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Abstract

Objective

To explore experiences with learning yoga through synchronous, online instruction among midlife and older women participating in a trial of therapeutic yoga for urinary incontinence.

Methods

We conducted an embedded qualitative study and assessed process outcomes within a multi-site randomized controlled trial of a group-based therapeutic pelvic floor yoga program vs physical conditioning program for midlife and older women with urinary incontinence. Participants were recruited from the San Francisco Bay Area from 2019 to 2022. The trial included twice-weekly small group instruction delivered via telehealth using the videoconference platform Zoom. Questionnaires and semi-structured interviews were used to assess satisfaction and explore experiences of learning yoga in an online format. Data were analyzed using descriptive statistics and a hybrid deductive/inductive qualitative thematic analysis approach.

Results

Questionnaire results showed 96% of respondents (n = 51) rated their overall experience with online yoga as “good to excellent.’’ Interview participants (n = 24) identified key challenges including navigating technology, configuring home environments, limited social connection, and not being in the physical presence of the yoga teacher. However, these challenges were offset by facilitators such as convenience, privacy, and perceived mind-body benefits, including improved incontinence symptoms. Effective teaching strategies contributing to a positive experience included detailed verbal instructions, visual demonstrations, solicitation of questions, and individualized feedback.

Conclusion

Synchronous, videoconference-based yoga instruction was effective at engaging midlife and older women in managing urinary incontinence. The online format provided convenience and privacy, making therapeutic yoga more accessible. Tailored teaching strategies and technical support significantly enhanced learning and satisfaction. This study suggests the potential for broader application of online therapeutic yoga programs for specific health conditions.

Keywords

yoga telehealth urinary incontinence women midlife older adults

Introduction

Yoga is a mind-body practice used to promote physical and mental well-being and is increasingly relied upon to manage an array of health conditions that affect older adults. In the United States, national survey data indicate that the proportion of U.S. adults over age 50 practicing yoga tripled from 2012 to 2016, with over half of practitioners reporting interest in yoga for specific health-related indications.^1-3 The rising popularity of yoga for self-management of aging-associated conditions reflects a growing interest in low-cost health interventions that do not require continuous supervision from clinical healthcare specialists.^4,5 This is especially relevant for the treatment of urinary incontinence, which is experienced by one in three women over the age of 50 and often associated with social isolation, depression, and functional decline. First-line treatment for incontinence includes pelvic floor exercises that can be challenging for women to practice effectively on their own and second-line pharmacologic treatments are often discontinued due to side effects and tolerability.⁶

Yoga instruction delivered via interactive videoconferencing (tele-yoga) provides numerous opportunities for increasing access and reducing travel burden for individuals seeking to learn the therapeutic application of yoga for specific health indications.⁷ Online access not only provides options for individuals who are based in communities with fewer affordable and accessible yoga studios, but even in communities with a high density of recreational yoga options, it can increase access to trained yoga teachers or yoga therapists that specialize in yoga as a complementary modality and integrative approach for specific health conditions.⁸

Recent studies have demonstrated the acceptability and feasibility of synchronous, video-based telehealth delivery of mind-body movement interventions which drastically increased during the COVID-19 pandemic.^9-15 Factors contributing to the success of online yoga interventions across a variety of populations include convenience and privacy.⁹ Online access to yoga interventions has been shown to provide a sense of safety and privacy among women Veterans across the aging spectrum living with post-traumatic stress disorder.¹¹ Among older adults, the quality of instruction has been found to be especially important in the context of synchronous online delivery.¹⁵ The transition to online yoga delivery has mixed results related to the social aspect of yoga interventions.⁹ Some studies have found shared experience and social connection to be drivers of engagement, while others have found weekly telehealth yoga classes were not effective in reducing social isolation or loneliness among older adults.^10,15 In all these studies, specific factors such as audio and visual quality, availability of variations/adaptations of poses, and efforts to build community play a role in perceptions of satisfaction.

Commonly reported challenges with online delivery include technical difficulties and internet connectivity as well as the home environment including lack of space and distractions.^9,11,14,15 Despite an increase in studies of online yoga interventions, few clinical trials of yoga delivered remotely have used in-depth qualitative methods to examine participants’ perspectives on the impact of the synchronous, video-based telehealth format on the context and process of the intervention or perceived effectiveness for a particular health concern.^9,15,16 The goal of this study was to explore experiences with learning yoga through synchronous, online instruction among midlife and older women participating in a trial of therapeutic yoga for urinary incontinence.

Methods

We conducted an embedded qualitative study and assessed process outcomes within a multi-site randomized controlled trial of a group-based therapeutic pelvic floor yoga program vs physical conditioning program for midlife and older women with urinary incontinence.¹² Participants in the Lessening Incontinence through Low-Impact Activity (LILA) trial were recruited from the San Francisco Bay Area from 2019 to 2022. Written informed consent was obtained from all participants prior to enrollment, study procedures were approved by the University of California, San Francisco Institutional Review Board (18-26341), and the trial was registered in ClinicalTrials.gov (Identifier NCT03672461).

Overview of the LILA Trial and Telehealth Delivery

The Lessening Incontinence through Low-Impact Activity (LILA) trial was a 12-week intervention of twice weekly small group instruction of therapeutic yoga techniques vs general physical conditioning exercises. Trial participants were women aged ≥45 years who reported at least daily incontinence, were not currently participating in organized yoga or physical conditioning programs, were willing to temporarily forgo standard clinical incontinence treatments, and met minimum mobility criteria (eg, ability to transition from a supine to standing position without assistance). Eligible women were randomized in equal ratios to either the therapeutic pelvic floor yoga program or the time-equivalent low-impact physical conditioning program focused on general muscle stretching and strengthening exercises.¹² Trial outcomes, along with eligibility criteria have been previously published.¹⁷

The therapeutic pelvic yoga program was designed to provide instruction and practice in yoga asana (poses), pranayama (breathing practices), and techniques chosen for their potential to improve bladder control in older women. The program was informed by the Iyengar yoga method, a form of Hatha yoga known for its potential therapeutic applications which has been employed successfully in other studies of yoga for a variety of indications.^18-24 This style of Hatha yoga differs from others in ways that were thought to maximize efficacy, safety and accessibility. These include: (1) emphasis on anatomical alignment and awareness of specific bodily structures; (2) incorporation of props to accommodate those with decreased strength or flexibility, increase comfort and duration of postures, and provide external stimuli to enhance awareness of body position and sensations; and (3) emphasis on mindful awareness rather than rapid cycling through postures.

The program focused on a core set of 16 yoga poses commonly used in Hatha yoga practice.¹⁷ These included active poses to engage the pelvic floor, as well as passive, supported postures to promote relaxation.¹⁷ Study sessions were led by one of 6 instructors, each of whom had either a minimum of 500 hours of yoga teacher training or certification from the International Association of Yoga Therapists, and had undergone study-specific training with the study expert yoga consultant. Instructors followed a study-specific guide to introduce participants to yoga poses, calling attention to ways in which postures could improve pelvic floor function, and guiding women in adapting postures and using props to accommodate physical limitations as needed. Participants were asked to practice yoga on their own for at least one additional hour per week and received a written manual with pictures and descriptions of each pose as well as a yoga mat, belt, bolster, and two blocks.

Between March 2019 and December 2019, the first two study cohorts completed the yoga intervention in person as originally planned. In March 2020, the study team had completed screening and randomization of the third cohort when shelter-in-place orders were issued in California due to the COVID-19 pandemic. Two of the three groups in this cohort had begun in-person instruction the week prior to shelter-in-place orders. At that point, the investigators and study team worked to transition the trial to telehealth using the videoconference platform Zoom, with input from study consultants, safety monitors, and the study sponsor (NIH).¹² Cohort 3 completed all trial activities online in May 2020; cohorts 4 (September-November 2020) and 5 (March-May 2021) were recruited with the expectation of videoconference-based instruction only. Cohorts 6 (September-November 2021) and 7 (March-May 2022) were recruited with the expectation that instruction would begin by videoconference but might transition to in-person; however, instruction was ultimately completed by videoconference only. Participants received tripods or stands for tablet computers if needed. Study personnel provided individual coaching to participants on using Zoom, positioning cameras, and lighting before the start of classes. Participants were required to have cameras on during study yoga sessions.

Interview Eligibility & Recruitment

Participants who had completed the yoga intervention via videoconference were eligible to participate in a semi-structured interview about their experience of learning yoga in an online format.²⁵ To achieve deeper understanding of contextual factors that might inform participants’ experience of and perspectives on learning yoga in an online format,²⁵ we purposively sampled by age (<65 and ≥65) and recruited participants from the four largest racial and ethnic groups in the trial (Asian, Black, Latina white, and non-Latina white). Study coordinators for the parent trial identified women across the sampling criteria and invited them by email and follow-up telephone calls to take part in a one-time semi-structured interview.

Data Collection

To assess satisfaction with and process outcomes from the video-based delivery of the yoga intervention, we developed a questionnaire that was distributed electronically at week 12 to participants in the planned telehealth cohorts in the fourth through seventh waves. Participants were asked to rate their experience on a 4-point scale (poor, fair, good, excellent) with the following aspects of telehealth delivery: overall experience, convenience, ability to see the instructor, instructor’s ability to see the participant, sound quality, personal comfort, degree to which confidentiality was respected, sense of personal connection with other participants, and opportunity to share their thoughts.

Semi-structured interviews focused on participants’ prior experience with yoga, as well as barriers and facilitators to learning to practice yoga in an online setting²⁶ (see Supplemental File 1). The qualitative study team included a medical anthropologist and certified yoga therapist (FMN), a medical anthropologist (MKG), a public health researcher (CK), two doctoral students in sociology (GPA, BA), a clinical research psychologist (MC), and the trial’s physician principal investigator (AH). Between January and June 2022, FMN and CK conducted one-on-one video interviews using Zoom (range: 34-57 minutes; mean: 45 minutes). Interviews were recorded and transcribed verbatim. Prior to each interview, participants provided written informed consent using DocuSign. After completion of the interview, participants received $50 in the form of gift cards.

Data Analysis

Demographic and clinical characteristics for participants who completed the telehealth questionnaire and semi-structured interviews were summarized with descriptive statistics. In addition to examining the full distribution of responses for the telehealth questionnaire items, we also examined the proportion of participants who reported at least a “good” experience on each aspect of tele-yoga instruction.

For semi-structured interview data, we used ATLAS.ti (version 23.2.1)²⁷ to manage and analyze transcripts using a hybrid deductive/inductive approach to qualitative thematic analysis.²⁸ We (FMN, BA, GPA) first independently reviewed three interview transcripts and applied deductive codes developed from interview guide domains. We then developed inductive codes to capture newly identified concepts not represented by deductive codes. Through an iterative process, FMN, BA, and GPA finalized the coding scheme, discussed findings after each set of three independently coded transcripts, and resolved disagreements about the presence, scope, or definition of codes and themes through consensus-based discussion.

Results

Participant Characteristics

Characteristics of the questionnaire respondents and interview participants are summarized in Table 1. Mean age was 63 years (SD 8.5; range 49-81) for questionnaire respondents and 6 years (SD 10.7; range 45-90) for interview participants. Among questionnaire respondents, 71% identified as White, 16% Asian, 16% Latina/Hispanic, 6% Black/African American, and 8% multiracial; among interview participants, 54% were White, 21% Asian, 17% Latina/Hispanic, 4% Black/African American, and 17% multiracial. Ninety percent of interview participants attended at least 22 of 24 intervention sessions. Among interview participants, 25% had no prior yoga experience, and 25% reported having regularly practiced yoga in the past but not recently; the 50% who had previously been exposed to yoga described a range of positive and negative prior experiences.

Table 1.

Participant Characteristics

Variable	Yoga arm telehealth questionnaire completers N = 51	Qualitative interview sample N = 24
Variable	Number (%)/Mean (SD)
Total No. of Participants	51 (100)	24 (100)
Age
Mean (SD)	62.4 (8.5)	62.8 (10.7)
Median (min - max)	63 (49-81)	66.5 (45-90)
Ethnicity
Hispanic or Latino	8 (16)	4 (17)
Not Hispanic or Latino	43 (84)	19 (79)
Unknown	—	1 (4)
Race
Asian	8 (16)	5 (21)
Black or African American	3 (6)	1 (4)
White	36 (71)	13 (54)
More than one race	4 (8)	4 (17)
Other	0 (0)	1 (4)
Education level
Some college/AA degree	8 (16)	3 (13)
College degree or more	42 (79)	21 (88)
Employment status
Retired	19 (37)	9 (38)
Employed full-time	20 (39)	6 (25)
Employed part-time	7 (14)	4 (17)
Fulltime homemaker	2 (4)	2 (8)
Unemployed	3 (6)	1 (4)
Other	—	2 (8)
Total urinary incontinence episodes per day	3.8 (2.6) [range 1-14]	3.5 (2.2) [range 1-9]
Self-rated general health
Fair	1 (2)	—
Good	15 (29)	9 (38)
Very good	26 (51)	11 (46)
Excellent	9 (18)	4 (17)

Questionnaire Results

Among the 51 questionnaire respondents, 96% rated their overall experience with online trial participation as “good to excellent” (Table 2). Convenience was also rated highly, with 90% rating convenience as “good to excellent.” Audio-visual aspects of telehealth delivery were rated highly, with “good to excellent” ratings for ability to see instructor (98%), instructor ability to see the participant (92%), sound quality (88%). Sense of personal connection was the lowest rated item, with 61% “good to excellent.” Table 3 compares questionnaire results with key themes from interviews.

Table 2.

Telehealth Delivery Questionnaire Results (n = 51)

	Poor	Fair	Good	Excellent
Overall experience	1 (2%)	1 (2%)	10 (19.6%)	39 (76.5%)
Convenience	2 (2%)	3 (5.9%)	14 (27.5%)	32 (62.8%)
Ability to see instructor	0 (0%)	1 (2.0%)	14 (27.5%)	36 (70.6%)
Instructor ability to see you	0 (0%)	4 (7.8%)	18 (35.3%)	29 (56.9%)
Sound quality	2 (3.9%)	4 (7.8%)	10 (19.6%)	35 (68.6%)
Comfort doing classes online	2 (3.9%)	4 (7.8%)	11 (21.6%)	34 (66.7%)
Opportunity to share your thoughts	2 (3.9%)	2 (3.9%)	10 (19.6%)	37 (72.6%)
Sense of personal connection	7 (13.7%)	13 (25.5%)	16 (31.4%)	15 (29.4%)
Confidentiality was respected	0 (0%)	0 (0%)	8 (15.7%)	43 (84.3%)

Table 3.

Comparison of Questionnaire and Interview Findings

Outcome of interest	Quantitative Data	Qualitative Theme(s)	Illustrative Quotations
Overall experience	96.1% good to excellent overall experience	Overall experience was not included as a specific theme; however, in general, interview participants reported positive overall experiences.
Convenience	90.3% good to excellent convenience	Convenience and privacy and comfort of the home setting are key facilitators to participation	“I could use all my own stuff in my own environment. And so [the teacher] could see how I was going to be doing it at home. And I could remember the way she talked to me in my own practices, as opposed to if I were in a studio, there would be two different places. And when I got home, I might do it differently. So I felt there was a continuity”
Technology	Participant ability to see instructor 98.1% good to excellent	Participants had a short period of “figuring out” the optimal video and audio set up.	“That was one thing you had to learn was when you needed your glasses on and when you didn’t. Or whether you needed gallery view or speaker view. Then you realize you just needed speaker view because if the teacher was going to show you something you needed to see it from across the room. Which is a lot of mechanics about doing it online. But once you got it it was fine.”
	Instructor ability to see participant 92.2% good to excellent	Limitations to “seeing and being seen” were mitigated by actively changing camera angles and use of gallery and spotlight features	“Every class I tried to move things around to see if I had a better view, if she had a better view of me as well. I Mean I think toward the end, it got better but I wouldn’t say that it was exactly how I would’ve wanted it. I Think unless you’re in person, then you can see all angles of her and she can see all angles of you as well.”
	Sound quality 88.8% good to excellent	Limitations to using touch as a sensory input in the online setting	“When [the teacher] would give a critique, sometimes it takes a little bit extra to understand how to take her words and change them into how you change your body. Whereas when somebody can put their hands on you, it can take like one tiny alteration, and it’ll make all the sense of the words that she said. But when you have only virtual, it takes a little bit more.”
Degree of social connection	60.8% good to excellent sense of personal connection with other participants	Limited opportunity for social connection in the online setting	“There was a little checking in at the beginning. Mostly initiated by the teacher checking in on people and then people would check in on each other. And then you would get to the [yoga] practice. And at the end of class sometimes people visited a little bit. But not for any big, huge … because it was online.”
	Opportunity to share thoughts 92.2% good to excellent	Participating in group class helped to destigmatize incontinence as a health condition	Well, it’s just easier because people were talking about it. This is what makes it… It’s not an easy subject to discuss with people. You kind of edge into these conversations with other women. And sometimes it happens and sometimes it doesn’t. But it’s just the fact that it is being talked about. . . I Just like the fact that it's talked about as matter of fact. Using the right words, discussing it and people being able to say what feels comfortable and what doesn’t. How embarrassing this could be or not. How annoying it can be or not. And it’s just a fact of life, talking about this. And the more it’s out in the open… but I just like the fact that it's easier to talk about.”
		Instructor solicitation of questions from participants was an effective teaching strategy	“I think that [the online setting] was not bad because we were like in real time doing it with somebody. And we could ask questions. Like I do remember, if I didn’t understand something or if I was having a hard time with something, I could just say like, “Hey, this is what I’m doing. Is that correct? Or what do I have to change to make this pose right?’”

This table shows how quantitative survey data and qualitative interview data align, with interview data providing additional context and detail to the outcomes from the survey.

Interview Findings

Participants described overall positive experiences with delivery of the pelvic yoga intervention via videoconference. However, participants reported several types of challenges with navigating online learning, as well as factors that supported a positive online learning experience.

Challenges and Limitations of Video-Based Pelvic Yoga Intervention Delivery

Specific barriers and challenges participants identified included (1) navigating technology, (2) home environment, (3) limited opportunity for social connection, and (4) limitations of not being in the physical presence of the yoga teacher.

Navigating Technology

Technology posed minor challenges for participants as they began the program and occasionally in subsequent weeks, but overall, it was not a major barrier to participation. As one participant said, technology related issues were “not too big of a deal.” During interviews, women described “glitches” such as issues with internet connectivity or zoom links not working. For example, one woman explained: “Sometimes we'd have Internet issues. Like every now and then each one of us would have like a frozen moment and then we’d have to log back in. Or some kind of tech issue with Zoom or Wi-Fi. Your laptop battery dying, that kind of stuff.” (ID# 80148, age 47, Asian)

Participants described how over time, they became more comfortable and competent with troubleshooting issues with the technology. A common suggestion for improvement was for the study team to provide more focused technology orientation and support for participants with varied technology literacy and comfort levels. For example: “I happen to just use computers all the time, but some people didn't use computers. But I think the difficult thing was training… I think it would've been helpful and say, okay, let’s see that you can see me and let me work it out with the other people. We can meet and see if we all are at the same level. Everybody was a different level.” (ID# 82082, age 66, Asian)

Configuring Physical Space and Negotiating Privacy in the Home Environment

Interviewees discussed the process of setting up their personal space for the online yoga sessions as “trial and error.” Most participants in the clinical trial did not have an established home yoga practice and, prior to the pandemic, were not accustomed to performing physical activity in a way that also required viewing a computer screen. One woman who lived in a “tiny little house” explained:

“I didn't have a coffee table, and I put the laptop on top of a book on top of a cat platform. And [the instructor’s] able to see my figure on the mat in the middle of the room. I had experimented with doing things half in the kitchen, half over here. And of course that was too much running around. So it took a few sessions for me to figure out how I could do the whole thing. And she does want to see where your feet are, which is important because it turns out one thinks one's feet are straight and they're not. But, yeah, the physical setting was a challenge. I spent an hour with a friend trying to figure out how I could do this and then finally we worked out…it took a lot of finagling. But I was game, so it was not a big deal. Once we got it figured out.” (ID# 80205, age 70, White)

A few participants commented on disruptions or distractions related to participating in the trial from home versus being in a more private yoga studio or in-person location. For example, participants discussed how they navigated privacy issues, especially when moving around their home to find optimal locations to practice yoga. One woman who had initially “wanted to do it in the privacy of my room” explained that “it didn't allow me enough space to really benefit. So, I think for the first week I did that and then I moved over to the living room. And it worked a whole lot better in the living room … space-wise and also for the instructor to see me.” Although she was using a common space, she explained how, “I gained enough confidence that I could just do it myself and then my kids know to just stay in their room or just not interrupt me. So, it kind of worked out. And they know, okay, she’s doing yoga, let’s leave her alone.” Another woman explained how she was practicing in a common space and “had the video on loud, and so once my husband had someone come in for a meeting and he was embarrassed because they were talking about the pelvic floor. But that was the only issue. And then I could've lowered volume.” (ID# 80325, age 71, White)

Limited opportunity for Social Connection in the Online Setting

Some participants expressed that the online format limited their ability to form strong social connections with other participants, often comparing it unfavorably to the organic interactions possible during in-person sessions. One participant explained:

“I don’t think we had too much interaction between other participants, aside from just all of us participating in the yoga sessions. … I don’t know, it’s hard to tell. I think in person it would’ve been like small talk beforehand and afterwards it could’ve been more personal interactions. But with Zoom you are on and then you log off. There’s no sticking around, changing shoes or whatnot.” (ID# 80148, age 47, Asian)

Another participant noted:

“You don’t really get to know the other people that are participatin’g very well. And it would’ve been nice to have some sort of camaraderie. And that’s why in-person, before a yoga class or afterwards, you get to know the individuals a little bit.” (ID# 80238, age 70, White)

Some participants expressed expectations of more interaction than they ultimately experienced. One woman said:

“I thought it was going to be more interactive, like that we would maybe quickly chat briefly, what have you. But no, I think pretty much everybody was on their own. Maybe a couple of times we laughed at something which was nice. But, yeah, I guess I was expecting something a little more social. But some people never done yoga and maybe some people were more shy. I don't know.” (ID# 80290, age 67, White)

One participant explained that while “[t]here was a little checking in at the beginning” of each class, significant interactions with other participants were rare:

“There was a little checking in at the beginning. Mostly initiated by the teacher checking in on people and then people would check in on each other. And then you would get to the [yoga] practice. And at the end of class sometimes people visited a little bit. But not for any big, huge … Because it was online.” (ID# 80150, age 68, White)

Despite a desire for more interaction, the minimal social connection provided during the online classes was appreciated by some, especially during the pandemic. One participant reflected on this sentiment:

“I would have liked to go for coffee as a graduation get-together. But it never happened because everybody was working, and I’m retired. But it was nice to have a nice interaction.” (ID# 82082, age 66, Asian)

This feedback underscores the varied but generally positive impact of social interactions within the limitations of an online setting.

Limitations of Not Being in the Physical Presence of Yoga Teacher

Participant Perspectives on Seeing and Being Seen

While questionnaire respondents rated their ability to see the instructor and the instructor’s ability to see them highly (Table 2), interviews provided additional insight into their experience with the visual limitations of the online format. Comparisons to practicing yoga online vs in the physical presence of the yoga teacher were common, even among women who were new to yoga. For example, one participant said, “Unless you’re in person, then you can’t see all angles of her, and she can’t see all angles of you as well.” Another participant explained how a “3-D” experience was not replicable in the online setting:

“That’s maybe one limitation of doing it on Zoom, that you do see the teacher doing the pose, for sure, but I guess when you are in person you have a kind of more of a 3-D view of the teacher. Or you can even go like this with your body [moves head and shoulders around]. And on Zoom you cannot do that in order to get a better angle on what she is doing. But then she would notice and most of the time I would say she would correct me. There is a difference, obviously, when the person is with you and sees your body for real in 3-D. So, yeah, that is something that cannot be replaced really by Zoom.” (ID# 80290, age 67, White)

Participants also described how over time, they became familiar with strategies to compensate for the 2-D limitations by actively changing camera angles. One woman said,

“We’ve all gotten pretty facile at just jumping up and tilting our cameras a little differently or whatever. We are used to it by now” (ID# 80162, age 59, Hispanic/Latina). Others explained how they learned “whether you needed gallery view or speaker view. Then you realize you just needed speaker view because if the teacher was going to show you something you needed to see it from across the room. Which is a lot of mechanics about doing it online. But once you got it, it was fine.” (ID# 80205, age 70, White)

Limitations to Using Touch as a Sensory Input in the Online Setting

Participants also noted how the online environment, without the physical presence of a teacher, precluded the skillful use of touch. For example, one woman who had prior experience with in-person yoga instruction explained, “The thing that you miss, of course you do, is your yoga teacher. So you know how [the teacher] can just walk around and can just do like, ‘I’m going to touch you with one finger and I’m going to move you an eighth of an inch,’ and all of a sudden you’re like, whoa!” (ID# 80162, age 59, Hispanic/Latina)

Another described how the “nature of online” is “a little bit more challenging” for her to embody verbal instructions: “when [the teacher] would give a critique, sometimes it takes a little bit extra to understand how to take her words and change them into how you change your body. Whereas when somebody can put their hands on you, it can take like one tiny alteration, and it'll make all the sense of the words that she said. But when you have only virtual, it takes a little bit more.” (ID# 80150, age 68, White)

Facilitators to Participation and Engagement with Video-Based Pelvic Yoga Intervention

Factors that supported participation and engagement with the online yoga program included: (1) convenience; (2) advantages of home setting; and (3) improvement with incontinence frequency and mind-body outcomes.

Convenience

Participants identified convenience as a key facilitator to participation, especially the elimination of travel time and the need “to drive across town and find parking or whatever and that kind of stuff.” (ID# 80095, age 59, Asian) Among participants who were working full-time, the online format provided easy access to instruction. Women working from home highlighted the convenience of “just take my laptop to the living room and do yoga there.” (ID# 80148, age 47, Asian).

Privacy and Comfort of the Home Setting

A common theme was that the online setting provided an environment in which participants could focus on themselves without comparison to others: “[O]line, it’s all about you. You’re not really looking at the rest of the class” (ID# 80205, age 70, White). Others highlighted how the online setting facilitated contextual learning. For example, one participant explained how, “I could use all my own stuff in my own environment. And so [the teacher] could see how I was going to be doing it at home. And I could remember the way she talked to me in my own practices, as opposed to if I were in a studio, there would be two different places. And when I got home, I might do it differently. So I felt there was a continuity” (ID# 80325, age 71, White)

The privacy of the online format also helped to mitigate fear of embarrassment and internal incontinence stigma. One participant shared: “I think for people who are working on particularly like incontinence, probably video is better. … Yeah, I feel comfortable being in my own space than being to think somebody’s going to judge me” (ID# 82082, age 66, Asian). This participant also noted that she would not have signed up for the trial had the yoga intervention sessions been in person. Another echoed this sentiment and said, “frankly, I don’t know that I'd do yoga without Zoom.” (ID# 80162, age 59, Hispanic/Latina)

A commonly shared perspective was that talking about incontinence in the context of the intervention groups helped to address stigma, regardless of whether participants were able to form close social connections in the online setting. Participants benefitted from not only their instruction on specific yoga techniques, but also the group dynamic and seeing others who shared their health conditions:

“Well, it’s just easier because people were talking about it. This is what makes it… It’s not an easy subject to discuss with people. You kind of edge into these conversations with other women. And sometimes it happens and sometimes it doesn’t. But it’s just the fact that it is being talked about. . . I just like the fact that it’s talked about as matter of fact. Using the right words, discussing it and people being able to say what feels comfortable and what doesn't. How embarrassing this could be or not. How annoying it can be or not. And it’s just a fact of life, talking about this. And the more it's out in the open… But I just like the fact that it's easier to talk about.” (ID# 80096, age 76, White)

Mind-Body Effects Contributed to Sustained Engagement

Participants described how, over time, they experienced noticeable improvements in their daily incontinence that motivated them to continue with the online yoga program despite the challenges described above. One woman reported that she “had a dramatic improvement that I could sneeze and not have to worry about whether I was going to wet my pants or not. So for me there was a dramatic improvement. And that’s why I wanted to continue on” (ID# 80238, age 70, White). Another participant explained:

I might have been in much more leakiness than I am now if I hadn’t started and … having an actual something that I can do. I don't need a machine, I don’t need to go someplace and exercise. I can do it right here. I can do it while I'm sitting or standing at the sink, those kinds of things. I do appreciate that. The subtleties of it. (ID# 80096, age 76, White)

This participant also described how improvement in “leakiness” was closely related to an increased body awareness she developed through participating in the pelvic yoga program:

“Well, one of the approaches that [the teacher] takes is to actually show us, and I love this part, show us what part of the body is involved. What the muscular structure is, what the bones structure is… how things support each other. Being able to visualize what is going on helps me pay more attention, helps me understand what’s going on and just putting energy in a place that's the problem.” (ID# 80096, age 76, White)

Another participant described how she had minimal expectation that the yoga intervention:

“… was actually going to help me with the incontinence. Like I was just like, I don’t know that this can help. Because the doctors tell you, do these exercises and it’s going to help with incontinence. And it doesn’t help. But getting together with [the yoga teacher], she explained probably that most of us were all doing those exercises the doctors was [sic] giving us, but we were doing them wrong because they never explain it to you really properly how to do it. So what she taught really helped me understand my body and how to use my body to help itself. And I saw that I was actually having a benefit. I was getting better.” (ID# 80185, age 45, White)

In addition to reduction in the frequency of incontinence, which was the primary efficacy outcome being tested in the trial, women also described additional benefits that supported continued engagement with the online yoga classes. In addition to increased strength and stamina, stress reduction was a commonly cited benefit: “I still sometimes I have like a very small leak. But less than it used to be.” (ID# 80290, 67, White)

Effective Teaching Strategies to Enhance Engagement in Interactive, Video-Based Therapeutic Yoga

Participants described multiple specific strategies used by the study yoga teachers that increased the effectiveness of online instruction. These included: (1) verbal instructions with detailed descriptions; (2) pairing verbal instructions with visual demonstrations; (3) soliciting questions from participants; and (4) instructors’ observation skills and individualized instructions.

Participants indicated that teachers made effective use of verbal instructions intermixed with detailed descriptions of various yoga poses. For example, one participant said, “I think that the instructor did really well with the situation we were put in. The way she would describe things or how to do a certain pose or how our breathing could help with the pose that we’re doing. So she was very good about kind of directing us as best she could without being physically there with us.”

Others described the effectiveness of pairing verbal instructions with visual demonstrations from multiple angles and varied distances from the camera:

“I remember she did poses in different views. I remember she did them closer to show us and then she would put the laptop farther away so we could see the whole body. She had variations. Like if we couldn’t do certain positions she would show alternates. Yeah, I thought she was good. She gave a lot of instructions that were easy to follow. . . . She always allowed us time at the end to ask questions if we didn't understand something or we needed clarification.” (ID# 80148, age 47, Asian)

Learning was enhanced by the opportunity for participants to ask questions during and after the yoga classes. One participant emphasized that the small class size and instructor openness to and active solicitation of questions was a key factor in the online classes being a positive experience. She explained that the teacher,

“. . . just really encourages questions and classes are small enough that you can really ask whatever questions you want. So one day I just said, ‘We’ve got to do tadasana [mountain pose] from the ground up.’ And she’s like, ‘Okay, let’s do it.’ And it’s become kind of a talisman of our group because. . . you think you’re just standing there but [the nuances have] just been so incredibly informative.” (ID# 80162, age 59, Hispanic/Latina)

Having a live teacher with personalized feedback was appreciated compared to a pre-recorded video: “I think that [the online setting] was not bad because we were like in real time doing it with somebody. And we could ask questions. Like I do remember, if I didn't understand something or if I was having a hard time with something, I could just say like, “Hey, this is what I'm doing. Is that correct? Or what do I have to change to make this pose right?’” Another participant noted how the interactive format allowed them to

“hear the other women’s questions. And so that became part of your education process. As we were all in the group together, so before class, during class or even after class, the openness of the questioning format was, I thought, of great benefit” (ID# 80358, age 67, Black/African American).

Other effective teaching strategies that contributed to a positive online learning experience included instructors’ observation skills and providing individualized instructions and “corrections.” For example, one participant explained that “Zoom was much better than I anticipated. … And I didn't see how that could possibly work with a teacher. But she could tell when I was cheating or doing something incorrectly or… I don't know how she could see it, but she saw all kinds of things and could work with it. And then it seemed much more personal than I ever anticipated it could be” (ID# 80325, age 71, White)

Another participant echoed this sentiment, saying,

“I really, truly enjoyed it tremendously. Truly enjoyed it. I was really quite surprised because I really questioned whether or not I would enjoy a Zoom, an online class. And I did. It was truly a wonderful experience. It was small enough where I got to know the other ladies and I just thought that the benefit was the smallness and the instructor's ability to correct as she saw what it was we were doing wrong. Or not quite correct. I thought that was the most powerful part of the entire instruction, the class format.” (ID# 80358, age 67, Black/African American).

Discussion

In this study among midlife and older women participating in a clinical trial for yoga for urinary incontinence, we found that synchronous, video-based instruction was successful in engaging participants through skillful teaching strategies. The timing of the study during the initial stages of the COVID-19 pandemic and subsequent shift to remote delivery provided a unique opportunity to examine participants’ experiences with navigating barriers to participation and maintaining engagement. Technology posed some challenges for participants, a common occurrence in telehealth mind-body movement interventions.^7,13,29,30 However, study participants described a process of “figuring out” that ultimately led them to manage technological challenges successfully. While the focus of this study was on telehealth delivery of the yoga intervention and not efficacy outcomes reported elsewhere,¹⁷ participants described how an enhanced sense of mind-body awareness and improved management of incontinence symptoms contributed to continued engagement with the study yoga practices.

Participants in this study reported that the convenience, comfort, and privacy of the livestream virtual yoga class facilitated their learning and satisfaction. Convenience has been noted as a key facilitator for online yoga interventions generally.^7,29 For selected health conditions such as urinary incontinence, where individuals might feel some degree of stigma or self-consciousness about their condition, online yoga instruction might feel psychologically safer and more accessible than a yoga studio or other in-person location.⁷ Further, the online yoga classes allowed midlife women to more easily fit participation into their schedules and in a familiar home environment that facilitated future practice on their own. While this was not a stated goal of the study, these findings could reinforce habitual yoga activity into the future, particularly as participants were able to see results of yoga participation in improved symptoms.

This study also shows practical implications for other online, livestream therapeutic yoga classes for specific health conditions. Online trials of yoga are often delivered asynchronously³¹; this study provides insight into the benefits of synchronous, real-time remote delivery. Synchronous delivery provides an opportunity for participants to interact with each other and the instructor. Although participants in our study reported they did not form especially strong social connections with other participants, some found meaning and sense of comfort in the shared experience during the COVID-19 pandemic, similar to other studies during this time period.¹⁵ Prior research has found the therapeutic alliance between teacher and student to be a mediating factor for the success of online yoga interventions.¹⁵ Participants in this study similarly highlighted specific teaching strategies such as individualized attention and active solicitation of questions that instructors used to create a therapeutic setting and collective experience among women with an often stigmatized health condition like incontinence.

Our earlier evaluation of rapid conversion to telehealth found that yoga instructors in the parent LILA trial identified limitations to their ability to observe participants’ alignment and form compared to in person instruction¹³; Those interviewed for the current study echoed this sentiment from the participant perspective. Some studies have found that participants report a preference for in-person yoga intervention over online delivery because of the inability of instructors to provide hands-on assistance.³² While the lack of hands-on assistance from study instructors was mentioned by some with prior in-person yoga experience, participants in this study highlighted effective teaching strategies used by instructors that mitigated some inherent limitations of the online setting. Specifically, they described instructors’ use of verbal instructions with detailed descriptions, visual demonstrations from multiple angles, and tailored instructions based on observation of individual participants. Prior research has identified the quality of instruction as a mediating factor in the success of online yoga interventions among older adults.¹⁵ A recent scoping review of online mind-body interventions among older adults identified the lack of feedback to participants as a key limitation⁹; in contrast, this study found individualized feedback to participants as a driver of engagement.

Participants also highlighted how instructors’ detailed instructions and descriptions of anatomy and physiology related to the pelvic floor and incontinence contributed to an enhanced sense of mind-body awareness that may not be focused on in other types of physical activity interventions for incontinence.³³ We are unable to make a direct comparison to the physical conditioning arm of the parent trial, as those participants did not participate in qualitative interviews about their experience. However, yoga in general has been shown to be an effective modality for the development of interoceptive awareness, embodiment, and mindfulness.^15,34,35 Online delivery of yoga may be especially suited to emphasizing this aspect of yoga practice since teachers are not able to use tactile cues or provide hands-on assistance.⁷ Importantly, the LILA yoga instructors were also advanced yoga teachers or yoga therapists, which may have contributed to their skill and ability to translate observing and teaching effectively in a videoconference setting. Future research on both the effectiveness of and participant satisfaction with online yoga interventions might benefit from examining differences arising from instructor characteristics.^36,37

Some limitations of the study exist. Interview participants volunteered to speak with researchers, and thus those participants with lower rates of satisfaction might not be represented in the sample. Participant perspectives might also have shifted with the passage of time; for example, had we discussed technological challenges with participants at the beginning of their program participation, they might have voiced greater frustration with their tele-yoga experience. Offering support for technological issues while empowering individuals to experiment and figure out solutions themselves might lead to heightened self-confidence with digital platforms and support continued engagement and adherence. Further, tailoring training for yoga instructors specific to the online environment, where more verbal instruction and attention to interoceptive awareness might be required than is typical for an in-person class, could also improve satisfaction with and effectiveness of online therapeutic yoga interventions.^7,38

Conclusion

Synchronous, videoconference-based yoga instruction was successful in engaging midlife and older women in a therapeutic yoga program for urinary incontinence. The online format offered convenience and privacy while supporting efforts to practice yoga to manage incontinence symptoms. Tailored online teaching strategies and technical support are critical to optimize learning and satisfaction in virtual mind-body movement interventions such as yoga. The findings suggest promise for the broader application of online therapeutic yoga programs for specific health conditions.

Supplemental Material

Supplemental Material - Learning Yoga Through Interactive Online Classes: Perspectives From Midlife and Older Women Enrolled in the LILA Trial for Urinary Incontinence

Supplemental Material for Learning Yoga Through Interactive Online Classes: Perspectives From Midlife and Older Women Enrolled in the LILA Trial for Urinary Incontinence by Francesca M. Nicosia, Mary K. Good, Berty D. C. Arreguin, Giselle Perez-Aguilar, Margaret A. Chesney, Celia P. Kaplan, Alison J. Huang in Global Advances in Integrative Medicine and Health

Footnotes

ORCID iDs

Francesca M. Nicosia

Margaret A. Chesney

Ethical Considerations

The Institutional Review Board at the University of California, San Francisco, approved our questionnaire and interviews (approval: 18-26341) on July 21, 2021. Respondents gave written consent for review and signature before completing questionnaires and starting interviews.

Consent to Participate

Written informed consent was obtained from all participants prior to enrollment using DocuSign.

Author Contributions

Conception/design of the research (FMN, AJH); data collection (FMN, CJK); data analysis (FMN, BA, GPA); data interpretation (FMN, MKG, MC, CJK, AJH); drafting the manuscript (FMN, MKG); intellectual contributions on text/revisions (AJH, MKG, MC, CJK); final approval (all authors).

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institutes of Health grants UL1 TR001872, R01DK116712, R01DK116712-04S1, and K24AG068601.

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

Data from this study is available from the corresponding author upon reasonable request; underlying qualitative datasets are not available due to IRB restrictions.*

Supplemental Material

Supplement material for this article is available online.

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