PSYCHOSOCIAL DETERMINANTS OF ATTENDING YOGA CLASSES: AN APPLICATION OF THE THEORY OF PLANNED BEHAVIOR. Brandon Eggleston

Transcription

1 PSYCHOSOCIAL DETERMINANTS OF ATTENDING YOGA CLASSES: AN APPLICATION OF THE THEORY OF PLANNED BEHAVIOR Brandon Eggleston Submitted to the faculty of the University Graduate School in partial fulfillment of the requirements for the degree Doctor of Philosophy in the Department of Applied Health Science of the School of Health, Physical Education, and Recreation Indiana University February 2009

2 Copyright 2009 by Eggleston, Brandon All rights reserved

3 ii Accepted by the Graduate Faculty, Indiana University, in partial fulfillment of the requirements for the degree of Doctor of Philosophy. Doctoral Committee Alice K. Lindeman Ph.D. Susan E. Middlestadt Ph.D. Bryan P. McCormick, Ph.D. David Koceja, Ph.D. August 8 th, 2008

4 (2009) (Brandon M Eggleston) ALL RIGHTS RESERVED iii

5 iv Dedication I dedicate this dissertation to my parents, Stephen and Susan Eggleston. There sacrifice and support for over 30 years are why I was able to get to where I am today. I would also like to dedicate this to The Maker who has blessed me with such wonderful parents and countless other loved ones. I pray that the work of this project would lead others closer to the Trinity that is God. May the Lord Bless and Keep Us All. I honor the light that is in you which is the same light that is in me. Namaste.

6 v Acknowledgements I would like to first acknowledge my dissertation co-chairs and committee members for all of their time, hard work, and support: Susan E. Middlestadt PhD, Alice K. Lindeman PhD, Bryan P. McCormick PhD, and David Koceja PhD. Second, I would like to acknowledge the Indiana Yoga Association and all participating yoga studios in this study for their support. Third, I would like to thank Wendy Gossard-Gleckler and Healing Spirit Yoga for their support since the beginning of my research in yoga practice. Fourth, I would like to thank Michael Reece PhD for his support of my graduate studies. Fifth, I would like to thank the all of my peers who helped me on this journey: Laurie Legocki PhD, Julie Shertzer PhD, Amanda Tanner PhD, Laurel Stevenson, Sonya Satinsky, Christopher Fisher, and Debby Herbenick PhD.

7 vi Psychosocial Determinants of Attending Yoga Classes The practice of yoga dates back 5,000 years and provides many physical, mental, emotional, and spiritual benefits for individuals that maintain a regular practice (NCCAM, 2007). Yoga may be a form of serious leisure: a voluntary activity that provides a sense of meaning and purpose in an individual s life, and can increase levels of well-being (Stebbins, 2004; Heo, 2007). The purpose of this study was to apply the Theory of Planned Behavior to understand intention to attend at least one yoga class each week for the next three months among individuals who have been attending yoga classes for at least three months (n = 157), and to observe if yoga is a form of serious leisure for individuals who attend at least one yoga class each week. Analysis predicting intention from global constructs of the Theory of Planned Behavior yielded a multiple correlation of 0.62 with beta weights for attitude (0.13, p < 0.05), subjective norm (0.06, ns), and perceived behavioral control (0.56, p < 0.01). Salient factors related to stronger intention to attend at least one yoga class each week included the facilitators of having time; having the money; a good studio location; and believing they will feel better and the advantages of believing that attending will improve flexibility; leading to feeling relaxed; and making one feeling centered. Additionally, perception of yoga as a serious leisure was significantly greater (p < 0.01) for individuals with a self-identified spiritual and committed yoga practice. Perception of yoga as serious leisure did not significantly contribute to life satisfaction. Implications for encouraging a regular yoga practice will be discussed regarding salient circumstances and consequences of attending at least one yoga class each week for the next three months.

8 vii Table of Contents Chapter Pages I. INTRODUCTION 1-7 Statement of Problem 2-2 Research Questions 3 Purpose of Study 3 Significance of Study 3-4 Delimitations, Assumptions & Limitations of Study 5-6 Definitions 6-7 II. REVIEW OF THE LITERATURE 8-39 Stress Management History and Philosophy of Yoga Yoga in the United States Health Outcomes of Yoga Well-Being and Quality of Life Determinants of Yoga Attendance 41 The Theory of Planned Behavior III. METHODS Selection of Participants Research Design 41 Procedures Measures Data Analysis IV. ARTICLE Abstract 52 Introduction Methods Discussion Conclusion References Tables 76-79

9 viii Chapters Pages V. ARTICLE Abstract 81 Introduction Methods Results Discussion References Tables Appendix A: References Appendix B: Data Collection Instrument Appendix C: Path Analysis 130 Appendix D: Bibliography Table Appendix E: Curriculum Vitae 1-7

10 1 I. INTRODUCTION Statement of the Problem Stress has been a part of mankind dating back to the Stone Age (10,000 BC). Evolutionary biologists view stress as a survival mechanism (Seaward, 2006). Today, stress can be defined as the physiological response to an outside event or factor (Bir & Khalsa, 2004). Causes of stress are known as stressors, and have been identified as an event or factor that leads to a physiological response. Stress has been linked to lifestyle of contemporary times, which demands that individuals be very productive citizens of society. A challenge for many individuals living in the United States today is how to properly manage their stress levels (Seaward, 1994). One of the major preventable causes of illness and disease in the United States is stress. Recent research has indicated between 70 to 80 percent of all disease and illness is linked to physiological, psychological, and environmental stress (Seaward, 2006). High stress levels have been identified as a preventable causal factor for mental health illnesses, substance abuse, hypertension, stroke, heart disease, cancer, headaches, migraines, and the common cold (Taylor, 2002; Seaward, 1994). Americans have a variety of methods available to deal with or manage stress (Rani & Rao, 2005). Some of these methods contribute negatively to their health and some positively. Common negative forms of stress management may include not participating in physical activity, emotional eating, and substance abuse (Seaward, 2006). One of the positive forms of stress management for a growing number of Americans is the use of Complementary and Alternative Medicine (CAM) modalities such as yoga, tai-chi, massage therapy, acupuncture, guided imagery, and meditation (DeMichelis, 2004; Seaward, 1994, 2006). A 2004 national survey

11 2 estimated that nearly 7.5% of the U.S. adult population has tried yoga and nearly half of those have practiced sometime in the last year (Saper, Eisenberg, Davis, Culpepper, and Phillips, 2004). The research community s interest in the effects of the practice of yoga has grown in the past two decades. Yoga has been tested as a treatment or therapy for stress and has shown to significantly decrease stress levels for many different types of people (DeMichelis, 2004; Seaward, 2006). Evidence-based research has documented how the benefits of yoga practice have gone beyond the management of stress and yoga is now used as a treatment for individuals with mental illness, heart disease, cancer, and treating acute injuries. Little research has addressed the attitudes, beliefs, and values that surround yoga practice. Science has not been able to explain why individuals begin and maintain their yoga practice (Yogasite, 2006). Yoga practice typically begins and is often maintained by individuals attending a yoga class on a regular basis, usually at least one class each week. Regular attendance to yoga classes is typically the precedent for an individual developing his or her own yoga practice (Iyengar, 2000). A regular yoga practice is a combination of home and group (yoga classes), which leads to many of the positive health outcomes as documented in the scientific literature. One mechanism to increase the practice of yoga in the United States is to increase the number of individuals attending a yoga class, specifically at least once a week (regular attendance). In order to increase participation of individuals into yoga practice it is necessary to understand psychosocial determinants of individuals that attend a yoga class on regular basis (DeMichelis, 2004). Psychosocial determinants may be the key to behavior change from irregular attendance to regular attendance of yoga classes, and then to a regular yoga practice. Research Questions

12 3 1) What psychosocial determinants are associated with intention to attend a yoga class at least once a week for the next three months among individuals who have been attending yoga classes for three months? 2) What yoga practice variables are associated with the perception of yoga as a serious leisure scale? 3) Is perception of yoga as a serious leisure activity associated with life satisfaction? Purpose of Study There were two purposes for this research study. The first purpose of this study was to identify the psychosocial determinants significantly associated with individuals attending at least one yoga class each week. Psychosocial determinants used in this study were derived from the theoretical constructs of the Theory of Planned Behavior: behavioral intention, attitude toward action, subjective norm, and perceived behavioral control (Ajzen, 1991). According to the Theory of Planned Behavior, once the relationships between theoretical constructs and behavior are known, interventions can be developed to target behavioral determinants that are strongly related to the behavior. The second purpose of this study was to identify relationships among level of yoga practice, perceptions of serious leisure, and their life satisfaction. How long and how frequent individuals practiced yoga was defined by number of years of yoga practice, number of yoga classes attended each week, and frequency of yoga practice at home. Significance of the Study To date no published studies could be located that addressed psychosocial determinants for practicing yoga. Numerous studies have been conducted to address health outcomes of practicing yoga, implementing treatment interventions, and determining the social demographic

13 4 characteristics of people who practice yoga (Saper et al., 2004), but it has not been determined why individuals attend classes. This study was designed to provide important information on how theoretical constructs of the Theory of Planned Behavior are associated with the behavior of attending yoga classes. The Theory of Planned Behavior has been applied to many behaviors, but with limited application to behaviors such as yoga class attendance (exercise class attendance and using CAM modalities) (Ajzen, 1991). According to DeMichelis (2004), an author on contemporary yoga practice, individuals often begin their individual yoga practice by first attending a class on a regular basis, and then develop a personal practice of yoga, which leads to many positive health outcomes. The results of this scientific study were designed with the intent of filling in gaps in scientific literature and providing information on what should be addressed in an intervention designed to increase frequency of yoga class attendance. Delimitations of the Study This study was delimited to a rather homogenous population. The study population was primarily female, Caucasian, college educated, years of age, and who had previously practiced yoga for at least three months. Generalizations to groups that differ on these social demographic characteristics may not necessarily be valid. However, the Theory of Planned Behavior assumes that many social demographic differences are not independent of the psychosocial determinants of behavior (Ajzen, 1991). Assumptions of the Study There were three assumptions for this study. 1. Behavioral intention is a good predictor of behavior.

14 5 The Theory of Planned Behavior assumes that an individual s intention to perform a behavior is a strong predictor of an individual actually performing the behavior. The Theory of Planned Behavior also suggests that there are three associated theoretical determinants of intention to perform a behavior: An individual s attitude toward action, subjective norm (who approves/disapproves of behavior), and perceived behavioral control (how much control of performing the behavior an individual has). 2. The attendance to yoga classes is a good predictor of yoga practice. A majority of individuals that develop a long-term yoga practice begin by attending a class from an experienced/trained yoga instructor. Yoga classes provide personal insight and attention for beginning yoga students, which provides an increase in the knowledge and efficacy of the poses. Individuals attend yoga classes for the purpose of having someone present who is able to guide them through a sequence of poses and to demonstrate how to do the yoga pose. 3. Yoga is practiced for many different positive health outcomes. The motivation and purposes for individuals to practice yoga are diverse. Dimensions of health addressed in yoga practice are physical, psycho-social, and spiritual. Each dimension of health has multiple benefits associated with yoga practice. Physical health motivations may be therapeutic, e.g., resolving low-back pain, headaches, insomnia, controlling diabetes, or preventative, such as flexibility, strength, and balance. Psycho-emotional health motivations for practicing yoga may include stress management, addressing mental health issues (depression and anxiety), and to improve ability to mentally focus. Spiritual health motivations for yoga practice are related to multiple religious beliefs both theist (Islam, Christianity, Hindi, and Judaism) and atheistic/agnostic.

15 6 Limitations of the Study The study was limited to observing the relationship of Theory of Planned Behavior constructs and an individual attending a yoga class. The only health outcome measured in this study was life satisfaction. The study did not measure any other health outcomes or other changes that individuals could attribute to the practice of yoga. Only individuals from yoga studios in the State of Indiana provided data and all data were self-reported. Definitions 1. Regular attendance of a yoga class is defined as attending at least one class each week over the past two months. 2. A yoga class is defined as a mind-body or exercise class/session with yoga in its title or description. A yoga class must practice poses and postures based from Hatha or one of its subsidiary styles of yoga (most listed in the survey instrument). 3. Yoga practice is defined as the regular act of using postures, breathing techniques, and meditation. Traditional yoga practices are practiced daily and more modern practices range in frequency from two to seven times each week. 4. A theoretical construct is defined as a systematic arrangement of ideas based on a specific theory or theories. 5. Attitude is defined as a set of beliefs related to the action of performing behavior with respect to the outcomes of behavior. Attitude is an overall evaluation of the behavior. 6. Subjective norm is defined as a set of beliefs about whether most people or approve or disapprove of the behavior. 7. Perceived behavioral control is an overall measure of perceived control over performing behavior.

16 7 8. Serious leisure is a voluntary activity that provides a sense of meaning and purpose in individual s life. 9. Life satisfaction is the degree to which individuals are content with choices and their outcomes over the course of their lives.

17 8 II. LITERATURE REVIEW Synopsis of the Literature The following chapter will examine scientific literature, history of yoga, and some health related fields. The first section will examine the health issue of stress in the United States and techniques used to manage and/or decrease stress levels, which includes the practice of yoga. The second section will examine the history and philosophy of yoga practice. Third, yoga practice in the United States will be reviewed to provide a background of its application and use. Fourth, a section on quality of life and well-being will review literature on measuring psychosocial wellness. Fifth, there will be a short summary on the lack of scientific literature on the psychosocial determinants of yoga practice. Lastly, a review of the Theory of Planned Behavior and its applications will be provided. Stress Management Stress can be defined as the physiological response to a physical, physiological, or psychosocial factor (Greenburg, 2006). A second definition from Seaward s Managing Stress (2004) is the experience of a perceived threat (real or imagined) to one s mental, physical, or spiritual well-being, resulting from a series of physiological responses and adaptations. Researchers have estimated that 70 to 80% of disease and illness in the United States is related to stress (Seaward, 2004). As of the year 2000, the leading causes of death in the United States were predominately lifestyle diseases, whose pathology develops over many years. Lifestyle diseases include cancer, heart disease, cerebrovascular diseases, chronic obstructive pulmonary diseases, and diabetes. Lifestyle diseases are far mostly preventable because they are directly related to habits and behaviors (Seaward, 2004; CDC, 2004). In the United States since 1980, there has been an increase in stress-related illnesses, and it is believed to be associated with

18 9 decreased opportunities for relaxation and leisure (Seaward, 2004). Individuals working the United States have increased expectations of working harder, longer, and being more productive in the workplace (Seaward, 2004). Each individual reacts to situations and events in life differently including in terms of their stress levels. Factors that cause a stress response in the body are called stressors, and there are many different situations and factors can cause a stress reaction. Theories on stress commonly agree that there are two types of stress, good and bad. Positive stress, called eustress, motivates individuals to perform at an optimal level. Negative stress, called distress, degrades an individual s ability to perform a given action (Greenburg, 2006). Distress is what many individuals commonly call stress in the United States, and this is why stress has a negative association to it. Initial stress is generally viewed as eustress until an individual reaches a threshold, at which the stress then becomes negative for the individual. An individual s ability to withstand stress and keep it as a positive, motivating factor varies from person to person and from day to day. Age, genetics, personality, environmental factors, and personal history all play a role an individual s response to stress (Seaward, 2004). Public health professionals have recognized the increase of stress-related illnesses, and have begun to promote various stress management techniques. Health educators have identified a variety of ways to deal with stress such as yoga, massage therapy, physical exercise, tai-chi, art therapy, music therapy, journal writing, biofeedback, meditation, mental imagery, and progressive muscle relaxation (Seward, 2004). Each stress management technique does not necessarily appeal to all people, which is why health educators have researched a variety of ways that are effective in decreasing negative stress (Greenburg, 2006).

19 10 History and Philosophy of Yoga Historians have uncovered seals with inscribed yoga poses dating back to 3,000 BC as the earliest record of yoga practice. Some experts hypothesize that yoga dates back as far as the Neolithic Stone Age and the time of Shamanism around 8,000 BC (DeMichelis, 2004). The term yoga was first used in the Sankhya philosophy of Buddhi, which means mind. The Buddhi philosophy focused around two entities that could be joined (yoga) which were Prakriti (nature) and Purusha (spirit). The original philosophy of yoga (2,500 BC) mentioned no deity in its foundational beliefs. However, in 1,500 BC, early Hindus adopted the principles of Prakriti and Purusha and applied them to the gods Shiva and Shakti, respectively. Shiva and Shakti formed a union (yoga) believed to have led to the creation of Earth. The adaptation of yoga to the Hindu culture led to the rise of Shamanism where early yoga techniques and ways of living were developed (Iyengar, 2000). Shamanism was founded on similar principles of living that are found in current yoga practice. A distinct difference between Shamanism and traditional yoga practice is that Shamanism focused on the community where yoga focuses on the self (DeMichelis, 2004). The first period of yoga practice is the Vedic or Archaic period (3, BC) within the style of practice is simply termed Vedic Yoga (Iyengar, 2000). Vedas are sacred scriptures from Brahmanism, the precursor to Hinduism. Vedas worshiped a divine power and preached for individuals to work past limitations of the mind and body. Leaders of this type of yoga were called Rishis and were seen as being able to view the ultimate reality of life. Rishis taught of both community and individual enlightenment through yoga practices. The Rishis taught Vedic yoga and preached Vedic yoga, leading to the development of isolation practices, part of present day yoga practice (Anatharman & Kabir, 1984).

20 11 The second period of yoga history, Pre-Classical Yoga, dates from 1500 BC-50 AD. This period continued the isolation practices and teachings of Vedic yoga and is distinguished by the creation of the Upanishads. The Upanishads were spiritual leaders who wrote the final 200 sacred scriptures that the Rishis started (DeMichelis, 2004). Specifically these teachings revolved around the teaching of the ultimate reality, the transcendental man, and the relationship between these two (Iyengar, 2000). These three principles formed the basis of yoga philosophy: Yoga is the recognition of the divine within the self, outside of the self, and the connection between the self and others outside the self. Around 500 BC, the first scripture specific to yoga was written known as Bhagavad-Gita or Lord s Song. The principle message of this text described how difficulties would be overcome by actions that are outside the individual s ego (Anatharman & Kabir, 1984). The Gita also mentioned three of the branches of yoga practice: Jnana (knowledge), Bhakti (loving devotion), and Karma (selfless actions). Three additional branches of yoga would later be developed: Hatha (Physical Mastery), Mantra (sound), and Raja (royal branch) (Iyengar, 2000). The Classical period of yoga began in the first century ( AD) marked by the Yoga Sutra, written by Patanjali in the second century. The Yoga Sutra is the sacred text of traditional modern yoga. This document produced the eight limbs of yoga: Yama (moral code), Niyama (self-discipline), Asanas (postures or poses), Pranayama (breath), Pratyahara (detachment from senses), Dharana (concentration), Dhyana (meditation), and Samadhi (ecstasy). A paradigm shift began at this time period with a focus on separating body and spirit for the purpose of cleansing the spirit (Patanjali & Woods, 2003). This shift led many yoga practitioners to ignore physical practices of yoga (specifically postures and poses) and focus on meditation. A focus on separating body and spirit was a contrast to the unification principle of body and spirit that was

21 12 part of the foundation of yoga s early teachings. However, by the end of the classical period there was a philosophical shift back to the focus on both the spirit and body (Iyengar, 2000). The beginning of the Post-Classical period of yoga is believed to have begun a few centuries past the writings of Patanjali in the fourth century AD ( AD) (Patanjali & Woods, 2003). Vedic principles were rejected, and a focus was placed on the physical body as a means to spiritual enlightenment. The style of yoga practiced today was developed during this Post-Classical period of yoga. The focus of this period was on five principles taken from previous periods of yoga: Savasana, asanas, pranayama, ayurvedic diet, and Dhyana (Iyengar, 2000). These five principles focus on an individual s ability not to control change, but rather instead to be able to accept change (Anatharman & Kabir, 1984; DeMichelis, 2004). Contemporary yoga has incorporated the five principles into an active part of yoga practice and lifestyle. Savasana is a term for rest, and incorporated as a short rest and final pose in most yoga classes today. Savasana is also known by the name corpse pose because an individual lies on his/her back with legs and arms extended, but relaxed. The purpose of savasana is to relax and rest the body, and to bring the body back to balance after performing asanas (Iyengar, 2000). Asanas are commonly referred to as the poses or postures of yoga practice. Many asanas have a range of level of difficulty from a basic pose to a full advanced version of the pose. Poses and postures of yoga practice increase strength, flexibility, and balance. Asanas comprise a majority of the time spent in yoga classes today (Iyengar, 2000; DeMichelis, 2004). Pranayama refers to an individual being mindful of breathing while practicing asanas. Pranayama is also defined as mindful, relaxed, and controlled breathing (Iyengar, 2000). Most yoga classes begin with basic sets of breathing exercises in which an individual breathes in only through the nose and primarily exhales through the nose as well (Anatharman & Kabir, 1984).

22 13 Breathing through the mouth should be practiced only when it is required in the specific pranayama or asana, or when the practice becomes too vigorous for nostril breathing only (Seaward, 2004). Pranayama s specific purpose is for an individual to maintain a regular rate of inhaling and exhaling, and typically the exhale is held out for a longer period than the inhale (DeMichelis, 2004). The fourth principle of proper diet is directly influenced by ayurvedic medicine. Ayurveda is a holistic medicine that focuses more on treating the cause of illness rather than the symptoms. An ayurvedic diet is not as commonly practiced in the United States compared to the principles of savasana, asanas, and pranayamas. However, research has shown there to be a strong positive correlation between yoga practice and healthy weight for middle-aged adults in the United States (Anatharman & Kabir, 1984). Researchers attributed this strong correlation more to a healthy diet and lifestyle of middle-aged adults that practice yoga than to the physical practice of yoga itself (savasana, asanas, and pranayamas) (DeMichelis, 2004). The principle of dhyana is practiced with varied frequencies and techniques among various styles of yoga. Dhyana is the principle of meditation and positive thinking. Dhyana focuses on being mindful of oneself and on the present moment, and not focusing on personal desires. An outcome of regular practice of dhyana is being released of selfish desires that lead to the bondage of self. Bondage of self is a spiritual term that refers to an individual being imprisoned or controlled by selfish desires. Dhyana focuses more on the spiritual, psychological, and emotional dimensions of health, and less on the physical dimension. Dhyana is sometimes taught separately from the other four principles because it does not involve any physical activity (DeMichelis, 2004). As a result of practicing the five principles of post-classical yoga, a new definition of fitness evolved around three requirements: First being aware of breath;

23 14 second, feeling light in the body, and third; having the ability to accept change (Iyengar, 2000). This definition of fitness is different than a modern definition of fitness, which is the state or condition of being fit, suitable, or appropriate (Seaward, 2004). Most of the common knowledge of yoga practice and philosophy comes from the sacred documents of the Yoga Sutra. Many yoga practitioners follow teachings of the Yoga Sutra such as other sacred texts such as the Holy Bible, Torah, and Koran (Iyenagar, 2000). A definition of yoga from the Yoga Sutra teachings is more abstract than contemporary definitions. Work alone is your privilege, never the fruits thereof. Never let the fruits of action be your motive; and never cease to work. Work in the name of the Lord, abandoning selfish desires. Be not affected by success or failure. This equipoise is called Yoga. (Patanjali & Woods, 2003) Another definition by the Kathopnishad describes yoga in both a philosophical and physical framework. When the senses are stilled, when the mind is at rest, when the intellect wavers not- then, say the wise, is reached the highest stage. This steady control of the senses and mind has been defined as Yoga. He who attains it is free from delusion. (Patanajali & Woods, 2003) Modern and contemporary yoga is based on Patanjali s contribution that describes the metaphysical nature of yoga through the explanation of the union of the body and mind. Patanjali describes eight shapes or limbs of yoga known as ashtanga or astanga: Yama, niyama, asanas, pranayama, pratyahara, dharana, dhyana, and samadhi (DeMichelis, 2004). Yama and Niyama are each composed of five parts for a total of ten guidelines for living. Many theologians and philosophical scholars view Yama and Niyama as being synonymous or at least very closely related to the Ten Commandments of Judaism and Christianity (Anatharman & Kabir, 1984). Yama is defined simply as self-control or self discipline. Yama is composed of five parts: Ahimsa (non-injury), satya (truthfulness), asteya (non-stealing), brahmacharya (celibacy),

24 15 and aparigraha (non-hoarding of material objects). Niyama is defined as rules for regulating life. The yama focuses on the precepts which are universal or general, whereas the niyama focuses on the rules of conduct for individual. The five parts of the niyama are shaucha (purification), santosha (contentment), tapas (penance by practicing austerities), svadhyaya (self-study of sacred texts), and ishvara pranidhana (meditation on God) (DeMichelis, 2004). The third limb of ashtanga yoga is asana which has been previously described as body postures or poses. The fourth limb is pranayama or control of the breath. Asanas and pranayamas are the two most common limbs practiced in the United States. The fifth limb is pratyahara or the reaction of the senses. The sixth limb is dharana or fixation of attention. The seventh limb is dhyana or devotion and fusive apprehension. The eighth and final limb of ashtanga yoga is samadhi or ecstasy (fully integrated consciousness) (DeMichelis, 2004; Iyengar, 2000). Yoga was first introduced to Western countries in the 19 th century in part as a result of the British occupation of the Indian Peninsula. Popularity in the United States rose from the rise of counterculture principles of the 1960 s. Post-classical philosophies transcended into the modern era of yoga practice. (DeMichelis, 2004). Yoga in the United States The practice of yoga came to the United States sometime towards the end of the 19 th century and beginning of the 20 th century from British businessman and immigrants. However, it did not begin to gain significant popularity until the 1960s and 1970s. The early appeal of yoga in the late 19 th century was that it was a different opportunity to gain a perspective on a better life by acquiring a broader worldview through principles of Hinduism and Buddhism (Iyengar, 2000; DeMichelis, 2004). As suggested previously, the decade of the 1960s was a time when alternative worldviews (counterculture movement) gained popularity. Many kinds of artistic

25 16 expression and an increased power of communication through media sources spread new ideas and ways of thinking throughout the United States. The anti-vietnam War cause, Civil and Equal Rights Movements, and the development of a global consciousness are all examples of the decade s paradigm shift to post-modernism. The philosophical assumption of post-modernism was a rejection of modernism. The shift provided opportunities of new ways to gain insight through practices of Eastern cultures and practices such as yoga. A common practice of many Eastern cultures is meditation, and yoga is often viewed as a moving meditation or meditation with physical movement (DeMichelis, 2004). Yoga in the United States steadily gained popularity from the late 1960s through the 1980s. Yoga s popularity accelerated in the 1990s with a broader appeal of the physical benefits that are a result of regular practice of yoga. A body type was identified with yoga described as a lean, muscle-toned, and long body (Reder, 2001). A second appeal of yoga practice involved the relaxed mindset that many regular yoga practitioners demonstrated. A growing stereotype of individuals that practice yoga was that they are calm, peaceful, and centered in mind, body, and spirit (DeMichelis, 2004). A third appeal of yoga was an alternative lifestyle that could complement the physical practice. Yoga was seen by many as a complement to ayurvedic medicine/lifestyle. The diet recommended by many yoga experts limits or excludes highly refined or processed foods, high fat foods, and red meat. A common principle of yoga leaders is to not live with the purpose of eating, but rather to eat to extend quality and quantity of life. A coined phrase used by the International Association of Yoga Therapy is eat to live, don t live to eat (IAYT, 2007). The yoga lifestyle also recommends simple living and to focus on the present moment as opposed to the past or future. In addition to mindfulness of the present moment, the yoga sutra teaches to

26 17 focus on the spiritual principles of living and less on obtaining physical possessions and fulfilling desires of the flesh (DeMichelis, 2004). The rise of yoga practice in the United States correlated with the rise in use of many different types of Complementary and Alternative Medicine (CAM) techniques in the 1990s. CAM gained popularity in the 1990s because of the rising number of individuals living with chronic diseases in the United States. The Centers for Disease Control and Prevention (CDC) continued to shift its focus to find new effective methods of preventing chronic illnesses including heart disease, cardiovascular disease, and cancer. The combined interests of the CDC and U.S. Congress in CAM led to the founding of the Office of Alternative Medicine (OAM) in After seven years, OAM s status was elevated to a center of the National Institutes of Health, and was renamed the National Center for Complementary and Alternative Medicine (NCCAM). Today NCCAM funds millions of dollars of research projects that test the efficacy of many different CAM modalities and currently supports over 250 studies (NCCAM, 2008). As the 21 st century began, the use of CAM techniques continued to gain popularity evident by the growth of NCCAM, which is one of fastest growing NIH centers. In 2004, the first U.S. national yoga survey was conducted (Saper et al., 2004). The popularity of yoga grew without the direction from a specific national organization, and very little was known on how many people practice, demographics, what styles of yoga are practiced, and where individuals practiced yoga. Results from Saper s study estimated that 15 million Americans had tried yoga at least one time in their lifetime, which was 7.5% of the U.S. adult population aged between 15 and 64 (200 million). A second estimation was that approximately 3.8% of the U.S. adult population had practiced yoga sometime in the previous year. Individuals that practiced yoga

27 18 were more likely to be female, Caucasian, college-educated, liberal, and non-religious (Saper et al., 2004). A study conducted in examined sociodemographic factors associated with the use of CAM practices (Conbroy et al., 2005). Previous research had identified sociodemograhic factors for conventional or Western medicine, but it was unclear if the same factors applied to CAM practices. Results from this study showed that individuals practicing CAM were more likely to be educated, not married, above thirty years of age, and to be Caucasian. Twenty-three different CAM practices including yoga, were analyzed for differences between users and nonusers. Conclusions revealed that sociodemographic factors did vary between CAM techniques and that many CAM modalities should be analyzed individually and not as a group. Differences in frequencies of practicing modalities of CAM were shown with the common practice of prayer (38%), osteopathy (79%), and chiropractic (37%) versus less frequent practices such as yoga (1.5%) and guided imagery (6.9%). Demographic differences (gender, age, race/ethnicity, were found among CAM techniques indicating that individuals using multiple types of CAM techniques varied from each other as much as those from non-cam users (Conbroy et al., 2005). A study conducted among individuals aged 65 or older found that 67% had used a CAM modality (Bell et al., 2006). The most commonly reported type of CAM was prayer with over 60% reporting the practice of prayer for better health. CAM use, excluding prayer, was 27% for those surveyed. Leading types of CAM used by adults aged 65 or older were prayer, relaxation techniques, non-vitamin/non-mineral natural products, and chiropractic medicine. Frequency of yoga practice among adults surveyed aged 65 or older was less than one percent (Bell et al., 2006). Use of CAM among older adults aged 65 or older (senior citizens) has grown since 1990 in the United States (Bell et al., 2006). Two groups of interest were analyzed in this study,

28 19 seniors who have been clinically diagnosed with hypertension and seniors without hypertension. The most frequently mentioned CAM technique was prayer with over 59% of seniors with hypertension and 53% without hypertension reporting use of prayer in the past year. Non-vitamin, non-mineral biologically based techniques were the second most frequently reported technique (11.8% hypertension, 14.4% non-hypertension) and third were relaxation techniques (9.1% hypertension, 8% non-hypertension). Yoga, tai-chi, and qigong were combined into one group of activities; 1.5% of seniors with hypertension reported use and 2.7% of seniors without hypertension reported use in the last year. Seniors that reported CAM use in the past year for any type of treatment or therapy reported use of yoga, tai-chi, and qigong 22% (hypertension) and 19% (non-hypertension), respectively (Bell et al., 2006). An online yoga survey of over 200 individuals who practiced yoga and used the website yogasite.com found that (Yogasite.com, 2006) over 90% of those surveyed practice postures (asanas), less than half meditated, and less than half practiced breathing exercises (pranayama). About 60% of individuals believed they were mindful of their diets, and 38% self-identified as vegetarian. The most popular yoga styles were Iyengar (25%), Ashtanga (23%), and Kundalini (22%). Less popular yoga styles were integral, kripalu, sivananda, and bikram. Fifty-six percent of those surveyed practice yoga to relieve mental and/or physical issues. About 55% reported that they first began their yoga practice to obtain relief from stress and 68% still reported that they felt stressed or anxious very often. Forty-two percent reported that they practiced yoga as a primary spiritual discipline (Yogasite.com, 2006). Almost two-thirds of those surveyed by Yogasite.com viewed themselves as healthier than the average American. Most individuals reported that they practiced yoga three to five times a week. Sixty percent attended yoga classes and forty percent practiced on their own. A most

29 20 respondents were female (64%); and with little difference in marital status: 43% married, 41% single, and 16% non-responding. Limitations of this survey were its sample size of 200 and it was conducted in 1998, which was six years prior to the larger study conducted by Saper (Yogasite.com, 2006). Media in the United States has focused its interest in marketing and advertising yoga, confirmed in print, radio, film, and television ads, which have been more likely to depict women, Caucasians, and college-educated individuals practicing yoga (Conbroy et al., 2005). Yoga has become a symbol of a physical activity that contributes positively in many areas of well-being. Yoga has been advertised as a complete workout for both body and mind because of its ability to tone the body and mind (Orsini-Meinhard, 2005). Yoga s effect on the mind and emotions is part of why yoga is a popular stress management technique, which is the most common way yoga is advertised by the American media (Bonadies, 2004; Rossler et al., 2006) The American media also promotes yoga as a physical activity that leads to improved physical health (DeMichelis, 2004). Many publishing companies now use pictures of individuals practicing yoga for covers of general books on health and wellness. Physical well-being has become a popular marketed benefit/outcome for yoga (Orsini-Meinhard, 2005). The result of the mass media market for yoga has led to Americans spending over 27 billion annually on yoga products (Yogasite.com, 1998; Orsini-Meinhard, 2005). Numerous sources have identified yoga as an emerging CAM technique in the United States because yoga provides many different health and wellness benefits. One of the sources is the interest in the research community which has seen a more than ten-fold increase in the number of peer reviewed journal articles on yoga from (DeMichelis, 2004). A second source is the growth and development of NCCAM in both the number of projects and amount of

30 21 funding for research (NCCAM, 2008). A third source is recent national surveys, which show how yoga practice in the United States has grown from a few thousand in the 1960s to over 7.6 million forty years later (Saper et al., 2004). A fourth source is the various forms of media which use yoga as a marketing tool in film, television, books, periodicals, and other forms of media (DeMichelis, 2004). Health Outcomes of Yoga The increased popularity of CAM has led to an increase in the number of evidence-based research studies. For centuries, Ayurvedic physicians have taught how yoga practice can lead to positive health outcomes (Iyengar, 2000). Today researchers provide scientific explanations for health outcomes that are associated with consistent practice of yoga (Baer, 2003). Studies examining the outcomes of yoga practice have ranged from treatment for stress-related disorders, to depression, anxiety disorder, obesity, heart and cardiovascular disease, cancer, low-back pain, insomnia, and other health outcomes (Brazier, Mulkins, and Verhoef, 2006; Patel, 1975; Peck, Kehle, Bray, and Theodore, 2005; Rao, 2005; Raub, 2002; Seaward, 2004; Vedamurthachar et al., 2006; Waelde, Thompson, and Gallagher-Thompson, 2004; Wilson, 1982). Preliminary research indicates that individuals often start yoga as a way to manage stress (Yogasite, 2006). A review of the literature conducted in 2007 found fifteen studies on yoga and stress (Grossman, Niemann, Schmidt, and Walach, 2004; Gura, 2002; Yogendra, Ambardekar, Lele, Shetty, Dave, and Husein, 2004). The definition of yoga varied in each research study with some using only the stretching component of yoga (asanas), others using only controlled breathing (pranayama), or meditation (dhyana), and a few used a combination of all three yoga components. Stress has been linked to 70-80% of disease and illness in the United States (Seaward, 2004). Stress has been strongly related to mental health conditions such as clinical

31 22 depression, generalized anxiety disorder, and substance abuse/addiction (Khalsa, 2004; Onciul, 1996). In a study of athletes, Ryba (2006) found that yoga practice provided periods of rest. Yoga poses reportedly allowed the athletes to feel both the effects of the posture and their bodies returned their natural state. Ryba concluded that yoga was effective in muscle recovery and rest for athletes. Stress is often related to an individual s lifestyle and occupation, with factors of highstress producing negative health outcomes for individuals. A recent study conducted on care givers for patients with dementia tested the efficacy of different stress-management techniques. Primary caregivers were identified as having high-stress levels with an increased rate of depression, anxiety and limited self-efficacy to reduce stress. An intervention using Kabat-Zinn s mindfulness meditation program was implemented on a weekly basis for six weeks for 12 caregivers (a combination of meditation and yoga). Results from this study (Waelde et al., 2004) concluded a significant decrease in the amount of depression and anxiety symptoms and increased self-efficacy to manage stress levels related to their occupation for individuals post treatment. Roosevelt University s Stress Institute is a leading national research institution, and has identified yoga stretching as an effective method for increasing relaxation and improving multiple stress-related variables including energy, awareness, joy, mental quietness, and disengagement (Ghoncheh & Smith, 2004). Researchers did acknowledge that yoga stretching has limited benefits if it only addresses aspects related to physical health. A comparison study was made between yoga stretching Progressive Muscle Relaxation (PMR). Yoga stretching incorporates postures and poses taken from yoga and removes elements focused on the breath, mindfulness, and other traditional practices. PMR combines stretching techniques (physical), and

32 23 using components of the Attentional Behavioral Cognitive (ABC) relaxation theory (psychological and emotional) for a comprehensive treatment for stress. ABC relaxation theory measures fifteen states that are associated with complete relaxation. Results indicated that over time individuals who practiced PMR had higher levels of joy, mental quietness, and physical relaxation, and lower levels of disengagement. Results from this study showed a greater reduction of stress-related variables came from techniques that focused beyond the physical symptoms of stress such as mind-body exercises. Individuals that used mind-body exercises such as PMR with ABC relaxation had greater stress reduction than stretching alone. Mind-body exercises treated more symptoms and causes of stress compared to physical exercise including stretching alone (Ghoncheh & Smith, 2004). West, Otte, and Gher (2004) researched the effects of Hatha yoga on stress levels of 69 college students. The goal of this study was to observe the immediate changes of stress levels caused by one of three treatments: yoga, African dance, and biology lecture. Pre and post measures were taken for perceived stress, positive and negative affect, and salivary cortisol levels. Results found a significant (p < 0.05) pre-post decrease in perceived stress, negative effect, and salivary cortisol levels of individuals who participated in a yoga class and in an African dance. The only significant pre-post effect for individuals in the biology lecture on stress was a significant decrease in positive mood. The authors concluded that over time an educational intervention on stress was not as effective as mind-body activities such as yoga and African dance (West et al., 2004). A study by Brazier et al. (2006) examined the effect of yoga and meditation as treatment for stress/anxiety among individuals living with HIV. Individuals were randomly assigned to either a yoga/meditation group or a control group which received no treatment for stress/anxiety.

33 24 Participants were measured at five different time points over the course of a 12-week yoga/meditation program. The instrument used to measure mental health was the MOS-HIV Health Survey. This MOS instrument measures nine dimensions of mental health: anxiety, depression, loss of control, positive effect, emotional ties, life satisfaction, psychological distress, psychological well-being, and a mental health index. Results from a repeated measures analysis identified that participants in the yoga/meditation group had significantly higher levels of positive affect, psychological well-being, and mental health index than the control group. Qualitative analysis found similar results with a theme of being okay and moving towards a greater level of well-being for individuals that were in the yoga treatment group versus those in the control group (Brazier et al., 2006). Findings from this study seem to suggest that yoga and meditation may lower stress levels for individuals living with a life-changing diagnosis like HIV. A study on stress management looked to find differences between Cognitive Behavioral Therapy (CBT) and yoga. Individuals were randomly assigned to a group and measured ten times over the course of four months. Results from this study found significant decreases in most stress variables over time for both treatments. However, there were no significant differences between CBT and yoga treatments. Conclusions from this study were mixed because there was no control group and no difference between the two types of treatment. However, there was a significant association (p < 0.05) for yoga being able to decrease stress levels in both psychological (perceived stress, stress behavior, exhaustion, anger, and quality of life index) and physical (heart rate, blood pressure, adrenaline, noradrenalin, and cortisol) measures related to stress (Granath, Ingvarsson, von Thiele, and Lundberg, 2006). A meta-analysis (Pilkington, Kirkwood, Rampes, and Richardson, 2005) identified studies examining evidence that yoga was an effective method to treat depression. The meta-