Underuse of Yoga as a Referral Resource by Health Professions Students

Abstract

Objective:

Nearly 38% of U.S. adults use complementary and alternative medicine approaches to manage physical conditions (e.g., chronic pain, arthritis, cancer, heart disease, and high blood pressure) and psychological or emotional health concerns (e.g., post-traumatic stress disorder, anxiety, and depression). Research evidence has accumulated for yoga as an effective treatment approach for these conditions. Further, yoga has increased in popularity among healthcare providers and the general population. Given these trends, this study explored perceptions about yoga as a viable complementary treatment to which health professions students would refer patients.

Participants:

More than 1500 students enrolled in health professions programs at a Pacific Northwest school were enrolled; data were obtained from 478 respondents.

Design:

The study assessed willingness to refer patients to yoga as a complementary and alternative medicine for 27 symptoms (identified in the literature as having evidence for yoga's utility), which were subsequently grouped into skeletal, physical, and psychological on the basis of factor analysis. Responses were assessed using a mixed-model analysis of variance with health profession and yoga practitioner as between-subjects variables and symptoms as a within-subjects factor.

Results:

In descending order of likelihood to refer patients to yoga were students in occupational therapy, physician assistant program, psychology, physical therapy, pharmacy, dental hygiene, speech and audiology, and optometry. All groups perceived yoga's greatest utility for skeletal symptoms, followed by psychological and physical symptoms. Findings also revealed a significant positive relationship between level of personal yoga practice and willingness to refer patients to yoga.

Conclusions:

Although students expressed some openness to referring patients to yoga, ratings of appropriateness were not accurately aligned with extant evidence base. Personal experience seemed to be a salient factor for accepting yoga as a referral target. These findings suggest the importance of developing strategies to make health professionals more aware of the merits of yoga, regardless of whether they themselves are yoga practitioners.

Introduction

The use of complementary and alternative treatment approaches with patients and providers in primary care and mental health care settings has grown significantly over the past decade.¹ In 2007, an estimated 38% of U.S. adults and 12% of U.S. children used complementary and alternative medicine (CAM) approaches in the prior 12 months to manage at least one of a range of physical and emotional health concerns, including pain, anxiety, and depression.^2,3 Looking at specific disorders, a meta-analysis revealed that approximately 50% of patients with cancer in the United States report using CAM.⁴ Use of CAM by these patients accounted for 11.2% of their out-of-pocket health expenses ($33.9 billion), demonstrating a substantial commitment of these patients to integrative care as a valuable avenue toward healing. More than 75% of primary care providers and 85% of behavioral health care providers report that they have referred patients to complementary or alternative treatment providers.⁵ In recognition of the increased use of CAM approaches, the National Center for Complementary and Alternative Medicine has seen its budget increase from $50 million in 1999 to $124 million annually in 2014 to support research on CAM therapies.⁶

Of particular interest to this study is yoga (broadly defined to include posture practice, breathing exercise, and mindfulness or meditation practices), which has been increasingly applied in a wide variety of settings and contexts over the past decade. Research,^{7

–53} summarized in Table 1, has resulted in ample evidence for yoga as an important and efficacious complement to the treatment of many mental and physical health concerns. Underscoring the role of yoga in healthcare, 40% of the 3000 members currently enrolled in the International Association of Yoga Therapists (IAYT) hold licenses as healthcare providers.⁵⁴ Relatedly, Birdee and colleagues⁵⁵ reported that 61% of yoga users described yoga as important in maintaining their overall health, and as many as 83% of practitioners reported using yoga to enhance their mental health.

Table 1.

Symptoms and Sample References Showing Evidence for Yoga's Effectiveness

	Samples of published evidence
Symptoms	Randomized controlled trial	Other evidence
Psychological
Anxiety	Satyapriya et al.⁷	Li and Goldsmith;⁸ Kauts and Sharma⁹
Anger	Kanojia et al.¹⁰	Noggle et al.;¹¹ Lavey et al.¹²
Depression	Sharma and Halder;¹³ Satyapriya et al.⁷	Uebelacker et al.;¹⁴ Kinser et al.¹⁵
ADD	Chaya et al.¹⁶	Jensen and Kenny¹⁷
Eating disorders	Carei et al.¹⁸	Mitchell et al.¹⁹
PTSD	Mitchell et al.²⁰	Staples et al.²¹
Poor self-esteem	Telles et al.²²	Sethi et al.²³
Physical
Arthritis	Garfinkel et al.²⁴	Garfinkel et al.²⁵
Cancer	Cramer et al.;²⁶ Buffart et al.²⁷	Geyer et al.²⁸
Chronic pain	Langhorst et al.;²⁹ Büssing et al.³⁰	Williams et al.³¹
Digestive disorders	Taneja et al.;³² Kuttner et al.³³
Insomnia	Halpern et al.³⁴	Bhaduri et al.³⁵
Fatigue	Bower et al.³⁶	Guner and Inanici³⁷
Headaches/migraines	John et al.³⁸	Kaliappan³⁹
Hypertension	Sharma and Halder¹³	Alexander et al.⁴⁰
Impaired immunity	Gopal et al.⁴¹	Guner and Inanici³⁷
Inflammation	Kiecolt-Glaser et al.⁴²	Kiecolt-Glaser et al.⁴³
Pregnancy	Satyapriya et al.⁷
Respiratory illness	Nagarantha and Nagendra⁴⁴	Vedanthan et al.⁴⁵
Restless legs syndrome	Innes and Selfe⁴⁶	Innes et al.⁴⁷
Skeletal
Poor balance	Tiedemann et al.⁴⁸	Schmid et al.⁴⁹
Low back pain	Williams et al.³¹	Cramer et al.⁵⁰
Neck pain	Michalsen et al.⁵¹	Cramer et al.⁵²
Poor posture	Pimentel do Rosario et al.⁵³	Schmid et al.⁴⁹
Poor range of motion	Alexander et al.³⁹	Guner and Inanici³⁷

ADD, attention-deficit disorder; PTSD, post-traumatic stress disorder.

Despite evidence for CAM in general and yoga in particular, only a portion of patients who may benefit from such treatments actually receive referrals. For example, Brems and colleagues⁵⁶ reported that only 30% to 50% of female breast cancer survivors, who may have benefitted, were referred to complementary and alternative services (including counseling, nutritional support, and yoga). Birdee and associates⁵⁵ found that only 22% of yoga users reported that their medical professionals recommended yoga. A survey of integrated practice physicians (medical doctors, doctors of naturopathy, and osteopathic doctors) identified the most commonly used CAM services to be chiropractic and acupuncture and the least used services to include homeopathy, osteopathy, massage therapy, and therapeutic yoga.⁵⁷

Thus, the literature to date suggests that yoga may be a relatively underused healthcare resource. Prior investigations have focused on current healthcare professionals and yoga practitioners. The current study seeks to augment extant data by focusing on openness to referral to yoga among current trainees in a variety of health professions. The authors agree with others that given the newness of yoga as a CAM recognized in the United States, current trainees might be more likely than seasoned practitioners to use this resource.^58,59 To that end, the current study surveyed health professions students at a private university in the Northwest United States to explore to what degree they perceived yoga as an acceptable complementary treatment for a variety of physical and mental health concerns.

Materials and Methods

Participants

To obtain the current sample, all students (n=1585) enrolled in 10 separate health professions programs across three colleges at a private university in the Northwest United States were sent an email to request their participation in a study about perceptions of yoga as a complementary treatment. Extant literature has demonstrated similar response rates for email and online surveys compared with conventional methods of study solicitation (especially for college students and other educated groups), while achieving higher-quality data.^60,61 A total of 513 hits on the survey were received, which led to 498 at least partially completed protocols. For items of relevance to the current study, 478 usable protocols remained, for a response rate of roughly 30%. Sample characteristics compared well to population demographic characteristics, with no statistically significant differences. Table 2 provides demographic characteristics for the participants.

Table 2.

Demographic Characteristics of Survey Participants (n=478)

Demographic variable	Participants (n)	Participants (%)
Health profession
Audiology and speech therapy	46	9.6
Dental health science	23	4.8
Occupational therapy	47	9.8
Optometry	113	23.6
Pharmacy	63	13.2
Physical therapy	60	12.6
Physician assistant	30	6.3
Psychology	96	20.1
Sex
Female	373	78.0
Male	83	17.4
Missing	22	4.6
Race/ethnicity^a
African American	4	0.8
Alaska Native/Native American	13	2.7
Asian/Pacific Islander	80	16.7
White	378	79.1
Hispanic	19	4.0
Missing	24	5.0

Mean participant age±standard deviation: 28.5±5.9.

Respondents were asked to identify all that applied; thus, totals can add to more than 100%.

Materials

We developed the Acceptability of Yoga Survey for this study, piloting it with a small convenience sample for feasibility and readability. The final protocol consisted of 22 questions, some open-ended and some offering discrete response choices. Questions assessed five domains: engagement in yoga practice, facilitators of yoga practice, barriers to yoga practice, yoga acceptability as supplemental treatment for physical and mental health concerns, and participant characteristics. The current study specifically looked at acceptability of yoga as a complementary treatment. The first part of this domain asked participants, “Would you refer clients or patients to yoga to support treatment they are seeking from your profession?” Participants responded to this question on a three-point scale, with the following options: No, probably not or never; Yes, for certain presenting concerns; Yes, without question. The second part listed 27 symptoms (e.g., anxiety, depression, back pain, cancer, arthritis, limited range of motion) selected on the basis of empirical evidence for yoga's utility in ameliorating the symptoms. Participants responded to each symptom on a four-point scale with the following options: Not Appropriate, Sometimes Appropriate, Mostly Appropriate, and Appropriate. The instrument was developed and administered through SurveyMonkey. A copy of the instrument may be requested from the corresponding author.

Procedure

After approval by the Pacific University Institutional Review Board, all students matriculated in health professions programs at Pacific University received a link to the online survey via a solicitation email sent to their university email account. Once potential respondents arrived at the website, they were presented with informed consent information. If they consented, they were directed to the protocol, completion of which required approximately 10 to 15 minutes. After responding, participants were invited to enter into a drawing for a chance to win one of 10 prizes (gift certificates to book stores or coffee shops, with one grand prize valued at $100). Data were not linked in any way to personal information collected for the drawing. The study was open for approximately 4 weeks, and students received two reminder emails.

Results

Data preparation

Respondent categorization

To prepare for the main data analyses, participants were categorized into a yoga practitioner grouping based on their self-reported yoga practice as conceptualized from a readiness-for-change perspective. Those who responded that they were active practitioners were categorized as yogis (n=139 [29.1%]); those who were not actively practicing but revealed an intention to start were categorized as contemplators (n=132 [27.6%]); and those with neither an active practice nor an intention to start were categorized as non-yogis (n=207 [43.3%]).

Data reduction

To develop a parsimonious set of dependent variables, a factor analysis was conducted for items assessing respondents' perceptions of appropriateness of referral to yoga as supplemental treatment for 27 symptoms. A principal components analysis with equamax rotation resulted in three factors with Eigenvalues above 1.0, accounting for 68.4% of the variance. On the basis of these factors, three subscales were developed: psychological symptoms, with 7 items; general physical symptoms, with 15 items; and skeletal symptoms, with 5 items. Reliability for all three scales was excellent, with the following Cronbach α coefficients: 0.92 for psychological symptoms, 0.96 for physical symptoms, and 0.89 for skeletal symptoms.

Main analyses

General referral

Analysis of the responses to the general question “Would you refer clients or patients to yoga to support treatment they are seeking from your profession?” was done by using a two-way analysis of variance with health profession (eight levels) and yoga practitioner (three levels) as independent variables. Results revealed statistical significance for the main effect of yoga practitioner (F[2,440]=23.34, p<0.001, partial eta squared [η_p ²]=.096) and main effect of health profession (F[7,440]=12.24, p<0.001, η_p ²=.163). By using the Duncan multiple range test, results for the yoga practitioner main effect showed that yogis were significantly more likely to make referrals than were contemplators or non-yogis; contemplators were more likely than non-yogis. Post hoc analyses for the health profession main effect showed that occupational therapy students were most likely to refer and optometry students were least likely. Table 3 shows means for this main effect. The yoga practitioner×health profession interaction effect was not significant (F[14,440]=1.61, p>0.05).

Table 3.

Referral Likelihood Means for Students Across Health Professions and Practitioner Status

Variable	Mean	Standard deviation
Profession
Audiology/speech	1.70	0.64
Dental health science	1.78	0.80
Occupational therapy	2.42	0.54
Optometry	1.54	0.66
Pharmacy	1.95	0.62
Physician assistant	2.31	0.60
Physical therapy	2.12	0.50
Psychology	2.16	0.59
Practitioner
Yogis	2.27	0.68
Contemplators	2.00	0.64
Non-yogis	1.71	0.61
Total	1.95	0.68

Based on ratings of (1) no, probably not, or never; (2) yes, for certain presenting concerns; and (3) yes, without question.

Appropriateness of yoga for specific symptoms

Responses to questions about yoga's appropriateness for a list of psychological, physical, and skeletal symptoms were analyzed by using a mixed-model analysis of variance with health profession (eight levels) and yoga practitioner (three levels) as between-subjects variables and symptoms (three levels) as a within-subjects factor. Results revealed a significant main effect for the within-subject symptoms factor (F[2,868]=133.04, p<0.001, η_p ²=.235) and main effect for the between-subjects yoga practitioner factor (F[2,434]=5.09, p<0.01, η_p ²=.023). Post hoc tests for the symptoms main effect showed that across all participants, skeletal symptoms (mean±standard deviation, 3.24±0.70) were rated as more appropriate for a referral to yoga than were both psychological and physical symptoms; psychological symptoms (mean, 2.90±0.77) were deemed more appropriate for a referral than physical symptoms (mean, 2.70±0.80). The main effect for yoga practitioner revealed that across all symptoms, yogis were more likely to refer (mean, 3.14±0.68) than contemplators (mean, 2.89±0.65) who were more likely than non-yogis (mean, 2.64±0.73).

In addition to the two main effects, the interaction between symptoms and yoga practitioner was significant (F[4,868]=3.35, p<0.01, η_p ²=.025). This interaction revealed yogis and contemplators placed equal appropriateness of referral for skeletal symptoms but differed significantly on appropriateness of referral for psychological and physical symptoms. Findings are shown in Table 4. No other main or interaction effects reached statistical significance.

Table 4.

Appropriateness of Referral by Symptom Across Practitioners

	Skeletal		Psychological		Physical
Variable	Mean	SD	Mean	SD	Mean	SD
Yogis	3.41	0.64	3.18	0.71	3.02	0.76
Contemplators	3.33	0.59	2.87	0.68	2.74	0.74
Non-yogis	3.06	0.76	2.72	0.80	2.47	0.8

Based on ratings of (1) not appropriate, (2) sometimes appropriate, (3) mostly appropriate, and (4) appropriate.

SD, standard deviation.

Discussion

Given the substantial body of literature supporting yoga as an effective intervention for many symptoms, these findings provide further evidence of the underuse of yoga as a CAM resource. Declared type of profession made a difference in perceived acceptability of referral, as did experience with a personal yoga practice. Optometry students, followed by audiology and dental health science students, were least likely to endorse yoga referrals, either in general or for specific symptoms. Occupational therapy students were most likely to refer, followed by physician assistants, psychology, and physical therapy students.

Regarding personal yoga practice, respondents familiar with yoga through their own practice were most likely to refer patients to yoga, followed by respondents contemplating a yoga practice; respondents with no current practice and no plan to engage in yoga themselves were least likely to refer patients. Referral likelihood was greater in all professional groups if the respondent had a personal practice. Perhaps the yogis in our study have had personal experiences demonstrating the effectiveness of yoga for health concerns (a question that was not asked in this study). Thus, it is possible that increasing the number of yogis among healthcare providers or increasing the opportunities for yoga practice within healthcare training programs may increase use of yoga as a CAM treatment. A shift toward more yogis in the health professions not only will likely enhance referral to yoga (and hence use) but may also ensure that providers can discern evidence of efficacy for yoga interventions, have better clinical mastery themselves, are more skilled with regard to rapport-building with patients, and may hold values that are more aligned with those of patients who are seeking CAM solutions to their health and mental health concerns.

Regardless of professional affiliation, all health professional students perceived yoga as most appropriate for skeletal symptom, followed by psychological symptoms, and then physical symptoms. Contemplators rated skeletal symptoms as highly as yogis did but diverged from yogis' perceptions on physical and psychological symptoms, rating both as a less acceptable referral target than yogis and rating psychological symptoms at the same level as non-yogis. For all practitioner groups, physical symptoms were endorsed as least appropriate for referral, despite robust empirical evidence demonstrating the efficacy of yoga for reducing a variety of health-related symptoms, including insomnia, hypertension, pain, and arthritis.

These findings are particularly interesting in the context of how the United States in general, and in the research literature in particular, defines (or has failed to define) yoga. Specifically, for decades, there has been little consensus on the operational definition of yoga, or what constitutes a yoga intervention. While recent work is beginning to change this lack of clarity (with successful efforts to use Delphi methods to identify key yoga protocol components, specific to presenting concern⁶²), protocols used in most research studies to date have varied widely and have been ill defined. As a historically Eastern tradition, yoga has included at least eight linked yet distinctive practices, including ethical practice, personal observances, posture practice, breathing exercises, sense withdrawal, concentration practices, meditation, and absorption. Many research protocols draw on several of these practices, and some only on individual aspects (such as posture practice).

Although the past lack of clarity is concerning in terms of replicability of research and generalizability of findings, it simply reflects the diverse views of what constitutes yoga in modern America (or the Western world). The most typical representation of yoga in the 21st century has been that of modern posture practice as represented in gyms and athletic clubs, contrasted with yoga as meditation and self-reflection to find absorption and awakening as practiced in the West at the turn of the 20th century.⁶³ The current findings are congruent with modern perspectives on yoga as a physical practice that is beneficial for musculoskeletal concerns (e.g., better balance and posture; pain relief), including perhaps weight loss and athletic pursuits. Psychological, and even more so physical, applications, while certainly acknowledged, appear to have less relevance to the budding professionals surveyed here, despite the empirical evidence. A market study conducted by Yoga Journal confirms this notion, as it found that the top five reasons readers started to practice yoga were flexibility (78.3%), general conditioning (62.2%), stress relief (59.6%), overall health (58.5%), and physical fitness (55.1%).⁶⁴ Ratings in the present study may well reflect such perceptions of yoga as a physical practice with a limited range of benefits.

Our work suggests that used of yoga intervention is lower than would be suggested by the evidence for its utility, a reality that is likely true for other CAM approaches. Such use may be enhanced through a variety of specific interventions, including interprofessional training opportunities, collaborations of health professions educators with organizations such as the International Association of Yoga Therapists, and community outreach to bring experiential yoga programs into health professions classrooms. To increase awareness of the benefits of yoga, an invaluable avenue may be to expose health professional students to yoga academically and experientially during their professional identity development. Given the momentum toward integrated care wherein multiple health professionals collaborate toward the health and well-being of patients, yoga trainings and experiences could take on an important interprofessional activity. Students from all health professions disciplines can come together to learn about yoga's utility and to practice yoga themselves. With such exposure, more health professionals may become practitioners of yoga themselves, a status that makes them more open to referring patients to yoga. Short of all health professional students becoming yogis, exposure to yoga in their academic settings may at least help them become better consumers of the yoga research literature, allowing them to be open to referral when the evidence base suggests the efficacy thereof. Exposure to other CAMs (e.g., massage, nutritional interventions) may similarly be of benefit in bringing more CAM referrals to all patients, regardless of where they enter the healthcare system.

Conclusions

Findings from this study suggest work remains to be done to educate health professionals on the utility of yoga for a variety of symptom presentations. Although some groups expressed openness to the idea of referring patients to yoga, perceptions of appropriateness were not accurately aligned with the research literature. Personal experience seemed to be a salient factor accepting yoga as a referral target. Because yoga is an excellent stress reduction strategy for faculty and graduate students, it may be a beneficial practice for institutions of higher education, especially in the health professions, to provide access to yoga for advanced students.* Practicing yoga during their education may increase students' openness to referral once they enter the work force. In addition to personal experience with yoga, perceiving yoga as a physical practice seemed to influence the acceptability of referral for specific symptoms. Those training health professionals on the efficacy of yoga may want to express a fuller definition of yoga than is typically supported by American gyms and popular media.

This study had limitations and cannot be considered the final work on all health professions students' perceptions of yoga as a viable CAM intervention. Self-report always leaves room for misrepresentation and error; studying in vivo practices related to referral would greatly enhance the study. More thorough investigation into the role of personal practice in professional referral will be important to determine whether this is due to personal experience or greater familiarity with research findings. Given the rapid growth of yoga practice among the U.S. population and the desire of patients for integrative healthcare, it is important to develop strategies to help healthcare professionals make prudent decisions about such referrals.

Footnotes

Acknowledgments

The authors gratefully acknowledge the contributions of Julia Ray, Lisa Girasa, Madison Davis, and Mark E. Johnson.

Author Disclosure Statement

No competing financial interests exist.

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