A. Purpose and Procedure

The purpose of this qualitative examination was to identify participant achievements, barriers and resultant goal changes, and general attitudes related to attaining individualized pre-set wellness home program goals during the post-workshop interval. Program managers telephoned participants to conduct wellness-counseling sessions during the four months following the workshop. Twenty-two of the 23 workshop participants had set goals for their home-based wellness program for this time period, which occurred prior to their final clinical assessment. Of these, 16 were contacted twice by telephone; six were contacted once, and one neither set goals nor could be contacted.

B. Structured Interview Questionnaire

Program managers used interview questionnaires entitled, "Workshop Participant Follow-Up Call" to guide the follow-up calling procedure. Each form had five sections: 1) Participant's general comments; 2) Nutrition--individual goals, barriers, changes; 3) Physical Activity-- individual goals, barriers, changes; 4) Lifestyle Management-- individual goals, barriers, changes; and 5) Other comments by participant. Based on submitted goal sheets, participant wellness goals were written onto the form before the call took place, which permitted a frame of reference for the otherwise open-ended interview. Each time a counseling follow-up call was conducted, the same form was used by the caller, allowing for consistency in the types of information collected.

C. Achievements

Responses summarized as a result of the total 38 follow-up phone calls indicated that four participants felt they were doing "very well" meeting all of their pre-set goals, with no barriers or changes to deal with. One man said, "I have been fantastic! My health has been good. I am enjoying doing these [activities], but now am more aware of [what I am doing]. " Most participants, however, reported they were either doing "well" or "pretty well" in spite of the fact they had faced barriers and made changes in their original plans. It became apparent that if participants faced a barrier in one activity area, they kept going in the other areas with a spirit of persistence, not discouragement. In listening to participants' shared stories and examples on the phone, program managers often witnessed a demonstrated sense of empowerment in these individuals, which was interpreted to have come from new health knowledge gained at the workshops. One participant said, "Things are going well. I have done all my goals except the physical activities. I have done other things to replace them and I am feeling great." Examples of achievements by participants included: regularly eating meatless dinners, doing resistive upper body strengthening exercises, and taking oneself out on a date.

D. Barriers and Goal Changes by Workshop Content Module

Three study subjects, on the other hand, disclosed that they had faced very difficult barriers halting their progress partially or completely (i.e. broken leg, severe shoulder pain and depression, or death in the family and depression) and were "not doing well" in achieving their wellness program goals. One man called the program office five months after the study's final assessment clinic and said he had been very depressed, inert and unreachable during the four-month follow-up period due to his mother's death, but had once again started his home wellness program and was feeling better. Of those participants who reported doing "well," "pretty well," or "not well," the most frequent barriers and changes were in the area of physical activity. The second most frequently reported set of barriers and goal changes occurred in the area of lifestyle management, with those in the area of nutrition conveyed least frequently.

1. Physical Activity

Based on these telephonic self-reports, participants revealed that they experienced the greatest number of barriers and resultant goal changes in the area of physical activity or exercise. Specifically, reported difficulty was with a) architectural, or transportation access, b) access to personal assistance, or c) interfering medical complications. Participants reported that they could not get a ride to the gym or swimming pool, for example. One woman could not do all of her stretching exercises because she told us, "My Dad cannot hold me for 30 seconds; so he holds me as long as he can." One woman revealed that she could not meet her exercise goal of using an arm bike because she did not have anyone to help her on and off the bike. She was playing wheelchair basketball instead. Because of a pulled muscle, one participant had to stop his physical activities for a week, but carried on with his other goals.

2.Lifestyle Management

The second most demanding set of goals to maintain was in the category of lifestyle management. Finding the emotional impetus to begin meditation or other exercises was often problematical. One man said he was too busy and too lazy to start meditation. One person did not like listening to meditation tapes. For some it was difficult to start writing in a personal journal. One man changed his meditation goal from five minutes per day to four or five times a week with no set amount of minutes per meditation. One woman was going to go on periodic "media fasts," not watching television. She had a difficult time starting this activity.

3. Nutrition

Nutritional goals were the easiest to set and attain, although increasing one's daily intake of water was the most frequently reported challenge. Participants lowered their goal expectations for this particular activity. One woman changed her daily water intake goal from six to eight cups to four to five cups. Eating breakfast daily was also a difficult goal to reach for a few. Participants otherwise reported successes like "I am eating new foods and one more serving of vegetables per day," and "I'm now eating two servings of fruit every day."

E. General Attitudes

Overall, workshop participants were consistently open to sharing their challenges and then brainstorming to find solutions that would help them overcome barriers. Study participants wanted to reach their wellness goals and expected positive results. Because of what appeared to be an internally held high degree of self-motivation among participants, program managers quickly became aware that it was important and much more effective to call not verbalizing a posture of discipline, reminders and correction, but, rather, conveying a spirit of warmth, care and support. Several participants expressed a desire to attend "booster" wellness workshops in the future to help them stay on track with their new health promotion activities.
3) Barriers to Participation in Physical Activity with Disability (BPADS) Sub-Study
The objective of this sub-study was to identify barriers to physical fitness that persons with spinal cord injury face and thus prevent them from participating in a physical fitness program. A comprehensive survey was administered to SCI patients participating in the wellness with SCI study. The Barriers to Physical Activity with Disability survey was used to identify such barriers to physical activity. Seventy-two SCI patients (ages 20-80) participated in the survey prior to starting the wellness with SCI program. The following neurological groups were used and the participants were distributed in the following manner: 9 paraplegia/incomplete, 26 paraplegia/complete, 11 tetraplegia/incomplete, 14 tetraplegia/complete, and 12 ambulatory.
In this survey, 73% of the participants stated they would like to be involved in an exercise program, yet only 45% were currently active in such a program. The participant's physician has recommended an exercise program in only 48% of cases. The major concerns identified about barriers to physical fitness were lack of motivation (54%), lack of energy (42%), cost of an exercise program (40%), not knowing where to exercise (36%), and lack of interest (34%). In addition, 52% of the participants stated they do not feel a fitness center would be able to meet their needs as an individual with SCI for a fitness program, and 34% cited accessibility and privacy as concerns about exercising in such a facility. There were no significant differences in barriers reported among those with paraplegia versus tetraplegia and complete versus incomplete injuries or subjects who were ambulatory. It was concluded that people with SCI face several barriers to physical fitness.