Rural community members
are underrepresented in health promotion research due to barriers including
cost, time, trust, and distance (Pender et al., 2019). Rural communities also
have significant health needs with residents who are more likely to be older,
experience higher levels of poverty, and be geographically and socially
isolated (Pender et al., 2019). These findings have been made worse by COVID-19
and are unlikely to improve as the population ages (Henning-Smith, 2020; Kotwal
et al., 2021). Effectively addressing the complex needs of rural
communities require partnerships with individuals and organizations that
understand the barriers and opportunities for health that exists in rural
settings (Leider et al., 2020).
Most older adults wish to
remain in their own homes and communities as they age, thus, strategies are
needed to support healthy aging in place (AAPR, 2018; US Center for Disease
Control and Prevention, 2016). Being physically active and socially engaged are
essential in working towards this goal (US Center for Disease Control and
Prevention, 2016; Cunningham et al., 2020; Majee et al., 2018; McPhee et al.,
2016; Carver et al., 2018). However, older adults in rural communities report
higher levels of physical inactivity and social isolation (Trivedi et al.,
2015; Watson et al., 2016; NewMyer et al., 2022). For example, in Wisconsin,
approximately one-third of older adults report doing no physical activity (PA),
with only 61% of rural residents reporting having access to PA facilities as
compared to 86% of urban dwellers (America’s Health Rankings, 2021). In
addition, older adults living in rural communities demonstrate a greater fear
of falling, with evidence showing that falls by rural dwellers are more likely
to result in a substantial decline in quality of life or death due in part to
decreased access to healthcare, lack of timely healthcare, and lack of access
to specialty care (Cho et al., 2013; Miller et al., 1998). Thus, there is a
need for PA programs designed to be implemented in rural settings which address
the unique challenges and barriers that exists in rural communities (Bhuiyan et
al., 2019).
Yoga, classified as a
form of complementary and alternative medicine, may offer a solution to engage
an older population, target balance and falls, and be implemented in numerous
settings due to its relatively low cost and minimal equipment needs (Wieland et
al., 2011). Using yoga as an intervention strategy has shown multiple benefits,
including but not limited to improved quality of life and sleep, arthritis
symptoms, balance, and postural stability (Woodyard, 2011; Moonaz et al., 2015;
Ni et al., 2014; Schmid et al., 2012). Additionally, community-based yoga
classes offer social support and connections, which has been associated with
better general health, higher activity levels, and lower levels of depression
(Robins et al., 2018). In older adults, yoga interventions were effective in
improving physical health domains such as physical functioning, balance, and
gait as well as improving psychological health and health-related quality of
life outcomes (Ni et al., 2014; Johnson et al, 2016; Loewenthal et al, 2023;
Marten, 2022; Sivaramakrishnan et al., 2019). Moreover, yoga interventions for
older adults have been shown to reduce fall risk and are associated with
improvements in cognitive functioning (Bartos et al., 2022; Hoy et al., 2021).
However, evidence suggests that rural residents are much less likely to
participate in yoga due to issues related to availability, access, and beliefs
about yoga practice which include associating yoga with specific cultural or
religious practices (Brown, 2018; PRRI and American Communities Project Staff,
2022; Sullivan et al, 2017; Wardle et al., 2012).
To address these
barriers, the Yoga for Seniors program was developed by author PM and
evaluated by an interdisciplinary research team in collaboration with community
partners located in Wisconsin (Smith et al., 2017). The program decreased
self-reported falls and improved balance measures in a small sample of rural
older adults. The program was then expanded to include standardized teacher
training and a week-by-week implementation process (Hamrick et al., 2017;
Oestreich et al, 2021). Certified instructors were contracted to travel to
rural communities up to 90 miles to implement the program. While successful in
addressing balance and occupational performance problems, the yoga teachers
reported that traveling to the sites was not sustainable, especially during
winter months (Oestreich et al., 2021) . Moreover, in-person
attendance was cited as a significant barrier by program participants.
Telehealth delivery was identified as a potential solution for these barriers.
Telehealth refers to
remote healthcare services supported through the use of communication
technologies (Kruse et al., 2017). Yoga programs delivered online or by
telehealth are a promising alternative that addresses accessibility barriers
while allowing flexibility in delivery and practice (Brosnan et al., 2021).
However, online delivery of health promotion programs, especially ones designed
to reach older adults, must address challenges in utilizing telehealth in a
rural setting (Rural Health Information Hub, 2020). Challenges include limited
access to affordable high-speed internet, lack of available technology and
equipment, and a lack of familiarity with video conferencing software (Rural
Health Information Hub, 2020; Perrin & Duggan, 2015; Vogels, 2021).
Finally, strategies are needed to address any potential mistrust of the program
and program staff who are from outside of the community. Thus, to develop a
yoga program that maximizes reach into rural communities, community
collaborators were engaged in an iterative process to adapt the Yoga for
Seniors program for telehealth delivery. In this report, we present the
process of community collaborator engagement and program adaptation, focusing
on incorporating strategies to overcome barriers in implementation and
dissemination of telehealth yoga programming in rural settings, and the
enrollment and process outcomes of the feasibility trial.
Methods
Building on existing
partnerships between academic researchers and community collaborators in
Wisconsin, Yoga for Seniors was adapted for telehealth delivery using an
iterative process guided by the RE-AIM Framework to ensure the resulting
program was useful, relevant, and ready for widespread and sustainable
dissemination (Glasgow et al., 2019; Glasgow et al., 1999). Adaptation
activities were guided by the five key outcomes of the RE-AIM Framework: reach,
effectiveness, adoption, implementation, and maintenance (Glasgow et al., 2019;
Glasgow et al., 1999). A feasibility trial of the adapted program was conducted
to examine the impact of the telehealth Yoga for Seniors program
compared to a waitlist comparison group on fear of falling, occupational
performance, and social isolation. The results of the pilot study will be
presented in a future report. The study was approved by the University’s
Institutional Review Board (protocol number 2021-1278) and was registered in
Clinicaltrials.gov (NCT05287529). Participating sites were in counties that
were identified as Rural Health Grant eligible by the United States Health
Resources and Services Administration (Health Resources & Service
Administration, 2022).
Original Program
Description
The original Yoga for
Seniors was a 12-week program developed for rural-dwelling older adults
(Smith et al., 2017; Hamrick et al., 2017; Oestreich et al., 2021). Based on
Hatha yoga, the program reduced self-reported falls and improved measures of
balance. Participants met as a group two times a week for 75 minutes at a local
site. In addition, participants were asked to complete 20 minutes of daily yoga
at home. The program offered poses that did not require getting up and down
from the floor and used a chair within arm’s reach for balance and stability.
Each session followed the same structure: 1) time to collect attendance, falls
information, answer questions, 2) community sharing time for thoughts and
comments on the class and the instructor to provide an overview of the specific
class structure, 3) centering discussions of the specific class theme and
focusing class attention to the present moment, 4) 45-minutes of yoga, and 5)
relaxation. Instructors also provided guidance on the specific poses for the
daily independent yoga practice.
Collaborator Engagement and
Program Adaptation
Adaptation of the Yoga
for Seniors program was built on the lessons learned and participant
feedback received during the implementation of the original program. The
project was a continuation of an ongoing partnership with a collaborative team
that included yoga practitioners and representatives from five Wisconsin Aging
and Disability Resource Centers (ADRCs). ADRCs provide services to support
older adults related to healthy aging, serve as centralized connection points
for older adults, and are potential adopters and disseminators of the program.
This group worked together to respond to the funding announcement and made
initial adaptations based on data from the previous Yoga for Seniors
offering. The grant supported funding for the academic research team and the
community collaborators which included the ADRC sites, yoga developer, and yoga
instructors.
After receiving the
notice of funding, an initial planning meeting with all partners was held,
followed by discussion groups with each ADRC site and the yoga practitioners.
Five discussion groups with ADRC site leaders were completed. Discussions
focused on identifying site-specific modifications required for telehealth
delivery and adaptations to existing protocols that increased the likelihood of
future long-term adoption by the sites. Table 1 provides a summary of the
discussions.
Two discussion groups
were held with the yoga teachers and the Yoga for Seniors program
developer. Discussions included program delivery and content, standardization
across sites, quality control procedures, and issues related to telehealth
program delivery. Because the developer and three of the five yoga teachers had
previously taught yoga via an online format, discussions were largely focused
on best practices, intervention standardization, and sharing strategies for
increasing the likelihood for successful implementation. Zoom video
conferencing software was the preferred software by the community partners and
was used for meetings, trainings, and program implementation (Zoom Video
Communications, n.d.). Considerations around utilizing available features in
the teleconferencing software such as Spotlight, hosting responsibilities,
monitoring attendance, and research-related responsibilities were discussed.
Adapted Intervention
Description
Summary reports of the
discussion groups were developed, and the results were combined with feedback
from prior program data to inform the adaptation. Adaptations to the study
protocol centered on maintaining safety for the participants and research team
during the ongoing COVID-19 pandemic. First, data collection protocols and plan
data measures were modified so that all data collection visits were contactless
due to the pandemic. Data collection was completed via mailed questionnaires
and videoconferencing sessions to facilitate safe participant and research team
interactions. Therefore, all gait and balance measures from the previous
studies that required in-person measurement were removed. The second
significant adaptation was the reduction of the program length from 12- to
8-weeks. All community sites noted that most of their health promotion programs
are 8-weeks with past experience showing less demand for longer programs by
community members. An additional week, or a “Zero Class” was added before the
first yoga class to help mitigate technology challenges. This class was co-led
by the research staff member and yoga teacher and attended by the community
site representative. The class focused on participants meeting and getting to
know the yoga teacher and other program attendees and to become oriented to and
practice using the technology. The decision to keep the yoga program
group-based and to offer synchronously was made early in the adaptation
process. Prior research shows that group classes in online settings can
potentially improve social connections within the group which can improve
program experience (Smith et al., 2018; Turcotte et al., 2024). Therefore, in
addition to the “Zero Class” activities, each session began with a community
building and participant engagement component. Because the original in-person
program included a social component that was well-received by program
participants, the community building activities were aimed to replicate this
component.
Adaptations made to the
telehealth delivery program based on feedback from the yoga practitioner group
and informed by best practices reported for online learning such as using
strategies to effectively communicate, minimize technological challenges, and
ongoing and proactive monitoring of participant engagement (Roddy et al., 2017).
Specific adaptations included, 1) removal of daily independent practice as
practitioners felt that participant safety could not be optimized during online
sessions in a way that lent itself to a positive home practice; 2) addition of
a “Zero Class” or “introduction meeting” to address issues such as placement
and positioning of the camera, computer, mat, and chair as well as the
different roles of the study team; 3) inclusion of a "talk with your
teacher” to provide an opportunity for participants to share any individual
limitations or concerns with the yoga teachers; 4) finally, all participants
were asked to keep their Zoom line unmuted during the sessions to facilitate time-sensitive
questions and to better enable participant monitoring for unexpected or health
events.
The final intervention
consisted of group yoga sessions led by an instructor on Zoom. Sessions were
started and hosted by a member of the research team along with a local ADRC
site representative. Due to staffing shortages and COVID-related time commitments,
the local representative was not required to attend all sessions but was asked
to do so as frequently as possible. This observer role was another adaptation
made for the telehealth version to provide a familiar face that welcomed
participants, addressed any community-specific concerns, helped the yoga
instructor and participants with technical issues, and assisted the yoga
instructor if a participant experienced a health emergency during the session.
The community site representative and the research team staff led the Zero
Class, which was designed to build consistency and familiarity within the
group. Whenever possible, the same staff person stayed with their assigned
community group throughout the program. When a staff substitution was made, the
individual filling-in was introduced to the individuals in the yoga class the
week prior to facilitate familiarity and continuity of programming.
In addition, participants
were provided with materials to support their learning and continued yoga
practice after the study. The Yoga for Seniors developer created a
course on Canvas, a web-based learning management system, that provided session
materials with videos showing poses and sequences of poses. Corresponding
materials for program sessions were made available each week. Participants continued
to have access to the site after the end of the program.
Program Implementation
After the program was
finalized, follow-up site meetings were scheduled with the research team, ADRC
site leader, and yoga instructor. These meetings focused on introducing the
community site to their yoga teacher, finalizing schedules, and reviewing the
final program content, training protocol, and data collection protocols. During
these meetings, site-specific recruitment strategies were reviewed and final
discussions regarding program content and implementation strategies were
completed.
Yoga Teacher Recruitment
and Training
Certified and experienced
yoga instructors were recruited. Instructors who were recruited had completed
the Duke University Integrative Yoga for Seniors Professional Training, which
focused on the delivery of yoga to an older adult clientele. Seven individuals
originally expressed interest in teaching for the program. Five individuals who
had prior experience teaching yoga to older adults and were able to teach
online classes during the daytime hours were selected. All five individuals
completed the 40-hour teacher training sessions. After training, one withdrew
due to unexpected caregiver responsibilities. The remaining teachers were
matched to a site and worked primarily with that site during the study period.
The teacher training was
a hybrid model delivered via Canvas that included interactive virtual group
trainings, individual check-ins, and self-paced online training. All teachers
were required to complete a series of tests and practice videos prior to program
implementation. Training materials were delivered during a mix of synchronous
and asynchronous sessions and covered the following: 1) program overview, 2)
research and background information; 3) program progression; 4) poses; 5)
specific contraindications; 6) adaptations and using a specialized visual mat;
7) question and community chat. An additional module specifically addressed
best practices for teaching yoga online.
Participant Engagement,
Recruitment, Enrollment, and Data Collection
Each community site
planned to offer two rounds of the adapted Yoga for Seniors program as
part of the pilot feasibility study using a waitlist comparison group, with
participants being assigned to the first or second offering. While most
participants were randomized to either the first or second offerings, 11
participants enrolled in the study after the first offerings had begun. The
study team decided that no interested community members should be turned away
for this pilot study. Thus, these participants were enrolled and assigned to
the second offering. These participants will be dropped for the main outcomes
analysis. However, because the goal of this report is to describe the
development of the intervention, data collected from all participants are
included in this report.
Guided by best practices
from the literature, recruitment plans were developed in consultation with the
community sites (Carroll et al., 2011; Craike et al., 2018). Participants were
recruited using site-specific strategies that included sending messages to
email listservs, distributing study flyers, advertising in local media, and
using snowball sampling. Due to COVID-19 related constraints, only four of the
five sites recruited participants. Additionally, staffing shortages and
COVID-related events placed significant strain on all community sites. Thus,
recruitment protocols were updated to refer interested participants directly to
the study team for initial contacts to minimize staffing constraints at the
community sites.
Interested community
members were screened for eligibility by the research team. Individuals were
eligible if they were 60 years or older, had not participated in a yoga program
in the last 6 months, were able to walk for 10 minutes, had a history of a fall
or a fear of falling, and were able to attend most program sessions. Because of
the online program delivery, individuals were also required to have vision at
or corrected to 20/40 or better and access to a stable internet connection.
Eligible participants completed
a virtual data collection study visit via Zoom. Before this visit, participants
were mailed a baseline questionnaire packet which included a copy of the
consent form. Informed consent was obtained via DocuSign© before or at the
beginning of the first data collection session. Data were collected at pre- and
post-intervention for participants assigned to the first program offering. For
participants assigned to the second offering, data were collected at baseline,
pre-, and post-intervention. Process measures were included in the final data
collection. The data and implementation tracking metrics were guided by the
RE-AIM framework, specifically reach (recruitment and retention strategies and
rates, enrolled participant characteristics), effectiveness (working with our
collaborator team to identify participant centered outcomes), adoption (work
with our collaborator team to collect data that could inform organizational
decisions to adopt or not adopt this program in the future), and implementation
(session attendance data, regularly meeting with yoga instructors and session
observers to identify implementation challenges early in the program, tracking
modifications or adaptations made during implementation). The research team met
with each yoga teacher prior to every session. In these meetings, the team
discussed program progress, best practices, and challenges encountered
delivering the yoga program. After the program ended, the research team met
with the yoga teachers to better understand their experiences implementing the
program. The research team also met with each
collaborating organization’s site representative to better understand their
experiences in participating in the program, focusing on what worked well and
aspects of the program to change in future offerings.
Results
Participant Recruitment and
Enrollment
The study flow is
presented in Figure 1. Sixty-four individuals were screened and 53 (86.9%) met
eligibility criteria. Four individuals elected not to enroll following a
discussion of the study and the consent form. One individual completed the
consent but withdrew before baseline data collection. Table 2 presents the
baseline characteristics of the 48 enrolled study participants by group
assignment. Study participants were majority white (98%), female (85.7%), and
attended some college or more (92%). 74.4% reported that this was their first
time participating in research. The most frequently cited reason for enrolling
in the program was interest in the benefits of yoga on balance and physical
mobility, stress reduction, and increasing physical activity levels. Many cited
that the program being offered via telehealth was a positive, noting the
convenience of participating from their homes and not typically having access
to a yoga program in their communities.
Across all participants,
there were mixed findings on the program length and session duration, with over
60% reporting that 8-weeks and 75-minutes were “Neither too much nor too
little”. In addition, participants provided mixed feedback on their preference
for the mode of future program offerings. As an aim of this pilot program was
to better understand participant preferences of future health promotion
programming formats, a question was included to assess preferences regarding
online, in-person, or hybrid formats. Participants reported liking both the
telehealth and in-person formats, preferring online delivery for location
flexibility, COVID-19 safety reasons, and not having to travel, but preferred
the in-person format for the social aspect, ability to better communicate with
the yoga instructor during the session, and the ability to facilitate community
building. Winter weather considerations were repeatedly listed as a
consideration for use of telehealth. 58% of participants reported that they
were able to access online content and yoga videos at home from the Canvas
platform. Most participants who did not access the online content had not
attempted to access Canvas due to little or no interest in creating an account
in a web-based learning management system.
Discussions with the yoga
teachers focused on aspects of the program that worked well and recommendations
to improve the program for future offerings. These included the impact of the
“zero class” to troubleshoot technology issues with participants and begin the
community building process within the group. Having a second observer present
during the sessions helped to facilitate community building and participant
engagement. During the sessions, this second observer allowed the instructor to
focus on the students. The observer was available to help with technology
problems, any other unexpected issues, and to help the instructor monitor
participants for potential safety concerns during the session. Improvements and
recommendations for future offerings focused on the lessons learned regarding
computer setup and equipment needed to create the best environment for the
instructors such as providing second computers, additional monitors, and
microphones.
Finally, due to the
ongoing pandemic, implementation protocols aimed to minimize program burdens on
the site staff. Discussions with collaborating organization’s site
representatives found that serving as a local contact for the community members
to answer questions, address concerns, and to distribute program materials was
helpful in building trust with the community members. Several sites provided
additional technical and resource support to their site participants. However,
all site representatives noted that the requirement to serve as a second
observer for future programs would place a significant burden on the current
site staff members. While many site observers attended as many sessions as
their schedules allowed, research staff served as the second observers for all
sites. Discussions focused on the need for future program offerings have
adequate resources available to fund the observer to avoid asking already
overburdened staff to serve in this capacity.
Discussion
Working with
community-based organizations that serve rural older adults, community members,
and yoga instructors, our team collaboratively adapted and implemented a
telehealth-based yoga program designed for older adults. While the primary
components of the original Yoga for Seniors program (poses, sequence,
and pace) were not altered, key telehealth adaptations included adding an extra
day of programming, including an additional staff member, creating online
supplemental materials, and removal of the home practice component. Unplanned
changes made during program implementation were mostly related to recruitment
challenges because of the COVID-19 pandemic. The adapted program appears to be
safe and was widely accepted by the participants, indicating that home-delivery
yoga programming for older adults via telehealth may be an alternative option
for rural communities that have limited access to trained yoga instructors and
facilities.
The adaptation and
implementation of the telehealth version of the Yoga for Seniors
intervention provided insights that will inform future iterations of this and
other health programming for rural communities. While the older adults enrolled
in the program were generally well versed in the use of Zoom and their digital
devices, the addition of a “Zero Class” provided a chance for the team to
troubleshoot technology issues with participants, work on camera positioning
and begin the community building process. These three components are
particularly important for telehealth delivery as technology interruptions can
disrupt the flow of the program, feedback from the instructors is a vital
component of participant safety, and community building has been shown to
address loneliness and social isolation. The Zero Class filled a need that was
similar to the informational video classes provided by Baumeister and
colleagues to increase acceptance of a telehealth pain intervention for older
adults (Baumeister et al., 2015). This type of orientation class may be
particularly important for programs intended for older, rural-dwelling adults
as they may have additional challenges such as less familiarity with yoga and
less experience with internet navigation and videoconferencing. Additionally,
providing an individual who served as a point of contact and was present at all
sessions appeared to improve the overall delivery of the program. Having a
second person observing the class sessions was important and allowed the yoga
instructor to focus their attention on their students. The observer role
included reaching out to absent participants at the beginning of the class to
ensure that they were not having technical issues joining the class. During
class, the observer monitored for safety events and dealt with unexpected
issues as they happened so the yoga teacher could focus on teaching the
content. In future iterations of physical activity programming delivered via
telehealth, the instructor or member of the community site will likely serve in
this role; however, for research projects, the individual that makes initial
contact with the participant may be best fit to provide a consistent point of
contact. It was invaluable to have local community organizations involved during
all phases of the program, from the inception of the grant, program adaptation,
and implementation. The community partners were actively involved in developing
strategies to engage and recruit community members, provided input on study
protocols, and served as a local contact for distributing program materials.
Several sites provided technical assistance to community members, with one site
purchasing and loaning participants tablet stands. The trusted and known site
representative was available to serve as a local connection point to answer
initial community member questions regarding the program and research process
before referring participants to the research team for further details. The
impact of a community’s existing public health infrastructure as well as impact
of resources on the successful delivery of health promotion programs has been
documented in the literature (Smith et al., 2018). It is vital to the success
of future programming that implementation models consider the current and
projected levels of commitment from rural community organizations. Staffing
shortages, the pandemic, and the increasing number of rural older adults aging
in place, especially those in need of additional supports, have significantly
increased the financial load and time commitments of community organizations
that serve this population. To address this, physical activity programs
delivered via telehealth must be able to work with these agencies and adapt
programming. The potential for these adaptations is vast and may include
everything from the inclusion of site personnel in daily class delivery to
relying on local organizations for planning and recruitment activities.
The telehealth delivery
of the yoga program received both positive and negative feedback from the
participants. Collecting data by videoconference was a potential barrier to
program enrollment for some community members. One potential participant
declined program enrollment because of difficulties using the video
conferencing software. However, the virtual data collection visit likely helped
to orient program participants who were less familiar with the technology and
provided an additional opportunity for practice before the yoga classes.
Additional technology issues encountered during program implementation were
similar to those encountered by other telehealth and virtual health programs
(Addington et al., 2018; Chang et al., 2021; Speyer et al., 2018). For example,
one participant traveled to a second location with a better internet
connection, while three participants missed sessions because of interrupted
connections. However, participants appreciated that they were able to attend
classes while traveling or during days when winter weather impacted travel. Our
experiences are similar to other groups developing a health promotion program
for telehealth delivery (Speyer et al., 2018). For example, in a study
evaluating the effectiveness of tai chi programs delivered in-person, via
telehealth, or by home-based videos, participants cited similar advantages of
the telehealth delivery mode such as the ability to still meet as a group, the
convenience and flexibility of location, and not requiring travel in bad
weather (Wu et al., 2010). Moreover, the study found that participants
preferred the in-person and telehealth versions over the home-based video
versions. Further examination of findings showed that the social support
received from the in-person and telehealth versions may have increased
participant retention compared to the home-based video program (Wu et al.,
2010). In another feasibility study examining a telehealth yoga program for
people with heart failure and chronic obstructive pulmonary disease,
participants noted that the flexibility in program location increased access
and their ability to participate in the program (Selman et al., 2015).
Technology also afforded
benefits and barriers to implementation that should be considered during
adoption. For example, visibility and sound challenges were encountered during
implementation. For some sites, instructors and participants found it challenging
to balance camera positions so that the students could see the instructor
versus positioning the camera so that the teacher could clearly see the
students’ movements. Numerous participants also cited mirroring of the
instructor’s movements as an area of difficulty as the instructor would
verbally state “right arm” but then move the arm on the left side of the screen
(instructor’s right arm on the left side of the participant’s screen).
Additional practical considerations included equipment needs for instructors
and participants to minimize distractions during class. For example, yoga
instructors needed a microphone and a second computer to be the most effective.
Teachers who were able to implement a two-computer adaptation found that having
one Zoom log-in dedicated to seeing the participants and another dedicated to
providing optimized camera placement for the participants to see the
demonstrations improved the teaching experience. For participants using
tablets, stands were needed to achieve proper camera placement. Multiple
studies have found similar challenges regarding technology (Addington et al.,
2018; Selman et al., 2015). Specifically for group yoga and physical activity
programming delivered via video conferencing, interventionists and participants
may need additional training and equipment to reduce these barriers. Equipment
such as larger or second screens for the instructors, better microphones and
audio systems, stands for tablets, having a dedicated person to help
troubleshoot technology issues, or providing internet access could reduce or
prevent some of these challenges. For our program, the second observer
attending the sessions was able to serve multiple important roles, including
being available to troubleshoot and assist with technology and other issues so
that the yoga instructor could focus on the yoga content. While the need for
additional staff may be a limitation, future offerings could fill this role
with volunteers, teachers in training, or local community organizations, depending
on available resources.
Finally, feedback
received for the Yoga for Seniors content indicated that while
telehealth delivery increased access to additional community members, the
program as designed may not be challenging enough for more mobile or already
physically active community members. This is similar to challenges encountered
by other telehealth programs, where the online format can make it more
difficult to provide an individually tailored program in a group class
(Addington et al., 2018). Moreover, our solution of using the Canvas Learning
Management Software system to provide access to the program content beyond the
program’s end was not an acceptable strategy with only 58% of participants
accessing the materials. Other strategies to support participants in sustaining
yoga practice beyond the program are needed for future offerings.
Our study has several
limitations. Data were self-report with the risk of information biases such as
recall and social desirability bias. Our study was based in one geographic
area, limiting generalizability to other rural communities outside of the Midwest.
Individuals who self-selected into the program were mostly women, possibly
limiting generalizability to men. Finally, our sample had higher education and
income levels compared to rural Wisconsin communities.
In summary, telehealth
yoga programs that are tailored for older adults in rural communities have the
potential to be scalable and accessible for communities that may not have
access to trained yoga teachers or facilities. Community organizations that will
ultimately disseminate the program, yoga teachers, and potential program
participants were engaged to maximize the feasibility of this community-based
telehealth exercise program. Our approach may be helpful for other communities
seeking to adapt evidence-based health programs to a virtual environment with a
goal of improving sustainability and dissemination.
Correspondence should be
addressed to
Susan J. Andreae, PhD, MPH
201A MSC, 1300 University
Ave
Madison, WI 53706
608.265.8195
sandreae@wisc.edu
Susan J. Andreae: 0000-0002-1336-7720
Thomas Casey: 0000-0002-3522-005X
Kristen A. Pickett: 0000-0002-4889-6817
Registered at
clinicaltrials.gov (NCT05287529).
Funding
Funding for this project was
provided by the UW School of Medicine and Public Health from the Wisconsin
Partnership Program through a grant to the UW Institute for Clinical and
Translational Research. This research was also supported by the Clinical and
Translational Science Award (CTSA) program, the National Center for Advancing
Translational Sciences (NCATS), grant 1UL1TR002373, National Institutes of
Health KL2TR002374 and the Eunice Kennedy Shriver National Institute of Child
Health & Human Development, the Office of Research on Women’s Health,
Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) program,
the Office of The Director, National Institutes of Health and the National
Cancer Institute, under Award Number K12HD101368. The content is solely the
responsibility of the authors and does not necessarily represent the official
views of the National Institutes of Health
Conflict of Interests
P. Mross is the founder and
CEO of Happy Wellness. Mr. Mross created the Yoga for Seniors program
and oversaw program implementation for this study. Other authors have no
conflict of interests to disclose.
Author contributions
Conceptualization: SJA, PM,
MM, KAP; Methodology, SJA, KAP.; Investigation, SJA, KAP; Writing – Original
Draft: SJA, KAP; Writing – Review & Editing, SJA, TC, PM, MM, AMM, KAP,
Funding Acquisition, KAP; Supervision: SJA, KAP; Project administration: SJA,
PM, MM, AMM, KAP
Creative Commons License
This work is licensed under
a Creative Commons
Attribution-Noncommercial 4.0 International License (CC BY-NC 4.0).
Acknowledgements
We are grateful for the men
and women that participated in this study. We thank the dedicated individuals
working in the Aging and Disability Resource Centers (ADRCs) throughout the
State of Wisconsin for their help on this project. We also thank the yoga
teachers Deborah Boggs, Carol Mermey, Judy Flavell, Joanna Heckert, and Sindry
Cosgrove for their time and service to the project. A special thanks to Mark
Ferree, Paige Gresens, and Jessica Schmidt as well as other SMIL research team
members for their time assisting with various components of the project.
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