Enhancing Access to Yoga for Older Male Veterans After Cancer: Examining Beliefs About Yoga
Background: Yoga is an effective clinical intervention for cancer survivors. Most studies of the positive effects of yoga on cancer patients report on predominantly middle-aged women with breast cancer. Less is known about the use of yoga in older adults, veterans, and those from diverse racial or ethnic backgrounds.
Methods: We examined strategies to enhance access to yoga in older veterans after cancer, focusing on education (study 1) and intervention (study 2). Study 1 included 110 participants with a median (SD) age of 64.9 (9.4) years who were mostly male (99%) cancer survivors who were interviewed 12 months after their cancer diagnosis. Study 2 included 28 participants with a median (SD) age of 69.2 (10.9) years who were mostly male (96%) cancer survivors who participated in a yoga program within 3 years of their cancer diagnosis. Standardized interviews assessed interest in and barriers to yoga while self-reporting assessed health-related quality of life and beliefs about yoga.
Results: In study 1, interest in yoga increased from 5.5 to 31.8% ( χ 2 = 22.25, P < .001) following education. In open-ended questions 4 themes related to negative beliefs or barriers emerged: lack of knowledge or skepticism, disinterest or dislike, physical health barriers, and logistical barriers. In study 2, beliefs were more positive following intervention for expected benefits ( t = 4.44, P < .001), discomfort ( t = 4.92, P < .001), and social norms ( t = 4.38, P < .001) related to yoga. Physical function improved after participation in a yoga class, especially for those with higher beliefs in yoga prior to class. Age was not associated with beliefs about yoga in either sample.
Conclusions: A portion of older veterans who are cancer survivors were interested in yoga but faced access barriers. Implications for practice and research include increasing knowledge about yoga benefits and addressing physical health and logistical barriers to enhance access to yoga for older veterans.
Analysis
Descriptive statistics were used in study 1 to characterize participants’ yoga experience and interest. Changes in interest pre- and posteducation were evaluated with χ2 comparison of distribution. The association of beliefs about yoga with 3 levels of interest (yes, no, maybe) was evaluated through analysis of variance (ANOVA) comparing the mean score on the summed BAYS items among the 3 groups. The association of demographic (age, education, race) and clinical factors (AJCC stage, physical function) with BAYS was determined through multivariate linear regression.
For analytic purposes, due to small subgroup sample sizes we compared those who identified as non-Hispanic White adults to those who identified as African American/Hispanic/other persons. To further evaluate the relationship of age to yoga beliefs, we examined beliefs about yoga in 3 age groups (40-59 years [n = 24]; 60-69 years [n = 58]; 70-89 years [n = 28]) using ANOVA comparing the mean score on the summed BAYS items among the 3 groups. In study 2, changes in interest before and after the yoga program were evaluated with paired t tests and repeated ANOVA, with beliefs about yoga prior to class as a covariate. The association of demographic and clinical factors with BAYS was determined as in the first sample through multivariate linear regression, except the variable of race was not included due to small sample size (ie, only 3 individuals identified as persons of color).
Thematic analysis in which content-related codes were developed and subsequently grouped together was applied to the data of 110 participants who responded to the open-ended survey questions in study 1 to further illuminate responses to closed-ended questions.35 Transcribed responses to the open-ended questions were transferred to a spreadsheet. An initial code book with code names, definitions, and examples was developed based on an inductive method by one team member (EA).35 Initially, coding and tabulation were conducted separately for each question but it was noted that content extended across response prompts (eg, responses to question 2 “What might make you more likely to come?” were spontaneously provided when answering question 1), thus coding was collapsed across questions. Next, 2 team members (EA, KD) coded the same responses, meeting weekly to discuss discrepancies. The code book was revised following each meeting to reflect refinements in code names and definitions, adding newly generated codes as needed. The process continued until consensus and data saturation was obtained, with 90% intercoder agreement. Next, these codes were subjected to thematic analysis by 2 team members (EA, KD) combining codes into 6 overarching themes. The entire team reviewed the codes and identified 2 supra themes: positive beliefs or facilitators and negative beliefs or barriers.
Consistent with the concept of reflexivity in qualitative research, we acknowledge the influence of the research team members on the qualitative process.36 The primary coding team (EA, KD) are both researchers and employees of Veterans Affairs Boston Healthcare System who have participated in other research projects involving veterans and qualitative analyses but are not yoga instructors or yoga researchers.
