Abstract
Objectives:
The authors explored the feasibility of virtual yoga-based breathwork and meditation among health care workers (HCW) during the COVID-19 pandemic.
Methods:
Consented employees of a large cancer center accessed a video of breathwork called “Simha Kriya” to be practiced for 4 weeks.
Results:
Of 217 participants who expressed interest within 2 weeks, 90 were recruited to the study in 1 month and 100 in 2 months. Of 69 participants who provided data between weeks 1 and 4, 77% perceived the intervention as useful.
Conclusions:
Yoga-based breathing practices were feasible and acceptable among HCW in the setting of a pandemic.
Introduction
Stress, fear, chaos, and anxiety has invaded everyone's life during the COVID-19 pandemic. Burnout and stress have been well documented, especially among health care workers (HCWs) and others at the pandemic's forefront. 1,2 There is a critical need for wellness resources during these unprecedented times. 3 –5 Yoga, meditation, and mindfulness have been reported to reduce stress and improve quality of life in healthy volunteers and cancer survivors. 6,7 An integral part of yoga is breathwork, which is traditionally called pranayama. Breathwork, or pranayama, has been found to enhance lung volumes and capacities. 8 There are several types of pranayama exercises varying in technique relative to rate and style of inhalation and exhalation, breath retention, exhalation technique, and use of mouth versus one or both nostrils to name a few. Since COVID is a respiratory virus, pranayama techniques might improve lung health and prevent and alleviate lung damage from the disease, and research is needed to test this hypothesis. In addition, yoga can also enhance the immune system. 9 In this study, the authors describe the interest, feasibility, and acceptance of a pranayama and meditation program that was virtually delivered, involving 5-min breathwork and meditation among employees at a large cancer center.
Methods
Participants
All employees of the University of Texas MD Anderson Cancer Center were eligible to participate. Participants were recruited from MD Anderson employee announcements and institutional websites after approval by the institutional review board. The authors excluded participants with epilepsy, brain aneurysm, pregnant or trying to get pregnant, brain bleeding in the past year, >70 years of age, recent abdominal surgery, and not cleared to exercise. Eligible participants were directed to detailed information about the study procedures and consented electronically.
Study procedures
A survey was completed at study recruitment, before receiving the breathwork video, and then again 1 and 4 weeks after starting the breathing practices. The authors measured adherence weekly.
Intervention
After the initial data collection, participants were sent a link to the video with instructions. The breathing practice and meditation that was tested in this pilot study is called “Simha kriya.” It was designed by Sadhguru, a Yogi and founder of Isha Institute of Inner Sciences. The rationale for choosing this practice is that it is short (only 3 min of breathing and 2 min of meditation), easy to learn, and is thought to increase lung capacity and the relaxation response.
The meditation details are attached in Supplement A. Briefly, the practice consisted of a three-step breathing practice: (1) forced exhalation with tongue sticking out (dog-like) for 21 times normally paced; (2) forced exhalation with tongue rolled upward for 21 times normally paced; and (3) breath retention for 30–60 sec. This was followed by a 2-min meditation, a total of 5 min. Participants were encouraged to practice one to two times daily for 4 weeks. Participants were in contact with the study team via e-mail for questions. Based on early feedback, the authors also added online practice sessions weekly for the participants to interact with the principal investigator to get their practice corrected and any questions answered.
Measures
The authors used the Research Electronic Data Capture (REDCap) database to record all outcome measures. 10 Participants reported how many times a day and how many days a week they practiced the technique. They completed the form on a weekly basis. Meditation perception questions were asked such as usefulness, feeling at peace, hopeful, or relaxed (Table 2), and responses were recorded as strongly agree, agree, neutral, disagree, and strongly disagree at weeks 1 and 4. 11 Participants also completed other questionnaires, and reported their breath holding time, which are currently being analyzed and will be reported elsewhere as secondary outcomes.
Responses to the Meditation Perception Questionnaire at Week 1 and 4
Not all participants answered these question (1–4 missing responses).
Statistical analysis
The primary outcome of this study was the feasibility. Feasibility was defined as having 50% of eligible participants consent to the study within 2 months of starting recruitment—50 out of 100. Program acceptability was defined as more than 50% of participants perceiving the intervention as useful. The authors used descriptive statistics to summarize the demographic variables and meditation perception questions using STATA-14.
Results
Within 2 weeks, 217 people expressed interest in participating in the study. The authors approached the first consecutive 139 participants for initial study screening. One participant was ineligible, and 100 participants consented (72%). The first 90 participants were recruited within 1 month and 100 participants within 2 months. Throughout the study period, 12 participants withdrew. Reasons for withdrawal were time constraints (2), health issues (1), death in the family (1), disliking the intervention (1), and no reasons specified (7).
Participant characteristics are summarized in Table 1. Of the 88 patients who participated in the study, week 1 data were provided by 69 participants, and week 4 data by 56 participants. At week 1, participants reported meditating a median of 3 times a week (interquartile range [IQR] 2–5), with 32 of 69 (46%) practicing at least 4 times a week and only 8 of 69 (12%) reported being unable to meditate. At week 4, participants reported practicing a median of 4 times a week (IQR 2–5), with 28 of 56 (50%) practicing 4 or more times a week and only 6 of 56 (11%) indicating they were not able to meditate.
Demographic Characteristics of Participants
Not all participants answered these questions.
Table 2 summarizes the participant's overall perception of the practice. Sixty-nine participants (69%) provided some data between weeks 1 and 4. Not all participants responded to all questionnaires. Fifty-three of 69 (77%; or 53% of n = 100) indicated “strongly agree or agree” that the breathing techniques and meditation were useful, with only one participant “disagreeing.” At both week 1 and 4, the vast majority of participants (>74%) indicated “strongly agree or agree” to finding the practice useful, feeling more at peace, and relaxed after the meditation, and that they will continue to engage in the practice. More neutral scores were indicated for “being more in control of my life after meditation” and “I feel more hopeful after meditation.” At week 4, 37 of 56 (66%) reported willingness to participate again, 79% reported that it was worthwhile to participate, and 80% would recommend this study to others. At the end of the study, 30 participants provided feedback. Only two participants reported not liking the breathing technique but still understood the objective and therefore continued practicing. One participant felt that the breathing practice was foreign and religious and that the questionnaires were burdensome. The majority of participants gave positive feedback, asking for more frequent reminders, one-on-one sessions, and their family's ability to participate.
Discussion
This study suggests that it was feasible to provide an online breathing and meditation program to HCWs during the COVID-19 pandemic. There was a high rate of interest expressed, and recruitment rates were high. Willingness to participate was equal among the clinical, research, and administrative staff. Due to the small sample size, no subgroup analysis was done to see the differences in adherence among subjects. At the final time point, most participants who provided feedback reported that the intervention was useful (80%). Overall, about half of the participants (53%) strongly agreed or agreed the intervention was useful, and this rate is assuming that the nonresponders did not find the intervention useful.
While all participating staff are employed in a medical center, research and administrative staff were the majority (65%). Only 28% of participants were clinical, including nurses, physicians, nurse practitioners, physical therapists, and patient care technicians. Still, as most participants (61%) were essential to working on campus, they were at potential risk of contracting COVID-19 at work via exposure to patients or colleagues. In a prior survey of health care workers in patient-facing roles, the participants reported COVID-19-related psychological distress and reported interest in wellness resources. 12 Mind–body interventions, including yoga, have been rapidly deployed to patients during the pandemic in some centers. 13 However, to our knowledge, only a limited number of studies provide yoga-based breathing with meditation for frontline health workers. 14
Overall, most participants reported that the intervention was worthwhile, that they would participate again, and recommend this pranayama and meditation practice to others. In addition, most reported that they feel more at peace, hopeful, and relaxed after the practice. Furthermore, the majority found the practice useful overall. This finding is consistent with another study involving mindfulness-based stress reduction audios for medical staff in China. 15
This study examined the feasibility of providing an online breathing technique and meditation for HCW during the COVID-19 pandemic. There are several limitations to note. Participation was voluntary, and this could result in a biased sample not generalizable to all HCWs. The study was also not randomized, limiting the conclusions that can be drawn about the intervention program. Considering that the study participants involved both frontline and other HCWs, including research and administrative staff, recruitment of only frontline HCWs may have yielded different results. Another limitation is that most of the study participants were women (88%), and therefore, the findings may not generalize to men. Only 56% of the participants completed the study. This high dropout rate could be because of lack of time, pandemic-related work burden, not liking the breathing practice, or not finding the practice helpful or inability to do the breathing practice without having more one-on-one support. Therefore, the positive outcomes may have been biased by participants who stayed throughout the study period. Due to lack of funding, the authors could not carry out a more objective lung health measure such as spirometry.
This study highlights the need for further studies and wellness interventions at times of stress for HCWs, such as pandemics. Pranayama interventions at times of respiratory viral pandemics should be offered virtually, and participants asked to practice in isolation, as the forced exhalation techniques may aerosolize the viral particles and increase the risk of exposure to others in close proximity. Future studies of breathing techniques in HCW should also include assessing these techniques' effects on objective outcomes such as lung function, sleep, and stress-induced sympathetic arousal and inflammation. Furthermore, future qualitative studies are needed to identify potential barriers and identify various mind–body techniques to help HCWs adapt to working in different environments, including remote and in-person.
Conclusion
Provision of a virtually delivered, yoga-based breathwork and meditation program to employees of a large cancer center during a pandemic was deemed feasible and demonstrated high rates of interest, adherence, and acceptance. This pilot study suggests that health care employees are interested in mind–body interventions during high-stress times and would use breathwork, or pranayama, as a part of daily routine.
Footnotes
Acknowledgments
The authors acknowledge the research team members Gomez, TI, Engle, R, Mallaih, S, Ochua, J for their outstanding study coordination. They recognize Ms. Natalie Schuren, the Department of Administrator, for her support in obtaining referrals for study enrollment.
Authors' Contributions
All authors have reviewed and approved of the article before submission.
Author Disclosure Statement
Dr. Subramaniam is the Director of Sadhguru Center for a Conscious Planet at Beth Israel Deaconess Medical Center, Harvard Medical School. Dr. Subramaniam has no financial conflict of interest related to the study or practice. No competing financial interests exist.
Funding Information
No funding was received for this article.
Supplementary Material
Supplement A
References
Supplementary Material
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