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Abstract

Introduction:

Living in an assisted living facility (ALF) can be stressful for some residents. Hatha yoga has been demonstrated to facilitate coping among the general population, but this has not been explored with residents of ALFs. The purpose of this study was to explore participants' proactive use of yoga during and after a yoga intervention in ALFs.

Methods:

An 8-week yoga intervention was implemented across four different ALFs with 15 participants (female = 13, male = 2). Attendance and engagement at twice-weekly yoga groups were tracked, and participants' yoga practice use outside of the intervention was tracked through weekly open-ended questions and explored in postintervention semistructured interviews. A conventional content analysis was employed to evaluate residents' perceived use of yoga.

Results:

Results yielded an overall theme of proactive coping with three subthemes related to the use of yoga: relaxing, energizing, and connecting.

Discussion:

This implies that yoga may be an effective strategy for some individuals to cope with stress, and promote a higher quality of life within an ALF community. Clinicians, staff, and administrators of ALFs may consider how they can support independent personal yoga practice as well as group yoga practice among residents.

Introduction

The number of older adults is increasing at an unprecedented rate worldwide; this increase is occurring in both absolute numbers and in proportion to the population.¹ Within the gerontological field, there has been a growing emphasis on maintaining quality of life through the end of life rather than solely prolonging the number of years lived.^2,3 However, though longevity has increased, the rates of age-related chronic illness leading to loss of independence remain at ∼21% for adults over age 65 years.⁴ Correspondingly there is an increased need for treatment and services related to maintaining quality of life and coping with chronic illnesses and related stressors.¹ For adults who need extra support to manage chronic illness or disability, there are many options for long-term care (LTC) services. LTC services offer many levels of support for medical and custodial care, as well as other services such as transportation services and social activities.⁵

Assisted living facilities (ALFs), a type of LTC service, may facilitate extended independence and higher quality of life by providing needed support for people who experience significant functional declines.^1,5 ALFs provide 24-h assistance, as needed, to help meet health care or personal care needs.⁶ Unfortunately, the transition to ALFs is also associated with stressors including relocation stress,⁷ changes in health status,⁸ interpersonal conflicts with other residents,⁹ and potential isolation from friends and family members.^8,10 Without adequate coping mechanisms, the cumulative impact of stressors may have a net negative impact on quality of life despite the additional supports in place.^10,11

Leisure stress coping, described by Iwasaki and Mannell,¹² is the purposeful use of leisure as a resource for coping with and transcending adverse events. Leisure stress coping is a hierarchical model that consists of both coping beliefs (beliefs that leisure activities can help manage stress) and coping strategies (cognitions or actions implemented as a coping strategy). Leisure stress coping has been shown to promote adjustment and growth in the face of disruptive events including chronic illness.^13,14 Specific leisure-coping strategies include palliative leisure (using leisure as a break and distraction from stressors), mood enhancement (using leisure to enhance mood and reapproach the problem with a new perspective), and leisure companionship (gaining companionship through leisure).¹² One specific leisure activity reportedly used in leisure stress coping is hatha yoga.

Hatha yoga has been demonstrated to be an effective stress-coping strategy for older adults with a variety of medical conditions and diagnoses.^15–18 Hatha yoga (referred to as yoga in the remainder of the article) is an ancient mind–body practice that incorporates three core components: physical postures (asana), breathwork (pranayama), and meditation (dhyana).¹⁹ As a holistic approach to well-being, yoga is an emerging complementary and integrative health modality used to promote well-being and mental health.²⁰ Yoga has been successfully implemented with older adults who have a wide range of health conditions and diagnoses.^7,21–23

Although researchers suggest that yoga may be an effective coping strategy, this has not been studied in ALF settings where the stressors and combination of different health conditions create a markedly different environment from other groups that could impact the perceived benefits of yoga practice. A pilot study was conducted in ALFs to evaluate the feasibility of implementing yoga in ALFs for participants with a variety of health diagnoses,²⁴ and to explore the impact of yoga on activity participation.²⁵ However, past analysis of this pilot study did not examine the relationship between yoga and stress coping. Thus, the purpose of this study was to explore the research question, how do residents of ALFs proactively use yoga during and after a yoga intervention?

Methods

Study design

This study used a conventional content analysis²⁶ to understand how residents in an ALF used yoga during and after a yoga intervention. This study used data from a larger project that also explored the impact of yoga on stressors, and the overall feasibility of yoga.^24,25

Participants

Participants were residents of four different ALFs in a rural southeast region of the United States. The ALFs ranged in size from 17 to 42 residents. Two of the facilities only had the ALF level of care, one facility had both ALF and a memory care unit, and one had independent living, ALF, and a memory care unit (see Adams et al.²⁴ for additional information on each ALF). To be included in the study, participants must have been living at the ALF level of care, been willing to provide consent, able to score at least a three on the MiniCOG, a screener for cognitive impairment that uses a three-word recall and a clock drawing task to assess cognitive ability.²⁷

Participants also must have answered no to all questions on the Physical Activity Readiness Questionnaire,²⁸ indicating they had no contraindications for physical activity, or secured physician approval to participate. Finally, participants must have committed to attending a yoga class twice a week for 8 weeks. Participants were excluded from the study if they were expected to leave the ALF within 10 weeks from recruitment, were unwilling to provide informed consent, were concurrently participating in another study, had a diagnosis of dementia, or had known upcoming surgeries or medical procedures that would occur within the study period.

The activity directors of each facility assisted in recruitment by identifying individuals within their respective facilities who may have been appropriate for the study. The principal investigator (PI) met face-to-face with all residents who met inclusion criteria to explain the study, and conducted further eligibility screening if they consented to participate. A university institutional review board approved the study, and all participants provided informed consent before participation.

Intervention

The PI, a certified yoga therapist through the International Association of Yoga Therapy (C-IAYT), developed the yoga sequence from evidence-based yoga interventions for older adults with the intention to increase positive emotions, and improve balance.^29,30 The intervention was an 8-week chair yoga program, delivered in a group format at each ALF, twice a week for ∼50 min each session. Group sizes ranged from 4 to 15 at each facility (see Adams et al.²⁴ for more details of implementation within each ALF).

Each intervention was conducted by one of two C-IAYTs and the research assistants were certified therapeutic recreation specialists. See Table 1 for a summary of the components in the yoga sequence and their anticipated benefits. Through the intervention, the physical postures and sequencing remained consistent, whereas the intention, mantra, and focus of the yoga practice progressed each week.

Table 1.

Components and Intended Benefits of the Yoga Sequence

Yoga component	Physical benefit	Duration (min)
Grounding	Stimulates parasympathetic nervous system. Improves body awareness.	2
Mantra	Regulates heart rate. Releases endorphins. Provides a focal point for meditation. Improved concentration.	1
Pranayama practice	Regulates blood pressure, activates the parasympathetic nervous system. Reduces anxiety.	1
Warming sequence	Increases blood flow to muscles and joints, boosts production of synovial fluid. Fascial release.	16
Moving across the midline	Improves interoceptive perception of the body in space	6
Asanas for strength, flexibility, and balance	Increases muscle strength. Increases flexibility of muscles, ligaments, and tendons.	31
Meditation	Improves focus. Reduces stress/anxiety. Increases pain tolerance.	6
Resting pose	Improves interoceptive awareness.	1
Moment of connection	Improves social connection.	1

Data collection

Data collection occurred in person at each ALF. Before the start of the intervention, demographic information was gathered including gender, education, marital status, self-reported perception of overall health, self-reported health conditions, age, and the length of time they had lived in an ALF. The PI and a trained research assistant collected qualitative data from participants at each ALF. Although there were multiple sources of data collected within the larger study,^24,25 this analysis consisted of qualitative data gathered each week and postintervention.

During the weekly open-ended questions, participants provided a written response to the following prompts: “(1) At the beginning of class I felt…. At the end of class I feel ______” and “(2) How have you used yoga this week?” Weekly questionnaires provided timely feedback regarding the impact of yoga on emotions and coping strategies rather than relying solely on memory after 8 weeks. In-person semistructured interviews were conducted with each participant after the intervention was completed.

Semistructured interviews were conducted in person at the respective ALF, and to reduce social desirability bias, the interviews were conducted by a research team member who had not been involved in implementing the intervention. The interviews were digitally recorded, and allowed participants to reflect on the intervention as a whole in the context of their personal use of yoga. During participant interviews, the PI asked participants “how do you cope with stress,” “have you used yoga to help cope with stress,” “will you please describe how you have used yoga to cope,” and asked participants to “describe any plans you have for continuing yoga,” and “describe any changes you've noticed physically or emotionally since you started yoga.”

Data analysis

Data were transcribed verbatim, deidentified using pseudonyms and stored in QSR International's NVivo 12 software. The PI conducted a conventional content analysis²⁴ exploring themes related to participants' purposeful use of yoga. The number of participants who discussed the theme was documented as the number of sources. The number of times a specific construct was referenced was also recorded. Several strategies were put in place to ensure trustworthiness, especially considering the PI also served as the interventionist in three of the four facilities.

First the PI engaged in bracketing through reflective journaling throughout the research process,³¹ a research assistant observed each class to confirm fidelity to the intervention protocol across sites, and debriefing occurred between the PI and the research assistant after each intervention when field notes were recorded. When analyzing qualitative data, care was taken to ensure themes were derived specifically from participant word without artifacts from field notes or PI perspective (identified through bracketing).

After data analysis was complete, an external auditor independently reviewed the data to compare findings and there was an agreement of final themes at 95%. Finally, the PI presented findings to willing participants for member checking. Approximately 73% of participants engaged in member checking and all confirmed the results of the preliminary analysis reflected their experience.

Results

A total of 17 people enrolled in the study and 15 people completed the intervention (1 was lost to follow-up because of death and 1 because of hospitalization). Of those who completed post-tests, there were 13 females, aged 56–97 years, who had lived in assisted living between 1 month and 8 years. Existing health conditions among the participants included osteoarthritis, osteoporosis, diabetes, anxiety, and depression (see Table 2 for full demographic details). The attendance rate was 75% on average for all participants who completed the intervention.

Table 2.

Demographics of the Sample

	Frequency	%
Gender
Female	13	87
Male	2	13
Other	0	0
Race
American Indian or Alaska Native	0	0
Asian	0	0
Black or African American	0	0
Hispanic or Latino	0	0
Native Hawaiian or Other Pacific Islander	0	0
White	15	100
Education
High school or less	8	53
Some college or higher	7	47
Marital status
Single (never married)	1	7
Currently married	3	20
Widowed	8	53
Divorced/separated	3	20
Self-reported overall health
Excellent	2	13
Very good	4	27
Good	5	33
Fair	4	27
Poor	0	0
Self-reported health conditions
High blood pressure	7	47
Arthritis	5	33
Mental health	5	33
Age (years)
<65	2	13
65–74	2	13
75–84	4	27
>85	7	47
Length of time in ALF
Less than 1 year	7	47
1–2 years	4	27
3–4 years	3	20
5+ years	1	7

ALF, assisted living facility.

During the interviews, all participants were asked what strategies they used to cope with stress. That question was followed up by directly asking whether they had used yoga as a coping strategy. Eleven of the 15 participants affirmed they had used yoga as a coping strategy. Of those 15, 6 participants identified yoga as a coping strategy before the PI asked about yoga specifically. When evaluating participants' independent use of yoga outside the intervention, three themes emerged: relaxing, energizing, and connecting.

Relaxing

When asked about the impact of yoga, participants most commonly used the words relaxed and calm (n = 13). Char, a participant who reported frequently experiencing intense anxiety, discussed how the breathwork in yoga helped her relax more:

I learned to breathe. I learned how to handle anxiety… I think just the whole thing… meant a lot to me…I could feel the stretch and I'd breathe, and I really hadn't done that in a long time. It really helps me to calm down… I'd come in sometimes, stressed….but I did the yoga and I was relaxed every time.

Charles discussed using yoga to calm down in response to the anger he experienced toward other residents:

Well, I'm thankful for it [yoga]. It's given me a way to becoming [sic] calmer. And sometimes there's turmoil here…sometimes those people act out and [yoga] gives me a place to go. And I can do it myself and it's not exactly the way [the instructor] did it, but I remember some of the moves and it makes me secure. I usually go to my own room to do [the yoga practice].

Energizing

Participants (n = 5) talked about feeling more energized, alert, or awake after participating in the yoga intervention. Diane reported that through the yoga intervention, they went from feeling lazy and sluggish to feeling “more energized and alive.” This sentiment was echoed by others, with Beth saying, “I feel a little more woke up than when I first came.” Charles expounded a bit saying “I love this. I love the poses. When I put my hands out [in mountain pose], I feel energy pouring through my body that I hadn't felt in a long time. I feel like my whole body is awake.”

Connecting

Most participants (n = 11) expressed that the social aspect and sense of connection were an integral aspect of the yoga intervention. Bonnie, a participant who had lived at the ALF for >3 years said the most powerful benefit of yoga was “… to get up with a group of friends…to get out of your room to get out of here and then maybe [do] some socializing…” Danna, who experienced paralysis on the left side of her body, discussed feeling increased connection through yoga saying: “This type of exercise… after we do it…I just feel loved and calm.”

She continued to say “…yoga has helped me realize… I'm not able to do what others can do but I can still be part of a group…even though I'm not able to do [every movement] I'm still a part of it.” Other participants discussed a sense of connection to God as well as to other residents. One participant, Darlene, said, “There have been times that I've told you I'm angry—I just had a confrontation with someone and I want to rip his head off, but I walk out of [yoga] feeling so peaceful, feeling so together, so connected to God.”

Charles, another resident discussed how yoga helped him feel a connection to God within the context of his personal religion saying, “…[yoga] helps me with my own religious experience. I did a lot of the work with my eyes closed and it was like meeting God and hearing his voice. Every now and then I'd open my eyes to see if I was doing it correctly…”

Discussion

The purpose of this study was to explore participants personal use of yoga during and after a yoga intervention in ALFs. Their personal engagement with yoga was assessed through weekly questionnaires and semistructured interviews. Eleven participants described yoga as a way to engage in proactive coping. Three themes emerged during the data analysis: relaxing, energizing, and connecting.

A myriad of articles discuss yoga as a form of relaxation.^32–34 The results of this study support findings of Clarke et al.,³⁵ who found 87% of yoga practitioners cited relaxation as a main reason for using yoga. This study also supports past findings, by demonstrating yoga is perceived as relaxing in a population that had not yet been evaluated.^24,25

Energizing was another subtheme specific to yoga. Ancient yoga philosophy describes prana as the energetic life force that flows through the body through channels called Nadis. The traditional belief is that yoga practice assists in opening and aligning the Nadis so prana can more freely flow through the body.³⁶ The results of this study include participants who described feeling energy flow through their bodies, and although this is not empirical evidence, it supports the traditional philosophy. Matthew Sanford, a contemporary yoga philosopher and teacher, discusses how aging brings an increased amount of silence and stillness in the body and believes that yoga can provide moments of movement and connection through what is called the subtle body.³⁷

From a less mystical perspective, we might explain this by discussing the impact of exercise on endorphins and enkephalins. Physical activity is widely known to stimulate the production of endorphins and enkephalins (natural opioids that are colloquially known as the feel-good hormones).³⁸ Moderate exercise is a more effective catalyst than higher intensity exercise for promoting the release of endorphins and enkephalins.³⁹ This neuropathway could potentially explain the energy and “awake feeling” that participants described.

Social connection was demonstrated through qualitative data as people identified the social component of yoga as particularly beneficial. These data correspond with other studies that report participants experienced an increased sense of social connection during yoga interventions.^40,41 Because participants in this study were already acquainted with each other, it is worth exploring why the yoga intervention facilitated companionship. One explanation is that the intervention and interventionists were novel and disrupted established patterns of interaction and conflict,⁹ thus fostering deeper social connection.

Another potential explanation is that synchronous movement engendered a stronger sense of connection and belonging than activities without synchronous movement. Findings may support previous studies that show synchronized movement increased prosocial behaviors, compassion, and positive relationships.^42–45 This is of particular note for yoga because in addition to body movement, yoga involved synchronous breath flow and attention. Furthermore, several studies have demonstrated an increase in serum oxytocin levels after a yoga practice, leading to increased social cognition and emotion recognition.^46–49

In addition to potential biological mechanisms for increased connection, participants also engaged in behaviors that may have impacted connection. Participants reported using yoga as a personal coping strategy when they were feeling angry or were engaged in interpersonal conflict. Perhaps yoga not only promoted a feeling of social connection during the group but also enabled participants to have more interpersonal effectiveness by providing a way to cope with difficult emotions.

Overall, the three themes aligned with the two of the coping strategies outlined by Iwasaki and Mannell.¹² Both relaxing and energizing themes could be considered a type of mood enhancement coping strategy. Relaxing was often discussed in contrast to a negative mood state (i.e., anger and anxiety), and energizing was discussed when participants were discussing improving their mood. Finally, the theme connecting as described in this study has some overlap with leisure companionship.

Limitations and future research

This study had several limitations that also present opportunities for future research. First, the sample size was small and was homogeneous in terms of race and other characteristics, and future research should identify sites that can include a more diverse sample. In addition, because of the small sample size, results may not be free from social desirability bias despite efforts made to reduce this effect. The study purposefully excluded people who demonstrated potential cognitive impairment, but considering that people with cognitive impairment represent a high percentage of those receiving LTC services, future research might include people with a broader range of cognitive functioning.

To disentangle the outcomes, a different novel recreation program should be implemented as a control group in future research so results can be compared between groups. Past studies indicate a strong connection between home practice and positive health outcomes⁵⁰; therefore, future studies should examine links between the frequency of independent practice and outcomes.

Conclusion

In summary, ALF residents who were enrolled in a yoga intervention not only participated in yoga during the scheduled intervention, but they also independently used the yoga they learned, to engage in a personal practice. Participants indicated that both the group practice and their personal practice helped them proactively cope with stressors by improving relaxation, increasing energy, and bolstering feelings of connection. These findings are important because they support the use of yoga as a stress-coping strategy for residents of ALFs. Furthermore, results from this study demonstrate that residents may desire to utilize yoga independently outside of group interventions. Further research might explore the best ways to support residents' individual practice outside of group to support leisure stress coping, and promote independence.

Footnotes

Authors' Contributions

E.V.A. contributed to conceptualization, data curation, formal analysis, investigation, methodology, project administration, writing—original draft, and writing—review and editing. B.M.C. was involved in methodology, resources, validation, and writing—review and editing. M.V.P. was involved in methodology, resources, project administration, writing—original draft, and writing—review and editing. A.A.S. carried out methodology, supervision, and writing—review and editing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Abbreviations Used

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Yoga Practice As a Coping Strategy for Older Adults in Assisted Living Facilities: A Qualitative Content Analysis

Abstract

Introduction:

Methods:

Results:

Discussion:

Introduction

Methods

Study design

Participants

Intervention

Data collection

Data analysis

Results

Relaxing

Energizing

Connecting

Discussion

Limitations and future research

Conclusion

Footnotes

Authors' Contributions

Author Disclosure Statement

Funding Information

Abbreviations Used

References