The effects of yoga on anxiety in female college students: A trial protocol

Written by Endeavour College of Natural Health | 2 December, 2021

woman doing a yoga pose with plants in background

We are proud to share the below research proposal designed by three of our current students Elena Yanchenko, Nicole Pugliese, and Vanessa Sharma. This student research proposal was selected to be published by the Journal of the Australian Traditional Medicine.

Abstract

Anxiety is a widespread mental health condition experienced as an array of symptoms in varying degrees in sufferers from all walks of life. The life of a student today can trigger or aggravate anxiety symptoms, leading to poor student outcomes and quality of life. The need for easily accessible and affordable treatment for anxiety for university students has led to the development of this theoretical study proposal. Yoga has been shown to assist in the management of anxiety symptoms. This proposal seeks to outline how a study could be conducted and analysed to further the research on females using yoga to manage anxiety symptoms, looking specifically at how this may benefit female students studying in tertiary institutions.

Thematising

Anxiety is a mental health condition that can cause an array of emotional, physical, cognitive and behavioural symptoms, which can be experienced uniquely by each individual. Common symptoms include nervousness, restlessness, sweating and trembling, insomnia or restless sleep, irritability, worry, muscle tension, fatigue, and an inability to focus, memorise, and keep up with study load. In addition, people with anxiety have a tendency to avoid certain places and activities that may trigger or aggravate their symptoms.1

Studying at a tertiary institution is one of the most critical periods of life. Students can experience many stressful events associated with studying, sometimes on a daily basis. Anxiety is a key issue that affects academic performance, quality of life, and well-being of students today.2 The prevalence and frequency of anxiety in students varies between different countries and universities, from 47% to 88.4%, with scores significantly higher for female students.3

Anxiety is one of the most common reasons students seek mental health support, but many universities fail to provide adequate mental health services. Students often wait weeks before seeing a counsellor, and the number of sessions made available may be limited.4,5 Even when help is available, anxiety can be difficult to recognise and diagnose, and its effects are often underestimated. Unfortunately, not all students with clinical anxiety will be diagnosed, which can potentially prolong recovery from other illnesses or worsen pre-existing health conditions.

Furthermore, anxiety may lead to chronic diseases and health consequences, including other mental health problems.5,6 Commonly used treatment options include psychotherapy, pharmaceuticals, lifestyle coaching, support groups, herbs and supplements, and other modalities of alternative medicine.1,6 Existing studies suggest an urgent need for interventions and preventative measures to support and improve the mental health of students.4

Research has shown that yoga can reduce anxiety and increase mental and emotional well-being.7-15 Yoga is an ancient Indian practice that focuses on bringing harmony and balance between body, mind and spirit. In Indian culture, it is considered an art and science of healthy living which typically consists of various methods and techniques including meditation, breathing techniques, physical exercises and postures, mindfulness techniques and relaxation.16 Yoga could be an affordable and useful method for reducing the symptoms of anxiety in students.

Designing

Human trials are essential to study the effects of yoga on anxiety among students. More women than men are drawn to yoga, with women consequently practising yoga more often than men.17 The proposed study will be conducted with female participants to further extend existing studies on females, looking specifically at female college students.

Baseline recruitment of participants will be one hundred female students from the University of New South Wales (Sydney). Participants must have at least two ongoing symptoms of anxiety lasting for at least one month, or a clinical diagnosis of anxiety, be willing to participate in the yoga class program, be able to attend all scheduled yoga classes during a two month period, follow the yoga teacher’s instructions during the class, be able to answer all questions, be able to rate symptoms and outcomes, and stay on any existing treatments for anxiety prior to the study and/or not introduce any new treatments for anxiety throughout the study.

The program will consist of 75-minute Hatha Vinyasa yoga classes conducted twice per week for 8 weeks. The classes will be conducted by experienced yoga instructors from My Wholistic Yoga School and held on campus for easy student access. Classes will include three to five minutes of breathing techniques, a 45-minute sequence of yoga poses, movements, stretching, five to ten minutes of relaxation, and finally 15 to 20 minutes of guided meditation and mindfulness techniques.

Interviewing

Semi-structured interviews will be conducted at baseline and upon completion of the intervention for comparison. In addition, all participants will be invited to complete questionnaires before and after the study to detect and evaluate changes in a list of outcomes using the Beck Anxiety Inventory.18 Biometric indicators of anxiety will be measured at baseline and completion, including resting heart rate and blood pressure. The qualitative data attained from semistructured interviews are intended to add depth to the study of a physical and spiritual practice such as yoga, and further the understanding of the participants’ experience in a real-life setting

Pre-intervention questions

(Baseline):

  1. How long have you been experiencing anxiety and in what ways has it affected your life?
  2. What factors do you feel most significantly affect your level of anxiety?
  3. What current methods, if any, do you employ for managing anxiety?
  4. Have you participated in yoga or mindfulness practices in the past, and, if so, for what reason(s)?
  5. Please rate your level of anxiety today out of 10, 0 being no anxiety and 10 being extremely high levels of anxiety.

Post-intervention questions:

  1. Was the practice (intervention) easily assimilated into your university schedule without inducing further anxiety?
  2. Were there other benefits noted other than effects on anxiety levels (e.g. physical strength/fitness, mental focus, academic achievements)?
  3. To what capacity would you continue this practice beyond the study completion?
  4. How would you describe the overall effects on your anxiety levels and overall quality of life?
  5. Please rate your level of anxiety today out of 10, 0 being no anxiety and 10 being extremely high levels of anxiety.

Analysis

Each interview will be voice-recorded (with permission) to avoid interviewer recall bias. The recordings will later be transcribed and then checked against the recordings. Transcriptions will be thoroughly read and re-read by researchers for familiarisation of information and initial identification of patterns which relate directly to the perceived benefits of the intervention on anxiety. Emerging common phrases, behaviours, and themes will be identified and marked or coded for analysis. Coded data will be used to create a structured framework of significant patterns/themes that address the study outcomes. The Constant Comparison Model (CCM) of analysis will be used to compare and contrast the themes that become prominent. This model is an inductive method of analysis based heavily on grounded theory, which continues to compare data until nothing more can be linked and/or learned.19,20

Computer Assisted Qualitative Data Analysis Software (CAQDAS) will be used to assist coding and developing the emergent themes, to support transparency of this data and meet current scientific quality standards. Each researcher will be assisted by NVivo, one of the most widely used CAQDAS programs, to code data into content themes using CCM. NVivo is used to manage the volume of data. NVivo is highly compatible with the grounded theory and thematic analysis approaches of this study.21

The Beck Anxiety Inventory questionnaire outcomes and biometric measurements will be compared from baseline to completion for statistical significance.

Verifying

Generalisability: generalizability from the results of the study will be limited, as it consists of female college students from the University of NSW, undertaking a single and specific form of Hatha Vinyasa Yoga. The results may vary with different styles of yoga, female populations from different colleges or universities, and from different countries and cultures. Therefore, results of the study cannot be generalised to the overall population.21

Reliability: There is high inter-rater reliability resulting from use of the CCM, which is based on grounded theory with proven reliability for coding data. The CCM is designed to be integrated throughout the entire research process, producing continual data analysis whereby researchers constantly move back and forth between codes and emerging data to assess similarities and differences. This ensures accuracy and verifies theory components.21

Test-retest reliability is high through use of the Beck Anxiety Inventory (BAI), a 21-item self-report inventory for measuring the severity of anxiety symptoms.18 Furthermore, participants will receive similar instructions before and after the study, thereby supporting test re-test reliability.

High internal consistency is made possible through the BAI’s Cronbach’s alpha ranging from 0.90 to 0.94 quantitative analysis, which is reliable over time-lapses.18

Validity: High Internal validity can be achieved due to implementation of the CCM by an analysis group consisting of more than one researcher. The CCM limits the possibility of the researcher(s) forcing a predetermined result, thereby allowing data and themes to emerge, and protecting against over-analysing qualitative data.19,20

The BAI is one of the most widely used and validated anxiety instruments as a result of its easily scored measure of anxiety, which will add to the study’s high construct validity.18

Limitations of the study include:

  • small sample size of 100 participants
  • single university sampled
  • single style of Yoga (Hatha Vinyasa)
  • unpredictable dropout rate (possible injury or illness, change to anxiety protocol, etc)
  • study results may not be reproducible with other styles of Yoga, or in other countries/cultures where yoga is less accepted due to cultural or religious beliefs
  • daily academic focus may change students’ perceived anxiety level depending on the time of year, for example during exams or finals
  • process of qualitative analysis is labour-intensive, thus timeconsuming and expensive, especially with CCM, coding line by line and ensuring all information is lodged within the code structure

Reporting

Reporting will include a discussion of participant interview quotes and observational anecdotes, separated by emerging themes, to reinforce the findings and their validity. A table showing the results of the participant interview analysis will be broken down into the most prominent themes and relationships. The results of all content themes at baseline interview compared with completion interview will be displayed as a bar graph showing the number of participants displaying each theme. Participant results for the BAI and biometric indicators (blood pressure and resting heart rate) will both be presented in separate line graphs. Each graph will contain a bell curve, showing the mean and standard deviations with scores of the participants at baseline and completion being compared on the same graph, with baseline and completion data represented on separate lines to assess any changes.

Ethical Matters

Ethical approval is provided by the University of NSW Sydney’s Human Research Ethics Committee.23 The study contains the following ethical criteria for participants:24

Informed Consent – participants will be given consent forms prior to the study informing them of the details of the study including its purpose, how the study findings will be used, source of funding, and information provided if a participant experiences distress during the study.

Voluntary Participation – participants are informed before the study of their right to withdraw from the study at any time without consequence. Participants will not be coerced or forced to stay in the study until completion, and are free to withdraw at any time without explanation.

Do No Harm – the participants' consent to perform the Yoga activities required of them with the possible risk of injury. If injury is sustained, they can withdraw from the study at any time. Due to the nature of the study, participants can voluntarily withdraw at any time if they feel the study triggers/causes any emotional or psychological distress.

Confidentiality - all details identifying the participants will be kept confidential and only made available to the research coordinator. All identifying information will be omitted from any reports or published documents.

References

  1. National Institute of Mental Health. Anxiety Disorders. 2018. https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml
  2. Beiter R, Nash R, McCrady M, Rhoades D, Linscomb M, Clarahan M, Sammut S. The prevalence and correlates of depression, anxiety, and stress in a sample of college students. J Affect Disord. 2015; 1;173:90-6. doi: 10.1016/j.jad.2014.10.054. Epub 2014 Nov 8.
  3. Asif S, Mudassar A, Shahzad TZ, Raouf M, Pervaiz T. Frequency of depression, anxiety and stress among university students. Pakistan Journal of Medical Sciences. 2020; 36(5), 971–976. https://doi-org.ezproxy. endeavour.edu.au/10.12669/pjms.36.5.1873
  4. Barr V, Krylowicz B, Mistler BJ, Reetz DR.College students’ mental health is a growing concern, survey finds. American Psychological Association. 2013;44(6): 13. https://www.apa.org/monitor/2013/06/college-students
  5. The Jed Foundation. Depression and anxiety among college students. 2020. https://www.jedfoundation.org/depresion-and-anxietyamong-college-students/
  6. The American Institute of Stress. Anxiety in college students: Causes, statistics & how universities can help. 2019. https://www.stress.org/anxiety-in-college-studentscauses-statistics-how-universitiescan-help#:~:text=Many%20types%20of%20anxiety%20disorders,%2C%20uncontrollable%20worry%2C%20and%20insomnia
  7. Albracht-Schulte K, Robert-McComb J. The effects of yoga and quiet rest on subjective levels of anxiety and physiological correlates: A 2-way crossover randomized trial. BMC Complementary and Alternative Medicine. 2018;18(1):1–11. https://doi-org.ezproxy.endeavour.edu.au/10.1186/s12906-018-2343-1
  8. Lemay V, Hoolahan J, Buchanan A. Impact of a yoga and meditation intervention on students’ stress and anxiety levels. American Journal of Pharmaceutical Education. 2019;83(5), 747–752. https://doi-org.ezproxy. endeavour.edu.au/10.5688/ajpe7001
  9. McCall M, Thorne S, Ward A, Heneghan C. Yoga in adult cancer: An exploratory, qualitative analysis of the patient experience. BMC Complementary and Alternative Medicine. 2015;15(245). https://doi-org.ezproxy.endeavour.edu.au/10.1186/s12906-015-0738-9
  10. Rashedi RN, Wajanakunakorn M, Hu CJ. Young children’s embodied experiences: A classroom-based yoga intervention. Journal of Child & Family Studies. 2019;28(12), 3392–3400. https://doiorg.ezproxy.endeavour.edu.au/10.1007/s10826-019-01520-7
  11. Saeed SA, Cunningham K, Bloch R M. Depression and anxiety disorders: Benefits of exercise, yoga, and meditation. American Family Physician. 2019; 99(10): 620–627. https://www.aafp.org/afp/2019/0515/p620.html
  12. Schmid AA, DeBaun-Sprague E, Gilles A., Maguire JM, Mueller AL, Miller KK, Van Puymbroeck M, Schalk N. Yoga influences recovery during inpatient rehabilitation: A pilot study. International Journal of Yoga Therapy. 2015;25(1):141–152. https://doi-org.ezproxy.endeavour.edu.au/10.17761/1531-2054-25.1.141
  13. Shohani M, Badfar G, Nasirkandy MP, Kaikhavani S, Rahmati S, Modmeli Y, Soleymani A, Azami M. The effect of yoga on stress, anxiety, and depression in women. International Journal of Preventive Medicine. 2018;9(1):21. https://doi-org.ezproxy.endeavour.edu.au/10.4103/ijpvm.IJPVM_242_16
  14. Stapp AC, Lambert AB. The impact of mindfulness-based yoga interventions on fifth-grade students’ perceived anxiety and stress. International Electronic Journal of Elementary Education. 2020;12(5), 471–480
  15. Stephens I. Case report: The use of medical yoga for adolescent mental health. Complementary Therapies in Medicine. 2019;43: 60–65. https://doi-org.ezproxy.endeavour.edu.au/10.1016/j.ctim.2019.01.006
  16. Basavaraddi IV. Yoga: Its origin, history and development. Ministry of External Affairs, Government of India. 2015. https://www.mea.gov.in/search-result.htm?25096/Yoga:_su_origen,_historia_y_desarrollo
  17. Park C, Braun T, Siegel T. Who practices yoga? A systematic review of demographic, healthrelated, and psychosocial factors associated with yoga practice. Journal of Behavioral Medicine. 2015:38(3), 460–471. https://doiorg.ezproxy.endeavour.edu.au/10.1007/s10865-015-9618-5
  18. Fydrich T, Dowdall D, Chambless DL. Reliability and validity of the Beck Anxiety Inventory. Journal of Anxiety Disorders. 1992; 6(1): 55–61. https://doi.org/10.1016/0887-6185(92)90026-4.
  19. Boeije H. A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Quality and Quantity. 2002; 36: 391-409. https://doi.org/10.1023/A:1020909529486
  20. Glaser BG, Strauss AL. The constant comparative method of qualitative analysis. The Discovery of Grounded Theory: Strategies for Qualitative Research. 1967;101:158. https://doi.org/10.4324/9780203793206-6
  21. Zamawe FC. The implication of using NVivo software in qualitative data analysis: Evidence-based reflections. Malawi Medical Journal: The Journal of Medical Association of Malawi. 2015; 27(1): 13–15. https://doi.org/10.4314/mmj.v27i1.4
  22. Leung L. Validity, reliability, and generalizability in qualitative research. Journal of Family Medicine and Primary Care. 2015; 4(3): 324–327. https://doi.org/10.4103/2249-4863.161306
  23. UNSW Sydney. (n.d.). Human research ethics & clinical trials governance. https://research.unsw.edu.au/more-low-risk-research
  24. Western Australian Centre for Health Promotion Research. Ethical considerations. 2010. https://mypeer.org.au/monitoringevaluation/ethical-considerations/

Endeavour College of Natural Health

Endeavour College of Natural Health is Australia's largest Higher Education provider of natural medicine courses.

The College is known as the centre of excellence for natural medicine and is respected for its internationally recognised academic teams and high calibre graduates. Endeavour offers Bachelor of Health Science degrees in Naturopathy, Nutritional and Dietetic Medicine, Acupuncture Therapies and Chinese Medicine, Undergraduate Certificates, a Diploma of Health Science and massage courses.

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