A Single Session of an Integrated Yoga Program as a Stress Management Tool for School Employees: Comparison of Daily Practice and Nondaily Practice of a Yoga Therapy Program

Abstract

Objectives:

The aim of this study was to assess the effect of the daily practice of a yoga therapy program learnt during a single session of an integrated yoga intervention that was developed by us as a stress management tool for school employees.

Subjects:

Ninety school employees.

Design:

Case–control study. Three months after the intervention, the subjects were assigned to a daily practice group (case: n=43) and a nonconsecutive daily practice group (control: n=47) according to their daily practice level of the yoga therapy program.

Interventions:

The subjects participated in a stress management education program based on an integrated yoga therapy session. The program included psychological education and counseling about stress management and yoga theories, as well as the practices of asanas, pranayama, relaxation, and cognitive structure based on Indian philosophy.

Outcome measures:

Assessments were performed before and after the program using the Subjective Units of Distress for mind and body and the Two-Dimensional Mood Scale. The General Health Questionnaire 28 (GHQ28) was used to assess the mental health state before the intervention and at 3 months after the program.

Results:

The subjects showed significant increases in their levels of calmness, comfort, and cheerfulness (p<0.001) and significant decreases in cognitive mind and body stress (p<0.001) after participating in the integrated yoga program. A comparison of the total scores on the GHQ28 using a two-way analysis of variance showed significant differences between the two groups in terms of both interaction (p=0.047) and the main effect (p=0.026).

Conclusions:

The present results suggested that a single session of an integrated yoga program was effective for reducing stress and that the mental health of school employees was promoted by the daily practice of the yoga therapy program.

Introduction

In Japan, stress management is now positioned as an important issue, as reflected in the preparation of mental health guidelines.¹ Teachers, in particular, suffer from greater job stress than workers of general corporations in Japan, and the absentee rate of Japanese teachers because of mental disease has increased by about 3-fold over the last 10 years.² Japanese teachers reportedly find it difficult to assist students, such as those with developmental disorders or attention-deficit/hyperactivity disorder, who need special support and to satisfy the requirements of their students' parents. In addition, they are busier and work longer hours to submit an increasing number of papers on different aspects of school education at the expense of spending time communicating with their students.³

The use of yoga to reduce stress has been attempted in various groups, including pregnant women,⁴ women during the climacteric period,⁵ patients with physical/mental disorders or diseases associated with stress (hypertension,⁶ pain,⁷ cancer,^8
–10 or psychiatric diseases^11,12), individuals who may be exposed to high levels of stress (e.g., managers,^13,14 university staff,¹⁵ or social workers¹⁶), children at educational facilities,^17
–19 and also for individuals suffering from postdisaster trauma (e.g., tsunami survivors²⁰). Yoga is an ancient Indian science and way of life that brings about relaxation and also induces a balanced mental state. It involves the technique of harmonizing individual dimensions (physical, vital, mental, and spiritual dimensions) based on the Taittreya Upanishad (a theory of the five sheaths of our existence) and Patanjali's Yoga Sutras. Yoga incorporating these techniques in their entirety is practiced as integrated yoga.^{4,5,8
–10,19

–22} According to past studies, an integrated yoga course for stress management requires about a week.^23

–28 However, for stress management courses held at educational facilities or industrial fields, the course often needs to be brief and should be provided in such a way that the techniques can be acquired in one to a few sessions of training, as the recipients may not always be interested in the practice of yoga. Bearing this in mind, we designed a program that could be administered in a single session as a component of stress management education and assessed the benefits of the program.

The aim of this study was to assess the effect of the daily practice of integrated yoga taught during a single session of an integrated yoga program that we developed as a stress management education tool for school employees.

Materials and Methods

This study was conducted with the approval of the Ethics Review Board of the Graduate School of Biomedical and Health Sciences, Hiroshima University.

Participants

The subjects were 90 volunteers (24 males and 66 females) attending a stress management workshop. All the participants were school staff members, including school managers, teachers, school nurses, school office workers, nutritionists, and cooks. Subjects who had any history of practicing yoga or any other relaxation procedures were excluded from the present study.

Intervention

In the design of stress management programs for individuals, emphasis should be placed on reducing the attendees' psychological resistance and enhancing their motivation to practice the techniques in daily life.²⁹ Programs with an easily and clearly understandable rationale and techniques that can be practiced easily and usefully are important prerequisites of stress management programs for general individuals who are not typically interested in yoga, especially if the amount of time available to administer the program is limited.

In this study, we administered the program as a single 3-hour session, as a component of a Stress Management Education³⁰ program. The program included group psychological education (60-minute session) intended to impart an understanding of the concepts related to stress (step 1), including the definition of stress, the types of stress, reactions, neuropsychiatry, immunology, and so on, and individual counseling (30-minute session) to encourage the participants to become aware of their own reactions to stress (step 2). In addition, stress management techniques (90-minute session) based on theory and practice were also included in the integrated yoga program to help cope with stress (step 3). Theoretical explanations (45-minute session) were provided regarding (1) deepening of relaxation through repeated cycles of tension and relaxation, (2) deepening of both motion and respiration through linkage between the two, (3) slow deep breathing practice (Pranayama), (4) concentration on attention enabling deep mediation (Dharana), (5) chanting of sacred verses (Svadhyaya), (6) Indian philosophy applicable to daily living (Karma Yoga), and (7) the theory of the five sheaths of existence (Pancha koshas) (citing the phrase, “Try to touch the inner core of oneself in solitude and establish in the experience that Ananda is the basic fabric of this universe, including the self”)²² (Table 1). The subsequent 45-minute training program was focused on controlling stress, shoulder stiffness, and lower back pain (Fig. 1).²³ In the training, the participants were instructed to concentrate on their body sense and breathing and to make suitable movements with their own body and mind.

FIG. 1.

Yoga therapy program based on the integrated yoga.

Table 1.

Theoretical Explanations Based on the Integrated Yoga

Type	Explanations
Asana	1. Deepening of relaxation through repeated cycles of tension and relaxation
Asana & pranayama	2. Deepening of both motion and respiration through their linkage
Pranayama	3. Slow deep breathing practice
Dharana & dhyana	4. Concentration on attention enabling deep mediation
Indian philosophy for daily living	5. Reading of sacred verses or books (Svadhyaya)
	6. Indian philosophy applicable to daily living (Karma Yoga)
	7. “Try to touch the inner core of oneself in the experience that is the basic fabric of this universe including the self” (Panchakoshas)

Study design and setting

After the single session of the integrated yoga intervention, the participants were recommended to practice what they had learned in the yoga therapy program on a daily basis. Three months after the intervention, the participants were asked whether they had practiced the yoga therapy program daily or not. We divided the participants into two groups based on whether they had continuously practiced the program for 3 months. As a result, the subjects were assigned to a daily practice group (DP group), in which the subjects had practiced the program more than 3 days a week for 3 months at home, at the workplace, or while commuting, and so forth, and a nonconsecutive daily practice group (NDP group), in which the subjects had practiced the program on 2 days or less each week.

Assessment

Immediately before the intervention and 3 months after the intervention, the General Health Questionnaire 28 (GHQ28) was used to assess the recent mental health status. The GHQ designed by Goldberg,^31,32 is a self-administered questionnaire that was developed to identify psychiatric morbidity in general practice. It is composed of 28 items organized in four subscales, and measures somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression. The responses to all the items are graded using a four-point scoring system: better than usual, same as usual, worse than usual, and much worse than usual. The cutoff total score for the diagnosis of good mental health is 5/6.

Immediately before and after the intervention, a test was conducted to assess the cognitive indicators of stress using the Subjective Units of Distress (SUD: ranging from 0, no stress, to 10, extreme stress) covering physical and mental aspects, as well as the Two-Dimensional Mood Scale³³ (TDMS: each of cheerfulness and stability level scored from −10 to +10, and each of comfort and awareness level scored from −20 to +20). Immediately after the intervention, the subjects were also asked to complete another questionnaire regarding (1) whether there were any stress management techniques in each group that individual subjects might desire to apply in their daily lives, and (2) any techniques at all that the subjects might desire to apply in their daily lives.

Data analysis

After performing the Kolmogorov–Smirnov test of normality, the physical/mental SUD scores and TDMS scores recorded before and after the intervention were compared using the Wilcoxon's signed rank sum test. The changes in the total score and the scores for each subscale on the GHQ28 in the DP group and the NDP group were assessed using a paired t-test. Comparison of the total scores on the GHQ28 recorded before and 3 months after the intervention between the two groups was performed using a two-way repeated-measures analysis of variance (ANOVA). Furthermore, the difference in the total scores on the GHQ28 recorded 3 months after the intervention between the two groups was assessed using a t-test.

The p-values in all the tests were 2-sided, and a p-value <0.05 was considered to denote significance. All the statistical analyses were performed using IBM SPSS Statistics, ver. 21.0.

Results

At 3 months after the intervention, the 90 subjects were classified into a DP group of 43 participants (13 males and 30 females) and an NDR group of 47 participants. Among the 47 participants in the NDR group, 23 (4 males and 19 females) practiced the program 1–2 days a week and 24 (7 males and 17 females) did not practice the program at all. There were no significant differences in the numbers of males and females (DP group: male/female=13/30, NDP group: male/female=11/36; p=0.485, chi-square test) or age (DP group: mean±SD=49.1±9.2 years, NDP group: mean±SD=47.2±8.3 years; p=0.302, t-test) between the groups. Furthermore, no significant differences in the stress levels observed before the intervention were seen between the two groups: total GHQ score (DP group: mean±SD=9.0±5.3, NDP group: mean±SD=9.7±6.4; p=0.575, t-test); physical (DP group: median=6.0, NDP group: median=5.0; p=0.545, Mann–Whitney U-test), and mental (DP group: median=5.0, NDP group: median=5.0; p=0.292, Mann–Whitney U-test) stress in the SUD; and cheerfulness (DP group: median=2.0, NDP group: median=0.5; p=0.080, Mann–Whitney U-test), stability (DP group: median=5.0, NDP group: median=5.0; p=0.973, Mann–Whitney U-test), comfort (DP group: median=6.5, NDP group: median=5.0; p=0.267, Mann–Whitney U-test), and awareness (DP group: median=−2.5, NDP group: median=−3.0; p=0.181, Mann–Whitney U-test) levels in the TDMS.

Comparison of physical/mental stress and TDMS scores recorded before and after the intervention

After the intervention, the scores for both physical stress (p<0.001) and mental stress (p<0.001) decreased, and the scores for stability (p<0.001), comfort (p<0.001), and cheerfulness (p<0.001) increased. No significant difference in the score for awareness (p=0.107) was observed before and after the intervention.

Comparison of the GHQ28 scores recorded before the intervention and at 3 months after the intervention

Regarding the changes in the total and subscale scores on the GHQ28, the total score and the scores for somatic symptoms, anxiety and insomnia, and social dysfunction significantly decreased in the DP group; on the other hand, no significant changes in either the total or subscale scores on the GHQ28 were observed in the NDP group (Table 2).

Table 2.

Comparison of the General Health Questionnaire 28 Scores Recorded Before the Intervention and 3 Months After the Intervention in Each Group

	Before the intervention, mean (SD)	3 months after the intervention, mean (SD)	p^a
DP group^b
Total scores	9.02 (5.33)	5.53 (4.50)	0.021
Subscales scores
Somatic symptoms	3.30 (1.94)	2.11 (2.02)	0.001
Anxiety and insomnia	3.34 (1.87)	2.20 (1.79)	0.002
Social dysfunction	1.97 (1.94)	0.86 (1.40)	0.001
Severe depression	0.39 (0.62)	0.34 (0.71)	0.688
NDP group^c
Total scores	9.72 (6.46)	9.38 (5.89)	0.712
Subscales scores
Somatic symptoms	3.65 (2.10)	3.44 (1.98)	0.515
Anxiety and insomnia	3.42 (2.20)	3.36 (2.35)	0.845
Social dysfunction	1.85 (2.01)	1.85 (1.98)	0.999
Severe depression	0.78 (1.73)	0.72 (1.39)	0.767

Paired t-test.

Daily practice group, in which the subjects had practiced the yoga therapy program more than 3 days a week.

Nonconsecutive daily practice group, in which the subjects practiced the yoga therapy program on 2 days or less each week.

A comparison of the total scores on the GHQ28 using two-way ANOVA showed significant differences between the two groups in terms of both interactions and the main effect (Table 3). Furthermore, a significant difference in the total score on the GHQ28 at 3 months after the intervention was observed between the two groups (p=0.002).

Table 3.

Comparison of the Total Scores on the General Health Questionnaire 28 Between the Two Groups

	Time				Effects
	Before the intervention		3 months after the intervention		Interaction: group×time			Main effect: group
	DP group, mean (SD)	NDP group, mean (SD)	DP group, mean (SD)	NDP group, mean (SD)	Freedom	F^a	p	Freedom	F^a	p
GHQ28 total scores	9.0 (5.3)	9.7 (6.4)	5.5 (4.5)	9.3 (5.8)	1	6.15	0.015	1	5.13	0.026

F-statistic in repeated measures analysis of variance.

GHQ28, General Health Questionnaire 28; DP, daily practice; NDP, nonconsecutive daily practice.

Discussion

After the intervention, the SUD scores for physical and mental stresses decreased, while the TDMS scores for stability, comfort, and cheerfulness increased. The results suggested that the participants were able to master the integrated yoga techniques for coping with stress, taught as a component of a stress management education program administered in a single session of 3-hour duration. A previous report showed that yoga practice reduced negative mood and enhanced positive mood, yielding emotional stability.³⁴ The results of the present study support this previous finding.

The mean total score on the GHQ28 before the intervention was 9.4. This score suggested that the participants had severe mental health problems because the cutoff point of the total score on the GHQ28 for the diagnosis of good mental health is 5/6. At 3 months after the intervention, the DP group showed a significant decrease in the score to less than 6, suggesting the resolution of the mental health problems. Moreover, the GHQ28 subscale scores for somatic symptoms, anxiety and insomnia, and social dysfunction also showed significant decreases. In contrast, no significant changes in either the total or any of the subscale scores of the GHQ28 were observed in the NDP group. These results are consistent with previous reports that showed the effects of successive yoga intervention sessions on improvements in the GHQ28 scores,²⁷ and the results of physiological monitoring and brain imaging for somatic symptoms,³⁵ anxiety,³⁶ insomnia,³⁷ and social dysfunction.³⁸ On the other hand, no significant change in the score for severe depression recorded before and at 3 months after the intervention was observed in the DP group. This is thought to be because the severe depression score before the intervention was too low to improve.

The daily practice of yoga has been reported to reduce perceived stress and to improve adaptive autonomic responses to stress.³⁹ The daily practice of the yoga therapy program in this study may have reduced physical and mental stress and increased comfort according to the TDMS, which is negatively correlated with the salivary cortisol level,⁴⁰ acted on the hypothalamus to create an antistress effect,⁴¹ and promoted general health in the DP group. In the future, methods of maintaining motivation in subjects to practice the yoga therapy program daily need to be identified.

A limitation of this study is that the yoga therapy program was administered by the first author of this article, who is a psychotherapist and a yoga therapist; therefore, the effects of the program administered by other therapists should be assessed. The second limitation is that the effect of the daily practice of the yoga therapy program was evaluated only using the GHQ28. Not only is it necessary to assess the effects using other scales, but biological, physiological, and/or qualitative methods should also be used.

Conclusion

The present results suggest that the daily practice of integrated yoga taught during a single session of an integrated yoga program that we developed as a stress management education tool is effective for improving mental health, including that of somatic symptoms, anxiety and insomnia, and social dysfunction, among school employees.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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