one of the common outcomes measuring rehabilitation achievement in people with spinal cord 
 injury is the level of community participation . previous studies reported that participation 
 directly reflected the potential to improve the quality of life ( qol ) after sci1 , 2 . this rather new concept has been used since the international classification of functioning , 
 disability and health ( icf ) replaced the former classification , the international 
 classification of impairments , disabilities , and handicaps ( icidh)3 , 4 . the concept of 
  participation  addressed in rehabilitation is defined in a positive way as the social 
 involvement in a life situation with more autonomy and the individual 's point of view , 
 whereas the previous concept of  handicap  is restricted to the fulfillment of roles that 
 were considered normal from a societal point of view3,4,5,6 . in the handicap concept , the participation issue was observed quantitatively and 
 objectively , such as the frequency with which an individual performed roles ( e.g. , hours of 
 paid work ) . however , such measurement information does not capture the individual 's 
 perspective concerning the impact of the disease and the problems they experience in 
 performing their life roles . therefore , the more subjective measurements of participation , 
 which assessed the perspective of the individual , were developed . although the icf model 
 does not comprise a subjective dimension , replacement of the term handicap with 
 participation and inclusion of a broader range of life roles presents a scope compatible 
 with capturing subjective information5 . therefore , an outcome measure developed based on the icf participation concept , which refers 
 more to autonomy and the personal fulfillment of role would be an essential tool for 
 personnel working in the rehabilitation field to evaluate and promote community 
 participation after sci . recently , three reviews focusing on the participation instruments were published7,8,9 . among eight instruments particularly based 
 on the icf model , the impact of participation and autonomy ( ipa ) is the one that is being 
 increasing used as a participation outcome instrument in clinical practice and 
 rehabilitation research7 , 10,11,12,13,14 . this instrument was first developed in the netherlands by 
 cardol et al . in 199915 and then 
 translated into english by sibley et al10 . it captures degree of perceived participation in two aspects : 
 including perceived participation in various life situations and the experience of problems 
 for participation . good reliability and validity of the ipa were demonstrated in people with 
 chronic disability , including people with sci6 , 10 , 15 , 16 . additionally , its responsiveness 
 properties have also been proven13 , 14 . in thailand , assessing community participation in people with sci after hospital discharge 
 is still overlooked in the rehabilitation arena . therefore , this study aimed to cross - culturally translate and then investigate 
 the psychometric properties of the thai version of the ipa as an instrument to be used to 
 evaluate the level of community participation in the thai sci population . initially , the participants were identified from the list of members of the do n't drive 
 drunk foundation , thailand . ( many victims of traffic accidents caused by drunk driving have 
 traumatic spinal cord injuries . this foundation aims to create awareness among drivers about 
 dangers of alcohol - impaired driving . ) then , the snowball sampling technique was used to 
 recruit the sample . the eligible participants were those aged from 18 to 55  years who 
 sustained a traumatic sci at least 1  year previously , had scores less than or equal to 11 on 
 the thai version of the hospital anxiety and depression scale , lived in the community , and 
 used a wheelchair as their primary mobility tool . the procedure of the study was approved by 
 the ethics committee , mahidol university institutional review board . english version of the ipa16 was 
 translated into thai with permission from the authors of the original dutch version and the 
 translated english version of the ipa . the translation process was performed following the 
 guideline for cross - cultural adaptation of self - report measures , which include forward 
 translation , synthesis of translation , back translation , cross - cultural adaptation and 
 pretesting17 . two forward translations 
 were independently produced by native speakers of thai , a physical therapist and a language 
 expert who had no medical background . the two draft translations of the questionnaire were 
 discussed and integrated into one common translation . this was translated back into english 
 by two native speakers of english who were blinded to the original version . in the stage of 
 cultural adaptation , all translations were reviewed and approved to produce the final 
 version by expert committees including two physical therapists , one statistician , and one 
 language professional . none of the items in the thai version of the ipa were adapted . the 
 final thai version of the ipa was then evaluated for the reliability and validity . this study was part of a study of the influential factors in community participation among 
 persons with sci18 . a total of 139 
 persons with sci were recruited to determine the validity of the ipa . the whoqol - bref - thai 
 version was selected as a validated questionnaire in this study because the whoqol - bref 
 domains contain similar traits as the ipa and the contents of items are applicable for 
 individuals with sci . moreover , none of the validated community participation instrument 
 ( thai version ) was used in thailand . to assess the reliability , the first 30 participants 
 were asked to complete the ipa twice with a 2-week interval . completion of the questionnaire 
 took place in the participant 's home or a convenient place . the ipa measures the degree of perceived participation in two aspects including the 
 perceived participation in various life situations and the experience of problems . the ipa 
 comprised 32 items in five domains ( autonomy indoors , family role , autonomy outdoors , social 
 life and relationships , and work and education ) and 8 items of the experience of problems 
 ( mobility , self - care , family role , financial situation , leisure , social relation , work , and 
 education ) . for the former aspect , the participants responded to each item by grading 
 his / her perceived participation and autonomy on a 5-point rating scale ( range : very good , 0 ; 
 very poor , 4 ) . the latter aspect focused on the perceived problems in participation 
 restriction measured on a 3-point rating scale : no problem , minor problem , and severe 
 problem . the participation 
 score ranges from 0128 , and experience of problems scores ranged from 016 , with higher 
 scores reflecting more restrictions in participation ( less community participation ) and/or 
 more experience of problems . the whoqol - bref , an abbreviated version of the whoqol , assesses health - related quality of 
 life . the whoqol - bref was translated into thai and tested for its psychometric 
 properties19 . the whoqol - bref consists 
 of 26 items , of which 24 items were grouped into four domains ( physical health , 
 psychological health , social relationship , and environment ) . the other two items are for 
 overall quality of life and general health , respectively . the intraclass 
 correlation coefficient ( icc3,1 ) was used to examine the test - retest reliability for the 
 subscale scores and total scores of the thai version of the ipa . icc values greater than 0.75 are considered good 
 reliability , and those less than 0.75 indicate poor to moderate reliability20 . spearman rank correlation coefficient was obtained to assess the convergent and 
 discriminant validity for the thai version of the ipa by correlation with the 
 whoqol - bref - thai version . correlations ranging from 0 to 0.25 suggest little or no 
 relationship ; values from 0.25 to 0.50 indicate a fair relationship ; values from 0.50 to 
 0.75 indicate a moderate to good relationship ; and values exceeding 0.75 indicate a good to 
 excellent relationship20 . factor analysis was also used to confirm the construct validity of the thai version of the 
 ipa . the current 
 age of the participants ranged from 18 to 55  years with an average age of 34.2  years ( sd = 
 8.4 ) . the duration after injury ranged between 1 and 38 , with an average of 10.6  years ( sd = 
 7.1 ) . the reliability test was done by using internal consistency and test - retest reliability . the internal consistency was high for the total ipa score ( cronbach 's  = 0.95 ) and all 
 domains ( cronbach 's  = 0.860.90 ) . the data showed a total ipa score icc reliability of 
 0.93 and domain iccs between 0.74 ( social life and relationships ) and 0.92 ( autonomy 
 indoors ) , indicating moderate to good reliability ( table 2 ) . convergent validity of the ipa was supported by the correlations between the ipa and four 
 domains of the whoqol - bref , the physical , psychosocial , social , and environmental domains . 
 the correlations between the  autonomy indoors ,   family role ,  and  autonomy outdoors domains of the ipa and the  physical  domain of the whoqol - bref were substantial ( r = 0.49 
 to 0.56 ) . moreover , the correlation between  autonomy outdoors  of the ipa and  social 
 relation  of the whoqol - bref showed higher correlation than expected ( r = 0.65 ) . the 
  social life and relationships  domain of the ipa was correlated with  social relation  of 
 the whoqol - bref ( r = 0.40 ) . the  work and education  domain of the ipa was correlated with 
 the  psychosocial  domain of the whoqol - bref ( r = 0.37 ) , also representing convergent 
 validity . discriminant validity was supported by no correlation between the  autonomy indoors ,  
  social and relationships ,  and  work and education  domains of the ipa and  environment  
 domain of the whoqol - bref . the correlation between the  family role  domain of the ipa and 
  environmental  domain of the whoqol - bref  was fair ( r=0.36 ) . however , the  autonomy 
 outdoors  domain of the ipa could not be clearly demonstrated to have discriminant validity 
 in this study ( table 3 ) . construct validity was proved by factor loadings with 5 components , which showed that 68% 
 of the total variance could be explained . most variance was explained by the factor autonomy 
 indoors ( 41% ) , followed by work and education ( 11% ) ( table 4 ) . community participation outcome is an important variable for evaluating the rehabilitation 
 achievement in people with spinal cord injury . this study conducted cross - cultural 
 translation and then investigated the psychometric properties of the thai version of the 
 ipa . in the process of cross - cultural adaptation , the authors considered that the item of 
  intimate relationship  was a quite sensitive question in traditional thai culture . this topic 
 is concealed , and people usually avoided discussing it openly . however , in present thai 
 society , people have become rather expressive about their sexual behavior and open minded 
 about couples cohabitating before marriage compared with in the past . therefore , this item 
 was considered to be still included in the thai version of the ipa with the understanding 
 that there may be missing data . the ipa was used to assess the activities involved in life 
 situation and social roles in everyday life ( such as fulfilling role at home , helping and 
 supporting others , and spending leisure time ) . from the experts ' opinions , thus , none of the items 
 in the thai version of the ipa were adapted . the findings of this study showed that the thai version of the ipa was a reliable and valid 
 measure of community participation in thai people with spinal cord injury . the test - retest 
 reliability with a 2-week interval was high ( icc values = 0.760.93 ) for total score and all 
 five domains , indicating that the thai version of the ipa was stable over time . the internal 
 consistency of the overall scale was also good ( cronbach 's  = 0.95 ) , reflecting that all 
 items measured the same underlying construct . the result of good reliability of the ipa 
 scale corresponded with previous studies6 , 10 . reported that the 
 cronbach 's alpha coefficient in each domain of the dutch version of the ipa ranged from 
 0.810.91 and that the test - retest reliability with icc values ranged from 0.83 to 0.916 . sibley et al . showed that the cronbach 's 
 alpha coefficient in each domain of the translated english version of the ipa ranged from 
 0.86 to 0.94 and that the the test - retest reliability with icc values was more than 
 0.9010 . therefore , the thai version of 
 the ipa could be considered a reliable measure of community participation outcome . regarding the convergent validity , the 3 domains of the thai version of the ipa including 
 autonomy indoors , family role , and autonomy outdoors were correlated with the physical 
 domain of the whoqol - bref , supporting the convergent validity . the autonomy outdoors and 
 social life and relationships domain of the thai version of the ipa were also confirmed to 
 have convergent validity by the moderate to high correlations with the social relation 
 domain of the whoqol - bref . unexpectedly , the work and education domain of the thai version 
 of the ipa was not found to be correlated with the social relation domain of the whoqol - bref 
 in the present study . however , the work and education domain of the thai version of the ipa 
 showed moderate correlation with psychological domain of the whoqol - bref , which was similar 
 to the results of a study by sibley et al.10 . they found moderate correlation between the work and education 
 domains of the english version of the ipa and the functional limitation profile ( emotional 
 subscale ) and sf-36 mental health component . a possible reason for this was that the content 
 of items in the work and education domain of the thai version of the ipa ( such as the chance 
 to do or keep a job the way one wants ) and items in the psychological domain of the 
 whoqol - bref ( such as satisfied in one 's life or the extent to which one feels life to be 
 meaningful ) might represent related issues of life . noticeably , the duration after injury 
 was long in most of the participants in this study , so they might have adjusted to their 
 disability . therefore , an 
 individual who could get the job as they wish might have good psychological functions . however , further studies would be required to support the convergent validity in the work 
 and educational domain of the thai version of the ipa for persons with sci in different 
 stages of adaptation . discriminant validity was confirmed by no correlation between 3 domains of the thai version 
 of the ipa , autonomy indoors , social life and relationships , and work and education , and the 
 environmental domain of the whoqol - bref . however , two domains of the thai version of the 
 ipa , family role and autonomy outdoors , could not be clearly demonstrated to have 
 discriminant validity in this study . this may be the results of autonomy outdoors and family 
 role being nearly related with all domains of the whoqol - bref . hence , future research might 
 be required to confirm discriminant validity of these two domains by using other tools with 
 distinctly different measuring concepts . construct validity of the thai version of the ipa was supported by factor loadings with 5 
 components . most of the items were loaded according to their designated factors . however , 
 there were six items that had a loading pattern deviation . the items of spending money , 
 supporting people , and living the life as one wants were loaded on the work and education 
 domain . this may imply that those items shared the consequences of employment , which allowed 
 people could spend their own money and support others as they wanted . the education or 
 training item was not loaded on the work and education domain , but it was loaded on the 
 autonomy outdoors domain . the two items composing leisure time and intimate relationship 
 were not strongly loaded on the same structure , which was similar to the results of cardol 's 
 study6 . thus , these six items might need 
 to be further confirmed to have construct validity . however , most of the items of the thai 
 version of the ipa were contained in the same domains as the english version of the ipa . therefore , the thai version of the ipa could be considered to have acceptable construct 
 validity . in conclusion , the present findings provide supportive evidence of appropriate psychometric 
 properties of the thai version of the ipa for measuring community participation in people 
 with spinal cord injury . it is a reliable and valid instrument that can be used to evaluate 
 the level of community participation . in addition , it might be used as a guideline for 
 developing interventions to promote community participation for thai persons with spinal 
 cord injury . the limitation of this study was that we used only one instrument ( whoqol - bref ) to examine 
 the validity of the thai version of the ipa . this might limit the results for discriminant 
 validity , especially in the autonomy outdoors and family role domains . therefore , a future 
 study may require distinctly different measurement concepts to confirm the discriminant 
 validity of these two domains .
[ purpose ] the present study aimed to cross - culturally translate and evaluate the 
 reliability and validity of the thai version of the impact on participation and autonomy 
 ( ipa ) in persons with spinal cord injury ( sci ) . 
 [ subjects ] one hundred and thirty - nine 
 persons with sci who lived in the community were recruited for this study . 
 [ methods ] the 
 ipa was translated following the guideline for cross - cultural adaptation of self - report 
 measures . 
 the reliability and validity was examined in 139 persons with sci . for the 
 test - retest reliability 
 , 30 participants completed the thai version of the ipa twice with 
 a 2-week interval . 
 [ results ] the translated questionnaire and its items had moderate to 
 good reliability , with the icc(3,1 ) ranging from 0.76 to 0.93 . 
 the internal 
 consistency for all domains was high , with cronbach 's alpha ranging from 0.86 to 0.90 . 
 the 
 convergent validity , discriminant validity , and construct validity were supported . 
 [ conclusion ] the thai version of the ipa is a reliable and valid instrument for assessing 
 the level of community participation in thai persons with spinal cord injury .