Objectives: While previous research has utilized remote delivery of yoga interventions, no research has specifically interrogated the effectiveness of remote yoga intervention delivery. In this secondary analysis of weight-maintenance trial data, we examined participant perceptions of essential yoga properties across in-person and remote formats, hypothesizing that perceptions would not differ following remote delivery. Methods: 24 women with overweight or obesity (34.6±4.1 kg/m2, 48.2±9.9 years) received a 12-week Iyengar yoga intervention (2x/week) following a 3-month behavioral weight loss program. Of 23 participants who completed follow-up questionnaires, 12 received the planned in-person intervention and 11 received a remote intervention (delivered live) due to the COVID-19 pandemic. The Essential Properties of Yoga Questionnaire (EPYQ) was completed online by participants and by the instructors to measure the perceptions of the relative emphasis placed on the essential components of the yoga intervention via 14 subscales. Linear regression models were used to compare perceptions of each EPYQ dimension across in-person and remote delivery methods, as well as between participants and instructors, independent of delivery method. Results: 13 of the 14 subscales did not differ between delivery modalities (p>0.05). Participants perceived more individual attention within in-person yoga (p = 0.003). For both delivery methods, instructors perceived breathwork, restorative postures, and body locks to be incorporated to a lesser degree compared to participants (β = -1.28, p = 0.003; β = -1.57, p = 0.019; β = -1.39, p = 0.036; respectively). No other significant differences across the participant and instructor scores were observed. Conclusions: Findings provide preliminary support for the use of live remote delivery of yoga, effectively communicating most essential yoga properties when compared to in-person classes. However, participants perceived more individual attention with in-person versus remote delivery; thus, future remote-based yoga interventions may benefit from providing additional individualized feedback.
Hatha yoga is an ancient Indian practice comprising spiritual, ethical, and physical aspects [[
The COVID-19 pandemic resulted in many behavioral interventions experimenting with live remote formats to deliver intervention content; however, research examining how these formats (in-person versus remote) differ in feasibility, participant understanding of the intervention materials, and effectiveness of the instruction is limited. One previous study did examine differences in delivery of a 12-week strength and flexibility exercise intervention across in-person and remote formats [[
To fill this knowledge gap, secondary analyses from a weight loss maintenance trial were conducted in which electronic questionnaires were used to 1) compare participant perceived delivery of essential yoga dimensions across in-person and remote formats (Aim 1) and 2) compare instructor and participant perceptions of these yoga dimensions independent of delivery method (Aim 2). We hypothesized that the delivery method of the intervention would not significantly impact participant perceptions of the yoga dimensions and that there would be no significant differences in these perceptions across the participants and instructors.
This study was a secondary analysis of a larger study. The larger trial compared a 3-month yoga intervention to a contact-matched control condition (cooking and nutrition classes) following three months of standard behavioral weight loss treatment. This standard treatment was designed to produce a 1–2 pound per week weight loss facilitated by weekly 60-minute group-based classes, prescribed caloric restriction, and moderate exercise prescription. Additional study details and primary findings related to weight, psychosocial factors, program satisfaction, and intervention adherence have been reported previously [[
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Table 1 Participant characteristics by intervention delivery method.
Total In-Person Delivery Remote Delivery Age 48.0±10.1 48.2±9.8 47.6±10.9 0.890 Gender Female 23 (100.0%) 12 (100.0%) 11 (100.0%) Height (cm) 161.9±6.0 162.9±4.7 160.9±7.3 0.430 Weight (kg) 86.3±12.9 91.2±12.3 81.0±11.8 0.055 BMI 33.1±4.6 34.6±4.4 31.3±4.4 0.085 Race 0.480 White 20 (87.0%) 11 (91.7%) 9 (81.8%) Not White 3 (13.0%) 1 (8.3%) 2 (18.2%) Ethnicity 0.590 Not Hispanic or Latino 20 (87.0%) 10 (83.3%) 10 (90.9%) Hispanic or Latino 3 (13.0%) 2 (16.7%) 1 (9.1%) Marital Status 0.400 Married 15 (65.2%) 7 (58.3%) 8 (72.7%) Divorced 2 (8.7%) 2 (16.7%) 0 (0.0%) Never married 4 (17.4%) 2 (16.7%) 2 (18.2%) Not married living with significant other 1 (4.3%) 0 (0.0%) 1 (9.1%) Other 1 (4.3%) 1 (8.3%) 0 (0.0%) Mean EPYQ score 3.5±0.6 3.6±0.4 3.3±0.7 0.240
1 Footnotes:
- 2 a) Data are presented as mean±SD for continuous measures, and n (%) for categorical measures.
- 3 b) Weight and BMI are presented as values at the start of the yoga intervention, not the start of the weight loss program.
- 4 c) Continuous variables were tested for differences across delivery groups using t-tests and categorical variables were tested using Chi-squared tests.
Written informed consent was obtained prior to enrollment, all study procedures were approved to be ethical and in alignment with the Declaration of Helsinki by The Miriam Hospital's Institutional Review Board (#1244203–5), and this study was registered on Clinical-Trials.gov (NCT03799289). Study data collection was conducted between January 2019 and June 2020 and the anonymity of all participants was maintained on all study records using participant identification numbers.
Iyengar yoga is a form of hatha yoga that focuses on breathing, postures, and meditation with the use of props (e.g., chairs, straps, blocks) to allow for correct postural placement and to reduce risk of injury. Based on oxygen consumption and metabolic equivalent response, Iyengar yoga is shown to have a lower energy expenditure than other styles of yoga [[
Of the 23 participants who completed the follow-up questionnaires, 12 received the planned in-person yoga intervention and 11 received a remote intervention due to the COVID-19 pandemic. Therefore, the participant enrollment timing was the primary determining factor in which participants were in each group. The yoga intervention remained the same between delivery formats and remote classes were delivered live via videoconferencing software with participant cameras turned on. Thus, instructors were able to provide corrections and students were able to ask questions using this remote format.
Following completion of the yoga intervention, the EPYQ was administered to both participants and yoga instructors to measure their perceptions of the emphasis placed on various components of the intervention via 14 subscales (Table 2). The EPYQ, developed and validated by Park et al. in 2018, Groessl et al. in 2015, and Elwy et al. in 2014, is a questionnaire collecting respondent perceptions of how much a yoga instructor mentioned or included various dimensions of yoga in a single yoga class [[
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Table 2 Comparison of EPYQ dimensions between delivery method and participants/instructors.
Effect of Delivery Method Effect of Participant/Instructor Interaction Acceptance / Compassion -0.47±0.38 0.233 -0.17±0.70 0.813 0.816 Breathwork -0.16±0.21 0.459 -1.28±0.38 0.003 0.918 Physicality -0.22±0.30 0.476 0.25±0.55 0.651 0.965 Postures (Asanas)–Active -0.22±0.31 0.490 0.17±0.57 0.774 0.790 Postures (Asanas)–Restorative -0.12±0.34 0.724 -1.57±0.62 0.019 0.841 Body Locks (Bandhas) -0.53±0.34 0.137 -1.39±0.62 0.036 0.977 Body Awareness -0.00±0.27 0.993 0.53±0.49 0.290 0.815 Mental & Emotional Awareness 0.11±0.30 0.725 -0.57±0.54 0.309 0.792 Health Benefits -0.62±0.37 0.109 -0.54±0.68 0.435 0.705 Individual Attention -1.03±0.29 0.002 -1.00±0.53 0.074 0.968 Social Aspects 0.20±0.28 0.473 -0.08±0.51 0.872 0.343 Spirituality -0.25±0.29 0.403 0.35±0.53 0.513 0.998 Meditation & Mindfulness -0.14±0.37 0.719 0.17±0.69 0.810 0.650 Yoga Philosophy -0.04±0.47 0.941 0.72±0.86 0.410 0.707
- 5 Footnotes:
- 6 a) Boldface text indicates significant results (p<0.05).
- 7 b) The reference category is the in-person delivery score where the Beta coefficient (β) indicates a difference between in-person and remote (remote score–in-person score).
- 8 c) The reference category is the participant scores where the Beta coefficient (β) indicates a difference between the participant and instructor scores (instructor score–participant score).
- 9 d) Interaction between the delivery method and participant/instructor.
- 10 e) All scores are on a scale from 1–5 where a higher score indicates that the respondent perceived the class to have more of that dimension.
This questionnaire was included as part of this trial to enhance scientific rigor so that the delivered yoga intervention could be more quantitively described. However, the necessary pivot from in-person to remote delivery of the yoga intervention also provided the unique opportunity for these secondary data analyses comparing delivery formats on these essential yoga properties; something that has not been previously examined. The EPYQ was designed for trained raters to measure, describe, and quantify the important dimensions in yoga interventions so that yoga is more adequately described within scientific manuscripts [[
Participant demographics were summarized using descriptive statistics. All EPYQ sub-scales were approximately normally distributed and contained no apparent outliers. Next, a single linear regression model for each EPYQ subscale compared the scores across delivery methods (Aim 1) as well as between the participants and instructors and the interaction between these factors (delivery method x participant/instructor) (Aim 2). In-person was used as the reference category for the delivery method comparison where the Beta coefficient indicates a difference between in-person and remote (remote score–in-person score). Similarly, the participant score was used as the reference category to the participant/instructor comparison where the Beta coefficient indicates a difference between the participant and instructor scores (instructor score–participant score). A significant interaction should be interpreted to mean that the difference between the instructor and participant scores are different between delivery methods. Finally, comparisons were made using independent sample t-tests for each EPYQ subscale score between in-person and remote delivery groups for participants to examine the impact of delivery method on participant perceptions of EPYQ dimensions (Fig 1). All analysis were completed using STATA v.17 and the alpha level was set to 0.05.
Graph: Footnotes: a) Values presented are the mean scores for the corresponding scale and delivery method. b) The error bars represent plus or minus one standard deviation from the mean score. c) * indicates a statistically significant difference between in-person and remote (p<0.05).
Table 1 presents the participant demographics. Overall, the intervention participants were 48.2±9.9 years old, were all female, had a BMI = 33.1±4.6 kg/m
Fig 1 presents the EPYQ subscale scores for participants by delivery method (Aim 1). Individual attention was significantly lower in remote (2.3±0.6) versus in-person delivery (3.3±0.8, β = -1.03, p = 0.002). However, no other significant differences between delivery methods were observed (p>0.05).
Table 2 presents comparisons of EPYQ scores by delivery method, participants versus instructors, and the interaction (Aim 2). For both delivery methods, instructors perceived breathwork, restorative postures, and body locks to be incorporated to a lesser degree compared to participants (β = -1.28, p = 0.003; β = -1.57, p = 0.019; β = -1.39, p = 0.036; respectively). No other significant differences across the participant and instructor scores were observed. The differences in the EPYQ dimensions perceived by participants versus instructors were not significantly modified by the delivery method. This can be observed by the fact that no significant delivery method x participant/instructor interaction effects were found for any EPYQ subscale (p>0.05 for all).
Participant perceptions of the yoga dimensions delivered across in-person and live remote delivery methods were not significantly different. However, participants did perceive greater individual attention with in-person delivery. Additionally, instructor perceptions of the various yoga dimensions delivered were largely similar to the perceptions of the participants, independent of the delivery method (in-person versus remote). Taken together, the current study findings were supportive of our hypotheses and provide preliminary support for the use of remote delivery of yoga interventions among women with overweight or obesity.
As assessed via Aim 1, study findings indicate that most essential yoga dimensions can be similarly communicated during live yoga classes delivered remotely and in-person among women with overweight/obesity. This finding is in agreement with the limited previous research comparing in-person versus remote delivery of exercise or yoga interventions. For example, one comparable study found no difference in exercise intervention effectiveness across in-person or remote delivery formats on changes in low back pain [[
While most yoga dimensions were not perceived differently across delivery methods, our results suggest that participants may perceive more individual attention with in-person versus remote delivery. While not tested directly here, this differential perception in individual attention may be due to a lack of perceived instructor eye contact, physical presence, or opportunity for postural adaptations using physical contact during the remote instruction. Additionally, interpersonal interaction between the instructor and participants before and after the class may be limited during the remote delivery of the class. Considering this, when teaching live, remote-based yoga classes, instructors may want to consider providing more individualized feedback to participants, individualized verbal cues/corrections, and provide opportunities to engage participants both before and after class within the virtual environment. As previously reported in the primary outcome paper, in-person and remote cohorts had similar program satisfaction ratings and high rates of attendance (82.2±26.8% versus 69.6±21.9% respectively, p = 0.22) [[
To our knowledge, this was the first study to compare instructor versus participant perceptions of yoga classes. In support of our Aim 2 hypothesis, instructors and participants largely perceived the delivery of the EPYQ dimensions in this Iyengar yoga intervention to be similar. However, when differences did occur (breathwork, restorative postures, and body locks), the instructors perceived the level of dimension delivery as lower than the participants. This may relate in part to the differential knowledge of yoga among participants versus instructors. For instance, one possible reason for increased perception of breathwork among participants versus instructors is that the former may interpret simple attention to or cueing of the breath throughout class as "breathwork," whereas instructors may more formally define breathwork as standalone pranayama exercises. Similarly, restorative postures and body locks entail very specific definitions and techniques. Given their expert knowledge of yoga, instructor perceptions of such practices are likely to be more accurate than participant appraisals. However, the difference in the perceptions between instructors and participants did not depend on the delivery method (i.e., no significant interactions were observed). Considering this, the results largely indicate that the perceived delivery of yoga dimensions by instructors are effectively being experienced by the participants in the class regardless of the delivery method (in-person or remote).
This study was strengthened most notably by its novel measurement of EPYQ yoga dimensions across remote and in-person delivery as well as across intervention participants and instructors which supported unique and informative comparisons. This study was however limited in its sample size and statistical power as it was a secondary analysis of only one arm of a larger study. In addition, the lack of diversity in participant demographics limits generalizability to other populations. Lastly, this study measured the EPYQ in a questionnaire format among yoga instructors and intervention participants. The measure was designed for use by raters specifically trained in understanding each essential property of yoga. It is not validated for less trained populations (e.g., novice yoga students) which may limit the internal validity of the findings. However, this study was interested in the participant's perceptions of the presence of each property and not necessarily the actual presence of said property, or other associated factors, such as their deeper comprehension thereof or proficiency in performing related techniques.
While future, more rigorous examination is needed, these preliminary findings suggest live remote-based yoga interventions may be a viable delivery method that effectively communicates the most essential yoga dimensions compared to in-person classes. However, future remote-based yoga interventions may benefit from more individualized feedback to participants, individualized verbal cues/corrections, and by providing opportunities to engage participants both before and after class within the virtual environment.
By Sally A. Sherman; Tyler D. Quinn; Beth C. Bock; Tosca D. Braun and Jessica L. Unick
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