Traumatic spinal cord injuries (TSCIs) significantly impact quality of life (QOL), particularly in developing countries like South Africa, where incidence rates are high. The WHO defines QOL as an individual's perception of their position in life, encompassing physical, psychological, social, and environmental aspects. Life satisfaction, a key component of QOL, is a cognitive and affective evaluation of the positivity in one's life. Individuals with TSCI often experience lower life satisfaction than the general population, influenced by socioeconomic factors (employment, income, environment, education) that are often pre-existing conditions in developing nations. Chronic pain, prevalent in the TSCI population, further diminishes life satisfaction. While socioeconomic factors impact life satisfaction in developing contexts, studies have shown its protective role in mediating the negative effects of pain and maintaining good health. Limited research exists on the interrelationship between life satisfaction, mental health (anxiety and depression), and pain in the TSCI population within developing countries. This study aimed to investigate this interrelationship in a South African context, hypothesizing that depression, anxiety, and pain would negatively correlate with life satisfaction.

Existing literature indicates a strong association between life satisfaction and psychological distress across various populations. TSCI, as a significant negative life event, is linked to increased risk of depression, anxiety, and stress. In developed countries, factors influencing mental health in the TSCI population include time since injury, gender, and pain; longer durations post-injury often correlate with lower anxiety and depression, potentially due to acceptance and improved coping. Males and those experiencing pain tend to exhibit higher levels of depression and anxiety, possibly related to resilience differences. While international research extensively examines QOL and mental health in TSCI patients, a gap exists regarding the interplay of chronic pain, mental health, and life satisfaction in developing nations, particularly South Africa, which has a unique demographic and etiological profile of TSCI.

This cross-sectional, analytical study used a convenient sampling strategy to recruit 70 adults with TSCI in Cape Town, South Africa. Participants were excluded if they could not provide informed consent or understand the questions. Data were collected via 20-30-minute telephonic interviews. Instruments used included: the WHOQOL-BREF (10 satisfaction items), the CESD-10 (depression), the STAI-T5 (anxiety), a one-item pain intensity measure from the ISCIPBDS, and the BPI's 7-item pain interference scale. The WHOQOL-BREF assesses satisfaction with various life aspects; the CESD-10 measures depressive symptoms; and the STAI-T5 assesses trait anxiety. Pain intensity was measured on a visual analog scale (0-10), and pain interference was assessed on an 11-point scale (0-10). Statistical analyses included descriptive statistics, reliability estimations (alpha and omega), intercorrelations (Pearson r), and mediation analyses (PROCESS macro, bootstrapped 95% confidence intervals) with life satisfaction as the mediator. Data normality was assessed using skewness and kurtosis.

The sample comprised mostly men (87.1%), unemployed (94.3%), with a mean age of 35.48 years (SD = 9.34). Most had secondary schooling (88.6%), and injuries were predominantly from gunshot wounds (40%) or motor vehicle accidents (27.1%). Eighty-three percent reported chronic pain, mainly below-level neuropathic pain (BL-NEUP) and musculoskeletal nociceptive pain (MNP). Analysis revealed significant moderate negative correlations between life satisfaction and both pain interference (r=-0.45, p<0.001) and pain intensity (r=-0.36, p=0.003). Significant positive correlations existed between pain (intensity and interference) and both depression and anxiety. Life satisfaction showed a significant negative correlation with depression (r=-0.45, p<0.001) and anxiety (r=-0.34, p=0.005). Mediation analyses indicated that life satisfaction fully mediated the relationship between pain intensity and both depression and anxiety. It mediated the relationship between pain interference and depression but not anxiety. Internal consistency estimates (alpha and omega) were generally acceptable (≥0.70), except for CESD-10 alpha which was below 0.70 but omega was 0.72.

This study demonstrates the significant association between pain (intensity and interference), lower life satisfaction, and increased depression and anxiety in adults with TSCI in a developing country. These findings align with research in both developing and developed contexts linking pain severity to depression and anxiety. The direct association between life satisfaction and improved psychological well-being highlights the importance of this construct. The mediating role of life satisfaction suggests that improving life satisfaction may be a crucial target for interventions aimed at reducing pain's negative impact on mental health. This finding supports previous research indicating a protective effect of life satisfaction on health by buffering against negative health aggravators. While the findings replicate some aspects of research from developed countries, the unique context of this study highlights the need for specific interventions tailored to developing country settings.

This study reveals significant associations between pain, reduced life satisfaction, and increased psychological distress in individuals with TSCI within a developing-country context. Improving life satisfaction may be a key strategy to improve mental well-being and manage pain in this population. Cognitive behavioral therapy (CBT) shows promise in improving life satisfaction among those with chronic pain, but more research is needed in the TSCI population. Future research should employ longitudinal designs and larger samples to fully understand the dynamic relationships between these factors and explore the potential of interventions targeting life satisfaction.

The cross-sectional design limits causal inferences. The sample size was smaller than anticipated due to limitations in accessing participants. Self-reported data might introduce social desirability bias. Future research should address these limitations through longitudinal studies with larger samples, and utilize objective measures to reduce the impact of bias.