Despite numerous physical (eg, functioning), psychological (eg, quality of life), and social (eg, inclusion) benefits of physical activity (PA) [1], more than 55% of adults (18-74 years) and 90% of older adults (≥60 years) who use wheelchairs are not physically active enough to accrue health benefits [2,3]. The sedentary nature of sitting in a wheelchair can trigger a chain of negative physiological and psychological events that can exacerbate physical, psychosocial, and mental sequelae overtime [4]. Therefore, the health benefits of PA may be amplified for manual wheelchair users [5,6]. For instance, even moderate amounts of PA could optimize functioning and slow the spiraling effects of deconditioning that are associated with disability [7].

Compared to the general adult population, manual wheelchair users face additional barriers to PA participation, including complex health problems [8], lack of accessible spaces, transportation challenges [9], and financial stress [10]. Thus, a need for accessible and affordable PA interventions for manual wheelchair users has been documented [10]. Successful community-based programs have addressed many of these facilitators and barriers for manual wheelchair users using various behavioral approaches (eg, Workout on Wheels [10]), and individuals with spinal cord injury, who account for approximately 80% of manual wheelchair users (eg, Get in Motion [11] and home visits [12]) with variable effects on PA. Two randomized controlled trials (RCTs) of interventions that used health care professionals to prescribe PA (ie, Workout on Wheels and Get in Motion) had small effect sizes on PA [10,11]. Although cofacilitation of a home-based strength-training program by a health care professional and peer trainer had a large effect on PA (ie, strength training), findings of this study are limited by a small sample size and lack of a control group [12].

Existing community-based PA programs have implemented important variables that are known to influence PA (eg, coping, action planning, and self-efficacy). However, participant retention was less than 75% and there was little documentation of PA maintenance over time. One explanation may be that participants in these programs were generally prescribed exercise-type activities (ie, aerobic and strength-training exercises), which may have limited their perceived choice in the activities performed (ie, an important predictor of PA uptake and adherence) [13]. Arguably, improving participation in meaningful activities that require any movement may be considered PA and even small improvements in PA may have a profound impact for manual wheelchair users. Therefore, providing manual wheelchair users with choice in activities represents an important consideration.

Motivations for uptake and maintenance of PA occur through complex psychological processes. Consideration of a multitude of psychosocial variables linked with PA (eg, autonomy, motivation, self-efficacy) is required to elicit large effects on PA that result in sustainable behavior change [14-16]. Self-determination theory provides a framework for cultivating an autonomy-supportive social environment that promotes behavior change through the facilitation of the three basic psychological needs of autonomy (ie, feeling free to choose one’s own behavior), competence (ie, interacting effectively with one’s environment by mastering challenging tasks), and relatedness (ie, feeling meaningfully connected to others within one’s social group) [13-15]. Satisfaction of these basic psychological needs will lead to greater intrinsic motivation [14]. An autonomous supportive environment positively influences behavior change [17], including uptake and adherence to PA [18]. Additionally, self-efficacy (ie, an individual’s situation-specific belief in his or her capability to accomplish a given task or behavior) is one of the most salient factors in predicting uptake and maintenance of PA [16,19,20]. Although perceived competence (from self-determination theory) and self-efficacy are often used interchangeably, a clear distinction between the two concepts has been made [21]. Therefore, distinguishing between competence and self-efficacy may have important implications for better understanding the psychological mechanisms driving changes in PA behavior [21].

The tenets of social cognitive theory provide a useful theoretical lens for incorporating self-efficacy into PA interventions [19,20]. Accordingly, self-efficacy is informed by skill mastery, vicarious experience, verbal persuasion, and reinterpretation of physiological and affective symptoms [16]. Although skill mastery is the most salient of these four sources, interventions that also include vicarious experience have been shown to enhance effects on PA behavior [22]. Therefore, considering integration of theoretical factors from both self-determination and social cognitive theories represents a useful approach to tailor the specific needs of manual wheelchair users for the uptake and maintenance of PA [18].

Targeting the important theoretical factors through strategic program implementation provides one way to cultivate an autonomy-supportive environment that enhances autonomy, motivation, and self-efficacy. First, allowing individuals to choose how they participate in meaningful activities may foster a sense of perceived autonomy, which is important for enjoyment and maintenance of the behavior [13]. Second, interventions led by a peer (ie, a person who has experiential knowledge of a specific behavior and similar characteristics as the target population [23]), can enhance self-efficacy and relatedness through vicarious experiences and shared characteristics. Peers provide an effective context for modeling because they are managing comparable conditions, have experienced similar situations, and are credible [24-26]. Adults try harder and experience higher levels of learning when they learn from individuals who have perceived similarities [27]. Peers have effectively increased PA in both clinical and community settings [12,28-30], and improved manual wheelchair skills in community-living adults [31].

Finally, telephone counseling represents an accessible and affordable approach to PA counseling with promising results for increasing PA among manual wheelchair users [10,11]. Opportunely, mobile phones are becoming ubiquitous and afford greater accessibility and convenience for manual wheelchair users. The use of mobile phones for PA counseling may further target autonomy, motivations, and self-efficacy. For example, the use of mobile phones to deliver a PA intervention offers various methods of contact (eg, voice calls, video calls), which may promote personal choice and autonomy. Video calls would enable face-to-face interactions with a peer, which may further enhance self-efficacy and relatedness through vicarious experience. Additionally, social support created by using existing social apps (eg, Facebook) for communicating with peers and monitoring PA goals may provide an avenue for enhancing motivation and self-efficacy [32,33]. For example, results from a recent RCT showed online social networks comprised of like individuals had larger effects on PA than receiving promotional PA messages from a website, and at a much lower cost [33]. Although the source of motivation that arises through online social networks was unclear, the authors suggested that even minimal exposure to online social cues could have a profound influence on PA [33].

The Smartphone Peer Physical Activity Counseling (SPPAC) program will use the power of peers and technology to foster critical psychosocial constructs as a precursor to PA (ie, autonomy, motivation, self-efficacy) providing a potential solution for delivery of broad-reaching and accessible PA intervention for manual wheelchair users with minimal costs. The proposed study protocol will evaluate the efficacy of the SPPAC program for improving PA in manual wheelchair users through a pilot RCT. Based on changes in PA in the intervention group compared to the control group, the primary objective is to provide effect size estimates of the SPPAC intervention on objective PA from baseline to postintervention (10 weeks) and at follow-up (3 months postintervention). Secondary objectives include exploratory evaluation of changes and relationships in subjective PA, wheelchair skills, motivation, self-efficacy (for overcoming barriers to PA, for manual wheelchair use), satisfaction of psychological needs for PA, and satisfaction with participation in PA. Finally, implementation of the SPPAC program will be examined.

This project is funded by the Craig H Neilsen Foundation and the Canadian Disability Participation Project. Proposals for additional project funds have been submitted to the Canadian Institute for Health Research (September 2016) and Fonds de Recherche du Santé Québec (December 2016). Two peer trainers have been recruited and trained and pilot evaluation of intervention implementation is currently underway. It is anticipated that enrollment for the proposed study will begin early in 2018, with final results by 2020.

Given the compelling evidence linking PA and quality of life, and the low rates of PA participation among manual wheelchair users, there is a clear need to find strategies to promote PA. On developing a theory-based PA program using the MRC framework, a pilot RCT is a prudent next step [41]. Establishing first effect size estimates for primary and secondary outcomes through a pilot RCT may provide justification for a subsequent efficacy RCT and variability data for future sample size calculations.

The best method to deliver PA interventions for manual wheelchair users is largely unknown. Although community-based telephone-delivered [10,11] and peer-delivered interventions [12] have shown preliminary success in manual wheelchair users, larger studies comparing modalities among this target population are required to determine how to best promote PA. The use of online social media also represents an effective solution for motivating adults without disabilities to participate in PA [33], but the influence of online social support for manual wheelchair users has yet to be evaluated. Grounded in theory, the SPPAC program of research will provide further insight about how peers, telephones, and social media can influence PA uptake and maintenance.

Behavior change is a complex and multifaceted phenomenon with multiple influencing factors. Therefore, successfully changing behavior over the long term requires multilevel interventions that consider individuals within their physical and social environments [77]. Application of two cognitive-based theories (ie, self-determination and social cognitive theories) posits that fulfilling the basic psychological needs (ie, autonomy, relatedness, and perceived control) drives behavior and that self-efficacy (synonymous to perceived control) is a strong and consistent predicator of behavior [15,16]. Therefore, cultivating an autonomy-supportive environment that enhances basic psychological needs, self-efficacy, and motivation through peer support provides a strong theoretical rationale that can effectively increase PA [18,12]. Evidence supports peer-led interventions that are grounded in social cognitive theory, both for improving PA in clinical and nonclinical populations [28] and for improving mobility outcomes for manual wheelchair users [31].

Gathering data on the important theoretical variables that are embedded within the SPPAC program will allow for exploration into mediating influences of complex psychological variables that will further our understanding about best strategies for changing PA behaviors in manual wheelchair users. The authors acknowledge the potential burden of the number of self-reported outcomes and the need for two meetings to collect objective PA data. However, it is anticipated that the self-reported outcomes can be completed in approximately 1 hour, and the tester will travel to obtain the Actigraph from the participants (or provide them with a postage-paid envelope for return to the research center) to reduce burden on participants. Future intervention studies can then integrate the most important behavior change determinants to best individualize PA programs for manual wheelchair users.

In addition to psychosocial factors, intervention dose and content represent important variables that need to be considered when promoting PA uptake and maintenance [78]. The Get in Motion program recommended up to 14 sessions of PA counseling over a 6-month period [11]. However, when asked about preferences for the SPPAC program, participants of focus groups (ie, manual wheelchair users, clinicians, and staff of community-based organizations) preferred that the SPPAC program consist of more contacts within a shorter timeframe [34]. The SPPAC program was designed accordingly [34]. In terms of optimal timing for promoting PA, a recent study among individuals with spinal cord injury suggested that the first 2 months are the most critical for successfully promoting PA [78]. However, a recent peer-led manual wheelchair training intervention showed increased participation in meaningful activities among manual wheelchair users up to 25 years after obtaining a manual wheelchair [31].

Beyond attaining knowledge of important behavioral factors influencing PA uptake and maintenance, the potential benefits of SPPAC include decreased environmental (eg, accessible facilities, transportation) and social barriers (eg, perceived stigma) to PA, limited burden on health care professionals, development of online social supports, and potential cost savings. Moreover, SPPAC has potential for application across age and diagnostic groups, a widespread geographic reach, and allows for a large trainer-to-participant ratio, all which may have time and cost efficiencies in program delivery. Future RCTs may evaluate some of the projected benefits of the SPPAC program.

Foreseen limitations of this study include the heterogeneity of the sample with regard to diagnoses. It is possible that diagnoses (as well as other sociodemographic factors, such as age) may influence the study outcomes. However, the purpose of this pilot study is to provide proof of concept of a novel intervention that may be adopted by manual wheelchair users in general. Future studies may examine diagnoses-specific interventions or consider stratification for various demographic variables. There is also a risk that participants (in both groups) may inadvertently discuss the study with other participants (eg, if they obtain health care services from the same clinic, if they are friends on Facebook) or with testers. Because the intervention is administered by phone on an individual basis, the study itself will not evoke a common meeting place for participants. Moreover, recruitment will target manual wheelchair users in remote geographic locations who may otherwise not have access to community-based programs. To reduce the risk of contamination, peer trainers will remind the participants during each session not to discuss the study with anyone outside of the intervention (including peers/friends or testers).

The SPPAC intervention aims to empower manual wheelchair users to manage their own health through implementation of autonomous supportive environments that also enhance self-efficacy through the use of a peer trainer and mobile phone technology. To our knowledge, no study has evaluated the combined potential of a mobile phone-delivered and peer-led PA intervention for manual wheelchair users. Such an approach may overcome many of the barriers to PA participation within this population, while incorporating important theoretical variables that are associated with behavior change. The SPPAC program has the potential to reach a large number of manual wheelchair users, thus may play an important role in addressing PA behavior change that could have a profound impact on health and health economics.