The study was reviewed and approved by the Institute's ethics committee. Written informed consent of the mental health professionals who helped in validation of the program and family caregivers who participated in the pilot study was obtained. A sociodemographic sheet eliciting information on their age, occupation, monthly income, and marital status was filled up by the researcher for both the mental health professionals and family caregivers.
The inductive method of inquiry (quintessence of qualitative research) in which general principles (theories/programs) are developed from specific observations was used to develop and test the feasibility of the program. The development of the yoga program was conducted in two stages. Stage-one involved development of the content and methodology for the yoga program. Stage-two involved face and content validation of the program. The feasibility of the program was tested in Stage-three of the study where the program was pilot-tested and feedback from the caregivers who participated in the program was elicited. The process involved in each stage of the development and feasibility testing of the program is delineated below .
Process of Inductive method of program development
Stage-One: Program development
Initially, a yoga program was developed by matching the needs of the caregivers.[10
] Classical texts such as Patanjali Yoga Sutra,[11
] Gheranda Samhita,[13
] and Hathayogapradipika[15
] were reviewed to understand the asanas/practices that would help directly or indirectly deal with each of the needs.
To help warm up the body to practice the asanas and pranayama, jogging, cycling, and hands in and out breathing was incorporated in the beginning of each day's program (Nagendra, 2008).
Suryanamaskara a set of yogic postures done in a sequence of postures routinely followed in several yoga schools, helps in bringing about general flexibility of the body and improving mental health as a preparation for asanas and pranayama (Satyananda Saraswati, 2008; Yogendra., 1997). Even the foremost classical text (Rigveda, 1st Mandala, 50th Sukta) emphasizes the benefits of the practice in destroying physical illnesses and the diseases of the heart (mind) [‘udyannadya mitramaha arohannuttaram divam /Hrdrogham mamasurya harimanam ca nasaya // (1st Rucha). “Rising this day, O rich in friends, ascending to the loftier heaven, Surya remove my hearts disease, take from me this yellow hue…”].
The goal of yoga practices in context of the needs expressed by the caregivers (such as managing illness behavior, managing socio-occupational concerns, physical and mental health, and managing marital and sexual issues of the patient) was to enable the caregivers to think clearly, have equanimity in emotions, improve their decision making as well as their response to a situation, and improve their attention. A review of classical yoga texts (Gheranda Samhita, Hatharatnavali, Hathapradipika) and contemporary yoga textbooks (Yogendra., 1997, Satyananda Saraswati, 2008; Nagendra, 2008) showed that asanas such as Padahastasana, ardhachakrasana, Vajrasana, Vakrasana, Salabhasana Bhujangasana, Savasana, Nadanusandana, Matsyasana, Nadishuddhi, Bhramhari, and Kapalabhatti had direct or indirect benefits in improving caregiver's ability to think clearly, improve their decision making/response to a situation/attention, and equanimity of emotions.
The satsang was used to educate the caregivers on how yoga could help tackle their needs and help in rehabilitation of the patient.
depicts the details of the yoga program developed in accordance with the assessed needs of caregivers. The table enlists practices that are applicable/not applicable in fulfilling the six assessed needs of the caregivers.
Yoga program in accordance to needs of caregivers [Practices applicable (A)/not applicable (NA)]
The ultimate aim of the yoga program was to reduce the burden of the caregivers either by addressing their needs or by developing yoga program which in turn would equip them with the ability and skills to reduce their burden—irrespective of the fulfillment of needs. As not all needs could be theoretically addressed by teaching yoga, we focused on the reduction of burden (aim of the study), irrespective of the expressed needs.
Thus, the framework of the yoga program was based on Integrated Yoga Therapy (IAYT) model developed by Swami Vivekananda Yoga Anusandhana Samasthana[3
] (SVYASA). This model incorporated the “Self Management of Excessive Tension (SMET)/ Cyclic meditation” approach which reflected not only the aim of the current study of reducing burden and improving coping among the caregivers, but also directly or indirectly dealt with the six broad categories of assessed needs elucidated in the first phase of this study.[10
Stage-Two: Face and content validation
For the purpose of content validation of the program, the researcher developed a structured questionnaire eliciting dichotomous responses such as Yes/No and qualitative comments on the appropriateness of each exercise and asana selected as a component of the entire yoga program. Ten experienced yoga therapy and research professionals (in and around Bangalore) were approached individually for the validation. The average number of years of work experience (SD) of the experts after their formal education was 14.8 (14.1) years. Through this methodology of content - validation, the researcher accumulated a list of comments for incorporating into yoga program. For face validation of the program, the researcher asked each of the professionals to rate the likelihood of the program achieving its objective of helping the caregivers reducing their burden and stress - on a five point Likert scale.
To arrive at a consensus on the contents and methodology of the yoga program, three rounds of iteration was conducted among the yoga professionals, i.e., the researcher made changes to the program based on comments given by the professionals and went back (iteration) to them for their further inputs on the modified program, three times before all the ten experts agreed on the contents and methodology (data saturation).
A standardized script of the final version of the yoga program was developed on incorporating the comments of the ten experts. The script included list of practices and asanas along with their step-wise procedure and pictures, detailed notes on each satsang topic (seven topics – one topic for each day; the script is available from the authors on request). A handout explaining the contraindication of practicing certain asanas during ailments along with the order and list of yogic practices and their pictures was developed in four languages (English, Hindi, Kannada, and Tamil) for distribution to the participants. Each satsang topic and notes was converted into power point slides in the four languages for ease of presentation to the participants.
Stage-Three: Pilot study and feasibility
The final version of the yoga program was pilot-tested on a group of eight in-patient family caregivers who were residing at National Institute of Mental Health and Neuro Sciences (NIMHANS) in Bangalore, India (NIMHANS has a 900-bed teaching hospital with training and research facilities in psychiatry and other neurosciences) during the period of the study.
Caregivers of patients with a diagnosis of schizophrenia were included in the study if they were to continue to provide care for them following discharge. Caregivers with psychiatric or neurological disorders and those caring for another relative with psychiatric illness were excluded. Of the eight caregivers recruited in the pilot study, three caregivers dropped out during the intervention. The mean age (SD) of the caregivers who completed the program was 49.6 (19.5) years. They had an average of 10.4 (3.8) years of education. All of them were females and three of the caregivers were parents. The average (SD) duration of illness of their patients was 12.2 (8.2) years and none of them had not received any prior structured training on how they should take care of their patient.
Participants were trained in performing yoga asanas under the guidance of a trained yoga therapist (based on the script developed; therapist trained by SVYASA). The intervention included sessions of about one hour daily for a period of seven days. During the entire period of the study, the ill relative continued to receive the routine treatment prescribed by the doctors at NIMHANS. At the end of the seven days, the caregivers were asked to fill a structured feedback form on their overall rating of the program, trainer, and the handouts distributed during the sessions.
Descriptive analysis of the quantitative (Likert ratings) feedback and content analysis of the qualitative feedback received from the caregivers was conducted. Each and every comment was given importance and the researcher tried to accommodate all of it into the yoga program.