|Year : 2021 | Volume
| Issue : 3 | Page : 229-238
|Development and feasibility testing of a brief yoga module on well-being and cognition of postgraduate mental healthcare students in tertiary settings
Adil Hakkim1, Aarti Jagannathan1, Hemant Bhargav2, Nishitha Jasti2, Shivarama Varambally2, Bangalore N Gangadhar3
1 Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Integrative Medicine, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
3 Department of Member Secretary, National Medical Commission, Govt of India, India
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|Date of Submission||07-Jun-2021|
|Date of Decision||02-Aug-2021|
|Date of Acceptance||27-Aug-2021|
|Date of Web Publication||22-Nov-2021|
| Abstract|| |
Background: Mental health-care students experience stress and burnout during their training period. Yoga has been found to be helpful in improving one's mental health and well-being. Aim: The aim of this study is to develop and test the feasibility of a brief yoga module for postgraduate mental health-care students. Methods: Amixed method design was used. Phase 1 involved development and validation of the yoga module using the qualitative exploratory method. Phase II tested the feasibility of the module on a sample of 28 first-year postgraduate students. These students participated in a 15-day (30 min/day) brief yoga module for improving their well-being and cognition (mirror neuron activation [MNA] and tower of London task as assessed on day 0, day 15 (2 weeks), and day 30 (4 weeks). Qualitative feedback of the student volunteers was also recorded. Results: Significant improvement in the well-being scores was observed in the students who adhered to the yoga practice after 2 weeks and 4 weeks. Functional near infra-red spectroscopy (fNIRS) data indicated that adherents showed significant activation of left somatosensory region of the brain and deactivation in the right primary somatosensory region during the static and active phase of the MNA task, respectively. Adherent group showed significant improvement in reaction time during “Zero-Moves” tasks of Tower of London. The qualitative thematic analysis showed that the module helped improve the well-being and mental health of the students. Conclusion: The yoga program was found to have high need and medium to high feasibility. A systemic integration of student well-being-oriented interventions including yoga in the curriculum of postgraduate mental health-care courses is advocated.
Keywords: Brief yoga module, feasibility testing, mental health-care students, mirror neuron activation, well-being
|How to cite this article:|
Hakkim A, Jagannathan A, Bhargav H, Jasti N, Varambally S, Gangadhar BN. Development and feasibility testing of a brief yoga module on well-being and cognition of postgraduate mental healthcare students in tertiary settings. Int J Yoga 2021;14:229-38
|How to cite this URL:|
Hakkim A, Jagannathan A, Bhargav H, Jasti N, Varambally S, Gangadhar BN. Development and feasibility testing of a brief yoga module on well-being and cognition of postgraduate mental healthcare students in tertiary settings. Int J Yoga [serial online] 2021 [cited 2021 Dec 2];14:229-38. Available from: https://www.ijoy.org.in/text.asp?2021/14/3/229/330799
| Introduction|| |
Health-care students experience significant stressors during their professional training., Research depicts that nearly 59% of professional health-care students in a tertiary care teaching hospital were found to have psychiatric morbidity. Higher stress rates are correlated to dysfunctional coping strategies, exhaustion, and psychological morbidity. Professional education can have a negative impact on the emotional well-being and academic performance of health-care students. The stressors of health-care training and its associated negative consequences (mental, emotional, and physical health) have been studied in various disciplines for undergraduate health-care students and university students, but studies are limited in postgraduate health care or university levels. Mental health-care professionals such as mental health social workers, clinical psychologists, nurses, etc., are said to experience greater mental health problems such as stress, burnout, emotional exhaustion, and depersonalization.,, This suggests a need for culturally appropriate psychosocial interventions to support the mental health of health-care students to enable them to complete their training successfully.
Yoga and meditation has been a proven and validated mode of intervention for various forms of stress and mental health problems across different populations. Yoga was found out to be effective in decreasing stress and improving general well-being in medical students. Research suggests that interventions, including yoga, mindfulness, and mind-body skills training, may be helpful in building the self-awareness and resilience needed for medical students, residents, and established physicians to mitigate burnout risk. Improvement was reported following the yoga-based Resilience, Integration, Self-awareness, Engagement (RISE) program for front-line professionals including health-care workers in their psychological health domains such as mindfulness, stress, resilience, affect, and sleep quality. A study by Prasad et al. reports reduced stress levels and improved sense of wellbeing after 6 weeks of yoga and meditation in medical students. An in-progress study by Khalsa S.B. et al. (ClinicalTrials.gov, Identifier: NCT03687450) on their onsite 6-week yoga-based RISE program in resident physicians observed improvements in total burnout, work exhaustion, interpersonal disengagement, stress, resilience, mindfulness, and sleep disturbance (unpublished results).
Yoga has been long culturally accepted in India and is feasible to implement as part of life-style change for improving well-being of individuals. In this context, the research team developed and validated a brief yoga module for postgraduate mental health-care students that could be practiced during their training period. The proposed intervention was envisaged as a health promoting activity that would help the mental health-care postgraduate students in strengthening their innate coping mechanisms and improving their well-being.
| Methods|| |
This study was a nonfunded pre-doctoral research study. It was reviewed and approved by the Institute Ethics Committee, at National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. The study was registered as a clinical trial under the Central Trials Registry-India (CTRI-REF/2019/12/030163). Written informed consent was obtained from the mental health-care students who volunteered to participate in the study.
A mixed method approach was adopted for this research study. An exploratory research design was used to develop the yoga module and a quasi-experimental prepost research design was applied for testing the feasibility of the yoga module. The research was conducted in two phases: (1) Phase I involved the development of the brief yoga module for well-being and (2) in Phase II, the developed Yoga module was tested for its feasibility on postgraduate mental health-care students.
Phase 1: Development and validation of brief yoga module
The researcher reviewed traditional (Patanjali Yoga Sutra and Hatha Yoga Pradipika) and contemporary yogic texts. Published literature on yoga interventions for students in India and abroad was also reviewed. These studies used different yoga modules such as, the Morarji Desai National Institute of Yoga Module for Students, the Swami Vivekananda Yoga Samsthana Module for students and the Positive Health Module of Yoga Appreciation Course in NIMHANS. The existing yoga modules for students were compiled and a list of 92 practices consisting of loosening practices, Asanas, Pranayama, Relaxation, Meditation, and Mantra Chanting were prepared. The practices were then scored by validators (n = 8) based on criteria: (a) Easy in level of learning, (b) self-practice in short time, and (c) able to provide relaxation and well-being. Practical and qualitative inputs for validation of the module were obtained from the experts; such as the duration, number of rounds of each practice, similarity in certain practices, order and modifications within the practice to accommodate the criteria and time duration of the module. The content validity ratio (CVR) was applied to finalize the module and practices. A CVR value of 1 denotes that the retained yoga practices were “essential.” Seventy nine yoga practices which had a CVR scores lesser than 1 and had unfavorable qualitative comments from the validators were removed from the yoga module list. The final brief yoga module for postgraduate mental healthcare students was deduced to 13 practices in total requiring 30-min duration [Table 1].
Phase 2: Feasibility testing of brief yoga module for postgraduate mental health-care students
The brief yoga module for mental health-care students was advertised among new students inducted into NIMHANS during the academic year 2019–2020. For this purpose, a flyer was prepared with the details of the Brief Yoga Module and distributed during the induction of the 1st-year batch. The students were also informed regarding the module, the research study and its objectives by the researcher through personal telephone call, E-mails, and WhatsApp messages. Students who confirmed participation were added to a WhatsApp group created with the objective of sharing information and updates regarding the Brief yoga module. The convenient time for conducting the module was discussed with the members of the group. The recruitment was done in two batches: The first batch consisted of 17 students who attended the 15-day brief yoga module and the second batch consisted of 15 students, of which 4 were repeaters from the first batch.
The module was conducted at the Department of Integrative Medicine, NIMHANS under the supervision of a trained yoga therapist. It was for duration of 15 days and each session was for a duration of 30 min.
The students were assessed before and after the practice of 2-week yoga module on wellbeing, using the Warwick-Edinburg Mental Well-Being Scale on day 0, 15 and 30; while continuous functional near infra-red spectroscopy (fNIRS) recording was performed during Scarborough Tower of London (STOL) task (to assess executive functions) and mirror neuron activation (MNA) task (to assess MNA) on day 0 and day 15. A qualitative interview was also conducted before their enrolment into the program (to understand the expectations from the program and reasons for participation) and after completion (Feedback on the module, trainer, perceived benefits/adverse effects, facilitators, and barriers in attending the programme). The sociodemographic details of the students who participated in the brief yoga program are indicated in [Table 2]. Those who attended at least 50% of the sessions, i.e., a minimum of 8 out of 15 sessions conducted, were considered as adherent (n = 13) and the remaining were considered to be under the nonadherent group (n = 15).
Data were analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY, USA: IBM Corp). The sociodemographic data were analyzed using the descriptive statistics; the outcome variables were analyzed using nonparametric statistics; Mann–Whitney to understand the group effects, Friedman Chi-square test with Bonferroni correction to understand time effects and Pearson's correlation to understand the correlation between outcome variable well-being and the socio-demographic data. The qualitative feedback was content analyzed using thematic analysis and triangulated with the quantitative results to assess the feasibility of the module (Braun and Clarke, 2006).
| Results|| |
The brief yoga program was conducted for 15 days with a total of 28 participants, out of which 13 were adherent and 15 were non adherent. There were no sociodemographic differences between the adherents and nonadherents.
The nonparametric test of Friedman's Chi-square test with Bonferroni correction showed that students who adhered to the yoga module improved in their well-being scores over a period of 30 days (χ2: 12.46, P = 0.002, significance post Bonferroni correction P = 0.017) as compared to those who were nonadherent from the study (χ2 = 4.792, P = 0.091) [Table 3].
|Table 3: Time effects over 30 days in well-being scores (Friedman's test)|
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The Wilcoxon signed-rank test which was conducted for post hoc analysis showed that the adherent group had a significant difference in their well-being scores between the period of starting (Day 0) of the brief yoga module and the end of the module, i.e., Day 15 (Z = −2.936, P = 0.003); however, there was no significant difference in well-being scores post completion of the module (Day 15-Day 30: Z = −1.135, P = 0.256).
The fNIRS results indicated that adherents as compared to nonadherents showed significant deactivation of left somatosensory region (Channel 5) and activation of right primary somatosensory regions (Channel 10) of the brain during the static and active phase respectively of the MNA task. Significant improvement was noted in the reaction time for “Zero-Moves” phase of the S-TOL task.
The qualitative data derived from the interviews brought out a total of 37 themes and 51 subthemes [Table 4] in the areas of reasons for participation, expectations from module, regarding pace and length of module, helpful factors about the brief yoga module and facilitator's style, unhelpful factors about the brief yoga module and facilitator's style, impact of brief yoga module for well-being, what students valued most regarding the brief yoga module, factors that helped in attending module regularly, barriers in attending the module sessions regularly, improvements to the module, barriers for self-practice of the brief yoga module, factors that affect well-being as a postgraduate mental health-care student, suggestions on what students perceived as helpful to promote well-being of postgraduate mental health-care students. Majority of the participants felt that the brief yoga module was “adequate” and 82% rated the intervention program as “good.” 41% of the students reported that the most valued aspect of the program was the experience of going through yoga. The students recommended the brief yoga module for all batches of postgraduate mental health-care students in the institute.
|Table 4: Themes and subthemes generated from qualitative feedback of students|
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| Discussion|| |
The goal of this mixed-method quasi-experimental study was to develop and test the feasibility of a brief yoga module for the well-being of the postgraduate mental health-care students in tertiary settings. For this, the study looked at the experiential account and inputs of the students who participated in the module apart from quantitative outcome measures such as well-being and cognition. This study is one of the few intervention studies conducted on the well-being of mental health-care students. The focus was on 1st-year students who are considered the most vulnerable group compared to the 2nd years or later year students who have adjusted and developed their own strategies to cope with the personal and professional demands of the training period.
In spite of multiple strategies, only 28 students enrolled to volunteer for the research and brief yoga module. This lower enrolment could be due to the multiple factors such as, their awareness and personal attitude toward yoga and its benefits, inability to involve in the research program due to academic and clinical commitments, having no felt need at present for such an intervention, already pursuing other self-care strategies or not preferring yoga, etc., Adherence to yoga has always been discussed as a barrier to test the effectiveness of yoga., This validates the need for a brief yoga module such as the one developed in this study, which showed improved well-being scores in those who practiced yoga for a period of 15 days. This also reflects the finding in several recent studies that like medication or other interventions, yoga needs to be practiced regularly (at least 3 times a week) to obtain significant benefits.
The feasibility of the brief yoga module was measured based on eight parameters described by Bowen et al., i.e., acceptability, demand, implementation, practicality, integration, expansion and limited-efficacy testing. The feasibility of this module ranged from medium to high, whereas adaptability is yet to be tested.
All the participants reported that they would recommend the module for the next batch of students. Positive in-session feedback given by the student volunteers on how they perceived the module, its practice and its effect in their daily life, suggests the acceptability of this module. When the workshop was announced for all students, i.e., even nonresearch students, the increase in the turnout of the participants observed across the workshop sessions indicates a general demand for such an intervention program. The different academic/clinical timings of the postgraduate students stood as a major barrier in their daily participation in the module. The unstructured nature of their work schedule and workload were reported as other barriers apart from few personal barriers such as mood, motivation and health problems. The number of female students was more in the nonadherent group compared to male students. Physical factors such as discomfort due to dysmenorrhea and fatigue were reported by the female students as a barrier in regularly attending the brief yoga module. To enhance the adherence to the yoga module, the module could be adapted in various ways to suit the needs and to overcome some of the reported barriers. Further, the timings of the program could be made flexible with an option of attending the sessions either in the morning or evening. The brief yoga-based workshop program can be easily integrated into the current tertiary mental health-care settings given the moderate demand and high acceptability of the program by both the students and the team at yoga center.
Irrespective of the course of study, the students exhibited similar well-being scores from baseline to follow-up. No other studies have been conducted comparing the well-being of postgraduate students across various mental health-care disciplines. The fact that the well-being of the students who attended more than 50% of the module improved over a period of just 15 days shows that the module was effective in producing effects within this short period of time. The qualitative data of this study and other publish research study also support this finding where the participants perceived improvement in their overall well-being and was expressed as: Feeling energetic, fresh, relaxed, peace of mind, improved concentration, and improved affect. Improvements in happiness, positivity, personal satisfaction, and self-confidence were also seen. It can be easily concluded from the responses that the majority of students were looking forward to improvement in mental health or a self-care routine. A few barriers to self-practicing the module identified in the study are workload, time constraints and lack of motivation which were also identified by Dayananda et al. in their study such as irregularity in lifestyle, occupational commitments as strong barriers; dullness, laziness, physical and mental overexertion, wandering of mind, unsteadiness of mind, procrastination, etc., as the barriers of moderate nature and systemic factors considered to impact the professionals were lack of flexibility and a poor work-life balance.
The MNA task results suggest significant deactivation in channel 5 corresponding to the left primary somatosensory region of the brain for the adherent group as compared to the nonadherent group during Static phase of MNA task. A plausible explanation for the deactivation in channel 5 during Static phase of MNA task without compromising the performance in the task could be improvement in the efficiency of that part of the neural network after the practice of yoga. The group effect between adherent and nonadherents denotes significant activation in the channel corresponding to the right somatosensory region (Channel 10) of the brain in adherents during the active phase of MNA task in comparison to the dynamic phase of MNA task. This indicates enhanced availability of HbO (oxyhaemoglobin) in that area of the brain during the MNA task. While, nonadherents exhibited deactivation in channel 10 during active phase of MNA task in comparison to dynamic phase of MNA task. The zero moves reaction time in STOL task also significantly improved between pre and postyoga intervention in adherents. The absence of other positive results is understood to be due to the low dose of intervention and less mean sessions attended by the participants which is deemed insufficient to show an effect on the fNIRS parameters.
Students' mental health and well-being has been the focus of the Ministry of Human Resource and Development, Government of India, with its “Manodarpan” initiative. Yoga as a part of curriculum for improving mental well-being of students, especially in health care, can be considered as part this initiative along with counseling services, proactive promotive and preventive initiatives and formal support system at workplace, and mental health services to ensure psychosocial safety nets for students. In the current study also, need for self-care and time for self, personal time were some of the recurring themes from the analysis, which reiterate the need to provide this module to students.
The study is the first yoga intervention study in India for postgraduate mental health-care students and had a mixed sample set of mental health-care students from multiple disciplines – M.Phil Psychiatric Social Work, M.Phil Clinical Psychology, MD Psychiatry and M.Sc. Psychiatric Nursing. The quasi-experimental mixed model of the study is one of its strengths as both qualitative and quantitative approaches in data collection and analysis is employed. The study focused mainly only on one primary outcome measure (wellbeing) and a secondary outcome (fNIRS). The repeated well-being assessment (pre, post, and follow-up) at three different points gives better credibility in terms of understanding the results. The study adds to the scarce existing qualitative literature on yoga intervention for mental healthcare students by qualitatively documenting the experiences of participants. The high acceptance of the module indicates the feasibility of upgrading the pilot intervention program and integrating into promotive mental student welfare services. The limitations of this study include: Lack of a control group/waitlisted group due to the time constraints in completing the research, low number of students enrolled in the study, and the high dropout rate.
| Conclusion|| |
A brief yoga module was found to improve the overall well-being and mental health of postgraduate students in a tertiary mental health-care institute. The module was found to be feasible on domains as such acceptability, demand, implementation, practicality, integration, expansion, and limited-efficacy testing. Future research needs to focus on integrating such modules as part of the student well-being initiatives in all mental health-care settings.
We would like to acknowledge and thank Dr. Ganesan Venkatasubramanian (Professor of Psychiatry, NIMHANS), Dr. Sreeraj VS (Assistant Professor of Psychiatry), Dr Bharath Holla (Assistant Professor of Integrative Medicine) for their support in conducting fNIRS in biophysics lab and fNIRS analysis and Dr Mariamma (Associate Professor of Biostatistics) in guiding in the statistical analysis. We also want to thank the staff and researchers from the Department of Integrative Medicine, NIMHANS for their support in conducting this project.
Central Trials Registry-India (CTRI-REF/2019/12/030163).Institutional Ethics Committee number: No NIMH/DO/BEH.Sc.Div./2019-20.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Department of Psychiatric Social Work, Room No: 106, Govindaswamy Building, 1st Floor, National Institute of Mental Health and Neurosciences, Hombegowda Nagar, Hosur Road, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]
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