Impact of yoga therapy in improving perceived stress, depression, and quality of life in elderly population: A randomized controlled trial

HR Shree Ganesh; Pailoor Subramanya; M Raghavendra Rao; HS Vadhiraj; Vivek Udupa

doi:10.4103/ijoyppp.ijoyppp_26_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 10 | Issue : 1 | Page : 62-68

Impact of yoga therapy in improving perceived stress, depression, and quality of life in elderly population: A randomized controlled trial

HR Shree Ganesh¹, Pailoor Subramanya², M Raghavendra Rao³, HS Vadhiraj³, Vivek Udupa⁴
¹ Division of Life Science, Swami Vivekananda Yoga AnusandhanaSamsthana, Bengaluru, Karnataka, India
² Department of Yoga Studies, School of Medicine and Public Health, Central University of Kerala, Kasaragod, Kerala, India
³ Department of Research, Central Council for Research in Yoga and Naturopathy, New Delhi, India
⁴ Department of Yoga and Naturopathy, SarvaKshema Hospital and Research Foundation, Udupi, Karnataka, India

Date of Submission	16-Oct-2021
Date of Acceptance	05-Feb-2022
Date of Web Publication	26-Apr-2022

Correspondence Address:
Dr. Pailoor Subramanya
Department of Yoga Studies, School of Medicine and Public Health, Central University of Kerala, Periya Post, Kasaragod - 671 320, Kerala
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijoyppp.ijoyppp_26_21

Abstract

Introduction: Geriatric population is vulnerable to physical and emotional discommodes that requires expert care from a holistic perspective. Depression, stress, anxiety, etc., are the common problems faced by the elderly. Holistic interventions such as yoga are reckoned to be a pillar in alleviating these issues; however, most of the studies in this arena are conducted on elderly who resides in shelter homes. Materials and Methods: Ninety-six participants were randomized to a yoga or waitlisted control group (n = 48 each). Yoga group received a set of yogic practices for 12 weeks. Assessments were done using Perceived Stress Scale (PSS), Geriatric Depression Scale (GDS), and older people quality of life (OPQOL). Results: Yoga group has shown statistically significant reduction in PSS (P < 0.001), GDS (P = 0.001), and improvement in the selected components of OPQOL such as social relationship (P = 0.014), neighborhood (P = 0.001), psychological well-being (P = 0.001), financial circumstances (P = 0.001), and OPQOL – total (P = 0.001). Discussion: The results indicate that yoga can successfully be implemented in the elderly population on an outpatient basis and can produce clinically beneficial effects. Nurses, physicians, and other therapists should consider integrating yoga in the elderly. Conclusion: The results of this study are encouraging to recommend yoga as a stand-alone mind-body rehabilitation program for older adults.

Keywords: Depression, elderly population, perceived stress, quality of life, yoga

How to cite this article:
Shree Ganesh H R, Subramanya P, Rao M R, Vadhiraj H S, Udupa V. Impact of yoga therapy in improving perceived stress, depression, and quality of life in elderly population: A randomized controlled trial. J Appl Conscious Stud 2022;10:62-8

How to cite this URL:
Shree Ganesh H R, Subramanya P, Rao M R, Vadhiraj H S, Udupa V. Impact of yoga therapy in improving perceived stress, depression, and quality of life in elderly population: A randomized controlled trial. J Appl Conscious Stud [serial online] 2022 [cited 2023 May 28];10:62-8. Available from: http://www.jacsonline.in/text.asp?2022/10/1/62/343853

Introduction

Aging is an inevitable phenomenon. With this unprecedented rise in aging population, there is a surge in health-care needs and challenges associated with this vulnerable group (Bhan et al., 2017). As per the 2013 data, India has 8% of its population above 60 years of age or more. This number is expected to increase by 18.3% in 2050 (Bhan et al., 2017; GOI Office of the Registrar General and Census Commissioner India, 2011; United Nations, 2013). Indian elderly population are equally burdened by communicable and noncommunicable diseases (Ingle & Nath, 2008). Among all the morbidities, elderly population are more prone to mental health morbidities which is reckoned as one of the greater challenge to be addressed (Lima & Ivbijaro, 2013). Mental health disarrays are associated with compromised quality of life, performance of day-to-day activities, and increased dependency on others (Lima & Ivbijaro, 2013). The demographic transition due to rapid urbanization/industrialization and subsequent disintegration of joint family culture in India has a huge role to play on diminished mental health of Indian older adults. Reports suggest that susceptibility to depression, anxiety, dementia, and suicidal tendency is directly proportional with the age (Parkar, 2015).

The prevalence of depression among geriatric population, as reported by a recent meta-analysis is 34.4%, which indicates that about 1/3^rd of India's elderly population is suffering from depression (Pilania et al., 2019). Similarly, the prevalence of anxiety disorders among the Indian geriatric population is estimated to be 10.8%. Further to these, there are studies suggestive of a greater proportion of elderly population in India, as like other developing countries, who are living with compromised health conditions which is associated with a higher prevalence of morbidity (Basu & King, 2013; Chatterji et al., 2008). All the aforementioned statistics suggests that the Indian geriatric population are thriving through a difficult situation where they have to deal with a greater level of stress. Thus, depression, chronic morbidity coupled with psychological stress can catalyze adverse events in older adults like functional disability, frequent hospitalization, and death (Carneiro et al., 2016).

Yoga, a 3000-year-old Indian traditional wisdom integrates the body, mind, and spiritual component of an individual to invigorate health (Atkinson, 2009; Williams et al., 2003). Numerous studies have demonstrated the mental health benefit of yoga in managing stress, cultivating positive emotion, and balancing the mind (Duan-Porter et al., 2016; Shohani et al., 2018). Yoga has also shown to ease psychological distress, depression, mood, thereby offering improvement in quality of life as well as physiological and functional measures in elderly population (Mooventhan & Nivethitha, 2017). Although there are many studies expressing the beneficial effects of yoga in the elderly, most of the Indian studies in this arena are focused on the special population among the elderly such as shelter home elderly, homeless population, etc., (Grover & Malhotra, 2015). Studies based on general community or elders living in own homes are scarce in this field (Bhandari & Paswan, 2021). Further, the feasibility of delivering yoga therapy in diverse clinical settings needs to be explored. This study focuses on assessing the effects of yoga intervention on perceived stress, self-reported depression, and quality of life in the elderly population not residing in any shelter homes who underwent yoga therapy on an outpatient basis.

Materials and Methods

Design

This study was conducted as a randomized controlled trial and was approved by Institutional Ethical review board. The trial was registered with Clinical Trail Registry of India (CTRI/2020/05/025268). This was a prospective, two-arm, randomized wait listed controlled study comparing yoga-based lifestyle intervention program with usual care with randomization done using computer-generated random numbers and opaque envelopes with group assignments by investigator who was not involved in the field implementation of the study. The participants were randomized to yoga (n = 48) and waitlisted control group (n = 48) with allocation ratio of 1:1. Allocation concealment was done by individuals not involved in the study.

Participants

The participants were elderly population residing at Udupi, Karnataka who were referred by their primary care physicians or voluntarily enrolled themselves in response to our advertisements in local newspapers and social media platforms. Consented participants were randomized either into a yoga arm or a wait-listed control arm. Elderly population who are literate, aged between 60 and 75 years and had a Zubrod's performance score ranging between 0 and 2 were included in the study.

Participants who had a history of yoga practice within the past 12 months of recruitment were excluded from the study. Other exclusion criteria for participation were uncontrolled diabetes, uncontrolled hypertension, endocrine disorders, known history of symptomatic heart disease, lung disease, dementia, on bronchodilator prescription, clinically requiring psychological support, poststroke profile, neuromusculoskeletal illnesses, major orthopedic disorders of the lower back, pelvis or lower extremities, rheumatoid arthritis, osteoarthritis, history of recent fractures/trauma affecting mobility, on a prescription drug therapy for metabolic abnormalities, physical conditions not suitable for exercise training, and tobacco users.

Sample size

Standardized effect size with cyclic meditation versus supine rest on low frequency power on heart rate variability was 0.25 and 0.75 for high frequency (HF) calculated using G power for paired differences. Considering a conservative estimate of effect size as 0.75 for HF, the effect size was 0.75 and for an alpha of 0.05, and 90% power the total sample size was 78 participants, i.e., 39 participants in each arm for a two group allocation. Taking into consideration, a dropout rate of 25% (9 subjects) we will recruit, approximately 48 participants in each arm (Sarang & Telles, 2006).

Those participants who were enrolled into yoga arm started with yoga protocol for 3 months in an outpatient yoga clinic immediately after the recruitment, whereas participants in the control group did not receive any interventions until the completion of the trial. We had 15 dropouts from the control arm owing to loss to follow-up, re-location from the study locality or the participant enrolling in to other yoga sessions elsewhere before the completion of the trial. We have included all the participants originally enrolled for the study in the final analysis based on intention to treat analysis. The trial flow diagram is depicted in [Figure 1].

Figure 1: Trial profile

Click here to view

Intervention

Yoga group received a customized yoga protocol that includes Sukshma vyayama (loosening exercises), a set of asanas (postures done with awareness), breathing exercises, pranayama (voluntarily regulated nostril breathing), and yogic relaxation. The in-person sessions were scheduled thrice per week for 12 weeks consecutively. All the participants were mandated to attend three in-person sessions per week and practice at home on the remaining days of the week.

Each of these sessions lasted for 1 h and was administered by a trained yoga therapist. The control groups remained as waitlist with routine daily activities and were offered the same yoga intervention after the completion of 12 weeks of waitlist control period.

Assessments

As discussed above, the main expected outcome measures were melioration of perceived stress, depression, and quality of life. The assessments were done using the following instruments.

Perceived Stress Scale

Perceived Stress Scale (PSS) is one of the widely used stress scale used to determine the magnitude of situations that are perceived by individuals as unpredictable, uncontrollable and detrimental compared to previous month of their life. The latest version of PSS is a 10-item scale designed as a self-appraisal of the effects stressors on one's life (Cohen et al., 1983).

Geriatric Depression Scale

A 15-item geriatric depression scale (GDS) instrument was used in this study to ascertain the status of depression in our study participants. GDS can be self-administered or can be utilized as an interview tool as the questions are of yes/no format which can be easily comprehended by the elderly population (Conradsson et al., 2013; Montorio & Izal, 1996).

Older people quality of life questionnaire

The OPQOL is a 35-item QoL measure which has a 5-point Likert scales representing: Life overall, health, social relationships and participation, independence, control over life, freedom, home and neighborhood, psychological and emotional well-being, financial circumstances, and religion/culture (Bowling, 2009).

Data analysis

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) Software, Version 18, IBM, New York, United States of America. The demographic characteristics of the participants are presented using descriptive statistics. While the two groups were comparable at baseline, they were not normally distributed. We therefore performed a nonparametric Wilcoxon's signed-rank test and Mann − Whitney test to assess the magnitude of the changes within and between the groups. An alpha of 0.05 was considered significant. Data were analyzed using an Intention to treat approach where missing values of dropouts were substituted by carrying forward their respective baseline values.

Results

We have recruited 96 participants who were randomized into either of the group (n = 48 per group). At the end of the trial, 81 participants (yoga = 48 and waitlisted control = 33) completed the study. The complete demographic profiling is tabulated in [Table 1]. Gender distribution was unequal across the groups.

Table 1: Demographic profiling of the study groups

Click here to view

Comparison of perceived stress scale score

There was a significant decrease in PSS scores within yoga group (P = 0.0001) on Wilcoxon's signed-rank test, whereas there was no significant change in the control group. Compared to control group, yoga group had statistically significant decrease in PSS scores (P < 0.001) on Mann − Whitney U-test. The detailed results are tabulated in [Table 2].

Table 2: Comparison of self-reported perceived stress and depression among the study groups using the Mann–Whitney test

Click here to view

Comparison of geriatric depression scale scores

There was a significant decrease in self-reported depression on GDS in yoga group following intervention (P = 0.001) on Wilcoxon's signed-rank test, whereas there was no change within the control group. There was a statistically significant decrease in self-reported depression score in yoga group as compared to control group (P = 0.001) on Mann − Whitney U test, as shown results in [Table 2].

Comparison of OPQOL scores

Wilcoxon's signed-rank test to assess within group showed a significant improvement in the various components of OPQOL such as psychological well-being, comfort in the neighborhood, financial well-being (P = 0.001) in both yoga and control group, whereas the total scores were significant only in the yoga group (P = 0.001). Mann − Whitney test to assess between group difference showed a significant improvement in social relationship (z = −2.45, P = 0.014), neighborhood (z = −6.18, P = 0.001), psychological well-being (z = −6.18, P = 0.001), financial circumstances (z = −7.06, P = 0.001), OPQOL – total (z = −9.09, P = 0.001) following intervention in yoga group as compared to the control group as assessed by older people quality of life questionnaire [Table 3].

Table 3: Comparison of scores on older peoples quality of life between yoga and control groups using the Mann–Whitney test

Click here to view

Discussion

Our result suggests that yoga therapy can successfully be implemented in the elderly population on an outpatient basis and can produce clinically beneficial effects for this vulnerable population. Our study has shown significant improvement in perceived stress, depression, and quality of life following 3 months of intervention in yoga group as compared to waitlisted control group.

Yoga as an intervention for depression is widely recommended by various studies (Bridges & Sharma, 2017; Lee et al., 2019; Mehta & Sharma, 2010; Ramanathan et al., 2017). Our results concur with these earlier studies which are mostly conducted as an in-house yoga programs in assisted living facilities. Systematic reviews on yoga and depression have reported that most of the previous studies on yoga and depression were short-term studies averaging 6 weeks of duration and a relatively small sample size (Bridges & Sharma, 2017). The present study took this fact in to consideration and has evaluated the effects of yoga for 6 months with 96 participants.

Yoga a scientific form of body mind therapy is hailed for its influence on maintaining mental health, offering happiness, and enhancing general well-being. Earlier studies have reckoned yoga to improve mobility, quality of sleep, tolerability to pain, functional status, and health related quality of life in older adults (Chen et al., 2010; Groessl et al., 2013; Kutz et al., 1985). Our study reiterates these findings on a larger sample size with a real-time participants living in the family settings. Considering the alarming numbers of depressive older population in India (Pilania et al., 2019), the results of this study are very important as heightened state of mental well-being and improvement in quality of life can be attributed to marked improvement in daily performance, reduction in age-related falls and injuries.

Our study also tried to demystify the general thought that yoga practice cannot be consistently delivered to older adults out-side the assisted living settings (Bhandari & Paswan, 2021). Earlier studies have reported various challenges such as concomitant health problems, body aches, lack of prioritization as challenges to run long-term yoga program in older population (Cadmus-Bertram et al., 2013; Cheung et al., 2015). In the present study, despite some loss to follow-up in the wait-listed control group, the entire yoga group completed the 3 months yoga program, which shows the acceptability and adherence of yoga as a mind body program among geriatric population.

Although we have included 96 participants in our study, considering the pluralistic health issues prevailing in geriatric population, future studies are warranted with stratified samples based on economic strata, physical ability, and medical conditions. The present study was conducted to understand the feasibility and usefulness of yoga in alleviating stress, depression and to improve quality of life in the elderly in out-patient settings. The results are encouraging to integrate yoga into geriatric care as it shares identical paradigms with elderly care guidelines that warrants a whole-person approach that gives more value to quality of life and functional independence than mere longevity (Bell et al., 2016). Large scale systematic review also recommends yoga to be used as an active form of practice in older adults which has multi-dimensional physical and mental health impact on this vulnerable population. Health-care providers with knowledge of yoga therapy, especially those nurses and/or therapists who are directly involved in geriatric nursing can upscale the quality of care amongst older adults to a greater extent.

Further the benefits of yoga are not limited to the recipients alone, robust studies have reported yoga to benefit the nurses and health-care providers by reducing their stress levels, alleviate burn outs, and improve sleep by providing serenity and mindfulness (Hilcove et al., 2021). Therefore, yoga functions as a synergetic tool that complement the recipient as well as the provider. A conducive environment that benefits all the players involved in healing is likely to induce holistic health benefits that will be meaningful (Vinson, 2019).

Conclusion

To the knowledge of the authors, this is the first study to evaluate the impact of yoga on self-reported depression, stress, and quality of life in the real-life setting outside institutional care. The results of this study are encouraging to recommend yoga as a stand-alone mind-body rehabilitation program for older adults.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Atkinson, N., (2009). Benefits, barriers, and cues to action of yoga practice: A focus group approach. American Journal of Health Behavior, 33(1), 3-14. doi: 10.5993/AJHB.33.1.1.
2.	Basu, S., & King, A. C., (2013). Disability and chronic disease among older adults in India: Detecting vulnerable populations through the WHO SAGE Study. American Journal of Epidemiology, 178(11), 1620-1628. doi: 10.1093/aje/kwt191.
3.	Bell, S. P., Patel, N., Patel, N., Sonani, R., Badheka, A., & Forman, D. E., (2016). Care of older adults. Journal of Geriatric Cardiology, 13(1), 1-7. doi: 10.11909/j.issn. 1671-5411.2016.01.019.
4.	Bhan, N., Madhira, P., Muralidharan, A., Kulkarni, B., Murthy, G., Basu, S.,… Kinra, S., (2017). Health needs, access to healthcare, and perceptions of ageing in an urbanizing community in India: A qualitative study. BMC Geriatrics, 17(1), 156. doi: 10.1186/s12877-017-0544-y.
5.	Bhandari, P., & Paswan, B., (2021). Lifestyle behaviours and mental health outcomes of elderly: Modification of socio-economic and physical health effects. Ageing International, 46(1), 35-69. doi: 10.1007/s12126-020-09371-0.
6.	Bowling, A., (2009). The psychometric properties of the older people's quality of life questionnaire, compared with the CASP-19 and the WHOQOL-OLD. Current Gerontology and Geriatrics Research, 2009, 1-12. doi: 10.1155/2009/298950.
7.	Bridges, L., & Sharma, M., (2017). The efficacy of yoga as a form of treatment for depression. Journal of Evidence-Based Complementary & Alternative Medicine, 22 (4), 1017-1028. doi: 10.1177/2156587217715927.
8.	Cadmus-Bertram, L., Littman, A. J., Ulrich, C. M., Stovall, R., Ceballos, R. M., McGregor, B. A.,… McTiernan, A., (2013). Predictors of adherence to a 26-week viniyoga intervention among post-treatment breast cancer survivors. The Journal of Alternative and Complementary Medicine, 19(9), 751-758. doi: 10.1089/acm. 2012.0118.
9.	Carneiro, J. A., Ramos, G. C. F., Barbosa, A. T. F., de Mendonça, J. M. G., da Costa, F. M., & Caldeira, A. P., (2016). Prevalência e fatores associados à fragilidade em idosos não institucionalizados. Revista Brasileira de Enfermagem, 69 (3), 435-442. doi: 10.1590/0034-7167.2016690304i.
10.	Chatterji, S., Kowal, P., Mathers, C., Naidoo, N., Verdes, E., Smith, J. P.,… Suzman, R., (2008). The health of aging populations in China and India. Health Affairs, 27(4), 1052-1063. doi: 10.1377/hlthaff. 27.4.1052.
11.	Chen, K. M., Fan, J. T., Wang, H. H., Wu, S. J., Li, C. H., & Lin, H. S., (2010). Silver yoga exercises improved physical fitness of transitional frail elders. Nursing Research, 59(5), 364-370. doi: 10.1097/NNR.0b013e3181ef37d5.
12.	Cheung, C., Justice, C., & Peden-Mcalpine, C., (2015). Yoga adherence in older women six months post-osteoarthritis intervention. Global Advances in Health and Medicine, 4(3), 16-23. doi: 10.7453/gahmj. 2015.041.
13.	Cohen, S., Kamarck, T., & Mermelstein, R., (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385. doi: 10.2307/2136404.
14.	Conradsson, M., Rosendahl, E., Littbrand, H., Gustafson, Y., Olofsson, B., & Lövheim, H., (2013). Usefulness of the geriatric depression scale 15-item version among very old people with and without cognitive impairment. Aging & Mental Health, 17(5), 638-645. doi: 10.1080/13607863.2012.758231.
15.	de Mendonça Lima CA, Ivbijaro G., Mental health and wellbeing of older people: opportunities and challenges. Ment Health Fam Med. 2013;10(3):125-7. PMID: 24427178; PMCID: PMC3822658.
16.	Duan-Porter, W., Coeytaux, R. R., McDuffie, J. R., Goode, A. P., Sharma, P., Mennella, H.,… Williams, J. W., (2016). Evidence map of yoga for depression, anxiety, and posttraumatic stress disorder. Journal of Physical Activity and Health, 13 (3), 281-288. doi: 10.1123/jpah. 2015-0027.
17.	GOI Office of the Registrar General & Census Commissioner India. (2011). Census of India 2011. New Delhi, India: GOI Office of the Registrar General & Census Commissioner India. Retrieved from: https://censusindia.gov.in/. [Last accessed on 2021 Oct 10].
18.	Groessl, E. J., Schmalzl, L., Mazzi, M., & Iszak, F., (2013). Yoga for low-income older adults: Silver age yoga. Journal of Yoga & Physical Therapy, 03(01), 131. doi: 10.4172/2157-7595.1000131.
19.	Grover, S., & Malhotra, N., (2015). Depression in elderly: A review of Indian research. Journal of Geriatric Mental Health, 2(1), 4. doi: 10.4103/2348-9995.161376.
20.	Hilcove, K., Marceau, C., Thekdi, P., Larkey, L., Brewer, M. A., & Jones, K., (2021). Holistic nursing in practice: Mindfulness-based yoga as an intervention to manage stress and burnout. Journal of Holistic Nursing, 39(1), 29-42. doi: 10.1177/0898010120921587.
21.	Ingle, G. K., & Nath, A., (2008). Geriatric health in India: Concerns and solutions. Indian Journal of Community Medicine, 33(4), 214. doi: 10.4103/0970-0218.43225.
22.	Kutz, H., Leserman, J., Dorrington, C., Morrison, C. H., Borysenko, J. Z., & Benson, H., (1985). Meditation as an adjunct to psychotherapy. Psychotherapy and Psychosomatics, 43(4), 209-218. doi: 10.1159/000287881.
23.	Lee, K. C., Tang, W. K., & Bressington, D., (2019). The experience of mindful yoga for older adults with depression. Journal of Psychiatric and Mental Health Nursing, 26(3-4), 87-100. doi: 10.1111/jpm. 12517.
24.	Mehta, P., & Sharma, M., (2010). Yoga as a complementary therapy for clinical depression. Complementary Health Practice Review, 15(3), 156-170. doi: 10.1177/1533210110387405.
25.	Montorio, I., & Izal, M., (1996). The geriatric depression scale: A review of its development and utility. International Psychogeriatrics, 8(1), 103-112. doi: 10.1017/S1041610296002505.
26.	Mooventhan, A., & Nivethitha, L., (2017). Evidence based effects of yoga practice on various health related problems of elderly people: A review. Journal of Bodywork and Movement Therapies, 21(4), 1028-1032. doi: 10.1016/j.jbmt.2017.01.004.
27.	Parkar, S., (2015). Elderly mental health: Needs. Mens Sana Monographs, 13(1), 91. doi: 10.4103/0973-1229.153311.
28.	Pilania, M., Yadav, V., Bairwa, M., Behera, P., Gupta, S. D., Khurana, H.,… Poongothai, S., (2019). Prevalence of depression among the elderly (60 years and above) population in India, 1997-2016: A systematic review and meta-analysis. BMC Public Health, 19(1), 832. doi: 10.1186/s12889-019-7136-z.
29.	Ramanathan, M., Bhavanani, A., & Trakroo, M., (2017). Effect of a 12-week yoga therapy program on mental health status in elderly women inmates of a hospice. International Journal of Yoga, 10(1), 24. doi: 10.4103/0973-6131.186156.
30.	Sarang, P., & Telles, S., (2006). Effects of two yoga based relaxation techniques on heart rate variability (HRV). International Journal of Stress Management, 13(4), 460-475. doi: 10.1037/1072-5245.13.4.460.
31.	Shohani, M., Badfar, G., Nasirkandy, M., Kaikhavani, S., Rahmati, S., Modmeli, Y.,… Azami, M., (2018). The effect of yoga on stress, anxiety, and depression in women. International Journal of Preventive Medicine, 9(1), 21. doi: 10.4103/ijpvm.IJPVM_242_16.
32.	United Nations., (2013). Profiles of Ageing 2013. Retrieved from: https://www.un.org/en/development/desa/population/publications/dataset/urban/profilesOfAgeing2013.asp. [Last accessed on 2021 Oct 10].
33.	Vinson, J., (2019). Be the change: Understanding quantitative, qualitative, & mixed methods in holistic nursing research. Beginnings, 39(5), 14-16.
34.	Williams, K., Steinberg, L., & Petronis, J., (2003). Therapeutic application of Iyengar yoga for healing chronic low back pain. International Journal of Yoga Therapy, 13(1), 55-67. doi: 10.17761/ijyt. 13.1.2w0153h1825311m6.