Developing a yoga programme for older adults in Scotland
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Current UK physical activity guidelines for older adults (65 years and above) recommend that they should aim to be active daily. Ideally, older adults should accumulate at least 150 minutes of moderate intensity activity per week in bouts of at least 10 minutes, or 75 minutes per week of vigorous activity for those who are already regularly active. Muscle strengthening activity is recommended on at least two days per week, and incorporating physical activity to improve balance and coordination on at least two days a week is recommended to those at risk of falls. The percentage of the Scottish older adult population achieving these guidelines is low. Recent data (2012-2014) suggests that only 14% of men and 12% of women in the 65-74 years age-group, and nine percent of men and four percent of women over 75 years met the muscle strength guidelines. The balance and coordination guidelines were met by 19% of older men and 12% of older women. Hence it is important to focus on improving adherence to muscle strengthening, and balance and coordination guidelines in this population. Moreover, targeted interventions should be developed to promote physical and psychological wellbeing among older adults. Yoga is an ancient practice that originated in India. Research evidence shows that yoga has numerous physiological and psychological benefits for older adults, and is recommended in the UK physical activity guidelines as a muscle strengthening activity. Despite the benefits of yoga, only 4% of adults aged 65-74 years and 0% of those aged 75 years and above in Scotland participated in yoga in 2016. The overall objective of this PhD was to develop a yoga intervention that is appealing, acceptable and appropriate for older adults in Scotland, and to recommend strategies to encourage yoga participation in this population. Intervention development frameworks prescribe establishing the evidence base, consulting with stakeholders (e.g. target population), and identifying the theory of change. Based on this, four studies were undertaken. Study 1 was a systematic review and meta-analysis assessing the effects of yoga on physical function and health related quality of life (HRQoL) in older adults not characterised by any clinical conditions. Twenty-seven records from 22 RCTs were included in the systematic review. The meta-analysis revealed significant moderate effects favouring the yoga group compared with inactive controls (e.g. wait-list control, education booklets) for physical function outcomes such as balance and lower body flexibility, and a small effect for lower limb strength. Compared with active controls (e.g., walking, chair aerobics) significant small effects favouring the yoga group were found for lower limb strength and lower body flexibility. For HRQoL, significant moderate effects favouring yoga were found compared to inactive controls for depression, perceived mental health, perceived physical health, and sleep quality; and small effects were found for vitality. Compared to active controls, a significant moderate effect was found for depression. Study 2 adopted qualitative methods to explore the perceptions of yoga in Scottish older adults. Findings highlighted the apprehensions that older adults with no yoga experience may have with respect to yoga participation such as finding yoga difficult and demanding, lack of information around yoga, and fear of embarrassment. This study also developed guidance for instructors and strategies to promote yoga in the older adult population. A knowledge exchange event was conducted with yoga teachers, studio owners and researchers, where some of these findings were validated and new insights compiled. Study 3 of the PhD project was a feasibility study to evaluate intervention components identified in Study 2. These intervention components were incorporated within three elements- a yoga taster session, a leaflet to promote yoga participation, and a handout to support home-based yoga practice. The experiences of a yoga instructor in delivering the taster session were also investigated. Focus groups, interviews and questionnaires with older adults and a yoga instructor were used to evaluate these elements. Overall, the yoga taster session was found to be appealing, acceptable and appropriate. Barriers such as apprehensions around finding yoga difficult, continuously getting down and up from the floor, and having heavy spiritual content were successfully addressed. Participants appreciated the leaflet and confirmed its potential as a promotional tool. It was felt that the home-based sessions could be useful in facilitating regularity of yoga practice. All three modes were effective in addressing the barrier relating to lack of information on yoga. The instructor observed that the aims and principles of the programme were clear from the brief provided. He offered additional inputs such as emphasis on a non-violent approach, adding breathing exercises after the corpse pose, and suggestions for handing different capabilities during a session. In Study 4, the final intervention was developed by combining components from studies 1, 2 and 3, and other relevant published literature. Intervention components were compiled under the following categories: (i) Yoga is difficult and demanding (ii) Continuous movement between getting up and down from the floor (iii) Class content details (class structure, poses to include and avoid, home-based session details) (iv) Breathing/spiritual content (v) Guidance for instructors (vi) Social interaction (vii) Class details (class environment, class size, duration and frequency, name, age-group) (viii) Yoga promotion strategies. Two theory of change models were developed. The first examined how the identified yoga promotion strategies could lead to increased participation or recruitment to a yoga programme, and the second explored how the programme components could improve adherence to a yoga programme. Findings from this PhD suggest that yoga is effective in improving physical and psychological wellbeing in older adults including flexibility, strength and balance. An appealing, appropriate and acceptable intervention for older adults has been developed, and strategies to encourage yoga participation among this population are suggested. Intervention components developed are of value to yoga instructors, programme developers and researchers working with an older adult population. Future studies could include further feasibility testing, a pilot study and a large-scale intervention.