1. Introduction
pinal Cord Injury (SCI) is one of the most traumatic events worldwide that affects all aspects of the patient’s life. According to the World Health Organization, 250000-500000 people suffer a SCI each year, and its prevalence is estimated to be 40-80 cases per million population. There is no comprehensive statistics for its prevalence in Iran, but according to one report, the annual incidence of SCI in Tehran is 44 cases per million population, and it is estimated that there are more than 70,000 patients with SCI in Iran. The most common average age at the time of SCI is 16-30 years, followed by ages 21-45 years and 46-60 years.
One of the important health aspects of patients with SCI is their psychological dimension. Between 20 and 45% of SCI patients suffer depression. Suicide rates are 4-5 times higher in people with SCI. Other psychological problems associated with SCI include substance abuse, divorce, anger, damaged self-image, and behavior disorders. Adaptation mechanisms are a series of acquired strategies that can help patients to cope with life and health-related problems. Coping refers to any kind of behavioral or cognitive adjustments that people make for managing their health and life stressors. This strategy can vary depending on the type of stress and the cultural context of the individual. The present study aims to evaluate the adaptive coping strategies of patients with SCI.
2. Methods 
This study is a hermeneutic phenomenological study conducted based on van Mann’s approach in six steps: 1. Turning to lived experience; 2. Investigating experience as we live it rather than as we conceptualize it; 3. Reflecting on the essential themes which characterize the phenomenon; 4. Describing the phenomenon in the art of writing and rewriting; 5. Maintaining a strong and oriented relation to the phenomenon; and 6. Balancing the research context by considering parts and the whole. Purposive sampling method was used to recruit 15 people with SCI living in Ardabil, Iran whose primary language was Azeri. Semi-structured and in-depth interview of patients was conducted after obtaining permission from the Ethics Committee of Ardabil University of Medical Sciences and a written consent from the participants. Some asked questions were related to talking about daily life, how subjects feel about their problems, and how they cope with their problem. Interviews were recorded and transcribed. Then, data were analyzed using the thematic analysis guided by van Mann including detailed, selective and holistic techniques. 
3. Results 
The mean age of participants was 53.13 years. Of the 15 participants, 4 were female and 11 were male. In terms of marital status, one was single and 14 were married (Table 1). 


Exploring the lived experiences of the patients related to coping strategies revealed six main themes including: accepting the incurability, desire for being independent, praying for divine help, patience & persuasion, time as a coping factor, and marriage.
4. Discussion
This study, which aimed to explore the coping strategies of people with SCI, revealed that they use effective coping strategies such as accepting the incurability, having desire for being independent, praying for divine help , being patient and persuasive, considering time as a coping factor, and marriage. This study indicated that the patients’ understanding of the incurability of SCI is very important for coping with loss, although it may lead to depression but it can help them accept it and continue to cope with the injury. 
The desire for independence can play a very important role in better self-care and self-efficacy in patients with SCI. Other studies also have reported that patients with SCI have a substantial tendency towards self-reliance and independence and try to maintain their independence in daily life activities as much as possible. One of other effective coping strategies found in SCI patients was praying to God and his prophets for help. Therefore, divine help, religious beliefs and spirituality play a vital role in adapting to chronic conditions. A study by Wilson et al. (2017) reported that spirituality was strongly associated with the quality of life of SCI patients, and strengthening of their religious beliefs can improve their quality of life and better adaptation [19]. 
One of the themes that reflected a coping strategy in SCI patients was patience & persuasion. In fact, patients with SCI maintain their mental well-being and even improve it by being patient and persuasive. It can be considered as a defense mechanism. Although this finding is not well reflected in other studies, it can be argued that strengthening of patience can help patients with SCI better cope with the injury. The Holy Qur'an has also emphasized all kinds of patience, especially patience in the face of adversity, that is, resilience after traumatic events and incurable diseases. A study by Valikhani and Khormaei (2015) on the prediction of pain based on patience showed that psychological factors, especially religious/psychological variables such as patience, can play an important role in relieving the physical and emotional dimensions of pain [24]. 
Patients in our study reported the time as a fundamental factor in coping with SCI. Heidegger, the famous phenomenologist also indicated the time as an essential facet of human being. Wijesuriya et al. (2012) in a study on patients with SCI also indicated to the important role of passing time in coping with SCI [25]. 
Marriage was the other important coping strategy in SCI patients. Their experiences showed that family formation increases life expectancy and better adaptation to disability. A study by Silveira et al. (2018) on life satisfaction and health status in patients with SCI showed that marital status is one of the predictors of life satisfaction, and married patients had higher life satisfaction than single patients. This finding is consistent with our result [27]. A study by Chan et al. (2000) found that people who got married before having SCI were more depressed than those who got married after having SCI. Since the effects of SCI are long-lasting, it affects not only the patient but also his/her spouse. Therefore, it is necessary for rehabilitation specialists to pay attention to the different needs of couples and the different ways to help them [28]. 
People with SCI use a variety of adaptive strategies to cope with the injury including acceptence of incurability, having desire for being independent, praying for divine help, being patient and persuasive, considering time as a coping factor, and marriage. Man, as a physical, mental, psychological and social being, always tries to adapt to disability after injury. Therefore, clinicians, psychologists and psychiatrists need to strengthen the reported coping strategies in SCI patients for their treatment.

Ethical Considerations
Compliance with ethical guidelines
This study obtained its ethical approval from the Research Ethics Committee of Ardabil University of Medical Sciences (Code: IR.ARUMS.REC.1397.123). Participants were fully informed about the study objectives and methods, and were assured of the confidentiality of their information. Prior to study, a written consent form was signed by all participants. 

Funding
The present study was extracted from the MA. thesis of Behnam Molaei at the Department of Psychiatry, Faculty of Medicine and Paramedical Sciences, Ardabil University of Medical Sciences, Ardabil. It was financially supported, as a research project, by the Deputy for Research of Ardabil University of Medical Sciences.

Authors contributions
Methodology and data analysis; Mahmood Shamshiri; editing & review, and data analysis: Behzad Eskandar Oghli; initial draft preparation and study report: Maryam Vafaee; psychology advising and data analysis: Behnam Molaei.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
We are thankful to the participants who shared their experiences with us. In addition, we acknowledge Ardabil University of Medical Sciences (ARUMS) for financial support of the research project.


References

1. van den Berg ME, Castellote JM, Mahillo-Fernandez I, de Pedro-Cuesta J. Incidence of spinal cord injury worldwide: A systematic review. Neuroepidemiology. 2010; 34(3):184-92. [DOI: 10.1159/000279335]. [DOI:10.1159/000279335] [PMID]
2. World Health Organization. Spinal Cord Injury. Geneva: World Health Organization; 2013. https://www.who.int/news-room/fact-sheets/detail/spinal-cord-injury
3. Rahimi-Movaghar V, Saadat S, Rasouli M, Ganji S, Ghahramani M, Zarei M, et al. Prevalence of spinal cord injury in Tehran, Iran. The Journal of Spinal Cord Medicine. 2009; 32(4):428-31. [DOI:10.1080/10790268.2009.11754572] [PMID] [PMCID]
4. Chen Y, Tang Y, Vogel L, DeVivo M. Causes of spinal cord injury. Topics in Spinal Cord Injury Rehabilitation. 2013; 19(1):1-8.[DOI:10.1310/sci1901-1] [PMID] [PMCID]
5. Fekete C, Wahrendorf M, Reinhardt JD, Post MW, Siegrist J. Work stress and quality of life in persons with disabilities from four European countries: The case of spinal cord injury. Quality of Life Research. 2014; 23(5):1661-71. [DOI:10.1007/s11136-013-0610-7] [PMID]
6. Paul C, Derrett S, McAllister S, Herbison P, Beaver C, Sullivan M. Socioeconomic outcomes following spinal cord injury and the role of no-fault compensation: longitudinal study. Spinal Cord. 2013; 51(12):919-25. [DOI:10.1038/sc.2013.110] [PMID]
7. Arya S, Xue S, Embuldeniya A, Narammalage H, da Silva T, Williams S, et al. Coping strategies used by traumatic spinal cord injury patients in Sri Lanka: A focus group study.Disability and Rehabilitation. 2016; 38(20):2008-15. [DOI:10.3109/09638288.2015.1111433] [PMID]
8. Peláez-Ballestas I, Boonen A, Vázquez-Mellado J, Reyes-Lagunes I, Hernández-Garduño A, Goycochea MV, et al. Coping strategies for health and daily-life stressors in patients with rheumatoid arthritis, ankylosing spondylitis, and gout: STROBE-compliant article. Medicine. 2015; 94(10):e600. [DOI:10.1097/MD.0000000000000600] [PMID] [PMCID]
9. Moghadam ZB, Ghiyasvandian S, Shahbazzadegan S, Shamshiri M. Parenting experiences of mothers who are blind in Iran: A hermeneutic phenomenological study. Journal of Visual Impairment and Blindness. 2017; 111(2):113-22. [DOI:10.1177/0145482X1711100203]
10. Creswell JW, Poth CN. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Essex: Vicki Knight; 2018. https://books.google.com/books?id=Ykruxor10cYC&printsec=frontcover&dq=
11. Shamshiri M, Mohammadi N, Cheraghi MA, Vehvilainen-Julkunen K, Sadeghi T. Disciplined care for disciplined patients: experience of hospitalized blind patients. Holistic Nursing Practice. 2013; 27(6):344-8. [DOI:10.1097/HNP.0b013e3182a72bcd] [PMID]
12. Van Manen M. Researching lived experience: Human science for an action sensitive pedagogy. Milton Park: Routledge; 2016. https://books.google.com/books?id=1LZmDAAAQBAJ&printsec=frontcover&dq=
13. Pereira HR. Rigour in phenomenological research: reflections of a novice nurse researcher. Nursing Research. 2012; 19(3):16-9. [DOI:10.7748/nr2012.04.19.3.16.c9054] [PMID]
14. Kessler D. Finding Meaning: The sixth stage of grief. New York: Scribner; 2019. https://books.google.com/books?id=H920DwAAQBAJ&printsec=frontcover&dq=
15. Nikbakht-Nasrabadi A, Mohammadi N, Yazdanshenas M, Shabany M. Toward overcoming physical disability in spinal cord injury: A qualitative inquiry of the experiences of injured individuals and their families. BMC Neurology. 2019; 19(1):171. [DOI:10.1186/s12883-019-1391-6] [PMID] [PMCID]
16. Jeyathevan G, Cameron JI, Craven BC, Munce SEP, Jaglal SB. Re-building relationships after a spinal cord injury: Experiences of family caregivers and care recipients. BMC Neurology. 2019; 19(1):117. [DOI:10.1186/s12883-019-1347-x] [PMID] [PMCID]
17. Krakowska N, Szmelcer BP, Zaborna D, Fortuna A, Wszelaki P, Florczak A, et al. Rehabilitation of patients with paraplegia-a review of the diversity of forms. Journal of Education, Health and Sport. 2019; 9(5):534-46. https://www.researchgate.net/publication/345627447_
18. Ebrahimi A, Bolhari J, Zolfaghari F. [Stress coping strategies and social support in depressive veterans with spinal cord injury (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2002; 8(2):40-8. http://ijpcp.iums.ac.ir/article-1-235-en.html
19. Wilson CS, Forchheimer M, Heinemann AW, Warren AM, McCullumsmith C. Assessment of the relationship of spiritual well-being to depression and quality of life for persons with spinal cord injury.Disability and Rehabilitation. 2017; 39(5):491-6. [DOI:10.3109/09638288.2016.1152600] [PMID]
20. Rahnama P, Javidan AN, Saberi H, Montazeri A, Tavakkoli S, Pakpour AH, et al. Does religious coping and spirituality have a moderating role on depression and anxiety in patients with spinal cord injury? A study from Iran. Spinal Cord. 2015; 53(12):870-4. [DOI:10.1038/sc.2015.102] [PMID]
21. Littooij E, Widdershoven GAM, Stolwijk-Swüste JM, Doodeman S, Leget CJW, Dekker J. Global meaning in people with spinal cord injury: Content and changes. The Journal of Spinal Cord Medicine. 2016; 39(2):197-205. [DOI:10.1179/2045772314Y.0000000290] [PMID] [PMCID]
22. Jones KF, Dorsett P, Briggs L, Simpson GK. The role of spirituality in Spinal Cord Injury (SCI) rehabilitation: exploring health professional perspectives. Spinal Cord Ser Cases. 2018; 4:54. [DOI:10.1038/s41394-018-0078-3] [PMID] [PMCID]
23. Amani R, Ebadi Z, Rezaei S. Study of Patience Domains in Quran. Quranic Knowledge Research. 2016; 7(25):133-56. [DOI:10.22054/rjqk.2016.7088]
24. Valikhani A, Khormaei F. Religion and pain: prediction of pain dimensions based on patience. Iran Journal of Nursing. 2015; 28(95):1-10. [DOI:10.29252/ijn.28.95.1]
25. Wijesuriya N, Tran Y, Middleton J, Craig A. Impact of fatigue on the health-related quality of life in persons with spinal cord injury. Arch Phys Med Rehabil. 2012; 93(2):319-24. [DOI:10.1016/j.apmr.2011.09.008] [PMID]
26. Asgari Z, Naghavi A. Explaining post-traumatic growth: Thematic synthesis of qualitative research. Iranian Journal of Psychiatry and Clinical Psychology. 2019; 25(2):222-34. [DOI:10.32598/ijpcp.25.2.222]
27. Silveira SL, Ledoux TA, Johnston CA, Kalpakjian C, O’Connor DP, Cottingham M, et al. Well on wheels intervention: Satisfaction with life and health for adults with spinal cord injuries. The Journal Of Spinal Cord Medicine. 2018; 17 December: 1-9. [DOI:10.1080/10790268.2018.1554333] [PMID] [PMCID]
28. Chan RC, Lee PW, Lieh-Mak F. Coping with spinal cord injury: Personal and marital adjustment in the Hong Kong Chinese setting. Spinal Cord. 2000; 38(11):687-96. [DOI:10.1038/sj.sc.3101085] [PMID]