The complexity of human functioning and disability in relation to various environments poses major challenges to scientific understanding. On the country level, economic resources and investment in the infrastructure and services likely play a major role in producing inequalities in functioning between higher and lower-resourced settings. Thus, the objective of the study was to examine whether functioning levels and underlying association patterns indeed differ between lower- and higher-resource countries using spinal cord injury (SCI) data as a case in point.
Observational cross-sectional data from a sample of 1048 patients from 14 countries, surveyed for the SCI Core Set project, were secondarily analysed. Assessment was based on 264 categories of the International Classification of Functioning, Disability and Health (ICF). In the analysis, a two part approach was taken. Firstly, frequencies of ICF categories between countries were compared. Secondly, differential association structures of ICF categories were analysed with probabilistic graphical models based on bootstrap aggregated LASSO regression.
Frequency analysis did not show a consistent pattern. Some problems were reported more often in lower-resource countries, while others were reported more frequently in higher-resource countries. Association patterns differed significantly between settings. Virtually no ICF cross-component association stayed stable across countries. Generally, clusters representing environmental facilitators were rarely associated with clusters representing functioning domains. Within the ICF components meaningful clusters were found.
Functioning is a multi-dimensional phenomenon demonstrating cross-country variation. The stability and validation of identified association patterns between lower- and higher resource countries are topics for ongoing research.