Pause… breathe & stretch: creating an evidence-based yoga resource for mainstream schools

Abstract

Physical activity (PA) benefits a range of neurological and mental health difficulties and is also positively associated with positive outcomes on cognitive function and academic attainment in children and young people (YP). Despite these well-documented benefits of PA, current statistics reveal a concerning mental health landscape among children and YP. Recent UK figures from 2023 indicate that around 20% of 8–16-year-olds presented with a probable mental health disorder. This is a major public health concern as evidence suggests that mental health in YP is a predictor for physical health and learning outcomes, as well as mental wellbeing and life satisfaction in adulthood. Globally, about one billion children and YP attend school on any given day and spend a large amount of their waking week in schools. As such, schools provide an opportune setting for health promotion programmes. Increasing YP’s opportunities to be physically active in schools may be one method to target the mental health prevalence in children and YP.

A mode of PA that requires limited equipment and cost is yoga, which is a multi-component and an inherently mindful practice. Yoga includes the use of physical movements and postures combined with breathing, relaxation, and mindful techniques to improve self-regulation through awareness of bodily sensations and thoughts. There is emerging evidence that yoga can enhance physical and mental health in children and YP and may offer a complimentary or even preventative measure for mental wellbeing. However, as schools are complex systems, it is critical to explore if and how yoga could be offered as part of the school day.

The overall aim of this thesis was to make evidence-based recommendations for the implementation of yoga in schools. To achieve this aim, the thesis had four objectives: 1. Scope the relationship between yoga programmes in schools and mental health and cognitive outcomes (Chapter Two) 2. Identify the barriers and facilitators to implementing yoga in the school environment (Chapter Three) 3. Develop a school-based yoga resource (Chapter Four) 4. Evaluate the feasibility of the resource (Chapter Five).

To achieve this aim, the Creating Active Schools (CAS) and Medical Research Council’s (MRC) most recent guidance for developing and evaluating complex interventions was followed alongside behaviour change theory to create an accessible and low-cost school-based yoga programme (SBYP).

Chapter Two presents a scoping review of 59 studies synthesising the evidence of yoga in schools and mental health and cognitive outcomes in neurotypical and neurodiverse youth (those who require additional support that is different from that received by those of the same age to ensure they benefit from education). Substantial evidence to support the use of SBYPs for the improvement of anxiety, self-concept, resilience, depression, self-esteem, subjective and psychological well-being, executive function, inhibition, working memory, attention and academic performance in neurotypical populations was found. Evidence to support SBYP in neurodiverse populations with improvements in self-concept, subjective well-being, executive function, academic performance, and attention was also found. The findings of this study provided a clear synthesis of the research field providing strong support for the use of SBYP for mental and cognitive health, as well as highlighting clear gaps in evidence between the two populations. Furthermore, only two studies in the review were conducted in the UK over 13 and 15 years ago. It was, therefore, difficult to conclude whether these programmes would be usable today or if programmes from other countries would be transferable to the UK context. Therefore, UK-specific research was required to address these uncertainties.

Chapter Three presents a qualitative study involving three key UK-based stakeholders and drawing on behaviour change theory to identify the barriers and facilitators experienced by stakeholders of yoga in schools and to gather recommendations for the development of future interventions. The COM-B model was used to provide an understanding of the capabilities, opportunities, and motivations experienced by providers and users of yoga in schools. Therefore, to address the study’s aim and to aid in the development of a future SBYP, focus groups were conducted. Eight secondary schoolteachers participated in one of three focus groups; eight yoga instructors in one of two focus groups; and seven school students (12-15 years old) in one of two focus groups. All but one of the study’s participants (n=22) were female. One of the main findings from the study was that schoolteachers have used yoga in the school environment previously but lack the psychological capability of knowledge and understanding of yoga to feel confident delivering it. Furthermore, all stakeholders stipulated that the classroom can be an inappropriate environment to host traditional types of yoga. Other barriers discussed were limited resources (time, space, and funding), and negative perceptions and beliefs from school staff and students. It was suggested that through the provision of physical opportunities, such as the training of school staff, and by creating a classroom-friendly resource, SBYPs may be more acceptable in the future. This study provided crucial UK-focused insights that could be used to facilitate the development and subsequent evaluation of a new SBYP.

Chapter Four details the development of the key output of this thesis; a safe, age appropriate, and low-cost classroom-based yoga resource. Using the MRC guidance, The Behaviour Change Wheel (BCW), findings from focus groups, and additional input from experts in other professional fields, a new SBYP, ‘PAUSE… Breath & Stretch’, was developed. PAUSE is a collection of four main components including: visual classroom poster with yoga movements and breathing techniques; an additional guidance booklet and online learning HUB for teachers and a 2.5-hour teacher training session. Experts from numerous other professional fields reviewed and provided additional input to ensure the resource was robust and safe for the target population. For teachers to effectively teach their students, building teacher self-efficacy within education programmes is critical and intervention success may be dependent on it. Therefore, these resources were developed to be educational for schoolteachers as well as to provide a responsive toolkit to use during class time. To facilitate schoolteachers using the resource, each component included behaviour change techniques (BCT) designed to enable behaviour change.

Following the MRC guidance for developing complex interventions, the next stage was to understand the feasibility of the intervention. Chapter Five therefore presents a feasibility study of PAUSE with 3 local secondary schools. This study explored schoolteacher knowledge and self-efficacy before and after attending the resource training session and at the end of the intervention duration. The study’s four main objectives included: understand how teachers use the resource week to week; assess the fidelity, usability and feasibility of the SBYP with schoolteachers; assess the acceptability and impact of the SBYP with schoolteachers and YP and; provide recommendations for refining the programme based on schoolteachers and YP’s experiences. A mixed methods design was adopted, which involved 8 secondary school teachers (from the Wellbeing, English, Food and Textiles and Information Technology departments) participating from 3 local schools. Teachers were asked to report on self-efficacy pre and post training sessions and at the end of the study. Researcher observations of the programme’s fidelity to ensure safety and provide additional feedback were conducted. Teachers also recorded weekly diaries to measure resource usage. Lastly, students and teachers completed questionnaires at the end of the study to measure enjoyment and acceptability as well as provide qualitative feedback for resource refinements.

The results from this study indicated that the resources improved teachers’ confidence to deliver yoga with most stating they would continue to use PAUSE in the classroom. Furthermore, both students and teachers reported benefits after using PAUSE and that the resources were well designed and enjoyable. The findings inferred that the data collection methodology would need to be reviewed in further trials to support participation. However, overall, findings indicated that PAUSE has the potential to be integrated successfully into secondary schools.

This thesis has several important implications for future research and practice regarding the promotion of yoga in schools. Firstly, this body of research adds to the evidence base supporting the use of yoga in schools to support children’s and YP’s wellbeing. Secondly, this thesis provides clear recommendations for researchers to develop and enhance future SBYPs.

Thirdly, a new feasible and acceptable yoga resource for schools in the UK to use was developed using intervention frameworks and behaviour change theory. There are now clear pathways for PAUSE programme refinement to improve the resources usability. The next step should include a larger trial to understand the transferability of PAUSE to other areas within the UK and across a broader range of ages. Further, programme theory should be developed to understand how PAUSE could improve mental health and physical activity measures.