Qualitative results from a randomized pilot study of eHealth Mindful Movement and Breathing to improve gynecologic cancer surgery outcomes.

PURPOSE: Improved management of pain and co-morbid symptoms (sleep disturbances, psychological distress) among women undergoing surgery for suspected gynecologic malignancies may reach a population vulnerable to chronic pain. PARTICIPANTS: Women undergoing surgery for a suspected gynecologic malignancy. METHOD: We conducted a pilot randomized controlled trial of eHealth Mindful Movement and Breathing (eMMB) compared to an empathic attention control (AC). Semi-structured interviews were conducted by telephone (n = 23), recorded, transcribed, coded, and analyzed using thematic analysis. FINDINGS: Participants reported overall high acceptability such that all would recommend the study to others. Positive impacts of practicing eMMB included that it relieved tension, facilitated falling asleep, and decreased pain. Participants also reported high adherence to self-directed eMMB and AC writing practices and described facilitators and barriers to practicing. CONCLUSIONS: This qualitative feedback will inform future research to assess the efficacy of eMMB for reducing pain and use of remotely-delivered interventions more broadly. CLINICAL TRIAL REGISTRATION NUMBER: NCT03681405.

Qualitative similarities and distinctions between participants' experiences with a yoga intervention and an attention control.

PURPOSE: This manuscript aims to compare and contrast acceptability and perceived benefits of yoga-skills training (YST) and an empathic listening attention control (AC) in the Pro-You study, a randomized pilot trial of YST vs. AC for adults receiving chemotherapy infusions for gastrointestinal cancer. METHODS: Participants were invited for a one-on-one interview at week 14 follow-up, after completing all intervention procedures and quantitative assessments. Staff used a semi-structured guide to elicit participants' views on study processes, the intervention they received, and its effects. Qualitative data analysis followed an inductive/deductive approach, inductively identifying themes and deductively guided by social cognitive theory. RESULTS: Some barriers (e.g., competing demands, symptoms), facilitators (e.g., interventionist support, the convenience of clinic-based delivery), and benefits (e.g., decreased distress and rumination) were common across groups. YST participants uniquely described the importance of privacy, social support, and self-efficacy for increasing engagement in yoga. Benefits specific to YST included positive emotions and greater improvement in fatigue and other physical symptoms. Both groups described some self-regulatory processes, but through different mechanisms: self-monitoring in AC and the mind-body connection in YST. CONCLUSIONS: This qualitative analysis demonstrates that participant experiences in a yoga-based intervention or an AC condition reflect social cognitive and mind-body frameworks of self-regulation. Findings can be used to develop yoga interventions that maximize acceptability and effectiveness and to design future research that elucidates the mechanisms by which yoga is efficacious.

Adaptation of a Personalized Electronic Care Planning Tool for Cancer Follow-up Care: Formative Study.

BACKGROUND: Most patients diagnosed with colorectal cancer will survive for at least 5 years; thus, engaging patients to optimize their health will likely improve outcomes. Clinical guidelines recommend patients receive a comprehensive care plan (CP) when transitioning from active treatment to survivorship, which includes support for ongoing symptoms and recommended healthy behaviors. Yet, cancer care providers find this guideline difficult to implement. Future directions for survivorship care planning include enhancing information technology support for developing personalized CPs, using CPs to facilitate self-management, and assessing CPs in clinical settings. OBJECTIVE: We aimed to develop an electronic tool for colorectal cancer follow-up care (CFC) planning. METHODS: Incorporating inputs from health care professionals and patient stakeholders is fundamental to the successful integration of any tool into the clinical workflow. Thus, we followed the Integrate, Design, Assess, and Share (IDEAS) framework to adapt an existing application for stroke care planning (COMPASS-CP) to meet the needs of colorectal cancer survivors (COMPASS-CP CFC). Constructs from the Consolidated Framework for Implementation Research (CFIR) guided our approach. We completed this work in 3 phases: (1) gathering qualitative feedback from stakeholders about the follow-up CP generation design and workflow; (2) adapting algorithms and resource data sources needed to generate a follow-up CP; and (3) optimizing the usability of the adapted prototype of COMPASS-CP CFC. We also quantitatively measured usability (target average score ≥70; range 0-100), acceptability, appropriateness, and feasibility. RESULTS: In the first phase, health care professionals (n=7), and patients and caregivers (n=7) provided qualitative feedback on COMPASS-CP CFC that informed design elements such as selection, interpretation, and clinical usefulness of patient-reported measures. In phase 2, we built a minimal viable product of COMPASS-CP CFC. This tool generated CPs based on the needs identified by patient-completed measures (including validated patient-reported outcomes) and electronic health record data, which were then matched with resources by zip code and preference to support patients' self-management. Elements of the CFIR assessed revealed that most health care professionals believed the tool would serve patients' needs and had advantages. In phase 3, the average System Usability Scale score was above our target score for health care professionals (n=5; mean 71.0, SD 15.2) and patients (n=5; mean 95.5, SD 2.1). Participants also reported high levels of acceptability, appropriateness, and feasibility. Additional CFIR-informed feedback, such as desired format for training, will inform future studies. CONCLUSIONS: The data collected in this study support the initial usability of COMPASS-CP CFC and will inform the next steps for implementation in clinical care. COMPASS-CP CFC has the potential to streamline the implementation of personalized CFC planning to enable systematic access to resources that will support self-management. Future research is needed to test the impact of COMPASS-CP CFC on patient health outcomes.

A randomized pilot of eHealth mindful movement and breathing to improve gynecologic surgery outcomes.

OBJECTIVE: To conduct a pilot randomized controlled trial of eHealth Mindful Movement and Breathing (eMMB) compared to an empathic attention control (AC). PARTICIPANTS: Women undergoing surgery for a suspected gynecologic malignancy. METHODS: eMMB is a brief yoga intervention delivered remotely during the perioperative timeframe. We assessed feasibility and participants completed assessments (baseline, weeks 2 and 4 postoperatively). We summarized feasibility, participant characteristics, and outcomes by intervention group and time. FINDINGS: Forty-three percent of eligible patients approached participated (n = 31). Adherence to the interventions was 77%. Percent of participants to complete outcomes was 81% at Week 2 and 84% at Week 4 (>70%; retention was the primary feasibility indicator). Average reductions in the primary outcome of pain intensity were larger in the eMMB group than AC group (Week 2 d = -0.38; Week 4 d = -0.46). IMPLICATIONS: This pilot study of eMMB supported feasibility and improvements in pain intensity that warrant a future efficacy study.

A Randomized Controlled Pilot Study of Yoga Skills Training Versus an Attention Control Delivered During Chemotherapy Administration.

CONTEXT: It is important to address fatigue and co-occurring symptoms during chemotherapy to preserve quality of life in patients with gastrointestinal (GI) cancer. OBJECTIVE: To conduct a randomized controlled pilot study of a Yoga Skills Training (YST) intervention compared to an attention control (AC) among adults diagnosed with GI cancer. METHODS: YST consisted of four 30-minute sessions delivered individually during chemotherapy plus home practice. AC provided empathic attention plus home diaries. Patient-reported (PROMIS T-score) assessments of fatigue, depressive symptoms, sleep disturbances, and psychological stress (Perceived Stress Scale) were collected at chemotherapy visits: baseline, Week 8, Week 10 and Week 14, and analyzed using a mixed effects model. Inflammatory cytokines were assessed at baseline and Week 10. RESULTS: Forty-four of 77 adults approached agreed to participate (57%; YST n = 23; AC n = 21). Participants' mean age was 58 years and 48% were men. Participants randomized to YST reported a larger decline in fatigue (-2.4 difference, d = 0.30) and depressive symptoms (-2.5 difference, d = 0.30) than AC participants from baseline to Week 10 and sleep disturbances at Week 8 (-3.9 difference, d = 0.50). Differences in magnitude of change in symptoms were consistent with or exceeded a minimally important difference. Psychological stress decreased more in the AC at Week 10 (d = 0.30). Reductions in inflammatory cytokines (IL-6, sTNF R1) were larger in the YST group than AC. CONCLUSION: YST showed promise for improving fatigue, depressive symptoms, sleep disturbances, and inflammation. YST is also feasible and reaches patients underrepresented in yoga research (i.e., GI cancer, men), thus warranting further examination.

Ensuring Yoga Intervention Fidelity in a Randomized Preference Trial for the Treatment of Worry in Older Adults.

Introduction: Yoga for treatment of worry in older adults is an intervention that is especially likely to translate into real-world practice. Assessing treatment fidelity improves confidence that effective interventions can be consistently applied and allows researchers to explore if any null results for effectiveness are indeed the result of a lack of intervention efficacy or lack of proper intervention implementation. Methods: This study describes treatment fidelity of a yoga intervention in a randomized preference trial that compared cognitive-behavioral therapy (CBT) and yoga for the treatment of worry, anxiety, and sleep in worried older (≥60 years) adults. Established methods for assessing treatment fidelity of CBT guided the procedure for ensuring that the yoga intervention was delivered as intended. The yoga intervention consisted of 20, 75-min, in-person, group, gentle yoga classes held twice weekly. Results: Six female instructors (mean age = 64 years) taught 660 yoga classes that were videotaped. Ten percent of these classes, stratified by instructor, were randomly selected for review. The average adherence score for yoga instructors was 6.84 (range 4-8). The average competency scores were consistently high, with an average score of 7.24 (range 6-8). Teaching content not included in the protocol occurred in 26 (38.1%) sessions and decreased over time. Observed ratings of instructor adherence were significantly related to ratings of competency. Instructor adherence was also significantly associated with lower participant attendance, but not with any of the other process or outcome measures. Conclusions: The larger range found in adherence relative to competence scores demonstrated that teaching a yoga class according to a protocol requires different skills than competently teaching a yoga class in the community, and these skills improved with feedback. These results may foster dialog between the yoga research and practice communities. Clinical Trial Registration No.: NCT02968238.

Development and psychometric properties of the Self-efficacy for Mindfulness Meditation Practice scale.

This study aimed to develop a self-efficacy measure for mindfulness meditation practice (Self-efficacy for Mindfulness Meditation Practice scale). The scale was developed through a process of expert consensus, cognitive interviewing, and evaluation among 199 mindfulness meditation practitioners who completed an online survey. The 9-item Self-efficacy for Mindfulness Meditation Practice scale was unidimensional with three subconstructs of attention, compassion, and emotion. The omega hierarchical coefficient for the total scale was 0.78, and test-retest reliability was intraclass correlation coefficient = 0.85 (95% confidence interval: 0.80, 0.89). This study provides preliminary evidence that Self-Efficacy for Mindfulness Meditation Practice scale is a reliable and valid measure of self-efficacy for mindfulness meditation practice.

Can Adults with Mild Cognitive Impairment Build Cognitive Reserve and Learn Mindfulness Meditation? Qualitative Theme Analyses from a Small Pilot Study.

BACKGROUND/OBJECTIVE: High levels of chronic stress negatively impact the hippocampus and are associated with increased incidence of mild cognitive impairment (MCI) and Alzheimer's disease. While mindfulness meditation may mitigate the effects of chronic stress, it is uncertain if adults with MCI have the capacity to learn mindfulness meditation. METHODS: 14 adults with MCI were randomized 2:1 to Mindfulness Based Stress Reduction (MBSR) or a wait-list control group. We conducted qualitative interviews with those who completed MBSR. Transcribed interviews were: a) coded using an emergent themes inductive approach informed by grounded theory; b) rated 0-10, with higher scores reflecting greater perceived benefit from, and understanding of, mindfulness meditation. Ratings were correlated with daily home practice times and baseline level of cognitive function. RESULTS: Seven themes emerged from the interviews: positive perceptions of class; development of mindfulness skills, including meta-cognition; importance of the group experience; enhanced well-being; shift in MCI perspective; decreased stress reactivity and increased relaxation; improvement in interpersonal skills. Ratings of perceived benefit and understanding ranged from 2-10 (mean = 7) and of 0-9.5 (mean = 6), respectively. Many participants experienced substantial benefit/understanding, some had moderate, and a few had minimal benefit/understanding. Understanding the key concepts of mindfulness was highly positively correlated with ≥20 minutes/day of home practice (r = 0.90) but not with baseline cognitive function (r = 0.13). CONCLUSIONS: Most adults with MCI were able to learn mindfulness meditation and had improved MCI acceptance, self-efficacy, and social engagement. Cognitive reserve may be enhanced through a mindfulness meditation program even in patients with MCI.

Yoga for symptom management in oncology: A review of the evidence base and future directions for research.

Because yoga is increasingly recognized as a complementary approach to cancer symptom management, patients/survivors and providers need to understand its potential benefits and limitations both during and after treatment. The authors reviewed randomized controlled trials (RCTs) of yoga conducted at these points in the cancer continuum (N = 29; n = 13 during treatment, n = 12 post-treatment, and n = 4 with mixed samples). Findings both during and after treatment demonstrated the efficacy of yoga to improve overall quality of life (QOL), with improvement in subdomains of QOL varying across studies. Fatigue was the most commonly measured outcome, and most RCTs conducted during or after cancer treatment reported improvements in fatigue. Results also suggested that yoga can improve stress/distress during treatment and post-treatment disturbances in sleep and cognition. Several RCTs provided evidence that yoga may improve biomarkers of stress, inflammation, and immune function. Outcomes with limited or mixed findings (eg, anxiety, depression, pain, cancer-specific symptoms, such as lymphedema) and positive psychological outcomes (such as benefit-finding and life satisfaction) warrant further study. Important future directions for yoga research in oncology include: enrolling participants with cancer types other than breast, standardizing self-report assessments, increasing the use of active control groups and objective measures, and addressing the heterogeneity of yoga interventions, which vary in type, key components (movement, meditation, breathing), dose, and delivery mode.

The Effects of Yoga on Patients with Mild Cognitive Impairment and Dementia: A Scoping Review.

Yoga is an ancient mind body practice. Although yoga has been used as a complementary health approach for enhancing wellness and addressing a variety of health issues, little is known about the impact of yoga on cognitive functioning in adults with mild cognitive impairment (MCI) and dementia. We conducted a literature review to examine the impact of yoga on persons with MCI and dementia. Eight studies were identified that reported on yoga as either the primary intervention or one component of a multi-component intervention in samples of persons with MCI or dementia. Results suggest that yoga may have beneficial effects on cognitive functioning, particularly on attention and verbal memory. Further, yoga may affect cognitive functioning through improved sleep, mood, and neural connectivity. There are a number of limitations of the existing studies, including a lack of intervention details, as well as variability in the frequency/duration and components of the yoga interventions. A further complicating issue is the role of various underlying etiologies of cognitive impairment. Despite these limitations, providers may consider recommending yoga to persons with MCI or dementia as a safe and potentially beneficial complementary health approach.

Convenient and Live Movement (CALM) for women undergoing breast cancer treatment: Challenges and recommendations for internet-based yoga research.

OBJECTIVE: To conduct a pilot trial of internet-based, cancer-adapted yoga for women receiving breast cancer treatment. DESIGN: Women undergoing radiation or chemotherapy for breast cancer were recruited for 12, 75-min, biweekly, cancer-adapted yoga classes delivered via internet-based, multipoint videoconferencing. Data were collected on feasibility and acceptability, including qualitative feedback from participants and the yoga instructor. RESULTS: Among 42 women approached, 13 declined eligibility screening, and 23 were ineligible. All 6 women who were eligible provided consent, but 2 withdrew prior to beginning yoga classes. The remaining 4 participants attended 1-11 of 12 online yoga classes. In post-intervention interviews, participants and the instructor agreed that internet-based yoga classes hold great potential for increasing access and improving psychological outcomes in adults with cancer. Qualitative feedback from participants revealed suggestions for future trials of internet-based, cancer-adapted yoga classes, including: continued use of group format; offering more varied class times to accommodate patients' demanding schedules and fluctuating symptoms; enrolling patients after they have acclimated to or completed cancer treatment; streamlining the technology interface; and careful attention to participant burden when designing surveys/forms. The instructor recommended closed session courses, as opposed to rolling enrollment; teaching the same modified poses for all participants, rather than individual tailoring; and using a large screen to allow closer monitoring of students' class experience. CONCLUSIONS: Internet delivery may increase patients' access to cancer-adapted yoga classes, but cancer-related and technological barriers remain. This study informs how to optimally design yoga classes, technology, and research procedures to maximize feasibility and acceptability in future trials.

Review of yoga therapy during cancer treatment.

PURPOSE: Reviews of yoga research that distinguish results of trials conducted during (versus after) cancer treatment are needed to guide future research and clinical practice. We therefore conducted a review of non-randomized studies and randomized controlled trials of yoga interventions for children and adults undergoing treatment for any cancer type. METHODS: Studies were identified via research databases and reference lists. Inclusion criteria were the following: (1) children or adults undergoing cancer treatment, (2) intervention stated as yoga or component of yoga, and (3) publication in English in peer-reviewed journals through October 2015. Exclusion criteria were the following: (1) samples receiving hormone therapy only, (2) interventions involving meditation only, and (3) yoga delivered within broader cancer recovery or mindfulness-based stress reduction programs. RESULTS: Results of non-randomized (adult n = 8, pediatric n = 4) and randomized controlled trials (adult n = 13, pediatric n = 0) conducted during cancer treatment are summarized separately by age group. Findings most consistently support improvement in psychological outcomes (e.g., depression, distress, anxiety). Several studies also found that yoga enhanced quality of life, though further investigation is needed to clarify domain-specific efficacy (e.g., physical, social, cancer-specific). Regarding physical and biomedical outcomes, evidence increasingly suggests that yoga ameliorates sleep and fatigue; additional research is needed to advance preliminary findings for other treatment sequelae and stress/immunity biomarkers. CONCLUSIONS: Among adults undergoing cancer treatment, evidence supports recommending yoga for improving psychological outcomes, with potential for also improving physical symptoms. Evidence is insufficient to evaluate the efficacy of yoga in pediatric oncology. We describe suggestions for strengthening yoga research methodology to inform clinical practice guidelines.

Yoga for Risk Reduction of Metabolic Syndrome: Patient-Reported Outcomes from a Randomized Controlled Pilot Study.

Lifestyle change is recommended as treatment for adults at risk for metabolic syndrome (MetS), although adoption of new behavioral patterns is limited. In addition, most existing lifestyle interventions do not address psychological stress or quality of life, both of which impact the burden of MetS. Yoga, a form of physical activity that incorporates psychological components (e.g., maintaining attention, relaxation), is a promising intervention for improving the burden of MetS. This randomized controlled trial assessed the feasibility and preliminary efficacy of a 12-week yoga program coupled with an evidence-based health education program (HED) compared to HED alone. A secondary, exploratory aim examined perceived stress, quality of life, and related psychological outcomes (mindfulness, perceived health competence, and mood). Sixty-seven adults at risk for MetS enrolled (mean age [SD]: 58 [10] years; 50% male; 79% non-Hispanic White). Preliminary results revealed significantly larger improvements in two quality of life domains (role-physical and general health perceptions) in the HED plus yoga group versus HED alone (ps < 0.05). This is the first study that implemented lifestyle education along with yoga to evaluate the potential unique effects of yoga on participants at risk for MetS. A larger clinical trial is warranted to further investigate these promising patient-reported outcomes.

Intervention Protocol for Investigating Yoga Implemented During Chemotherapy.

OBJECTIVE: Fatigue and other treatment-related symptoms are critical therapeutic targets for improving quality of life in patients with colorectal cancer during chemotherapy. Yoga is a promising intervention for improving these therapeutic targets and has been primarily investigated in the group-class format, which is less feasible for cancer patients with high symptom burden to attend. Thus, we developed a protocol for implementing yoga individually in the clinic among patients receiving chemotherapy. METHODS: We followed recommended domains for developing a yoga protocol to be used in an efficacy trial. These recommendations include consideration to the style, delivery, components of the intervention, dose, specific class sequences, facilitation of home practice, measurement of intervention fidelity, selection of instructors, and dealing with modifications. The intervention protocol was developed by an interdisciplinary team. PROTOCOL: Yoga Skills Training (YST) consists of four 30-minute in-person sessions and was implemented while in the chair during chemotherapy infusions for colorectal cancer with recommended daily home practice for eight weeks. Therapeutic goals of the YST are to reduce fatigue, circadian disruption, and psychological distress. Elements of the YST are awareness meditation, gentle seated movement, breathing practice, and relaxation meditation. Attention, comfort, and ease are also highlighted. CONCLUSION: This description of a protocol for integrating yoga with conventional cancer treatment will inform future study designs and clinical practice. The design of the YST is novel because it implements yoga-most commonly studied when taught to groups outside of the clinical setting- individually during clinical care.

Feasibility of a Brief Yoga Intervention for Improving Acute Pain and Distress Post Gynecologic Surgery.

BACKGROUND: Women undergoing surgical procedures for suspected gynecologic malignancies frequently experience pain and psychological distress related to surgery. Yoga may reduce these negative surgical outcomes. The primary objective of this pilot study was to assess the feasibility of evaluating a perioperative brief Yoga Skills Training (YST) in this population. Secondary objectives were to (1) assess the immediate effects of the YST on pain and psychological distress; and (2) provide preliminary data for future studies. METHOD: Adult women scheduled to undergo an exploratory laparotomy for a suspected gynecologic malignancy were recruited to this one-arm feasibility study. Each woman received the YST, which consisted of three 15-minute sessions, one before and two after surgery. The following constructs were assessed: feasibility (rates of accrual, intervention adherence, measure completion, retention, and level of satisfaction), immediate effects of the YST (visual analogue scale ratings of pain and distress immediately before and after each session), and descriptive statistics for measures to be used in future studies. RESULTS: Of the 33 eligible women, 18 were approached and 10 agreed to participate (mean age = 54.7 years; 90% White). Two women discontinued the study prior to starting the YST sessions. Of the eight participants who received the YST, five completed the pre-surgery session (63%) and seven completed (88%) both post-surgical sessions; one woman withdrew after one YST session. Participants reported high satisfaction with the YST. Acute pain and distress decreased from before to immediately after the YST session with moderate to large effects: pain, d's = -0.67 to -0.95; distress, d's = -0.66 to -1.08. CONCLUSIONS: This study demonstrated reasonable indicators of feasibility. In addition, patients showed short-term reductions in pain and distress. Next steps include attention to improving staff availability and intervention implementation in order to feasibly evaluate the perioperative YST, which shows promise for reducing postoperative pain and distress.

A brief yoga intervention implemented during chemotherapy: A randomized controlled pilot study.

OBJECTIVES: Fatigue and other treatment-related symptoms (e.g., sleep disturbance) are critical targets for improving quality of life in patients undergoing chemotherapy. Yoga may reduce the burden of such symptoms. This study investigated the feasibility of conducting a randomized controlled study of a brief yoga intervention during chemotherapy for colorectal cancer. DESIGN: We randomized adults with colorectal cancer to a brief Yoga Skills Training (YST) or an attention control (AC; empathic attention and recorded education). SETTING: The interventions and assessments were implemented individually in the clinic while patients were in the chair receiving chemotherapy. INTERVENTIONS: Both interventions consisted of three sessions and recommended home practice. MAIN OUTCOME MEASURES: The primary outcome was feasibility (accrual, retention, adherence, data collection). Self-reported outcomes (i.e., fatigue, sleep disturbance, quality of life) and inflammatory biomarkers were also described to inform future studies. RESULTS: Of 52 patients initially identified, 28 were approached, and 15 enrolled (age Mean = 57.5 years; 80% White; 60% Male). Reasons for declining participation were: not interested (n = 6), did not perceive a need (n = 2), and other (n = 5). Two participants were lost to follow-up in each group due to treatment changes. Thus, 75% of participants were retained in the YST and 71% in the AC arm. Participants retained in the study adhered to 97% of the in-person intervention sessions and completed all questionnaires. CONCLUSIONS: This study demonstrated the feasibility of conducting a larger randomized controlled trial to assess YST among patients receiving chemotherapy for colorectal cancer. Data collected and challenges encountered will inform future research.

Development and Psychometric Properties of the Yoga Self-Efficacy Scale (YSES).

BACKGROUND: Yoga is a behavioral practice that uses physical movement, breathing, and meditation to improve health and promote personal transformation. Ancient yoga philosophy proposed that an individual's confidence about yoga, a concept similar to self-efficacy, will affect the likelihood of improved health from yoga practice. The purpose of this study was to develop and examine the psychometric properties of a self-efficacy measure for yoga practice (the Yoga Self-Efficacy Scale; YSES). METHODS: Yoga practitioners were recruited to evaluate the psychometric properties of YSES via a secure online survey. We collected data on additional measures to further examine construct validity. After two weeks, participants were invited to complete YSES items again to assess test-retest reliability. RESULTS: A majority of participants (N = 309) were White (85%), female (82%), and yoga instructors (56%). The 12-item YSES is unidimensional with a Cronbach's alpha of 0.93. Test-retest reliability is r = 0.79 (n = 170). YSES scores are positively correlated with health competence, health-related quality of life, and years practicing yoga, supporting construct validity. Also, yoga teachers scored significantly higher on the YSES than non-teachers (p < 0.001). Non-significant relationships with education, income and sex supported discriminant validity. YSES maintained internal consistency and construct validity for all yoga styles surveyed. CONCLUSION: YSES is a reliable and valid measure of self-efficacy for yoga practice that may provide insight into barriers to adopting and maintaining yoga as a health behavior.

Complementary Tools to Empower and Sustain Behavior Change: Motivational Interviewing and Mindfulness.

Improving health behaviors is fundamental to preventing and controlling chronic disease. Healthcare providers who have a patient-centered communication style and appropriate behavioral change tools can empower patients to engage in and sustain healthy behaviors. This review highlights motivational interviewing and mindfulness along with other evidence-based strategies for enhancing patient-centered communication and the behavior change process. Motivational interviewing and mindfulness are especially useful for empowering patients to set self-determined, or autonomous, goals for behavior change. This is important because autonomously motivated behavioral change is more sustainable. Additional strategies such as self-monitoring are discussed as useful for supporting the implementation and maintenance of goals. Thus, there is a need for healthcare providers to develop such tools to empower sustained behavior change. The additional support of a new role, a health coach who specializes in facilitating the process of health-related behavior change, may be required to substantially impact public health.