Preferences for and Experiences With Yoga in Appalachian Veterans: A Mixed Method Study

Introduction

Complementary and Integrative Health (CIH) therapies, such as yoga, acupuncture, and massage, improve chronic pain, mental health, physical functioning, and overall well-being.^1-8 Approximately one-third of U.S. adults use CIH therapies and use among Veterans increased by 70% between 2016 and 2019.^9,10 The Veterans Health Administration (VHA) now prioritizes the integration of CIH therapies into conventional clinical care as part of the VA Whole Health System to meet the complex needs of its Veteran population given growing evidence supporting their efficacy.^11-13 The CARA Act mandated expanded CIH offerings within the Veterans Health Administration (VHA)^14-16 with the goal to increase access to care.^3,5,6,8 However rural Veterans, especially those in regions such as Central Appalachia, face significant barriers to CIH services such as transportation, limited access to classes, and shortage of trained providers.^17-19 Cultural attitudes may pose additional challenges, with some Veterans perceiving these therapies as unfamiliar or incompatible with their values. ²⁰ These barriers limit both the accessibility and acceptability of CIH therapies for rural Veteran populations and highlight the need for tailored approaches.

In recent years innovative methods have been proposed to increase the accessibility of CIH therapies in populations that experience barriers to care (eg, telehealth, drop-in).^21,22 However, understanding patient preferences is a critical first step to designing interventions tailored to unique populations. ²³ Previous studies on Veteran preferences for CIH therapies have been conducted in urban population ²⁰ and clustered analyses for multiple CIH services together. Thus, there is a critical gap in understanding not only what rural Veterans would favor in terms of CIH therapies, but more specifically, what services they might want or benefit from.

This study seeks to fill these gaps by examining rural Appalachian Veterans’ knowledge of and preferences for yoga-a multicomponent mind-body-spirit practice that has diverse lineages, purposes, and aims,^24-26 and is definitively hard to study. ²⁷ Studying patient preferences for yoga is critical given yoga’s robust potential for relieving Veterans’ mental and physical symptoms and enhancing quality of life by improving self-regulation, interoceptive awareness, and stress physiology.^13,28-32 The goal of this study was to identify optimal yoga class formats that may be tailored to the needs of Appalachian Veterans who are more likely to experience chronic health conditions compared to their non-Appalachian counterparts ³³ and may, thus, substantially benefit from the far-reaching effects of yoga. ³⁴ This clarity may help guide service provision targeted toward meeting the needs of Appalachian Veterans thereby making CIH services more accessible to rural populations.

Methods

This cross-sectional study was approved as non-research by the Salem VA Health Care System (Salem VA) Institutional Review Board Chair.

Results

Forty nine of the 68 Veterans who were asked by their provider to complete the survey did so, reflecting a 72% completion rate (see Table 1). Veterans were predominantly recruited from the surgery pre-admission clinic. Twenty-eight (57%) reported hearing about yoga before and nearly one-third of respondents reported a history of yoga practice, primarily at home. Approximately half of respondents had heard about yoga on television or from a friend and preferred a group format close to their primary care clinic. Preferences for format were mixed, with the largest portion of respondents preferring video. Preferences varied widely for group sizes, with smaller class sizes or individual being preferred by most. The majority of respondents preferred 30-45-minute classes held once per week and to be referred by a provider.

OPEN IN VIEWER

Table 1.

Summary of Responses to Surveys on Preferences for VA Yoga Classes (N = 49)

	N	%
Clinic recruitment
Surgery pre-admission clinic	20	41
Pain clinic	10	20
Primary care	13	27
Specialty care	6	12
History of yoga practice	15	30.6
Where have you heard about yoga?
TV	26	53.1
Friends	23	46.9
Internet	18	36.7
Family	17	34.7
Social media	13	26.7
Healthcare provider	10	20.4
Other veterans	4	8.2
Other (all my life; neighborhood; YMCA)	3	6.1
Where do you practice? (of N = 13, 26%)
Home	5	38.5
Gym or studio	5	38.5
Military	2	15.4
With a therapist	1	7.7
VA offered yoga preferences
Format
Group	27	55.1
Individual	18	36.7
Video	16	32.7
Asynchronous website	10	20.4
Face-to-Face	9	18.4
Asynchronous mobile app	5	10.2
Location
Close to primary care	25	51
Close to mental health	11	22.4
Close to pain clinic	19	38.8
Other (outside, anywhere, building 77)	9	18.4
Duration of class, in minutes
30	15	30.6
45	19	38.8
60	9	18.4
90	0	0
Frequency
Once per week	21	42.9
Twice per week	15	30.6
Once every other week	6	12.2
Monthly	3	6.1
No response	4	8.2
Group size
Individualized	8	16.3
5 people	1	22.4
10 people	1	24.5
15 people	1	2
20 people	6	12.2
No response	11	22.4
Recruitment
Provider initiative	34	69.4
TVs in waiting rooms	17	34.7
Flyers	16	32.7
Outreach events	16	32.7
Facebook posts from the VA	12	24.5
Written veteran testimonials	8	16.3

Veterans reported a variety of responses to open-ended questions. Specific locations at the Salem VA were mentioned, including “outside” or “anywhere.” A few (n = 4; 8%) of the Veterans suggested pre-class sign-ups to know how large the class would be (spacing) and to allow the instructor to prepare. Five Veterans provided disparate implementation considerations including: 1) wanting classes at home; 2) need community care; 3) cannot take off work; 4) need yoga on another scheduled day; and 5) want walk-in and pre-sign-up options. Of those who heard yoga was exercise, respondents reported learning that it was “decent for stretching, alternative to chiro” or that it was “downward dog, [blood pressure] relax, flex.” Many also reporting hearing that yoga was relaxing (“helping you relax” and “relax, mind, meditation, stretching”) and “good for overall health.” A few minor themes emerged as well such as “I know it’s go[o]d for your joints and mental health but couldn’t explain further” or that it was “a lot of breathing techniques.” When asked about barriers to participation, the majority did not know where to start or what resources were available. Most of those who reported a history of yoga practice stated their most recent practice was several years prior. When asked about the mental health benefits of yoga, more than half reported a sense of relaxation while two Veterans shared that it was a “failure; [they] couldn’t get out of [their] head”).When asked about quality-of-life improvements three quarters of Veterans provided positive feedback. Among those, four (40%) specifically mentioned being more limber/flexible and one (10%) stated it “made it not hurt to get out of bed for a week.”

Discussion

This study highlights both engagement in and challenges to practicing yoga at a VA serving primarily rural Veterans in Central Appalachia, an understudied and under resourced population. ³⁵ These Veterans reported engaging in yoga at rates similar to other Veteran populations (22.4% ²⁹ ) and at higher rates than the general population (13.2% ²⁶ ) highlighting interest in yoga amongst this unique group of individuals. Yet only two Veterans in the current study indicated that they have some form of current yoga practice. Therefore, addressing not only barriers to access and implementation strategies but also identifying ways to support sustained engagement may be critical for Veterans to truly experience the benefits that yoga offers.

The present study was the first to identify preferences for yoga classes in rural Veterans within Central Appalachia. Most desired to be referred to yoga services by their providers and for yoga classes to occur once per week in small groups that lasted 30-45 min and were located close to their primary care clinics. This result echoes previous research ³⁶ that suggests yoga-based interventions in 1:1 or virtual settings that do not facilitate opportunities for social engagement are less attractive to this population. Other preferences, such as formatting, varied significantly, suggesting that a wide variety of options (eg, in-person, telehealth, website, mobile application) may be needed to address the wide-ranging needs of Central Appalachian Veterans.

Veterans identified potential barriers that may be addressed to promote use of yoga in the Central Appalachian population, including 1) perceived lack of ability to perform yoga, 2) lack of knowledge about the benefits of yoga, 3) uncertainty about where to begin a yoga practice, and 4) lack of knowledge about available resources. These concerns highlight the strong need for adapted yoga classes for Veterans with injuries, disability, and chronic illness. These findings also suggest the need for strong dissemination strategies^36,37 including strategically sharing information on the benefits of yoga and information on where and what type of yoga classes are available.

Participants reported a strong desire to learn about the benefits of yoga from clinicians. Yet only 20% reporting that they had discussed yoga with their healthcare provider. These results align with existing research that suggests only 22% of those currently practicing yoga were clinician referred. ³⁸ Thus, interventions to increase provider buy-in may be warranted to enhance the reach of yoga services in Veterans from Appalachia who may rely heavily on their clinicians for guidance and recommendations. Previous studies have indicated that healthcare providers are more likely to recommend CIH services when they are knowledgeable about their benefits ³⁹ and that brief educational interventions for providers led to an increase in knowledge about yoga and increased referrals to yoga services. ⁴⁰ Furthermore, providers who engage in yoga are more like to refer patients to the practice. ³⁸ The VHA is currently engaging in significant efforts to train clinicians on Whole Health and to provide employee wellness services, including yoga. ¹⁵ Thus, integrating educational programs focused on the clinical benefits of yoga into the existing infrastructure may represent a low burden, high yield opportunity to increase clinician knowledge about yoga, thus increasing yoga use among Central Appalachian Veterans.

The VHA’s highly prioritized Whole Health System may provide additional resources that could be leveraged to increase the use of yoga in Central Appalachian Veterans. Participants in this study reported that most of their existing knowledge about yoga had come from TV or friends. To increase Veteran knowledge about Whole Health, many VA Medical Centers place televisions in patient waiting areas with educational messaging about Whole Health. Specific information on the physical and mental health benefits of yoga, as well as class schedules for available yoga classes could be added to Whole Health content shown on televisions. The Whole Health System also emphasizes the role of peer support specialists. ¹⁵ These peer support specialists could provide education about the benefits of yoga to their fellow Veterans and be trained to conduct peer-led yoga sessions to increase the acceptability of yoga in Central Appalachian Veterans.

Limitations and Future Directions

While this study sheds light on Central Appalachian Veterans’ inclinations toward yoga, there were limitations that should be considered. The original study design aimed to collect rich information from a set of focus groups of Veterans from Appalachia; however, due to challenges in recruitment the approach was shifted to survey-based qualitative data. While Veterans were recruited from a wide variety of services and the completion rate was high, the lack of in-depth qualitative findings leave remaining gaps in yoga preferences that should be explored in future qualitative studies using a thematic analysis. Given this study’s focus on yoga, questions about experiences with and preferences for other CIH services were not examined and serve as fertile ground for future research efforts. For example, participants preferred in-person format for yoga but may prefer mobile applications for mindfulness. The design of the survey did not clarify that they could skip the questions about preferences and barriers for yoga if they were not interested in yoga which may have left participants feeling obligated to provide an answer. However, some Veterans chose to use of the open-ended questions allowed for Veterans to express a lack of preferences or interest as indicated in Table 2. Moreover, participants were allowed to choose multiple options on the survey to indicate their preferences, limiting our ability to discriminate between preferences for the certain formats vs another (eg, video vs in-person). Future research using large datasets may also be used to explore how engagement in CIH services may differ based on individual health conditions or demographic characteristics, including but not limited to rurality. This critical information could lead to more tailored recommendations from providers to Veterans and provide guidance on what formats should be accessible in particular populations.

OPEN IN VIEWER

Table 2.

Summary of Responses to Open-Ended Survey Items Related to VA Yoga Classes

	N	%
What have you heard about yoga? (of N = 28)
Exercise	9	32.1
Relaxation	8	28.6
Good for overall health	8	28.6
Barriers to yoga practice (of N = 16)
Not sure where to start/Unaware of resources	6	37.5
Not flexible enough to try	4	25
Uninterested	3	18.8
No reason	2	12.5
Prefer weightlifting	1	6
Most recent yoga practice (of N = 12)
“A Long time ago”	5	41.7
10 years	2	16.7
47 years	1	0.83
6 years	1	0.83
5 years	1	0.83
Yesterday	1	0.83
Four times per week	1	0.83
Mental health benefits of yoga (of N = 14)
Calm/Relaxed/Reduced stress	8	57.1
General benefits	3	21.4
No benefits	2	14.3
Improvements in flexibility	1	7.1
Quality of life benefits of yoga (of N = 13)
Positive changes	10	76.9
Some/Maybe impact	2	15.4
Did not “stick with it long enough to receive a benefit”	1	7.7

Conclusions

This study contributes the first data on the preferences for and experiences with yoga in rural Central Appalachian Veterans, which is crucial area of study given yoga’s robust potential to improve complex mental and physical health conditions commonly experienced by this unique and understudied population. Results revealed a strong interest in yoga with specific desires for formatting and highlight key factors that would improve accessibility, understanding, and engagement in yoga. Use of this information, coupled with use of existing resources within the VHA, particularly the Whole Health System, may improve the uptake of yoga, ultimately benefiting the health and well-being of these Veterans.