This study investigated the perceived EBs in the Finnish population with SCI for the first time and analyzed the responses by gender, age, time since injury, and SCI severity. The climate was an outstanding barrier, the reason 72% of the respondents reported difficulties in daily life and the leading EB perceived to cause serious restrictions. Public access was another serious barrier and most often perceived to make life “a little harder”. Problems with accessing private homes and long-distance transport reportedly restricted the participation of nearly half the respondents. Short-distance transport, finances, and political decisions were considered barriers by four out of ten respondents. Individuals with more severe injuries (groups C1–C4 AIS A, B, C; C5–C8 AIS A, B, C; and T1–S5 AIS A, B, C) perceived more restrictions because of EBs than respondents with AIS D classification; these differences were highlighted in the items reported as barriers most frequently. Most EBs that stood out as prominent causes of restrictions are modifiable. Attention should be paid to reducing their effects on the lives of people with SCI.

It was positive that the “no influence” group was the largest for many items, and the “a lot harder” answers constituted a small minority. Extensive comparisons with other studies using the NEFI-SF are challenging due to dissimilar methods; for example, many studies have used the total number of barriers (barrier vs. no barrier) in their analyses [5, 7, 16,17,18]. However, the Finnish individuals with SCI seemingly perceived fewer EBs than those with SCI in some other countries [4, 5, 16, 17]. For instance, on a dichotomized scale, the Finns reported fewer EBs than the respondents of the International Spinal Cord Injury Survey (InSCI) sample of 22 countries (FinSCI: median 4, IQR width 5; InSCI: median 5, IQR width 6). On average, the most relevant EBs restricting life were the same as in the InSCI, as were the least reported barriers.

Our results resemble those found in Switzerland and Germany; there were minimal differences in the order of importance of the barriers reported the most in all three countries [3, 6,7,8]. Many EBs have generally been observed in countries with low resources [4, 16]; accordingly, it is no surprise that the distributions of perceived EBs are similar in the high-income European countries. Nonetheless, the Finnish people with SCI answered “a lot harder” statistically significantly more frequently than their European colleagues for most of the same top seven items in those countries (Appendix D) [3, 8].

The climate—the most frequently perceived EB among the FinSCI respondents—has been viewed as a remarkable barrier in many populations [5,6,7,8, 18,19,20,21,22]. Weather extremes are common in Finland, which likely explains the strikingly high percentage of participants regarding the climate as a serious barrier. Over three-quarters of the FinSCI participants submitted their responses by the end of March; hence, the survey’s timing during snowy months may have highlighted the relevance of climate in their opinions. Snow and ice make surfaces uneven and slippery, often restricting or blocking walking and moving in a wheelchair [19, 21, 22]. Furthermore, SCI affects thermosensitivity and -body regulation, especially in those more severely injured [23]. Weather and temperatures cannot be controlled. Nevertheless, the blocking impact of snow and ice can be actively lessened during Finland’s characteristically long winters. This could be done, for instance, by taking care of snowplowing and clearing public places (e.g., roads, pedestrian areas, building entrances, parking lots, public transport stops, and curb cuts) of barriers [21, 22].

Long-distance transport was perceived to pose challenges for almost half the respondents and serious difficulties for a fifth. Living far from community centers often means long rides to access health care and amenities and has been linked to perceived activity limitations in persons with SCI, which may result in functional decline [24]. In Finland, 5.5 million people live in an area circa the size of Germany. Consequently, traveling extended distances is necessary for many, especially after centralizing medical care for people with SCI. Vehicle ownership has been associated with satisfaction with transport [25]. Lack of adapted vehicles (or other forms of reliable, accessible, and frequently available transport), shortage of suitable parking, and the high cost of motoring in Finland might be some reasons Finnish people with SCI considered moving long distances an outstanding barrier [20,21,22, 24,25,26,27].

Challenges with public and private home accessibility and the lack of adapted assistive technology for moving short distances were perceived to cause significant participation difficulties for the respondents. Finances and political decisions were other issues viewed as hampering the lives of a noticeable part of our sample—common discoveries in studies on EBs and participation by people with SCI [4,5,6,7,8, 16, 17, 19,20,21, 24,25,26,27,28]. Society can influence all these matters, and steps could be taken to address them. The needs of people with disabilities should be considered through legislative and other measures, such as civil engineering, to develop policies, infrastructure, and transport that is friendlier and more equal to all citizens. Social attitudes and support are some of the strongest environmental factors enhancing or restricting participation [19,20,21, 25,26,27,28]. Other people’s attitudes were among the least reported barriers in this study. The stances toward people with SCI in Finland may be relatively neutral or even encouraging. This might play a part in the respondents’ low total score of perceived barriers.

The results of the statistical analyses were unsurprising. Severely injured people reported EBs as restricting their lives more than those with milder injuries, which was highlighted in the items most frequently perceived to make life harder. Similar observations have been made in some earlier research in which having complete SCI has been associated with perceiving more barriers, but the evidence is not solid [6, 8, 16]. In our sample, the climate was perceived to produce statistically significantly more serious but not minor difficulties in the two groups of the highest injury level (compared with the AIS D group). It is conceivable that the climate was a serious barrier for them for numerous reasons; therefore, few consider it a minor restriction. Women reported restrictions by EBs more often than men. The effect size remained small, calling into question the result’s clinical relevance; however, the result aligns with previous research [16]. Those who had been injured longer had slightly higher NEFI-SF total scores, although the clinical relevance is negligible with the small correlation coefficient. Even so, any of these identified effects are at the population level and may not capture differing patterns within subgroups. Understanding such subpopulation patterns is a valuable avenue for future research.

Our study’s sample was contacted utilizing the patient databases of all three specialized SCI clinics in Finland—the only three centers decreed by the Finnish government since 2011 to offer services for the whole SCI population, including people injured before 2011 [10: Supplementary Fig. A]. This enabled us to reach most of the target group and compare the generic and lesion characteristics between respondents and non-respondents. Nevertheless, long-term injuries may be underrepresented in the registers. Another advantage of this study was that the SCI severity of all participants had been classified according to the ISNCSCI, as the International Spinal Cord Injury Core Data Set (version 2.0) recommends [29].

The 50% response rate contains the possibility of response bias, and we can see from the registered data that young people did not respond often. Additionally, people needing help completing questionnaires may be missing; however, injury severity comparisons do not indicate this. Nevertheless, the response rate was adequate for this type of extensive questionnaire, and the number of respondents was sizeable compared to similar studies performed in more populous countries [30]. The sparsity of missing responses in the NEFI-SF items further increases the reliability of our results. This article concentrated solely on analyzing the NEFI-SF responses, allowing for specific analyses of individual NEFI-SF items. Yet, a limitation is that this study focuses exclusively on EBs without analyzing interactions between different parts of the FinSCI questionnaire (e.g., activity and participation).

Statistical analyses were performed using the original three-class scale (“no influence”/“a little harder”/“a lot harder”), contrary to some studies, in which the NEFI-SF answers were dichotomized or combined for analyses, or only descriptive results were presented. However, skewness of responses undermines the reliability of the logistic regression models in three items, and the pseudo-R2 statistics are low, suggesting the models explained only some of the variation in reported EBs. This implies that factors other than those this study focused on are important for predicting perceived EBs. Because each question was analyzed separately, a type I error (some variable appearing statistically significant by chance) is possible.

The results of the multinomial regressions should be interpreted with caution. The models lack power when, in many items, only a small percentage of respondents perceived them as barriers. The large group choosing “no influence” may consist of people having varying reasons for being unaffected (e.g., they may have good functioning, stay home because of poor functioning, or be positive people less inclined to complain about things). Lacking positive answer categories, the NEFI-SF does not measure the possible beneficial effects of environmental factors on participation. Also, the four-week timeframe of the measure is short, which may have a bearing on the high frequency of “no influence” responses. More psychometric studies on the NEFI-SF are needed.

The female gender and older age categories are slightly over-represented in our sample, although the effect sizes were very small. The possibility of our models not reaching high predictive power because of the biased sample cannot be excluded; it is uncertain that nonsignificant results are due to a real absence of effect. More advanced statistical analyses could be done to explore the matter thoroughly, considering the respondents’ different background characteristics, such as family situation.

The reliability of self-assessment is debatable, especially considering the paradox of barriers [31]: Individuals who potentially would encounter the most barriers restricting participation may avoid activities and situations in which they would be exposed to barriers; thus, reduced participation results in fewer reported barriers. Conversely, those in a better position to overcome barriers generally attempt to participate more often; hence, they become more exposed to the EBs through participation, which generates reporting more barriers. Over 10% of the respondents reported no problems, which could partly be the paradox of barriers at work. Other explanations might be the floor effect of the NEFI-SF [3] or those people reporting no barriers may have good functionality, just as the AIS D group (containing the most respondents) reported fewer restrictions due to EBs than other respondents.