Approval for this project was granted by the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal. We certify that all applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during this research study.

This qualitative study used a constructivist paradigm with an interpretive phenomenology methodology, and an integrated knowledge translation approach to inform the objective of this research. This approach acknowledges the unique life experiences of individuals with a disability as well as the clinical experience of HCPs. It additionally permits an exploration through the analysis of first-person narratives constituting participants’ experiences, views, and needs. An in-depth content analysis was subsequently used to systematically determine participants’ preferred design features of an online physical activity platform. A participatory or user-centered design, which supports cocreation through the involvement of key stakeholders, was also applied.

Convenience sampling was used to recruit individuals with an SCI and HCPs. Recruitment took place at three rehabilitation sites in the province of Quebec: Rehabilitation Site 1 was a Montreal-based secondary inpatient and outpatient rehabilitation hospital, Rehabilitation Site 2 was a Montreal-based tertiary inpatient and outpatient rehabilitation hospital, and Rehabilitation Site 3 was a Quebec City–based secondary and tertiary inpatient and outpatient rehabilitation hospital with postdischarge physical activity programs.

Recruitment of individuals with an SCI was done via the telephone. The researchers contacted interested persons with an SCI from Montreal and Quebec City. The eligibility criteria were as follows: age ≥18 years, discharged from inpatient services from one of the three rehabilitation sites, ability to communicate in English or French, ability to independently make informed decisions, access to the internet and an email address, and ability to use a computer independently or with assistance.

HCPs were recruited from the affiliated institutions through presentations to clinical teams to explain the objective of the study and the required time to participate. Interested HCPs contacted the researchers via email.

After obtaining informed consent, two trained researchers conducted individual 1-hour sessions with HCPs and individuals with an SCI at the individual’s affiliated rehabilitation site or in their home. Prior to their scheduled session, the individuals completed a demographics questionnaire.

In the first part of the session, participants spent 30 minutes navigating selected content on the SCI Action Canada website. Using a think-aloud approach, participants verbally expressed their immediate positive and negative thoughts on how the content and structure of the website may influence the motivation and volition of persons with an SCI to engage in physical activity. The two researchers tracked the content that participants independently navigated through, with the use of a comprehensive checklist containing the BCTs and MoDs integrated in the website. They also prompted participants to navigate through the features they overlooked. The website navigation session was recorded using Camtasia software, version 8 (TechSmith, Okemos, MI), provided by McGill University.

Subsequently, the two researchers conducted semistructured interviews comprised of open-ended questions during the second part of the session. Participants responded to questions regarding physical activity engagement following an SCI. Individuals with an SCI were asked about the type, frequency, and social aspect of, as well as barriers to, their involvement in physical activity since their injury. HCPs were asked about their experience with physical activity prescription for their patients and expounded on strategies to improve physical activity adherence within the SCI community. All participants explored the importance of physical activity for individuals with an SCI. They were also asked to provide feedback on the website navigation portion of the session, including the site’s ease of use, appeal, and delivery format, as well as perceived usefulness of embedded and absent physical activity resources. Furthermore, the individuals were asked to rate their likelihood of integrating a Web-based portal into their physical activity practice, on a scale of 0 (unlikely) to 10 (very likely). Using a similar scale, HCPs were asked to rate the degree to which they would promote such a physical activity platform in practice. All interviews were audio recorded using Camtasia software.

The length of each session ranged from 46 to 90 minutes. All sessions were transcribed verbatim. Pseudonyms were assigned to each participant. Quotations from French-speaking participants were translated to English for the purpose of this paper. In addition, the demographics questionnaire, interview guide, and navigation checklist used throughout the study were reviewed by a team of stakeholders, which included three clinical researchers, a knowledge translation specialist from SCI Action Canada, a coordinator for a Quebec adapted sports organization, and a consultant living with an SCI who promotes community integration.

Descriptive statistics were used to summarize the characteristics of all participants and the responses on questionnaires for individuals with an SCI. All transcripts from the site navigation and interview sessions were reviewed. An in-depth thematic analysis was conducted by four members of the research team to derive common themes. Content analysis was guided by participants’ rich feedback on the perceived ability of select Web-based features to impact the motivation of the individuals to initiate and maintain engagement in physical activity. The two authors who conducted the interviews also maintained field notes with thematic logging of significant moments during and after the individual sessions, which served as a component of data triangulation to contribute to the analytical process. Codes representing core concepts were identified in the transcripts. Through extensive discussion surrounding emerging commonalities, subthemes were formed and then grouped under “umbrella” key themes. All derived themes have connections to BCTs and MoDs, as outlined by Abraham and Michie [45]; this was paramount to contribute to the evidence and overall rhetoric surrounding their value as embedded components of Web-based self-management portals aimed at ameliorating health-related behaviors. The four researchers who carried out the analysis met regularly to resolve any discrepancies in order to ensure consistency of the findings. Data saturation was achieved at 21 participants. The median and mean ratings attributed to the likelihood of integrating a Web-based portal into physical activity practice or promotion were calculated.

Thirteen persons with an SCI, seven from Montreal and six from Quebec City, agreed to participate in the study. Ultimately, data collected from 12 individuals were included in the study, as data from one participant, whose condition turned out to be inaccurate, were removed. The majority of the sample was male (n=10) between the ages of 19 and 68 (mean 46.8, SD 17.1) years. Most of these individuals had a nontraumatic SCI (n=8) and a level of injury located between T1-S5 (n=6). Most participants were discharged from rehabilitation for more than 12 weeks (n=9). Ten of the participants had been participating in physical activity for over 6 months. Lastly, most subjects spent at least 2 hours per day navigating the internet, in general (n=8). Demographic information of these individuals is presented in Table 1.

Nine HCPs, six from Montreal and three from Quebec City, agreed to participate in the study. They had an average of 13.7 (SD 11.9) years of experience working with the SCI population. Additional demographic information of the HCPs can be found in Table 2.

In total, 5 themes with 14 subthemes emerged (Textbox 1).

The aim of this study was to highlight the Web-based features that have the potential to influence the motivation and volition of individuals with an SCI to self-manage their participation in physical activity. This is the first study of its kind to use an in-depth qualitative research design to understand the needs, preferences, and lived experiences of members of the SCI community and HCPs in the preliminary stages in the development of a Web-based self-management program. Through an in-depth inductive thematic analysis, 5 core themes and 14 subthemes emerged. The first three themes (knowledge, possibility of achievement, and self-regulation) align well with the two phases of the Health Action Process Approach framework and thus BCTs, while the last two themes (interactivity and format) align with MoDs (Figure 1).

Tools that enhance one’s knowledge and convey a possibility of achievement can provide persons with an SCI the motivation to form an intention to participate in physical activity [46]. Participants expressed an interest in resources that offer guidance on their condition and physical activity, strategies to overcome barriers, and information on the risks and benefits. Inclusion of BCTs that improve knowledge of one’s condition has been attributed to increased levels of self-efficacy and physical activity behavior [24,25,37]. Participants also identified that models of individuals with an SCI successfully practicing physical activity help reinforce the intention to adopt healthy behaviors, as they contribute to a positive outlook on their condition through relatability [13]. This BCT has also been linked to improved clinical and psychological outcomes [24,47].

Participants expressed that self-regulation tools such as action planning, goal setting, and tracking are conducive to initiating and maintaining physical activity. These BCTs have demonstrated effectiveness in increasing one’s physical activity engagement and sense of control in various populations by transforming their intention into a behavior [24,25,30,47,48]. Participants’ perspectives, however, were mixed regarding the value of having reminders and rewards on a website. Although a number of the individuals and HCPs expressed that reminders have the potential to keep oneself engaged in physical activity, others perceived this function as burdensome and stressful. These findings are echoed in the literature: One systematic review demonstrated that a reminder system had the largest favorable effect on physical activity levels [36]. Conversely, Williams and French [47] associated this system with decreased self-efficacy among study participants, while a systematic review reported small and nonsignificant effects on physical activity when interventions contained reminders [24]. In terms of rewards, a portion of this study’s participants viewed positive reinforcements as a necessity to their physical activity practice compared to others who stated that the health benefits from regular physical activity engagement are enough of a reward on their own. Interestingly, two studies have found that a system that rewards participants based on effort or progress positively influences one’s self-confidence with respect to their physical activity participation. However, these same studies did not report significant effects where interventions rewarded participants only for successful behavior. We suggest that focusing on smaller short-term progress may increase one’s sense of self-efficacy regarding physical activity engagement [27,47,49].

Additionally, participants identified the importance of including interactive features on the website. For example, some participants suggested that online access to HCPs may afford individuals with an SCI a sense of reassurance and support needed to cope with setbacks in physical activity. In fact, having access to a HCP over the phone was found to increase adherence to physical activity among individuals in both the motivational and volitional phases of behavior change [26,38]. In contrast, others mentioned that online access to HCPs would not be a necessary feature, as they have sufficient contact with an HCP in their community. Participants also expressed a preference for online discussion forums where they can interact with peers (fellow persons with an SCI), exchange knowledge, and integrate within the active SCI community. In their study, Allin et al [44] highlighted the importance of including these community-type resources on a Web-based platform.

Furthermore, our findings reveal that the way in which information is displayed on a Web-based platform (format), including the appearance, language, and ease of use, influences the degree to which individuals are drawn to and potentially utilize Web-based resources. Recent studies have stressed the importance of addressing features and functions including usability, readability, and visual esthetics to assure end-users’ engagement in Web-based interventions [50,51]. However, research remains limited on the specific elements that constitute effective Web design [50]. More research on the impact of format on behavior change is needed to contribute to evidence supporting its value in online self-management portals. Ultimately, the interactive features and format of the website contribute to the degree of appeal of the BCTs identified by the first three themes and therefore have an influence on individuals’ motivation and volition to engage in physical activity.

Our research builds upon Munce and colleagues’ [15] cross-sectional study, which explored general components of self-management programs for individuals with an SCI. They reported, among others, participants’ desires for portals to be internet-based and to include a physical activity component. Although numerous Web-based self-management portals exist, website quality remains low and few incorporate theoretical frameworks, BCTs, and MoDs into their design [20,21].

The SCI Action Canada website is one of the most developed Web-based self-management systems that currently exists. Its design was guided by the HAPA framework and thus incorporates various BCTs and MoDs that have been linked to increased physical activity engagement among individuals with an SCI. As such, it was used as a starting point for our research, anticipating that several areas of improvement would emerge from our results, which was the case. First, the content should be updated and enhanced to reflect the needs and preferences of the SCI community. Second, interactive features, including contact with peers and professionals through the same system, should be embedded within the website. Third, while not currently incorporated into health care, introducing self-management tools to patients early on in their recovery process is an integral step to ensure a continuum of care.

Murray et al [52] found that new technology has the greatest likelihood of becoming implemented if it aligns with the organizational objectives and expertise of existing HCPs and positively influences their relationships with patients. Dwarswaard and colleagues [2] also demonstrated that individuals living with a chronic condition expect HCPs to play a vital role in their self-management, which was similarly expressed by our study subjects. Given the sudden onset of an SCI and the trajectory and intensity of rehabilitation services, embedding HCPs into this process to ensure a continuum of care is critical. This can inform the need for a self-management portal to be presented and endorsed by HCPs before discharge as well as the incorporation of interactive features on the system to ensure users feel supported in the long-term.

This study’s findings support the need to include numerous persuasive technologies in a Web-based physical activity portal. Our results align with the literature, which has found that multimode tailored interventions that incorporate video, audio, discussion forums, and chat enhance interactivity, skills, and knowledge building, thus positively influencing patient engagement and health-related outcomes [27,35,53,54]. Furthermore, previous interventions that included multiple BCTs had larger influences on behavior change than those that incorporated fewer change techniques [24].

Finally, the robust user-centered design permitted us to delve into specific Web-based components favored by members of the SCI community. As such, this study supports the need to engage persons with an SCI and HCPs early on in the design of an online self-management portal. In addition, the high ratings of these key stakeholders on the likelihood to use a website tailored to one’s needs illustrate not only the willingness of participants to use such a website, but also the degree to which it is valued in improving one’s self-management in physical activity. As such, the educational and material resources included on the proposed self-management portal should be made easily accessible and cater to individualized needs [14,38].

First, when considering the generalizability of this study’s findings, it is important to note that the majority of the individuals who participated (83%) reported that they have been engaging in physical activity for more than 6 months. In addition, most participants (n=8) spend at least 2 hours on the internet daily. The characteristics of our sample may be attributed to the self-selective nature of our recruitment strategy, as members of the SCI community with an interest in physical activity likely shared an interest in this study’s topic. As such, the results may not be representative of individuals with an SCI who are in an early stage of physical activity engagement or who lack access to Web-based resources. Moreover, due to our methodology and small sample size, we were unable to derive conclusive similarities or discrepancies in the findings between subjects, despite reaching saturation with 21 participants. Although this was not part of our initial objective, future research will involve conducting further analyses with more study subjects to determine subgroup clusters as we continue to develop the platform. A strength of this more engaged and technologically savvy sample, however, is that they were able to reflect on the motivational strategies they use or have used in their experience with physical activity to provide valuable feedback on Web-based persuasive technologies. These insights will guide us in shaping a platform integrated into care in a way that attracts less active individuals with an SCI to initiate behavior change and maintain engagement when discharged back to the community. Further research is needed to consider the perspectives of individuals with an SCI at a rudimentary stage of physical activity engagement.

Second, some participants reported that they did not have sufficient time to navigate the website, which may have influenced their exploration of the available resources. These participants may not have been able to conceptualize the impact of certain Web-based features they initially overlooked due to the time limit. Third, participants were asked to comment on several BCTs (eg, reward system and goal setting system) that have been shown to be effective in the literature but were not embedded within SCI Action Canada. Participants likely formed an opinion based on the hypothetical value of these tools without having had a genuine opportunity to interact with them on a website. Fourth, due to time and resource constraints, only persons with an SCI living in urban areas were recruited. As their perspectives may vary from those who live in more rural settings, the findings may be more applicable to an urban context.

To our knowledge, this is the first study to highlight the Web-based features that should be considered in the design of a Web-based self-management platform targeting physical activity. The Health Action Process Approach, as well as BCTs and MoDs, add value to the promotion of physical activity engagement, as they shed light on the potential for Web-based features to enhance the motivation and volition of persons with an SCI. The in-depth analysis and report of the needs and preferences of both individuals with an SCI and HCPs in this study serve as an essential preliminary step in the design of an online physical activity portal. Once a prototype is created, its ability to influence adherence and behavior change will need to be evaluated. Lastly, our study contributes to the growing body of knowledge on disability and chronic disease management. Many of the challenges in the self-management of physical activity experienced by individuals living with an SCI in the self-management of physical activity are similarly experienced by members of related disability populations. As such, we highly encourage fellow researchers to utilize and build upon our robust methodology as a platform to deepen the understanding of the needs and preferences of other disability populations in the interest of promoting and enhancing quality of life. Further research is therefore warranted in this area.