Abstract
Background
While mind-body movement interventions such as qi gong, tai chi, and yoga are recommended in clinical practice guidelines for several common health conditions, implementation of these interventions within healthcare settings is rare. A systematic synthesis of implementation determinants–commonly referred to as barriers and facilitators–is needed to increase adoption or other implementation outcomes such as reach or sustainability within healthcare systems. Thus, the objective of this review is to: (1) identify determinants of qi gong, tai chi, and yoga for health conditions; and (2) evaluate whether determinants differ by intervention type, health condition, implementation setting, or implementation outcome.
Methods
In this systematic review, we will include original research articles in English that identify determinants to adoption of qi gong, tai chi, and yoga by adults with health conditions. We will search MEDLINE, EMBASE, Web of Science, CINAHL, PsycInfo, Google Scholar, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and WHO Clinical Trials database from inception. We will code determinants identified in each article using a codebook informed by the Consolidated Framework for Implementation Research (CFIR). We will report on how determinants relate to intervention type, health condition (e.g., low back pain, fall prevention), implementation settings (e.g., primary care clinic, community organization), or implementation outcome (e.g., adoption, sustainability). Study quality will be assessed using the Mixed Methods Appraisal Tool.
Discussion
Findings will inform implementation strategies by identifying context-specific determinants that influence uptake of qi gong, tai chi, and yoga for health conditions. Results will provide practical insights to guide clinicians, researchers, and health systems in integrating mind-body movement interventions within diverse healthcare and community settings.
Conclusion
This review will generate a comprehensive synthesis of implementation determinants to support the use of qi gong, tai chi, and yoga in evidence-based care for health conditions.
Keywords
Background
Select Clinical Practice Guidelines That Recommend Qi Gong, Tai Chi, and Yoga
In the healthcare context, implementation science involves the study of methods to promote the systematic uptake of evidence-based practices into routine clinical care.37,38 Understanding the implementation determinants of an evidence-based practice–commonly referred to as barriers and facilitators–is an important first step in developing effective implementation strategies that increase the use of these interventions in a specific setting or context. Furthermore, barriers to intervention use can occur at multiple socio-ecological levels.39-44 For example, barriers of mind-body movement interventions in healthcare settings can occur at the level of the patient (e.g., competing health demands), referring provider (e.g., low self-efficacy to describe or refer to tai chi), health system (e.g., referral to yoga is not possible in electronic health record), or policy-maker (e.g., payers not reimbursing mind-body movement interventions).45-51 Thus, identifying and prioritizing modifiable barriers is needed to design tailored implementation strategies that can increase the use of qi gong, tai chi and yoga for specific health conditions that are recommended by clinical practice guidelines. 52
The Consolidated Framework for Implementation Research (CFIR) was developed to guide the systematic assessment of implementation determinants. 53 CFIR includes 67 distinct constructs–providing a comprehensive taxonomy of implementation determinants–which are organized into 5 domains: Innovation (e.g., tai chi), Outer Setting (e.g., policy makers including insurers), Inner Setting (i.e., the setting where implementation occurs such as a health system or clinic), Individuals (e.g., clinicians that may refer to Qi Gong), and the Implementation Process. 53 The systematic assessment and mapping of determinants to these specific constructs can be used to develop tailored strategies to increase the use of evidence-based practices. 54 As clinical guidelines increasingly support the use of qi gong, tai chi, and yoga for specific health conditions, and healthcare systems or community organizations begin to implement these interventions,55-58 there is a growing need to understand implementation determinants to increase the effectiveness and efficiency of these implementation efforts.49,59,60 This need is driven by the persistent gap between strong clinical evidence supporting these interventions and their limited real-world uptake, highlighting the importance of identifying which contextual factors help or hinder their integration into routine care. While the explicit use of implementation science theories or frameworks (e.g., CFIR) in implementation of mind-body movement interventions is just emerging,49,61 there are lessons to learn from prior literature. However, we are unaware of systematic reviews that summarize the existing knowledge around implementation determinants of mind-body movement interventions.
The purpose of this systematic review will be to: (1) apply CFIR constructs to identify and report barriers and facilitators to the use of qi gong, tai chi, and yoga in treating various health conditions, and (2) identify sources of heterogeneity in determinants of intervention use, including variation in barriers and facilitators by type of mind-body movement intervention, health condition, implementation setting, or implementation outcome. 62
Methods
Design
Description of CFIR Domains
The protocol for this systematic review was registered with the international prospective register of systematic reviews (PROSPERO #CRD42024569493). This study protocol is informed by the PRISMA guidelines for study protocols (PRISMA-P), and reporting of the review findings will be informed by the PRISMA guidelines. 63
Eligibility Criteria
This systematic review will include original peer-reviewed empirical studies including cross-sectional and longitudinal observational studies, randomized and non-randomized clinical trials, and qualitative and mixed method evaluations of implementation or quality improvement programs. We will conduct reference list checking, as described by the Terminology, Application, and Reporting of Citation Search (TARCiS) statement, 64 on the articles that we include in our review as well as other relevant articles (e.g., systematic reviews, literature reviews).
Inclusion Criteria
Studies are eligible if they meet the PICOS framework (Population, Intervention, Comparison, Outcome, Study design). (P) We will include studies of adults with a specific health condition or those considered “at-risk” for a given health condition and described by the authors as such (e.g., older adults at risk for falls, cancer survivors). We will also include studies of other key informants (e.g., clinicians, health system or community leaders, policy makers). For example, we will include studies of clinicians if qi gong, tai chi, or yoga is relevant to a health condition they manage (e.g., geriatricians may recommend tai chi for knee osteoarthritis or fall prevention). (I) We will include studies of qi gong, tai chi, or yoga. We will also include multicomponent interventions (e.g., combined acupuncture-yoga intervention, mindfulness-based stress reduction) if we can identify facilitators or barriers specific to the qi gong, tai chi, or yoga component of the program.61,65 (C) Studies with or without a comparator group will be included (O) The outcomes of interest are the determinants (i.e., barriers or facilitators) to use of qi gong, tai chi, or yoga in adults with health conditions. When possible we will specify whether the determinants are specific to a particular implementation outcome such as feasibility, adoption or sustainability. We will not include studies that only measure implementation outcomes (e.g., measuring feasibility without collecting information on barriers or facilitators) or studies identifying barriers or facilitators that may only be relevant to the conduct of clinical trials (e.g., barriers to recruitment of trial participants). (S) We will include qualitative and quantitative studies that report one or more barriers and/or facilitators.
Exclusion Criteria
Healthy populations (i.e., those without a specified health condition or not designated as at-risk for a health condition); populations under the age of 18 years; conference proceedings, commentaries, editorials, dissertations, letters, books, book chapters, and reviews; and articles written in languages other than English will be excluded. We will exclude studies written in languages other than English because it may be difficult to accurately code translated text while maintaining a common language from the field of implementation science (i.e., CFIR constructs) where term homonymity, synonymy, and instability are major challenges.66-68 Although our search strategy includes grey literature sources to ensure that all potentially eligible peer-reviewed studies are identified, only peer-reviewed empirical articles will be included in the final review.
Search Strategy
An initial search of studies was conducted from database inception until May 2024 using the electronic databases: MEDLINE (OVID platform), Embase (OVID platform), CINAHL, PsycInfo, and Web of Science. In addition, a grey literature search was conducted using Google Scholar, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials database in March of 2025. Searches for all data bases will be updated prior to completion of the review.
Search terms were variations on 2 concepts: qi gong, tai chi, or yoga AND barrier, facilitators, or implementation. Search strings varied slightly depending on the MESH and subject heading terms within each database. Truncation (*) was used to capture variations in terms. Results were limited to the English language. See Online Appendix 1 for full search strategies for each database. Endnote was used to remove duplicates and double-checked by librarians with expertise in systematic review methods. Additional duplicates were identified and removed in the systematic review software, Covidence (Veritas Health Innovation, Melbourne, Australia).
Data Extraction
Through team meetings and the use of exemplar articles, an extraction form was developed (Online Appendix 2) to capture information on each study. We will extract the following information on general study characteristics: author(s), year, country where the study was conducted, study design, sample size, and data collection method (e.g., interviews, focus groups, surveys). We will collect information on the sample including participant demographic characteristic such as age, sex, race/ethnicity, and other characteristics that define the population of interest (e.g., military veterans, healthcare workers). We will identify what stakeholder perspectives(s) are being captured (e.g. patients, instructors of mind-body movement interventions, primary care providers, medical specialists, medical educators, hospital leadership, community leaders, policy makers). We will extract information on strength of evidence of the intervention for the specific health condition as justified by the original investigator. The authors rationale for implementation efforts will be characterized as: (1) the mind-body movement intervention is recommended for the specific health condition (e.g., a guideline recommending yoga for low back pain 9 ); (2) a component of the mind-body movement intervention is recommended for the specific health condition (e.g., a guideline recommending exercise or mindfulness for cardiovascular health 69 ); or (3) implementation is occurring without a clinical practice guideline supporting either the intervention or its components for the specific health condition.
Definitions of Implementation Outcomes 70
aAcceptability, appropriateness, and feasibility are considered pre-implementation outcomes, i.e., outcomes that can precede implementation efforts that can predict other implementation outcomes such as adoption or sustainability. 71
Barriers and facilitators will be identified through coding of relevant quantitative data (e.g., surveys) and qualitative findings (e.g., themes) from the results section of each study using a codebook informed by CFIR version 2.0. 53 We have piloted this codebook in several prior and ongoing studies designed to inform the development of implementation strategies.49,52 We will also allow for emerging determinants (i.e., those that are not captured by CFIR) to arise throughout the coding process. Data from each article will be independently reviewed and extracted in duplicate by 2 reviewers. Disagreements in data extraction will be resolved by senior reviewers and/or team consensus meetings.
Data Synthesis and Qualitative Meta Analysis
We will describe the frequency of identified barriers and facilitators and use heatmaps to illustrate high-density areas of CFIR. 72 We will explore whether barriers and facilitators differ based on intervention type (e.g., tai chi vs yoga), health condition (e.g., back pain vs cancer symptom management), setting (e.g., primary care clinic vs community organization), and implementation outcome (e.g., adoption vs sustainability). In regard to health condition, we will explore whether barriers and facilitators differ when qi gong, tai chi, and yoga are being implemented for different clinical indications (e.g., fall prevention, osteoarthritis, or symptom management in cancer care). In regard to setting, we will explore whether barriers/facilitators differ when qi gong, tai chi, and yoga are implemented in different contexts. Clinical settings may include primary care clinics, medical specialty clinics (e.g., pain medicine, rheumatology, orthopedics, physical medicine and rehabilitation, integrative medicine, sports medicine), community settings (e.g., nursing homes, community centers, parks, home-based programs), or other specific settings where qi gong, tai chi, or yoga may be delivered for health conditions. In regard to implementation outcomes, we will explore whether barriers and facilitators differ when a specific implementation outcome is specified. We will characterize each study as having no specified implementation outcomes or one or more of the following implementation outcomes: acceptability, appropriateness, feasibility, adoption, fidelity, penetration, cost, and sustainability of intervention delivery. 70
Risk of Bias Assessment
Study quality will be assessed using the Mixed Methods Appraisal Tool (MMAT) Version 2018. 73 The MMAT is a grading check list that can be used to assess the risk of bias in 5 types of study designs: (1) Qualitative, (2) Quantitative randomized controlled trials, (3) Quantitative non-randomized trials, (4) Quantitative descriptive, and (5) Mixed methods. Two reviewers will independently use the appropriate checklist to grade each included study. Discrepancies between the 2 reviewers will be discussed at team meetings and/or arbitrated by a third reviewer.
Discussion
The benefits of qi gong, tai chi, and yoga have been established for several health conditions. Thus, we anticipate our systematic review will identify studies on barriers and facilitators to the appropriate, evidence-based use of these interventions for specific health conditions. For example, guidelines endorse one or more of these mind-body movement interventions for low back pain (American College of Physicians 9 ), osteoarthritis (American College of Rheumatology and the Osteoarthritis Research Society International guidelines 27 and the American College of Rheumatology and Arthritis Foundation 74 ), hypertension (International Society of Hypertension Global Hypertension 25 ), and fall prevention (United States Preventive Services Task Force 26 ). While several studies have looked at barriers to implementation of a specific intervention or within a particular clinical context, we are unaware of any publications that have synthesized what is known about implementing qi gong, tai chi, or yoga across broad settings where people with health conditions receive services. Furthermore, our review will include a comprehensive search that is broad enough to inform our understanding of whether implementation barriers and facilitators differ by intervention type, health condition, implementation setting, or implementation outcome.
One reason for the absence of prior reviews may be the limited familiarity, awareness, or use of CFIR or other evolving determinant frameworks44,75 within the clinical research communities studying mind-body movement interventions. Applying the common language codified in CFIR to code the existing literature may help synthesize and better document prior work, thus elucidating known barriers and informing future implementation efforts. It may also be that heterogeneity exists in the factors that influence the implementation of mind-body movement interventions (e.g., if barriers to implementing tai chi for knee osteoarthritis are different than the barriers that impede implementation of yoga in cancer care). Understanding these differences will aid the development of implementation strategies that are appropriately tailored to the intervention, health condition, implementation setting, or the relevant implementation outcomes.
Identifying barriers is essential for developing effective implementation strategies that can support their adoption in routine care settings. Implementation strategies that target specific known barriers may be more effective than general strategies. While developing implementation strategies that have multiple components is also thought to be effective, it is important to tailor resources to those strategies most likely to be successful within a specific context.76,77 Thus, identifying a range of barriers and facilitators, and whether they are relevant to a range of contexts, is essential to inform future dissemination and implementation efforts in research and practice.60,78 Our qualitative meta-analysis will help us to organize and interpret information on implementation determinants using the common set of terminology defined in CFIR domains and constructs.
Our systematic review protocol has important limitations. First, we anticipate that few studies we will identify will use contemporary frameworks from the field of implementation science. 72 We will code or translate language on barriers or facilitators to the CFIR lexicon, which could introduce bias. To limit potential bias, we will have weekly team meetings to conduct implementation science training for all team members, to discuss discrepancies in double coded transcripts, and create an audit trail of how disagreements are resolved through consensus. While our preliminary searches support the feasibility of identifying many relevant articles, we anticipate that some of our subgroups of interest (i.e., subgroups based on intervention type, health condition, implementation setting, or implementation outcome) may have a smaller number of studies, limiting our ability to explore barriers and facilitators in all potential subgroups.
We anticipate our findings will be reported in multiple manuscripts utilizing and organizing the determinants and framework that best synthesize the perspectives of the stakeholders (e.g., one that is patient-focused, another that is healthcare system-focused). Additionally, this review will inform the implementation of tai chi for knee osteoarthritis in 4 large healthcare systems in the context of a multi-site embedded pragmatic trial funded by the National Center for Complementary and Integrative Health (NIH Grant #: UG3AT012413; ClinicalTrials.gov ID: NCT06384898). We also anticipate our review will inform other implementation efforts of qi gong, tai chi and yoga for specific health conditions in health care systems or community organizations. 79
Conclusion
This systematic review will generate a comprehensive synthesis of implementation determinants affecting the adoption of qi gong, tai chi, and yoga for specific health conditions. By applying the Consolidated Framework for Implementation Research (CFIR) to organize findings across diverse populations and contexts, our review will provide a foundation for developing tailored evidence-informed implementation strategies. The results will guide healthcare systems, community organizations, and policymakers in optimizing the integration and sustainability of mind-body movement interventions recommended in clinical guidelines. Ultimately, this work aims to advance equitable access to effective nonpharmacologic care options and support the broader translation of evidence-based mind-body practices into routine care.
Supplemental Material
Supplemental Material - Determinants of Qi Gong, Tai Chi, and Yoga Use for Health Conditions: A Systematic Review Protocol
Supplemental Material for Determinants of Qi Gong, Tai Chi, and Yoga Use for Health Conditions: A Systematic Review Protocol by Ryan S. Wexler, Christopher T. Joyce, Rocky Reichman, Cora Pereira, Emma Fanuele, Emily Hurstak, Lance Laird, Helen Lavretsky, Chenchen Wang, Rob Saper, Karen S. Alcorn, Brian S. Mittman, Eric J. Roseen in Global Advances in Integrative Medicine and Health
Footnotes
Acknowledgements
We would like to acknowledge Joanne Doucette, an expert systematic review librarian who helped our team develop the search strategy for this review.
ORCID iDs
Ethical Considerations
Ethics approval will not be obtained for this review of published, publicly accessible data. The results from this systematic review will be disseminated through conference presentations and journal publications.
Author Contributions
Study concept and design: RSW, CJ, RR, CP, and EJR. Acquisition, analysis, or interpretation of data: RSW, CJ, RR, CP, EM, EH HL, CW, RS, BM, KSA, JD, and EJR. Critical revision of the manuscript for important intellectual content: RSW, CJ, RR, CP, EM, EH, HL, CW, RS, BM, KSA, JD, and EJR. Statistical analysis: n/a. Obtained funding: n/a. Administrative, technical, or material support: CJ, EJR. Study supervision: EJR. All authors read and approved the final manuscript.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: National Center for Complementary and Integrative Health (K23AT010487, K24AT007323, U24AT009676, UG3AT012413, UH3AT012413), National Institute of Neurological Disorders and Stroke (K12NS130673), the National Institute of Allergy and Infectious Diseases (NIAID), the National Cancer Institute (NCI), the National Institute on Aging (NIA), the National Heart, Lung, and Blood Institute (NHLBI), the National Institute of Nursing Research (NINR), the National Institute of Minority Health and Health Disparities (NIMHD), the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), the NIH Office of Behavioral and Social Sciences Research (OBSSR), and the NIH Office of Disease Prevention (ODP).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Registration
PROSPERO #CRD42024569493.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of NCCIH, NIAID, NINDS, NCI, NIA, NHLBI, NINR, NIMHD, NIAMS, OBSSR, or ODP, or the NIH.
Supplemental Material
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References
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