Table 3 Barriers and facilitators of the intervention from qualitative interviews with participants

Social connection

Group setting

The group setting assisted learning, was fun, and allowed participants to benchmark their abilities and progress against similar others

F age 72: “Because people can support each other and learn from each other and also I think it's supportive, you don’t feel as though—the focus is dispersed amongst the group, so you can hide in a way if you know what I mean.”

Severe asthma specific class

Participants enjoyed speaking with others about their illness/medication experiences, felt less self-conscious about symptoms (eg, cough), and believed the shared experience of severe asthma enhanced togetherness and supportiveness

F age 78: “Well, it was very interesting doing the yoga with lots of other asthmatics. That was really good. Because a lot of people with asthma don’t really talk about it. So, you might know someone with asthma but you don't sit and yap about your asthma. Occasionally, you might. But things that came out in class about what this one or that one was doing, or how—it was good just to think you're not alone and that happens to someone else too.”

M age 73: “Yeah, I didn’t worry about the cough. I did apologise a few times if I cough loud and that sort of thing, but I wasn’t the only one coughing… That’s why it felt more comfortable I think than just being in a group of people without those sort of problems.”

Instructor

The instructor’s attitude, personality, attention, explanations and feedback enhanced learning and facilitated a positive class environment, increased retention and instilled a desire to do home practice. However, participants expressed hesitation at attending classes with a different instructor, which may be a barrier to continued practice

F age 49: “I've never done yoga before so I don't know what to expect from a yoga teacher, but he was just special, I mean seriously I fell in love with him, he was just wonderful. So patient and so good at communicating and taking it at our pace was the best thing, but also explaining the why, that was huge.”

F age 78: “There's a few yoga places around, but I'd rather do—if [a new instructor] knows what [the intervention instructor] did, it would be better.”

Broader community connection

Participants were able to talk about their experiences with yoga, or even practice yoga, with friends, family and others, in a way that may not have been possible with an exercise less well-known in the community

M age 75: “…I've quite openly been proud of the fact that I've been in yoga classes, talking to people that aren't involved in it, like my friends at the pub… So I've been comfortable to tell them that I've been a participant in it.”

Setting and commitment

Structured, closed-group programme

Participants appreciated that the programme gradually built on skills such that they could see changes in their ability and confidence. They felt a commitment to attend, or that it became a habit/routine to attend, which facilitated retention. However, participants described disappointment and frustration at being unable to attend due to illness or commitments, which was a barrier to continued practice

F age 61: “When we first started this I thought, 4 months, that’s a long time. Commitment wise from us but also from you guys to provide that, those classes for that amount of time. But what it did by having that sort of time, [the instructor is] sort of in your psyche now, in your head… I think that little voice is always going to be there now.”

F age 70: “[I attended classes] for a month or something and then personal reasons, I couldn't do it…I was really devastated I couldn't come back for it, because I was really feeling I was getting a lot from it. So I don't know, maybe if I could have come longer, I would have gotten more, but I did feel benefit from what I did get.”

Time of day

Participants suggested that working may be a barrier to attendance; participants found fitting the class around their schedules challenging

F age 61: “Well, I didn't like that I had to rush from [work] to get here. That was hard…So, if it was a little bit later it would have helped.”

Research study

Participants prioritised attendance because it was a research study; they wanted to contribute to knowledge, trusted the people who put the programme together, and appreciated where it was conducted. Although this context increased retention, for some it was a barrier to ongoing practice as they viewed participating as a “one-time-thing”

F age 49: “…I thought I'm in a study, I need to maximise the effects of this study, I need to be full all in participation [sic]… you can't go into something like this half-heartedly and go oh well, you'll get your test results based on a half-hearted attempt. So, that's why I was so keen to do it and do everything that I'd been told to do.”

F age 57: “Also the fact it was run via the hospital and it was science, there had to be some degree of thought I think behind that.”

Changed mindset

Confidence

Participants reported confidence to try exercises or activities of daily living that they usually would not attempt, or push themselves further in their activity than they usually would

M age 68: “I feel more confident to do various things and more confident that I'll be able to do them longer and more confident that…there'll be no unfavourable repercussions of pain subsequently.”

Motivation

Participants reported motivation to exercise or do daily activities, often ascribed to awareness of their physical activity levels or the positive effects they experienced from physical activity

M age 73: “Yeah, well, besides all the extra walking, I’m finding that I feel more like I want to do things more so now, and the extra things I do, well, it’s probably what I was doing before, but this time with a bit more willingness to do it now.”

Understanding of yoga

Many participants had pre-conceived ideas about yoga; the yoga exceeded their expectations and shifted attitudes—they developed an understanding of yoga and saw why it might be beneficial for asthma. All reported incorporating aspects of yoga in their daily routine

F age 57: “Yeah, I was I was dubious. I mean somebody of my age trying something totally new physically, it's like, whoa. And particularly when I generally have coffee [in a particular suburb near a yoga studio] and I do not fit the dynamic of the yoga class I see going into that room.”

F age 61: “But this [yoga programme], knowing the purpose of it and actually being able to recognise how valuable it would be. Even though I had done yoga before, I didn’t really link it to be, [participant’s name] this could really help with how you manage your asthma.”

Positive outlook and sense of calm

Many participants spoke about having a more positive outlook on life, decreased worry, and achieving a sense of “calm”

F age 70: “Mindset, yeah, opens your mind up to bigger and better things and, yeah, just be happy…It has made a really big difference in my attitude to daily life.”

F age 62: “I think it was, yes, getting out of myself, coming to a place. The relaxation and just the working with my body to help it get all of the stress it had been under.”

Addressing breathing and asthma symptoms

Connecting breath and movement

Many found the focus on connecting breath with movement particularly helpful for managing day-to-day activity and intentional exercise. They thought that improved posture was helpful to broadening the chest and improving breathing

F age 62: “I went to the gym for all of those years and never thought about my breathing. If anything, when I was lifting heavy weights, I used to hold my breath. Now I've learnt to concentrate on my breath, while I’m doing those exercises, and I can lift heavier weights now, because I'm monitoring the oxygen going into my system.”

Relaxation and stress reduction

Many found the focus on relaxation/stress reduction helpful for reducing anxiety and increasing a sense of control over symptoms of breathlessness, cough and wheeze

F age 49: “I find that the stressful side of things can bring on asthma, and this would teach people to destress.”

F age 78: “Well, mainly with the yoga, I breathe better and I can manage my breathing so that if I get out of breath, I can sit down and concentrate and deep breathe and get out of the tight feeling and relax. Relaxation is very important.”

Breathing exercises

Some connected the learning in the yoga class with previous experience of breathing exercises (eg, speech therapy), which they used as a tool to achieve more physical activity

M age 75: “I think I had most of the breathing exercises in practice before I went [to the yoga class], to be quite honest. It was only [the yoga instructor] giving me a reminder of what I'd been taught elsewhere to do.”

Intersection of different elements

Breath, relaxation and movement

Participants felt the combination of breath, relaxation and exercise/movement was beneficial

F age 70: “Having tried over the years quite a few [other types of exercise], this is the one I found that helped me the most in the body, the breathing, the mind, the attitude… It was a whole package… I found it gave me great confidence because I've never been one to have a lot of confidence, so it did give me confidence to try other things… not just sit at home and, as I said, get up and move and do things.”

Fitbit and yoga

The Fitbit brought awareness of physical activity or motivated people to start their own new physical activity outside, and yoga was a way to learn different skills that facilitated physical activity outside of class

F age 49: “Having the combination of the yoga and the Fitbit to make me aware of my movement, that's a big thing to make me aware of every little bit counts, and you watch the little steps add up. So, that applies with when you're doing the yoga as well, you realise that every little bit adds up. Before Fitbit or yoga, I would avoid steps at all costs, I'm an elevator person. Hills, avoid hills, anything that was going to exert me because I knew that the result of exertion was asthma. In that regard, asthma was controlling me.”

Intervention and medication

Participants used the intervention to get back to being physically active now that they felt better on new medication. Participants reflected that if they felt unwell, they were uncertain whether they could keep up with the classes or exercises

F age 61: “I think the medication definitely has made a big difference but this [intervention] on top of it reinforces the fact that it’s not a dead end, you know.”

M age 68: “I might have struggled a bit with some of these yoga activities before the [monoclonal antibody therapy]… [the medication] freed me up to be active but these yoga activities are getting back my physical fitness.”

Improved asthma and comorbidity

The programme had benefits for a range of comorbidities personal to each individual. People also reported their health, particularly pain, impeded their ability to follow the class. The tailored approach allowed them to overcome physical barriers; participants particularly appreciated the instructor being responsive to the needs of the class

M age 68: “Well, at the beginning of it I thought, I don't know how I'm going to go with this yoga, because it's hurting my back a bit; but I noticed at progressive times I came and I still did the activities where I didn't do them strenuously – I did them in a subtle, non-strenuous manner – and I found out that the recovery period got less and less to the point that now those activities don't hurt my lower back anymore.”