By Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.
The usefulness of a medical intervention (either a pharmaceutical or a behavioral treatment) in either clinical practice or research should be evaluated not only by its efficacy but also by its cost-effectiveness, patient acceptability, and treatment adherence. Compliance or adherence describes the degree to which a patient correctly follows the prescribed treatment recommendations. Patient nonadherence can include not accurately carrying out the instructions, such as chanting the wrong mantra or breathing improperly in a yoga intervention, which can be due to misunderstanding the instructions. Nonadherence is also notoriously due to not carrying out the prescribed treatment such as not doing the yoga practice when scheduled, or not doing it for long enough, which is due to a number of factors such as time constraints, forgetting, or even completely ignoring treatment protocols. Apart from being a possible threat to the health of patients, nonadherence also carries a significant economic cost. The field of behavioral medicine views the reasons for nonadherence as ‘barriers’ to the accomplishment of a specified behavioral intervention. Those barriers may be subjectively reported by the patient or objectively measurable and include cultural issues, financial concerns, time constraints, space, and technological limitations.
Despite the promise and general popularity of yoga and yoga therapy, there are a number of barriers to yoga practice. One of these is the general public perception that yoga is primarily for women. Surveys in the general public consistently show that 75 to 80 percent of yoga practitioners are female. In fact, according to a 2015 University of Miami study, men are half as likely as women to engage in mindfulness practices. This same study found that those with a higher level of education were more likely to adopt a mindfulness practice and that non-Hispanic blacks and Hispanics were less likely to do so. A 2016 study by researchers from Simon Fraser University in Vancouver, Canada found that time constraint was the most common barrier for yoga practice. Other prevalent barriers include the belief that yoga requires great flexibility, is difficult to practice, and/or that it is unsuitable for special populations such as children, the elderly, or the obese. Those with larger bodies face high levels of stigma in relation to yoga (and physical activity in general) and this may serve as a strong barrier to their participation. Other significant barriers are beliefs that yoga is a religious practice or that it is inconsistent with one’s cultural heritage. On the other extreme, there is even a belief that yoga is nothing but physical postures. Finally, socioeconomic factors such as the cost impediment to yoga classes (such as transportation to classes and child care costs) can deter certain disadvantaged and low socioeconomic status populations from practicing yoga. These barriers are problematic because patients and research participants may entirely withdraw from the treatment before deriving any therapeutic benefits from their yoga practice.
Despite the benefits and growing acceptance of yoga and the importance of addressing barriers to practice, the literature has few studies on the factors contributing to the adherence to regular yoga practice. One such study was conducted by the SVYASA yoga university in Bengaluru, India and published in the International Journal of Yoga in 2014. The researchers evaluated students who had undergone a 1-month residential instructors’ course at the yoga university and found that irregularity in lifestyle, family, and occupational commitments were perceived as the strongest barriers to practice. Similarly, a 2009 focus group study of 50 participants from the University of Maryland School of Public Health also found the largest barrier to be lack of time, especially when taking yoga classes. The study included 36 yoga practitioners and one fourth of them found classes to be too costly. For the 14 people who had never previously practiced yoga, negative beliefs about the high level of flexibility required, that yoga is dominated by women or “new age” individuals with alternative lifestyles were significant barriers to participation.
A 2013 study by Mary Quilty, Sat Bir Singh Khalsa, and other colleagues highlighted this disparity in demographics for yoga participants. This study surveyed 604 adults who had registered for 4-week beginners’ yoga programs within the Yoga Yoga network of studios in Austin, Texas and found the yoga demographics to be primarily female (87 percent), white (88 percent) and college educated (79 percent). Similar to other studies, they again found the primary barrier to practice was time constraints and availability. Interestingly, respondents perceived yoga to be primarily an exercise activity (92 percent), although there was also a strong perception of it being a spiritual activity (73 percent). The main reasons for their participation was for general wellness (81 percent), physical exercise (80 percent) and stress management (73 percent). In fact, 98 percent of participants believed that yoga would improve their health, making this internal motivator a significant facilitator to the practice of yoga.
Another notable study explored the perspectives of students and their classroom teachers on the implementation of a school-based yoga program. Too often, the opinion of these two key stakeholders have been ignored in favor of program implementers. This 2017 study by the University of Cincinnati and Johns Hopkins Bloomberg School of Public Health researchers focused on qualitative perspectives of 22 fifth and sixth-grade students and their teachers after a 16-week school-based mindfulness and yoga program in three public schools. Those schools serve low-income urban communities and therefore provide us with valuable insight into this underserved demographic. In this context, the most frequently mentioned instructor quality valued by youth was “respect,” which the youth associated with “fairness” and “not yelling a lot”. However, conflicts in scheduling was a major challenge to youth program participation since attending yoga required that they miss other activities they enjoyed, such as art class. Although teachers reported positive expectations from the program, factors that could enhance buy-in included training staff on the program goals and generalizing the yoga mindfulness skills into the classroom.
While the previous study focused on youth from low-income communities, a recently published 2017 study at Brigham and Women’s Hospital and Harvard Medical School (including one of the authors, Sat Bir Singh Khalsa, as part of the research team) investigated the barriers and facilitators to yoga among low-income, racial/ethnic minority adults. Examinations of beliefs surrounding yoga participation among vulnerable populations are lacking in the literature and so this study bridges that gap. Twenty-four adults with and without prior yoga experience were recruited from an urban housing community to participate in an individual interview or focus group. The results highlighted barriers to engagement that included the perception that yoga lacks physicality and weight loss benefits. In addition, subjects talked about fear of injury, lack of perceived ability to perform the exercises, preference for other physical activities, and scheduling difficulties. On the other hand, the facilitators of yoga engagement included having a quality yoga instructor who provides individualized instruction, beginner level classes, and information highlighting the potential benefits of yoga such as stress reduction. It is interesting to note that participants were unsure about whether yoga provided sleep benefits and if the benefit was purely physical exhaustion. Therefore, much work remains in promoting yoga and educating on its benefits and underlying mechanisms.
Apart from adequate promotional messaging, in order to address the other significant barriers of cost and time, strategies are being developed to deliver yoga digitally, on demand, and in the comfort of participants’ homes. A 2017 commentary by the PrairieCare Medical Group in Minnesota explored the use of technology-assisted relaxation for pediatric patients that had been prescribed as Mind-Body techniques. Healthcare providers already know that delivering treatments through “play” experiences is an ideal way to provide therapeutic interaction and this is often termed “therapeutic play”. Given the prevalence of video games, children and teens may be particularly suited to therapeutic multimedia games that help them connect with the imagistic, emotional, and sensory elements of the right brain for symptom management and healing. There are currently several interactive mobile apps that promote yoga and other Mind-Body practices such as “Yoga by Teens”, “Take a Chill”, and “Breathing Bubbles”. A recent study published in the Journal of Alternative and Complementary Medicine in 2017 evaluated the feasibility of a home-based TeleYoga intervention on patients with both chronic obstructive pulmonary disease (COPD) and heart failure. Fourteen participants took part in either an 8-week TeleYoga intervention or an educational control group. The yoga classes were transmitted live via an internet connection to the participants’ televisions. The researchers found that the yoga intervention participants were adherent to classes despite technical issues. In addition, these frail patients were able to safely participate, enjoyed the program, and their dyspnea after exercise improved.
In conclusion, detailed evaluation of barriers to yoga practice is a new and growing area of research with promising insight into the adherence issues in yoga practice. The common barriers to yoga therapy appear to be time, cost, beliefs about yoga being a religion, impression that yoga is only for women, and fear that yoga requires great flexibility, as well as a lack of clarity as to the benefits of the practice. It is important for yoga therapists and researchers to address these barriers when delivering yoga interventions to ensure adherence and treatment success. Future studies should focus on minorities and men as well as medically underserved and vulnerable populations to better understand their specific barriers. Findings from future research could reveal what catalysts promote the initiation of yoga beyond benefits that most already know. For instance, is hearing about the health merits of yoga sufficient or is experiencing yoga necessary to address barriers to practice?
Nikhil Rayburn grew up practicing yoga under mango trees in the tropics. He is a certified Kundalini Yoga teacher and has taught yoga to children and adults in Vermont, New Mexico, Connecticut, India, France, and Mauritius. He is a regular contributor to the Kundalini Research Institute newsletter and explores current yoga research.
Sat Bir Singh Khalsa, Ph.D. is the KRI Director of Research, Research Director for the Kripalu Center for Yoga & Health, and Assistant Professor of Medicine at Harvard Medical School. He has practiced a Kundalini Yoga lifestyle since 1973 and is a KRI certified Kundalini Yoga instructor. He has conducted research on yoga for insomnia, stress, anxiety disorders, and yoga in public schools. He is editor in chief of the International Journal of Yoga Therapy and The Principles and Practice of Yoga in Health Care and author of the Harvard Medical School ebook Your Brain on Yoga.