Psychology
2012. Vol.3, Special Issue, 775-781
Published Online September 2012 in SciRes (http://www.SciRP.org/journal/psych) http://dx.doi.org/10.4236/psych.2012.329117
Acceptance of Disability among Chinese Individuals with Spinal
Cord Injuries: The Effects of Social Support and Depression
Jie Jiao, Mark M. Heyne, Chow S. Lam
Department of Psychology, Illinois Institute of Technology, Chicago, USA
Received June 16th, 2012; revised July 17th, 2012; accepted August 10th, 2012
This study explored the roles of perceived social support and depression in acceptance of disability among
Chinese individuals with spinal cord injuries (SCI). Design: An exploratory and cross-sectional study was
conducted in an outpatient rehabilitation center in Guangzhou, China. One hundred Chinese individuals
with SCI completed the Multidimensional Scale of Perceived Social Support, Center for Epidemiological
Studies Short Depression Scale, and Acceptance of Disability Scale. Results: In general, there was low
acceptance of disability and a high prevalence of depression among Chinese individuals with SCI. Higher
acceptance of disability was associated with less depressive symptoms and higher level of perceived so-
cial support. Furthermore, depression was shown to mediate the relationship between perceived social
support and acceptance of disability. Conclusion: Depression is an essential factor in the process of ac-
ceptance of disability. Cross-cultural studies are needed to facilitate a better understanding of the adjust-
ment process following disabilities and apply culturally sensitive interventions to promote acceptance of
disability.
Keywords: Acceptance of Disability; Depression; Social Support; Spinal Cord Injuries; Chinese
Introduction
Among the myriad ways that adjustment to disability has
been conceptualized and studied, the concept of acceptance of
disability (AD) has received significant attention in the reha-
bilitation literature. At its core, AD is considered to be a proc-
ess of perceiving one’s disability as non-devaluing (Wright,
1983). To achieve this end, one must adjust his or her value
system such that “actual or perceived losses from disability do
not negatively affect the value of existing abilities” (Keaney &
Glueckauf, 1993: p. 200). As a psychosocial variable, AD is
one of the best indicators of positive adjustment following an
acquired disability (Elliott, Uswatte, Lewis, & Palmatier, 2000)
and has significant implications in vocational rehabilitation.
Research has shown that AD facilitates employment and inde-
pendent living (Green, Pratt, & Grigsby, 1984) and is signify-
cantly associated with work status (Melamed, Groswasser, &
Stern, 1992), social integration, and overall community integra-
tion (Snead & Davis, 2002).
There appear to be four specific value changes that charac-
terize successful AD: enlargement of scope of values—the abil-
ity to perceive value in abilities that have not been lost as a
result of the disability; subordination of physique—the ability
to evaluate self-worth based on nonphysical as well as physical
attributes; containment of disability effects—the ability to view
the disability itself as a single characteristic of oneself, but not
the only characteristic; and transformation from comparative to
asset values—the ability to recognize the value of one’s own
unique combination of characteristics and abilities rather than
making comparisons to an outside and often unattainable stan-
dard (Wright, 1983). Assessment of these four core values has
been shown to be a valid method of evaluating psychosocial
adjustment following acquired physical disability (Elliott,
Kurylo, & Rivera, 2002).
The psychosocial variable that has perhaps the most consis-
tent association with adjustment to disability in people with
spinal cord injuries (SCI) is depression. Higher reported de-
pressive symptomology has been related to lower adjustment in
studies of varying sample sizes (Attawong & Kovindha, 2005;
Elliott, 1999; Krause, Brotherton, Morrisette, Newman, &
Karakostas, 2007; Martz, Livneh, Preibe, Wuermser, & Otto-
manelli, 2005). The salient relationship between depression and
AD in those years removed from the occurrence of SCI sup-
ports the idea that AD encompasses more than one’s immediate
emotional reaction to a physical disability. AD comprises cog-
nitive and affective elements which interact to determine one’s
adjustment to a chronic and disabling health condition. It may
be that those with high AD are able to de-emphasize the impor-
tance of physical attributes and place more value on their char-
acterological attributes, leading to a sense of empowerment and
a more positive outlook on their current situation; conversely,
those with low AD may be preoccupied with the negative im-
pact of their disability, leading to a sense of helplessness and
leaving them more susceptible to prolonged and/or recurrent
episodes of negative mood and experience.
Social support has also been shown to be positively associ-
ated with health, well-being, and coping with a stressful event
such as SCI (Chronister, Johnson, & Berven, 2006). Some
findings indicate that social support serves to buffer depression
and suicidal intent, as well as enhance quality of life and life
satisfaction (Beedie & Kennedy, 2002; Kemp & Krause, 1999).
One of the characteristics of a collective culture such as China
is the strong social support from family members and friends
for those with disabilities (Morris & Peng, 1994; Yang, 1981).
Having a strong social network and supportive relationships is
particularly desirable for Chinese people (Triandis et al., 1986),

J. JIAO ET AL.
and should serve to alleviate depression and facilitate adjust-
ment to disability.
A study by Belgrave (1991) found that social support was a
significant predictor of AD among 170 African Americans with
disabilities. Furthermore, Post and colleagues (1999) reported
that there was a moderate to strong negative correlation be-
tween social support and depression, and a positive correlation
between social support and well-being, self-esteem, adjustment,
and life satisfaction among people with SCI. Beedie and Ken-
nedy (2002) followed a group of individuals with SCI longitu-
dinally and found that high quality of social support was asso-
ciated with lower hopelessness and depression scores, with this
association becoming more pronounced as rehabilitation pro-
gressed. Sherman, Devinney, and Sperling (2004) compared the
impact of two types of social support, past peer-mentoring ex-
perience (PME) and current live-in partner (LIP), on adjustment
after SCI. They found that PME was associated with higher
occupational activity and life satisfaction, while LIP was asso-
ciated with greater mobility and economic self-sufficiency.
These results attest the differential impacts of social support
sources. The significance of social support on subjective well-
being and quality of life has also been reported in other studies
(Hampton, 2004; Hampton & Qin-Hilliard, 2004). In summary,
people who report greater social support experience less emo-
tional distress and better adjustment to their disabilities.
Being the most populous country in the world, China also
has the largest number of people with disabilities. Unlike the
US, there is no official record of the incidence of SCI in China,
though the number of individuals with SCI is expected to be
high and on the rise given the increase in automobile and con-
struction accidents (Hampton, 2001). To better understand how
Chinese with SCI might differ from Westerners in their adjust-
ment to disability, it is first necessary to know whether the
Chinese differ from Westerners in their manifestation of de-
pressive symptoms, as depression is the most consistent psy-
chosocial correlate of SCI. Previous epidemiological studies
have found the lifetime prevalence of depression to be between
3% and 17% in the United States (Kessler et al., 1994), but as
low as .19% in China (Hwu, Chang, Yeh, Chang, & Yeh, 1996).
One of the proposed reasons for this large discrepancy in de-
pression prevalence is the more somatic presentation of psy-
chological distress in the Chinese (Draguns, 1996), leading to
medical diagnoses other than depression. The overall results of
studies investigating symptom reporting in Chinese with de-
pression suggest that the tendency of the Chinese to interpret
putative symptoms of depression with a somatic explanation is
stronger if they are less acculturated to a Western-style culture
(Parker, Chan, Tully, & Eisenbruch, 2005; Yen, Robins, & Lin,
2000).
Despite their significant relationship with each other, as well
as with other psychosocial and disability-related factors, the
effects of depression and social support on AD within the con-
text of physical disability have not received much attention in
non-Western samples. The correlates of AD in the Chinese may
be somewhat different from those in U.S. samples, stemming
from differing psychological reactions, differing social and
physical environments, or differing cultural conceptualizations
of disability. The more collectivist self-concept apparent in
Eastern cultures suggests that long-term AD may be different in
Chinese individuals with SCI, especially given the traumatic,
chronic, and life-changing nature of this disability, and the
more somatic orientation of symptom reporting among native
Chinese. For this reason, the study of the association between
AD, depression, and social support, which often being viewed
as buffer to anxiety and depression, is necessary given the pau-
city of research done with Chinese SCI population.
The purpose of the current study was to explore the relationship
between perceived social support, depression, and AD among
Chinese individuals with SCI. It was hypothesized that both
depression and social support would significantly predict AD. It
was also hypothesized that high perceived social support would
attenuate, or even nullify, the impact of depression on AD. In
other words, we hypothesized that social support would serve as
a mediator of the relationship between depression and AD.
Method
Participants
The current study is part of a major collaborative project
between the Guangdong Provincial Vocational Rehabilitation
Center and the Illinois Institute of Technology’s (IIT) Reha-
bilitation Psychology Program. Participants were patients re-
ferred by their treating rehabilitation professionals at the reha-
bilitation center, located in Guangzhou, China. To be included
in the study, participants had to be at least 18 months post-SCI,
as indicated by medical record or self-report. The justification
for this inclusion criterion was to avoid the transient impact of
the traumatic event related to the SCI and assess more stable
and enduring cognitive and psychological constructs. Partici-
pants had to be able to complete all instruments through face-
to-face interview or phone interview.
Exclusion criteria: Exclusion criteria included concomitant
traumatic brain injury (TBI), developmental disabilities, or a
history of hospitalization for a psychiatric disorder, as indicated
by medical record. Those with TBI or a developmental disabil-
ity were excluded to ensure that all participants could under-
stand and complete study measures. Those with a history of
psychiatric hospitalization were excluded to avoid the potential
influence of a previous psychiatric condition on the psychoso-
cial variables of interest in this study.
Procedure: Two hundred twenty-five individuals were ini-
tially identified from the rehabilitation center as possible par-
ticipants for the study. Based on inclusion and exclusion criteria
and willingness to participate, the final sample consisted of 100
in and outpatients. The age range of the participants was from
19 to 77 (Mean = 37.68, SD = 11.77) and 37 percent of the
participants had some college education. At the time of the
study, more than 70 percent of the participants were married
and less than half of the participants were working (full time =
31%; part time = 7%; home maker = 3%; student = 2%). Each
participant was paid 30 RMB ($4.50) for their interview. Inter-
views took place either in person or by phone; in-person inter-
views lasted approximately 40 minutes and phone interviews
lasted 60 - 80 minutes. All interviews were conducted by a
physician or graduate research assistant trained in the admini-
stration of all measures. Prior to study participation, all partici-
pants provided written or verbal informed consent. Data were
collected from January 2007 through December 2008.
Measures
Demographics and injury-related characteristics: Demo-
graphic information was collected on gender, age, marital status,
education level, and work status. Work status was classified
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J. JIAO ET AL.
into one of six categories: full-time; part-time; student; retired;
homemaker; unemployed. Type of injury was determined by
neurologic level and the extent of lesion; injuries were classi-
fied as either tetraplegia or paraplegia based on diagnosis indi-
cated in the medical record or self-report.
Acceptance of disability: Acceptance of Disability Scale
(ADS; Linkowski, 1971) is a 50-item measure examining psy-
chosocial adjustment among people with disabilities. The scale
evaluates the degree to which people find meaning in their cir-
cumstances and maintain positive beliefs about themselves.
Participants rate each item on a 6-point scale ranging from 1
(disagree very much) to 6 (agree very much), with 15 of the
items reverse scored. Higher scores indicate greater acceptance
of disability. The scale demonstrates high reliability, with an
internal consistency coefficient of .93, and significant construct
and concurrent validity (Linkowski, 1971). The Chinese ver-
sion of the ADS (Wu & Lu, 1999) has been translated and
back-translated, and it has been found to be appropriate for use
with a Taiwanese sample.
Depression: Center for Epidemiologic Studies Short De-
pression Scale (CES-D 10; Andresen, Malmgren, Carter, &
Patrick, 1994) is a 10-item self-report measure designed to as-
sess symptoms of depression in the general population. The
full-length 20-item version of the CES-D (Radloff, 1977) was
designed to de-emphasize somatic complaints relative to other
depression scales, and the CES-D 10 is a shorter version of this
instrument. Considering the substantial medical complications
related to SCI, the CES-D 10 helps to avoid the problem of
over-diagnosing depression based on somatic symptoms. Par-
ticipants are instructed to rate items on a 4-point scale ranging
from 0 (rarely or none of the time) to 3 (all of the time), with 2
items reverse scored; a higher score indicates higher depressive
symptoms. When compared to the 20-item version of the CES-
D, the CES-D 10 has demonstrated strong predictive accuracy
(kappa = .97), and test-retest reliability is comparable to that of
other measures of depression (r = .71) (Andresen et al., 1994).
Internal consistency reliability in a sample of patients with
chronic disease was .84 (Lorig, Sobel, Ritter, Laurent, & Hobbs,
2001.) The CES-D has been widely used in various cultures,
and it has specifically demonstrated construct validity within a
sample of Chinese married couples (Cheung & Bagley, 1998).
Social support: Multidimensional Scale of Perceived Social
Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988) is a
12-item self-report measure of the perceived level of support
from three sources: family, friends, and significant other. Par-
ticipants rate items on a 7-point scale ranging from 1 (very
strongly disagree) to 7 (very strongly agree), with higher scores
indicating a higher level of perceived social support. The
MSPSS has demonstrated very good internal reliability, with
Cronbach’s alpha ranging from .85 - .91 (Dahlem, Zimet, &
Walker, 1991; Zimet et al., 1988). The measure has also shown
construct validity, as evidenced by its negative association with
measures of anxiety and depression (Zimet et al., 1988), and
factorial validity, as factor analysis confirms that individuals do
make distinctions between sources of social support (Dahlem et
al., 1991). The Chinese version of the MSPSS has shown good
internal consistency as well, ranging from .82 to .94 (Chou,
2000; Short & Johnston, 1997; Zhang & Norvilitis, 2002).
Statistical Analysis
To examine the relationship among perceived social support,
depression, and AD, bivariate correlation was utilized. Given
that little research has been done among the Chinese population,
associations of demographic variables (i.e., age, gender, educa-
tion) with these psychosocial variables were also examined
through correlational analysis. Hierarchical regression analysis
was used to evaluate the independent contributions of depress-
sion and perceived social support to AD. Because this was a
pilot study concerning AD within the Chinese population,
demographic variables were entered in the first block of the
regression model. Total score on the perceived social support
scale (MSPSS) was entered in the second block given its crucial
impact in Chinese culture. Total score on the depression scale
(CES-D 10) was entered in the model last to reveal its unique
contribution to AD with all other variables controlled. The po-
tential mediating role of social support in the relationship be-
tween depression and AD was tested following the procedure
recommended by Judd and Kenny (1981, as cited in Baron &
Kenny, 1986).
Results
Preliminary and Correlational Analyses
Means and standard deviations of the sample’s scores on the
MSPSS, CES-D 10, and ADS are provided in Table 1.
Of note, approximately 67 percent of participants met the
criterion for depression using the CES-D 10 cut-off score of 10
suggested by Andresen et al. (1994). After dichotomizing the
sample using the above criterion (depressed vs. non-depressed),
it was found that the individuals in the depressed group re-
ported a significantly lower level of perceived social support (t
= 4.44, p < .01) and acceptance of disability (t = 4.59, p < .01)
than those in the non-depressed group. The average total score
on the MSPSS was 60 and 71, respectively; the average total
score on the ADS was 172 and 198, respectively.
Bivariate correlation analyses showed that there were no sig-
nificant correlations between the demographic variables and the
MSPSS score. Similarly, only education was significantly re-
lated to CES-D 10 score (r = –.20, p < .05), with people with
higher education reporting less depressive symptoms. For the
ADS, all three demographic variables showed a significant
bivariate correlation with the ADS score. Female gender was
associated with higher AD (r = .24, p < .05). Age was nega-
tively related to their ADS score (r = –.22, p < .05), and educa-
tion level was positively associated with the ADS score (r = .34,
p < .01). Of interest, for the sample as a whole, age was nega-
tively associated with education level (r = –.33, p < .01). After
controlling for education, the relationship between age and the
ADS score became non-significant.
There were significant correlations among the ADS score,
CES-D 10 score, and MSPSS score. The ADS score was nega-
tively correlated with the CES-D 10 score (r = –.57, p < .01)
and positively correlated with the MSPSS score (r = .28, p < .01).
The MSPSS score was also negatively correlated with the
Table 1.
Means ans standard deviations of scores on perceived social support,
depression and acceptance of disability measures for the entire sample.
Measure M SD n
MSPSS 63.81 12.86 99
CES-D 1011.44 5.44 99
ADS 182.18 29.80 94

J. JIAO ET AL.
CES-D 10 score (r = –.45, p < .01), indicating that higher per-
ceived social support is associated with less reported depressive
symptoms.
Regression Analysis
Hierarchical regression analysis showed that neither age nor
gender in the first block was significantly predictive of the ADS
score. Education however, was found to be a significant pre-
dictor of the ADS score (β = .27, t = 2.59, p = .01), indicating
that people with higher education tended to have higher accep-
tance of their disability. In the second block, the MSPSS score
was also a significant predictor of the ADS score (β = .28, t =
2.96, p = .004); the addition of the MSPSS score accounted for
an additional 7.7% of the variance in the ADS score. The
CES-D 10 score was entered in the regression model last, sig-
nificantly increasing the amount of the variance explained by
16.6%. The complete model accounted for almost 40% percent
of the variance in the ADS score, with the CES-D 10 score
being the single significant predictor (β = –.48, t = –4.87, p
< .001); the MSPSS score no longer significantly predicted the
ADS score (β = .04, t = .46, p = .65), and education level was
only marginally significant (β = .18, t = 1.96, p = .054). Our
hypothesis that both depression and perceived social support
would predict AD was partially confirmed, as the CES-D 10
score was a significant predictor of the ADS score, while the
MSPSS score was not.
Depression as a M ediator
As stated above, when the CES-D 10 score was added to the
regression model, the prediction of the ADS score by the
MSPSS score became non-significant, suggesting that depress-
sion mediated the relationship between perceived social support
and AD, rather than social support mediating the relationship
between depression and AD. To formally examine the potential
mediating role of depressive symptoms in the relationship be-
tween perceived social support and AD, the following proce-
dure was utilized (Judd & Kenny, 1981, as cited in Baron &
Kenny, 1986): regressing the mediator (i.e., the CES-D 10
score) on the independent variable (i.e., the MSPSS score) to
test for a significant association; regressing the dependent vari-
able (i.e., the ADS score) on the independent variable to test for
a significant association; and regressing the dependent variable
on both the independent variable and mediator to test for a sig-
nificantly lower degree of association between the independent
variable and the dependent variable with the mediator included
in the model (Table 2).
The test results as shown in Tables 3-5 met the three criteria
proposed by Baron and Kenny (1986), which are as follows: the
MSPSS score significantly predicted the CES-D 10 score in the
first regression equation; the MSPSS score significantly pre-
dicted the ADS score in the second equation; the CES-D 10
score significantly predicted the ADS score in the third equa-
tion, while the MSPSS score was not a significant predictor of
the ADS score. Thus, it can be stated that depresssion serves as
a mediator of the relationship between social support and AD.
That is, with depression controlled, perceived social support no
longer has a significant association with AD. In sum, our hy-
pothesis that perceived social support would mediate the rela-
tionship between depression and AD was not supported; instead,
it was depression that mediated the relationship between per-
ceived social support and acceptance of disability.
Discussion
The current study is a pilot study exploring the relationships
among perceived social support, depression, and AD in a sam-
ple of Chinese individuals with spinal cord injuries. It is well
established in the Western literature that acceptance of disabil-
ity is positively related to social support, and negatively associ-
ated with depression. However, very few studies have exam-
ined the relationship among all three of these variables, spe-
cifically, the contributions of perceived social support and de-
pression to AD, and the mechanism by which they operate.
This line of research is particularly pertinent to the Chinese
rehabilitation population, given the extreme challenges inherent
Table 2.
Summary of hierarchical regression analysis for variables predicting
acceptance of disability.
Variable B SEB β
Step 1Age –.238 .261 –.097
Gender 11.411 7.431 .158
Education 5.587 2.157 .269*
Step 2Age –.329 .252 -.134
Gender 8.671 7.187 .120
Education 5.468 2.069 .264*
MSPSS .659 .223 .281**
Step 3Age –.178 .227 –.072
Gender 8.810 6.407 .122
Education 3.677 1.881 .177
MSPSS .104 .229 .044
CES-D 10 –2.628 .539 –.484**
Note: R2 = .149 for Step 1; ΔR2 = .077 for Step 2; ΔR2 = .166 for Step 3; *p < .05;
**p < .01.
Table 3.
Regression analysis summary for perceived social support predicting
depression.
Predictor VariableB SEB β
MSPSS –.189 .038 –.450**
Note: R2 = .203; **p < .01.
Table 4.
Regression analysis summary for perceived social support predicting
acceptance of disability.
Predictor VariableB SEB β
MSPSS .663 .236 .283**
Note: R2 = .080; **p < .01.
Table 5.
Regression analysis summary for perceived social support and depres-
sion predicting acceptance of disability.
Predictor VariableB SEB β
MSPSS –.033 .232 .014
CES-D 10 –3.052 .537 –.562**
Note: R2 = .323; **p < .01.
778

J. JIAO ET AL.
in AD and the increased cultural emphasis on social support.
This study focused on the population of Chinese individuals
with SCI because of the increased rate of injury and the trau-
matic impact on the individuals and their families. SCI has been
studied extensively in the Western literature because of its tre-
mendous impact on rehabilitation resources. In developing
China, rehabilitation services are still limited in scope, and
optimizing rehabilitation outcome using available resources is
the main focus of Chinese rehabilitation professionals. Addi-
tionally, a better understanding of the adjustment process of
Chinese individuals with SCI will fill an existing gap in the
rehabilitation literature and help develop cultural competency
among Western rehabilitation professionals.
Results showed that, as a whole, participants reported a low
level of acceptance of disability; the mean ADS score in this
sample was 182, whereas in a Western sample of rehabilitation
clients a mean ADS score of 217 has been reported, with scores
of 180 and below being considered indicative of low AD
(Jointer, Lovett, & Goodwin, 1989). Compared with their West-
ern counterparts, this Chinese sample demonstrated a lower
level of AD. In terms of depressive symptoms, the mean
CES-D 10 score was 11, with more than 60 percent of partici-
pants meeting the criterion for depression using the suggested
cut-off score of 10 reported by Andresen et al. (1994). This
level of depressive symptomology is much higher than that re-
ported in the Western rehabilitation literature (Richards, Kew-
man, & Pierce, 2000). Due to the physical complaints com-
monly reported by individuals with SCI, this study used the
CES-D 10 to prevent over-diagnosing depression in this popu-
lation based on somatic symptoms. Thus, we believe that this
result accurately reflects the depression prevalence among
Chinese individuals with SCI, as somatic symptoms have been
controlled by the depression measure chosen. It should be noted
that the participants in this study were at least a year-and-a-half
post-injury. Based on our findings and methodology, we are
confident that those met the criterion for depression were not
experiencing inflated symptomology due to very recent onset of
injury or a preponderance of somatic symptoms. We believe
that our findings are an accurate reflection of the significantly
lower level of perceived social support and acceptance of dis-
ability in those with higher depressive symptomatology.
The present study confirmed the findings reported in the
Western literature that female individuals are more accepting of
their disability. In addition, education was positively associated
with AD. Consistent with previous research, age did not dem-
onstrate a significant association with AD. As for the relation-
ship between perceived social support, depression, and AD, our
results replicated existing findings in the literature (Attawang &
Kovindha, 2005; Belgrave, 1991; Perry, Nicholas, & Middleton,
2009; Post et al., 1991): perceived social support was shown to
be positively associated with AD and negatively associated
with depression; depression and AD were negatively associ-
ated.
By way of hierarchical regression analysis, the prediction of
AD by perceived social support and depression was examined.
In the regression model, education was the single significant
demographic predictor of AD, with higher education contribut-
ing to higher AD. Perceived social support was added in the
second block of the model, and depression was added in the
third and final block. For the overall regression equation, de-
pression was the single significant predictor of AD. Surpris-
ingly, perceived social support was no longer a significant pre-
dictor after depression was added into the regression model.
The non-significant role of perceived social support in the
final model was unexpected, given the seeming importance of
social support to well-being cited in the Chinese literature
(Chan, Lee, & Lieh-Mak, 2000). Results indicated that per-
ceived social support did not have a direct effect on AD, nor
did it impact the relationship between depression and AD. In-
stead, depression mediated the relationship between perceived
social support and AD. In other words, depression appears to be
the generative mechanism through which perceived social sup-
port influences AD. That is, depression seems to be the essen-
tial factor in the process of acceptance of disability. Due to the
drastic life changes resulting from their disability, Chinese
individuals with SCI are likely to be sensitive to the negative
impact on their social network, which can induce substantial
guilt and self-blame. Furthermore, their collectivist cultural up-
bringing dictates that Chinese individuals seek out and require
feedback from their family and friends to establish their self-
concept. So low perceived social support can be especially
detrimental. This low level of perceived social support may
exacerbate already existing adjustment difficulties and make
these individuals more vulnerable to developing psychological
problems such as depression. The results of the present study
indicate that depression is prevalent among Chinese individuals
with SCI, and it has a marked impact on the process of accep-
tance of disability.
The most significant finding of this study is the essential role
of depression in the relationship between perceived social sup-
port and acceptance of disability. Rather than being mediated
by social support, depression mediates the relationship between
social support and acceptance of disability, having a pervasive
and direct impact throughout the adjustment process. For social
support to facilitate acceptance of disability, it must operate by
mitigating individuals’ depressive symptoms. One explanation
for this finding is that Chinese individuals with SCI are par-
ticularly vulnerable to depression as the result of their disabling
condition. More than 60 percent of the participants in this study
met the CES-D 10 criterion for depression (Andresen et al.,
1994), and this prevalence is higher than that documented in the
Western literature (Richards et al., 2000). Another possible
explanation for only the indirect impact of social support may
be that those with SCI need social support aside from family,
friends, and significant others, as measured by the social sup-
port scale used in this study. Subsequent studies should invest-
tigate whether support from rehabilitation professionals or peo-
ple with similar conditions plays a more direct role in the ad-
justment process.
The current study holds important implications. Given its
pervasive and direct impact on the rehabilitation process, de-
pression should be carefully assessed and closely monitored in
Chinese individuals with SCI. When working with these indi-
viduals, rehabilitation professionals should pay close attention
to both presenting somatic symptoms and emotional function-
ing, as this population appears to be at significant risk for de-
pression. Additionally, though social support is likely an im-
portant factor in adjustment to disability, it is not a panacea. It
is often assumed that as long as individuals with SCI have
support from their family and friends, they will make a smooth
adjustment to their disability. This is especially believed to be
true for those from a collectivist cultural background such as
the Chinese. Rehabilitation professionals need to guard against
the tendency to oversimplify and generalize the rehabilitation

J. JIAO ET AL.
process of people from different cultural backgrounds. Finally,
the results of the present study do not undermine the impor-
tance of social support. Instead, it suggests that the conceptu-
alization of social support and its measurement be broadened
(e.g., interaction with rehabilitation professional, interaction
with people with similar condition), both in research and prac-
tice, to further examine and utilize its contribution to adjust-
ment to disability.
Limitation
The present study has several limitations. First, we used a
convenient sample, and participants had been receiving outpa-
tient rehabilitation services which are not commonly accessible
for the majority of Chinese individuals with disabilities. Also,
approximately 37 percent of the participants had some college
education, which is higher than the level of education reported
in the general population. These factors may limit the gener-
alizability of the current findings to the larger population of
Chinese individuals with SCI. Second, ours was the first study
to use the ADS scale with Chinese individuals from mainland
China. Studies examining the reliability and validity of this
scale for this particular population are needed. Third, as dis-
cussed previously, the social support scale used in this study
focuses mainly on support from family, friends, and significant
others. The scale does not include social support from other
resources. For example, it does not include perceived support
from professionals or people with similar conditions, which
might partially account for the non-significant prediction of
acceptance of disability by perceived social support. Future
studies on acceptance of disability, social support, and depress-
sion would benefit from the inclusion of a broader range of de-
mographic, disability-related, and psychosocial variables, such
as employment status, marital status, functional limitations, and
self-efficacy. The interaction among these variables could shed
further light on this important rehabilitation topic.
Conclusion
In summary, the results of the present study indicate that the
prevalence of depression is alarmingly high among Chinese
individuals with SCI. Depression is negatively associated with
perceived social support, and is predictive of lower acceptance
of disability. Depression is an essential factor in the adjustment
process, and it mediates the relationship between social support
and acceptance of disability. Further research is needed to con-
tinue investigating the effects of depression and perceived so-
cial support on acceptance of disability in populations from
different cultures. Cross-cultural studies will help rehabilitation
professionals develop a better understanding of the adjustment
process and apply effective and culturally sensitive intervene-
tions to promote acceptance of disability.
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