. Coping with spinal cord injury:personal and marital adjustment in the Hong Kong Chinese set-ting. Spinal Cord 2000;38:687-96.

6. Cleveland M. Family adaptation to traumatic spinal cord injury:response to crisis. Fam Relat 1980;29:558-65.

7. Jaworski T, Richards S. Family adjustment to spinal cord injury.Available at: http://images.main.uab.edu/spinalcord/pdffiles/FamilyAdjustment.pdf. Accessed September 1, 2008.

8. Richards JS, Kewman DG, Pierce CA. Spinal cord injury. In:Frank RG, Elliot TR editors. Handbook of rehabilitation psychol-ogy. Washington (DC): American Psychological Association; 2000.p 11-28.

9. Sipski ML, Richards JS. Spinal cord injury rehabilitation: state ofthe science. Am J Phys Med Rehabil 2006;85:310-42.

0. Dryden DM, Saunders LD, Rowe BH, et al. Utilization of healthservices following spinal cord injury: a 6-year follow-up study.Spinal Cord 2004;42:513-25.

1. Elliott TR, Kennedy P. Treatment of depression following spinalcord injury: an evidence-based review. Rehabil Psychol 2004;49:134-9.

2. Kennedy P, Rogers BA. Anxiety and depression after spinal cordinjury: a longitudinal analysis. Arch Phys Med Rehabil 2000;81:932-7.

3. Kennedy P, Duff J. Post traumatic stress disorder and spinal cordinjuries. Spinal Cord 2001;39:1-10.

4. Bombardier CH, Stroud MW, Esselman PC, Rimmele CT. Dopreinjury alcohol problems predict poorer rehabilitation progressin persons with spinal cord injury? Arch Phys Med Rehabil

2004;85:1488-92.

5. Heinemann A, Rawal P. Spinal cord injury. In: Zaretsky H,Richter E, Eisenberg M, editors. Medical aspects of disability: ahandbook for the rehabilitation professional. 3rd ed. New York:Springer; 2005. p 611-47.

6. Kolakowsky-Hayner SA, Gourley EV, Kreutzer JS, Marwitz JH,Meade MA, Cifu DX. Postinjury substance abuse among personswith brain injury and persons with spinal cord injury. Brain Inj2002;16:583-92.

7. Hammell KR. Psychosocial outcome following spinal cord injury.Paraplegia 1994;32:771-9.

8. Lin KH, Chuang CC, Kao MJ, Lien IN, Tsauo JY. Quality of lifeof spinal cord injured patients in Taiwan: a subgroup study. SpinalCord 1997;35:841-9.

9. Berkowitz M, O’Leary P, Kruse D, Harvey C. Spinal cord injury:an analysis of medical and social costs. New York: Demos Med-ical Publishing; 1998.

0. Yasuda S, Wehman P, Targett P, Cifu DX, West M. Return towork after spinal cord injury: a review of recent research. Neu-rorehabilitation 2002;17:177-86.

1. Elliot TR, Rivera P. Spinal cord injury. In Nezu A, Nezu C, GellerP, editors. Handbook of psychology. Vol 9, Health psychology.Hoboken (NJ): Wiley; 2003.

2. Boschen KA, Tonack M, Gargaro J. The impact of being a supportprovider to a person living in the community with a spinal cordinjury. Rehabil Psychol 2005;50:397-407.

3. Kreuter M. Spinal cord injury and partner relationships. SpinalCord 2000;38:2-6.

4. Blanes L, Carmagnani MI, Ferreira LM. Health-related quality oflife of primary caregivers of persons with paraplegia. Spinal Cord2007;45:399-403.

5. Kemp B, Krause JS, Adkins R. Depression among African-Americans, Latinos and whites with spinal cord injury: an explor-atory study. Rehabil Psychol 1999;44:235-47.

6. Raj JT, Manigandan C, Jacob KS. Leisure satisfaction and psy-chiatric morbidity among informal carers of people with spinalcord injury. Spinal Cord 2006;44:676-9.

7. Holicky R, Charlifue S. Ageing with spinal cord injury: the impactof spousal support. Disabil Rehabil 1999;21:250-7.

8. Kester BL, Rothblum ED, Lobato D, Milhous RL. Spouse adjust-ment to spinal cord injury: long-term medical and psychosocialfactors. Rehabil Couns Bull 1988;32:4-21.

9. Weitzenkamp DA, Gerhart KA, Charlifue SW, Whiteneck GG,Savic G. Spouses of spinal cord injury survivors: the added impactof caregiving. Arch Phys Med Rehabil 1997;78:822-7.

0. Schulz R, Tompkins C, Wood D, Decker S. The social psychologyof caregiving: physical and psychological costs of providing sup-port to the disabled. J Appl Soc Psychol 1987;17:401-28.

1. DeVivo MJ, Fine PR. Spinal cord injury: its short-term impact onmarital status. Arch Phys Med Rehabil 1985;66:501-4.

2. DeVivo MJ, Hawkins LV, Richards JS, Go BK. Outcomes of postspinal cord injury marriages. Arch Phys Med Rehabil 1995;76:130-8.

3. DeVivo MJ, Richards JS. Marriage rates among persons withspinal cord injury. Rehabil Psychol 1996;41:321-39.

4. Craig A, Hancock K, Dickson H. Improving the long-term adjust-ment of spinal cord injured persons. Spinal Cord 1999;37:345-50.

5. Kreuter M, Sullivan M, Dahllof AG, Siosteen A. Partner relation-ships, functioning, mood and global quality of life in persons withspinal cord injury and traumatic brain injury. Spinal Cord 1998;36:252-61.

6. Chan RC. How does spinal cord injury affect marital relationship?A story from both sides of the couple. Disabil Rehabil 2000;22:764-75.

7. Meade MA, Lewis A, Jackson MN, Hess DW. Race, employment,

and spinal cord injury. Arch Phys Med Rehabil 2004;85:1782-92.

Arch Phys Med Rehabil Vol 90, August 2009

3

3

4

4

4

4

4

4

4

4

4

4

5

5

1378 ETHNICITY AND MARITAL STATUS IN SPINAL CORD INJURY, Arango-Lasprilla

A

8. Molenberghs G, Geert Verbeke G. Models for discrete longitudi-nal data. New York: Springer; 2006.

9. Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed.New York: Wiley; 2000.

0. Oropesa RS. Normative beliefs about marriage and cohabitation:a comparison of non-Latino whites, Mexican-Americans, andPuerto Ricans. J Marriage Fam 1996;58:49-62.

1. Fuentes MG, Baker JG, Markello SJ, Wood KD. Discharge tohome among Hispanic and non-Hispanic stroke survivors: doesfamily make a difference? Int J Rehabil Res 1999;22:317-20.

2. Zea MC, Garcia JG, Belgrave FZ, Quezada T. Socioeconomic andcultural factors in rehabilitation of Latinos with disabilities. In:Garcia JG, Zea MC, editors. Psychological interventions andresearch with Latino populations. Boston: Allyn & Bacon; 1997.p 217-34.

3. DeVivo MJ, Richards JS, Stover SL, Go BK. Spinal cord injury.Rehabilitation adds life to years. Western J Med 1991;154:602-6.

4. National Spinal Cord Injury Statistical Center. Annual report forthe Model Spinal Cord Injury Care Systems. Birmingham: Na-tional Spinal Cord Injury Statistical Center; 2006.

5. Schoenborn C. Marital status and health: United States, 1999-

2002. Adv Data 2004;351:1-32. a

rch Phys Med Rehabil Vol 90, August 2009

6. Kessler RC, Essex M. Marital status and depression: the impor-tance of coping resources. Soc Forces 1982;61:484-507.

7. Putzke JD, Elliott TR, Richards JS. Marital status and adjustment1 year post-spinal-cord-injury. J Clin Psychol Med Settings 2001;8:101-7.

8. Krause JS. The relationship between productivity and adjust-ment following spinal cord injury. Rehabil Couns Bull 1990;33:188-99.

9. DeJong G, Branch LG, Corcoran PJ. Independent living outcomesin spinal cord injury: multivariate analyses. Arch Phys Med Re-habil 1984;65:66-73.

0. Kreider RM, Simmons T. Marital status: 2000 (Census 2000brief). US Census Bureau; 2003.

1. US Census. Household relationships and size: marital status.Available at: http://factfinder.census.gov/servlet/STTable?_bm�y&-geo_id�01000US&-qr_name�ACS_2007_3YR_G00_S1201&-ds_name�ACS_2007_3YR_G00_&-redoLog�false.Accessed September 2, 2008.

Supplier. SAS Institute, 100 SAS Campus Dr, Cary, NC 27513.