Complementary Therapies in Medicine 32 (2017) 11–18

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Complementary Therapies in Medicine

journal homepage: www.elsevierhealth.com/journals/ctim

Understanding North American yoga therapists’ attitudes, skills and

use of evidence-based practice: A cross-national survey
Marlysa Sullivan a,∗ , Matthew Leach b , James Snow a , Steffany Moonaz a
a
Maryland University of Integrative Health, 7750 Montpelier Road, Laurel, MD 20723, United States
b
University of South Australia, North Tce Adelaide, SA 5000, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Little is known about the adoption of evidence-based practice (EBP) by yoga therapists (YTs).
Received 3 February 2017 Objective: To determine the attitudes, skills, training, use, barriers and facilitators to the use of EBP
Received in revised form 13 March 2017 amongst North American YTs
Accepted 13 March 2017
Design: Cross-sectional, descriptive survey
Available online 19 March 2017
Methods: Self-identified YTs practicing in North America were invited to participate in an online survey.
YT attitudes, skills, training, utilisation, barriers to use, and facilitators of EBP use were measured using
Keywords:
the 84-item Evidence-Based practice Attitude and utilization SurvEy (EBASE).
Attitudes
Evidence-based practice
Results: 367 members responded (∼20% of eligible participants). Attitudes towards EBP were generally
Skills positive with 88% agreeing that professional literature and research findings were useful for the practice
Survey of yoga therapy. Most (80%) were interested in improving their skills and the majority agreed that EBP
Utilization improves the quality of care (68%), assists in making decisions (74%) and takes into account the YTs clinical
Yoga therapy experience when making clinical decisions (59%). Moderate to moderately-high levels of perceived skill
in EBP were reported mostly utilizing online search engines (51%). Lack of clinical evidence was the only
notable barrier to uptake reported by YTs (48%). Facilitators to EBP included access to online EBP education
materials (70.6%), ability to download full-text journal articles and access to free online databases in the
workplace (67.3%).
Conclusion: North American YTs report positive attitudes, moderate to moderately-high levels of per-
ceived skill and moderate uptake of EBP. This aligns them with other complementary and integrative
health practitioners. Initiatives to support the adoption of EBP are proposed as a means of improving best
practice in yoga therapy.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction
1.1. Background
Evidence-based practice (EBP) is an important framework for
clinical decision making, taking into consideration the patient’s
perspective (i.e. values, rights and preferences), the best avail-
able evidence, and clinician expertise.1–14 The move towards EBP
was prompted by a need to deliver safe and effective clinical care,
informed by the best available evidence, rather than solely relying
on tradition, authority and intuition.1,4,15,16 Most health profes-
sions have embraced EBP, with positive attitudes towards EBP
∗ Corresponding author.
E-mail addresses: msullivan1@muih.edu
(M. Sullivan), matthew.leach@unisa.edu.au (M. Leach), jsnow@muih.edu (J. Snow),
smoonaz@muih.edu (S. Moonaz).
reported among allied health (AH) and complementary and inte-
grative health (CIH) professionals.4,5,8–11,13,17–25 These professions
also reportedly engage in EBP, albeit in varying degrees.5,9,11,13,19–23
The benefits of EBP are numerous, including greater quality and
consistency of care, improved patient outcomes, increased pro-
fessional accountability, improved healthcare delivery, enhanced
professional credibility, facilitation of interdisciplinary collabo-
ration, economic and resource efficiency, patient empowerment,
and improved clinical decision making.1,2,5,10,25–29 These benefits
indicate that clinicians and healthcare organizations have a pro-
fessional, ethical and social responsibility to engage in EBP, and to
apply the principles of EBP to clinical decision making.1,5,15,27,29
Despite the rhetoric of EBP, most health professions engage in
EBP at relatively low levels5,9,11,13,19–23 ; for many professions, the
level of engagement is still not known. In CIH practice, evidence
suggests that lack of time, insufficient evidence, and a misunder-
standing of EBP are considerable barriers to EBP.5,11,17,19,20 Other

http://dx.doi.org/10.1016/j.ctim.2017.03.005
0965-2299/© 2017 Elsevier Ltd. All rights reserved.
12 M. Sullivan et al. / Complementary Therapies in Medicine 32 (2017) 11–18
studies point to an incompatibility between EBP and individualized
patient care (an element of critical importance to CIH professions)
as an obstacle to EBP engagement.30 Notwithstanding, there is
a disproportionally high representation of chiropractors in these
studies, with little to no representation from other disciplines (such
as yoga therapy); as such, the current evidence may not necessarily
reflect the state of the art of EBP across CIH.
Yoga therapy, which is grounded in the principles and practices
of the ancient tradition of yoga, has a unique explanatory model
of health and disease that differs from biomedicine. According to
the International Association of Yoga Therapists (IAYT), yoga ther-
apy is distinguished from general yoga in that it is “the appropriate
application of these [yoga’s] teachings and practices in a therapeu-
tic context”.31 In other words, yoga therapy includes a focus on
the therapeutic relationship, and works with improving function,
“eliminating, reducing, or managing symptoms that cause suffer-
ing”, and changing the “relationship to and identification with their
[the client’s] condtion”.31 As an emerging profession, it is antici-
pated that the distinction between general yoga teaching and yoga
therapy should become more clear as the field develops, and as
educational standards, accreditation and credentialing processes
become further refined.32
Yoga therapy, like many CIH practices, places the client at the
forefront of the clinical decision making process. As such, yoga
therapy faces similar challenges to many other traditionally-based
CIH practices in trying to converge research evidence with tradi-
tional knowledge, while simultaneously giving consideration to
the needs/expectations of clients and clinical expertise.5,10,33,34
However, unlike other CIH disciplines, there has been very little
discourse or exploration of EBP uptake in yoga therapy.
1.2. Objectives
Given the apparent benefits of EBP, the paucity of research on
EBP in yoga therapy represents a significant knowledge gap in the
field. In addressing this gap, a cross–section of the North American
yoga therapist population were surveyed to ascertain their atti-
tudes, skills, training and use of research evidence, as well as the
barriers and facilitators of EBP use. The findings of this survey will
be instrumental in determining the extent to which yoga thera-
pists engage, and are prepared to engage in EBP; this will in turn
inform the development of appropriate strategies that may assist
in improving the uptake of EBP in yoga therapy (if indeed required)
in order to close the practice-research gap.
2. Methods
2.1. Design
Cross-sectional, descriptive survey design.
2.2. Objectives
The objectives of the study were to:
1. Explore the attitudes of North American yoga therapists toward
EBP.
2. Establish the level of self-reported EBP-related skill among North
American yoga therapists.
3. Ascertain the degree of EBP uptake among North American yoga
therapists.
4. Document the level of training in EBP and related areas among
North American yoga therapists.
5. Identify barriers and facilitators to EBP uptake in North American
yoga therapy practice.
6. Assess the association between North American yoga therapist
attitude, skill and use of EBP and the demographic characteristics
of providers.
2.3. Sample
Participants were a convenience sample of self-identified prac-
ticing yoga therapists in North America (i.e., the U.S. and Canada),
who were members of IAYT. As of October 27th 2015, IAYT had
5163 North American members, of whom 4772 resided in the US
and 391 resided in Canada. IAYT membership is open to a wide
variety of yoga professionals, including yoga therapists and yoga
teachers. While it is estimated that only one third of IAYT mem-
bers were practicing yoga therapists eligible to participate in the
survey (Pers comm., IAYT Director, 2016), this could not be con-
firmed as yoga therapy certification had not yet commenced at
the time the survey was administered; as such, the sample size
was calculated conservatively on the entire 5163 members. Based
on this target population, the study needed to survey at least 358
therapists to achieve at worst ±5% margin of error with 95% confi-
dence for any individual survey item (SurveyMonkey Sample Size
Calculation Software, California, USA).
2.4. Data collection
2.4.1. Description of questionnaire
The Evidence-Based practice Attitude and utilization SurvEy
(EBASE) was originally developed to evaluate the attitudes, skills
and use of EBP amongst clinicians.16 The questionnaire has
broad application and has to date been administered to vari-
ous clinical groups, including chiropractors, naturopaths, Western
herbal medicine providers, traditional Chinese medicine providers,
homeopaths, and nurses.5,11,15,20 Two studies have evaluated the
psychometric properties of EBASE, revealing that the questionnaire
has good internal consistency, content validity, construct validity,
and acceptable test-retest reliability.16,26
EBASE contains 84 items, divided into seven parts. The first
six parts evaluate a specific component of EBP: attitude (Part A),
skill (Part B), education and training (Part C), use (Part D), barriers
to EBP (Part E), and facilitators of EBP (Part F). Section G solicits
information on participant demographics. Survey response items
are mostly presented as four- or five-point Likert scales, with the
exception of items covering demographics, education and training,
and some aspects of EBP use.
Three subscores can be calculated from EBASE. The attitude sub-
score is the summation of scores from the first seven items in Part A
plus the reversed score of the eighth item in Part A. Attitude scores
range from 8 (predominantly strongly disagree) to 40 (predomi-
nantly strongly agree). The skill subscore is the sum of scores for
all thirteen items in Part B. Skill scores range from 13 (primarily
low-level skill) to 65 (primarily high-level skill). The use subscore
is the summation of scores from the first six items of Part D. Use
scores range from 0 (mainly infrequent use) to 24 (mainly frequent
use).
2.4.2. Adaptation of questionnaire
Several survey items were modified slightly to specify the target
population of the current study (e.g. the term ‘yoga therapy’ was
substituted for ‘CAM’). Response options in sections assessing edu-
cation and training (Part C) and demographics (Part G) were also
modified for a North American audience. None of these changes
altered item meaning, and thus were not expected to affect the
validity or reliability of the instrument in a significant way.
 M. Sullivan et al. / Complementary Therapies in Medicine 32 (2017) 11–18 13

2.4.3. Administration of questionnaire Table 1

Demographic characteristics of sample (n = 367).
A link to the online survey was emailed to 5163 North Ameri-
can IAYT members in October 2015. The email provided a detailed Variable Subcategory Result
description of the study including the objectives, description Age, n (%) <20 years 0 (0.0)
of involvement, rights of participants, and contact information 20–29 years 3 (0.8)
for the researchers. The survey was administered using the 30–39 years 39 (10.6)
SurveyMonkeyTM web-based platform. A follow-up (reminder) 40–49 years 93 (25.3)
50–59 years 136 (37.1)
email was sent two weeks later.
60–69 years 93 (25.3)
The EBASE questions were accompanied by a workforce survey 70+ years 3 (0.8)
and the findings of that questionnaire are published elsewhere.35 Missing 0 (0.0)
The combined surveys were open for five weeks in October and Sex, n (%) Female 335 (91.3)
November 2015. The combined survey had an approximate com- Male 32 (8.7)
pletion time of fifteen minutes, with the EBASE component taking Missing 0 (0.0)
approximately ten minutes to complete. Highest qualification, n (%) High school diploma 13 (3.5)
Associate degree/Diploma 31 (8.4)
Bachelor degree 106 (28.9)
2.5. Data analysis Master’s degree 139 (37.9)
Professional doctorate 18 (4.9)
Survey responses were downloaded from SurveyMonkeyTM into PhD 30 (8.2)
Other 30 (8.2)
SPSS (v.21.0) for data cleaning and statistical analysis. Partially-
Missing 0 (0.0)
completed surveys were excluded from the analysis if less than
20% of items were completed. The management of missing data Years since receiving highest <1year 24 (6.5)
qualification, n (%)
was not required due to the forced choice format of most survey
1–5 years 39 (10.6)
items; the only missing data (e.g. demographic information) were 6–10 years 50 (13.6)
deemed unsuitable for imputation. Categorical data were analysed 11–15 years 36 (9.8)
using frequency distributions and percentages. Measures of central 16+ years 212 (57.8)
tendency and variability were used to describe data where val- Not applicable 6 (1.6)
Missing 0 (0.0)
ues were normally distributed, and medians and the interquartile
range used where data were not normally distributed. Cramer’s V Years practiced in the field of <1 year 20 (5.4)
yoga therapy, n (%)
was used to assess relationships between nominal-level variables,
1–5 years 126 (34.3)
and Kendall’s Tau correlation coefficient (T) to test for associations 6–10 years 102 (27.8)
between ordinal-level variables. 11–15 years 66 (18.0)
16+ years 53 (14.4)
Missing 0 (0.0)
2.6. Ethical considerations
Hours per week in clinical Yoga therapy (Practice) 8.0 (4.0,15.3)
practice, research and
The Institutional Review Board (IRB) of the Maryland University education, Median (IQR)
of Integrative Health reviewed the protocol and assessed the study Participating in research (Research) 0.0 (0.0,1.0)
to be exempt from IRB oversight. Participants were informed of Training yoga therapists (Education) 0.0 (0.0,2.0)
the purpose of the research, data were collected anonymously, and Clinical setting in which yoga Solo practice 149 (40.6)
consent was implied by completion of the survey. therapy is primarily
practiced, n (%)
Yoga studio 84 (22.9)
3. Results Within an institution 26 (7.1)
With a group of orthodox providers 15 (4.1)
Community/religious centre 14 (3.8)
The workforce survey was circulated to 5163 members of IAYT; With a group of CAM providers 12 (3.3)
367 of these members responded to the survey. Respondents had to Specialised facility 8 (2.2)
self-identify as yoga therapists before completing the survey and, With CAM & orthodox providers 7 (1.9)
as discussed previously, the eligible respondents within the mem- Client’s home 6 (1.6)
With a partner 6 (1.6)
bership comprised an estimated one third of members. Therefore,
Other 9 (2.4)
while the absolute response rate was 7.1% (based on the entire Missing 31 (8.4)
North American IAYT membership), the likely response rate was
Regional location of practice, n Urban 144 (39.2)
approximately 20%. (%)
Suburban 140 (38.1)
Rural 52 (14.2)
3.1. Description of sample Missing 31 (8.4)

Geographical location of West US 91 (24.8)

Participants were predominantly female (91.3%) and aged
practice, n (%)
40–69 years (87.7%) (Table 1). The highest qualification held by the Northeast US 89 (24.3)
majority of participants was a Master’s degree (37.9%), followed Midwest US 59 (16.1)
by a Bachelor’s degree (28.9%), which for many, was awarded 16 South US 58 (15.8)
or more years ago (57.8%). Most respondents had worked in the British Columbia, Canada 12 (3.3)
Ontario, Canada 11 (3.0)
area of yoga therapy for 1–10 years (62.1%), mainly as practitioners Alberta, Canada 8 (2.2)
(Median 8 h/week; IQR 4.0,15.3); few respondents were involved Other, Canada 5 (1.4)
in research (Median 0 h/week; IQR 0.0,1.0) or education (Median Other, not further specified 2 (0.5)
0 h/week; IQR 0.0,2.0). Participants primarily worked in solo prac- Alaska 1 (0.3)
Missing 31 (8.4)
tice (40.6%) or in a yoga studio (22.9%), which were largely located
in an urban (39.2%) or suburban area (38.1%). These practices were CAM – Complementary and alternative medicine; IQR – Interquartile range.
14 M. Sullivan et al. / Complementary Therapies in Medicine 32 (2017) 11–18

Table 2
Participant attitudes toward evidence-based practice (n = 367).

1 2 3 4 5 Median
Strongly Disagree Disagree Neutral Agree Strongly Agree (IQR)
n (%) n (%) n (%) n (%) n (%)

Professional literature (i.e. journals & textbooks) and research 5 (1.4) 16 (4.4) 22 (6.0) 183 (49.9) 141 (38.4) 4 (4,5)
findings are useful in my day-to-day practice
I am interested in learning or improving the skills necessary to 6 (1.6) 23 (6.3) 44 (12.0) 161 (43.9) 133 (36.2) 4 (4,5)
incorporate EBP into my practice
EBP is necessary in the practice of yoga therapy 6 (1.6) 32 (8.7) 44 (12.0) 165 (45.0) 120 (32.7) 4 (4,5)
EBP improves the quality of my client’s care 7 (1.9) 47 (12.8) 64 (17.4) 145 (39.5) 104 (28.3) 4 (3,5)
EBP assists me in making decisions about client care 8 (2.2) 39 (10.6) 50 (13.6) 171 (46.6) 99 (27.0) 4 (3,5)
EBP takes into account my clinical experience when making 10 (2.7) 47 (12.8) 94 (25.6) 133 (36.2) 83 (22.6) 4 (3,4)
clinical decisions
The adoption of EBP places an unreasonable demand on my 20 (5.4) 57 (15.5) 93 (25.3) 130 (35.4) 67 (18.3) 4 (3,4)
practice
EBP takes into account a client’s preference for treatment 20 (5.4) 79 (21.5) 103 (28.1) 107 (29.2) 58 (15.8) 3 (2,4)
There is a lack of evidence from clinical trials to support most 35 (9.5) 87 (23.7) 71 (19.3) 120 (32.7) 54 (14.7) 3 (2,4)
of the treatments I use in my practice

EBP – Evidence-based practice; IQR – Interquartile range.

dispersed across North America, with most situated in the Western
(24.8%) or Northeastern United States (24.3%).
3.2. Attitudes toward EBP
Attitudes towards EBP were generally positive, with participat-
ing yoga therapists generating a median attitude subscore of 31
(IQR 27,34; range 8–40). More than three quarters of respondents
agreed or strongly agreed that professional literature and research
findings were useful in their day-to-day practice (88.3%), and that
EBP was necessary in the practice of yoga therapy (77.7%); most
were also interested in improving the skills for incorporating EBP
into their practice (80.1%) (Table 2). There was agreement among
most participants that EBP also improves the quality of patient care
(67.8%), assists in making decisions about patient care (73.6%), and
takes into account a therapist’s clinical experience when making
clinical decisions (58.8%).
There were no statistically significant associations between
yoga therapist attitude and demographic characteristics, apart from
a weak, statistically significant inverse association between atti-
tude subscore (categorised by quartiles) and number of years
practiced in yoga therapy (T = −0.159, p = 0.001). There was a sta-
tistically significant but very weak association between attitude
and skill subscores (T = 0.190, p < 0.0001), and attitude and use sub-
scores (T = 0.153, p < 0.0001)
3.3. Skills in EBP
Respondents reported a moderate to moderately-high level of
perceived skill in EBP, with a median skill subscore of 47 (IQR 41,54;
Range 19–65). Moderately-high to high ratings of perceived skill
were reported for problem identification (e.g. Identifying answer-
able clinical questions [70.3%] and identifying knowledge gaps in
practice [78%]), and evidence acquisition (i.e. Locating professional
literature [83.9%], online database searching [73.6%] and retriev-
ing evidence [67.3%]) (Table 3). Low to moderate skill-levels were
reported for the conduct of systematic reviews (69%) and clinical
research (78.5%).
There was a weak, statistically significant association between
participant skill level and the following demographic variables:
highest qualification obtained (T = 0.184, p < 0.0001), number
of years since receiving the highest qualification (T = −0.178,
p < 0.0001), number of years practiced in yoga therapy (T = 0.166,
p < 0.0001), and hours per week in clinical practice (T = 0.154,
p < 0.0001), participating in research (T = 0.359, p < 0.0001) and
training yoga therapists (T = 0.162, p = 0.001). There was no statisti-
cally significant association between skill subscore (categorised by
quartiles) and other demographic characteristics. There was a sta-
tistically significant but very weak association between skill and
attitude subscores (T = 0.190, p < 0.0001), and a weak association
between skill and use subscores (T = 0.312, p < 0.0001)
3.4. Training in EBP
More than 90% of respondents reported some training in
evidence-based practice/medicine (94.6%, n = 347/367), evidence
application (91.8%, n = 337/367) and critical thinking/analysis
(95.1%, n = 349/367). Most yoga therapists had received educa-
tion in these three aforementioned areas either as a component
of a professional training program (61.0% [n = 224/367], 53.1%
[n = 195/367] and 55.0% [n = 202/367], respectively) or through per-
sonal study (65.7% [n = 241/367], 63.8% [n = 234/367] and 65.7%
[n = 241/367], respectively). Approximately one-half of respon-
dents had received no training in the conduct of clinical research
(47.1%, n = 173/367) or systematic reviews and meta-analyses
(47.1%, n = 173/367).
3.5. Use of EBP
The median use subscore for respondents was 13 (IQR 11,18;
Range 6–30), indicating a moderately low uptake of EBP amongst
participating yoga therapists in the month preceding the sur-
vey. Although a slight majority of yoga therapists (51.4%) had
used an online search engine to search for practice-related lit-
erature or research in the preceding month, most respondents
engaged in the specified EBP-related activities no more than 10
times in that month, including reading/reviewing professional
literature (74.1%) or clinical research findings (84.4%), or using
professional literature/research findings to assist clinical decision-
making (85.5%) (Table 4). Fewer participants had used online
databases to search for practice-related literature/research (72.4%),
professional literature/research findings to change practice (81.7%),
or consulted colleagues/industry experts (78.0%) or referred to
magazines, layperson/self-help books, or non-government/non-
education institution websites to assist clinical decision-making
(75.4%), with more than two-thirds of respondents engaging in each
of these activities less than six times in the previous month.
Participants drew from a variety of information sources to
inform clinical decision-making; the most frequently used source
was traditional knowledge (median rank 3; IQR 1,5), followed by
personal intuition (Median 4; IQR 2,7) and textbooks (Median 5;
IQR 3,7) (Table 5). Respondents were least likely to refer to pub-
 M. Sullivan et al. / Complementary Therapies in Medicine 32 (2017) 11–18 15

Table 3
Participant self-reported skills in evidence-based practice (n = 367).

1 2 3 4 5 Median
Low Low-moderate Moderate Moderate-high High (IQR)
n (%) n (%) n (%) n (%) n (%)

Identifying answerable clinical questions 3 (0.8) 26 (7.1) 80 (21.8) 172 (46.9) 86 (23.4) 4 (3,4)
Identifying knowledge gaps in practice 1 (0.3) 9 (2.5) 71 (19.3) 183 (49.9) 103 (28.1) 4 (4,5)
Locating professional literature 5 (1.4) 9 (2.5) 45 (12.3) 166 (45.2) 142 (38.7) 4 (4,5)
Online database searching 10 (2.7) 30 (8.2) 57 (15.5) 138 (37.6) 132 (36.0) 4 (3,5)
Retrieving evidence 4 (1.1) 36 (9.8) 80 (21.8) 151 (41.1) 96 (26.2) 4 (3,5)
Critical appraisal of evidence 6 (1.6) 34 (9.3) 97 (26.4) 151 (41.1) 79 (21.5) 4 (3,4)
Synthesis of research evidence 11 (3.0) 35 (9.5) 90 (24.5) 141 (38.4) 90 (24.5) 4 (3,4)
Applying research evidence to patient cases 7 (1.9) 24 (6.5) 77 (21.0) 167 (45.5) 92 (25.1) 4 (3,5)
Sharing evidence with colleagues 17 (4.6) 43 (11.7) 84 (22.9) 129 (35.1) 94 (25.6) 4 (3,5)
Using findings from clinical research 17 (4.6) 37 (10.1) 88 (24.0) 142 (38.7) 83 (22.6) 4 (3,4)
Using findings from systematic reviews 41 (11.2) 58 (15.8) 89 (24.3) 111 (30.2) 68 (18.5) 3 (2,4)
Conducting systematic reviews 78 (21.3) 81 (22.1) 94 (25.6) 75 (20.4) 39 (10.6) 3 (2,4)
Conducting clinical research 128 (34.9) 86 (23.4) 74 (20.2) 47 (12.8) 32 (8.7) 2 (1,3)

IQR – Interquartile range.

Table 4
Participant use of evidence-based practice (i.e. number of times each activity was performed over the last month) (n = 367).

1 2 3 4 5 Median
0 1–5 6–10 11–15 16+ (IQR)
times times times times times
n(%) n(%) n(%) n(%) n(%)

I have used an online search engine to search for practice 32 (8.7) 146 (39.8) 86 (23.4) 43 (11.7) 60 (16.3) 3 (2,4)
related literature or research
I have read/reviewed professional literature (i.e. professional 15 (4.1) 169 (46.0) 88 (24.0) 43 (11.7) 52 (14.2) 2 (2,4)
journals & textbooks) related to my practice
I have used professional literature or research findings to assist 61 (16.6) 192 (52.3) 61 (16.6) 19 (5.2) 34 (9.3) 2 (2,3)
my clinical decision making
I have read/reviewed clinical research findings related to my 53 (14.4) 196 (53.4) 61 (16.6) 24 (6.5) 33 (9.0) 2 (2,3)
practice
I have used an online database to search for practice related 133 (36.2) 133 (36.2) 38 (10.4) 26 (7.1) 37 (10.1) 2 (1,3)
literature or research
I have consulted a colleague or industry expert to assist my 88 (24.0) 198 (54.0) 46 (12.5) 14 (3.8) 21 (5.7) 2 (2,2)
clinical decision making
I have referred to magazines, layperson/self-help books, or 115 (31.3) 162 (44.1) 51 (13.9) 16 (4.4) 23 (6.3) 2 (1,2)
non-government/non-education
institution websites to assist my clinical decision making
I have used professional literature or research findings to 137 (37.3) 163 (44.4) 37 (10.1) 14 (3.8) 16 (4.4) 2 (1,2)
change my clinical practice

IQR – Interquartile range.

Table 5 evidence was reported as informing 51–75% [91 (24.8%)], 76–99%

Sources of information used to inform clinical decision making (ranked by most
[50 (13.6%)] or 100% of their practice [5 (1.4%)].
frequent to least frequently used source)* (n = 367).
There was a weak, statistically significant association between
Information source Median (IQR) use and gender (towards female gender; V = 0.153, p = 0.047), high-
Traditional knowledge 3 (1,5) est formal qualification (T = 0.125, p = 0.006), number of years since
Personal intuition 4 (2,7) receiving the highest qualification (T = −0.115, p = 0.020), and hours
Textbooks 5 (3,7) per week in both clinical practice (T = 0.101, p = 0.018) and partic-
Consulting fellow practitioners or experts 5 (3,7)
ipating in research (T = 0.143, p = 0.006). No statistically significant
Published clinical evidence (i.e. clinical trials) 5 (3,9)
Client preference 6 (3,7) associations were found between use subscore (categorised by
Clinical practice guidelines 6 (3,8) quartiles) and other demographic characteristics. There was a sta-
Personal preference 8 (5,9) tistically significant but very weak association between use and
Trial and error 8 (6,10)
attitude subscores (T = 0.153, p < 0.0001), and a weak association
Published experimental/laboratory evidence 10 (7,11)
Popular media (e.g. magazines, websites) 10 (8,11) between use and skill subscores (T = 0.312, p < 0.0001).
Other 12 (8,12)

Sources were ranked from 1 = most frequently used, to 12 = least frequently used. 3.6. Barriers to and facilitators of EBP uptake

Thirteen potential barriers to EBP uptake were listed in the

lished experimental/laboratory evidence (Median 10; IQR 7,11)
and popular media (Median 10; IQR 8,11) to inform their clinical
decision-making.
When participants were asked to specify the percentage of their
practice that was based on evidence from clinical trials, 60.1%
(221/367) indicated that less than half of their practice was based
on such evidence. For the remaining respondents, clinical research
survey; the only factor considered by a large proportion of yoga
therapists as being a moderate or major barrier to uptake was the
lack of clinical evidence in yoga therapy (47.7%, n = 175/367). For
the majority of respondents (>63%), the listed factors were either
not a barrier or only a minor barrier to EBP use. The factors reported
by most yoga therapists as not being a barrier to EBP uptake were
lack of resources (75.2%, n = 276/367), lack of interest in EBP (65.1%,
n = 239/367), and insufficient skills for locating (62.9%, n = 231/367),
16 M. Sullivan et al. / Complementary Therapies in Medicine 32 (2017) 11–18
applying (61.6%, n = 226/367), interpreting (59.1%, n = 217/367) and
critically appraising research (57.8%, n = 212/367).
Ten potential facilitators of EBP uptake were presented in the
survey; most respondents (>62%) indicated that these factors would
be moderately to very useful in improving EBP uptake in yoga ther-
apy. The factors considered by at least two-thirds of respondents as
being very useful facilitators of EBP use were access to online edu-
cation materials related to EBP (70.6%, n = 259/367), the ability to
download full-text journal articles (69.2%, n = 254/367), and access
to free online databases in the workplace (67.3%, n = 247/367).
4. Discussion
4.1. Summary of findings
This is the first known study to investigate the attitudes, skills
and uptake of EBP amongst currently practicing yoga therapists in
North America. The findings indicate that yoga therapists, like CIH
and allied health practitioners, manifest positive attitudes towards
EBP, demonstrate a moderate to moderately high level of perceived
EBP skill, and participate in EBP-related activities at a moderately
low level.4,5,8–11,13,17–19,20–25,36
4.2. Demographics
Demographically, yoga therapists shared several similarities
with other CIH providers in that they were predominately female,
aged forty years or over, held a higher education qualification,
and practiced as sole practitioners.5 Yoga therapists differed from
other CIH practitioners in the number of hours worked per week,
with yoga therapists working substantially fewer hours than their
CIH counterparts37–38 ; among other reasons, this might reflect the
evolving nature of the yoga therapy profession.5
4.3. Attitude towards EBP
Yoga therapists generally valued EBP, to an extent that was simi-
lar to both allied health and CIH practitioners. In fact, median EBASE
attitude subscores for yoga therapists (median = 31) were compara-
ble to those recently reported for US chiropractors (median = 32)20
and Western herbalists (median = 31).23 Likewise, yoga therapists
were aligned with allied health and CIH practitioners in their belief
that research findings are useful in day-to-day practice, EBP is nec-
essary for clinical practice, EBP improves the quality of client care
and EBP assists in decision making.4,9,5,13,20,23 These positive atti-
tudes are encouraging as attitude is an important predictor of EBP
use.21,38
4.4. Knowledge of EBP
There was less agreement among yoga therapists on whether
EBP takes into account clinical expertise and client preferences.
This suggests a possible misunderstanding of EBP among yoga ther-
apists; in particular, a misperception that EBP is primarily about
the utilisation of research evidence in clinical practice, rather than
the integration of the best available evidence with clinical experi-
ence and patient preference to inform clinical decision making.1
This misinterpretation of EBP is not confined to yoga therapists
however, but is an issue common across CIH and allied health pro-
fessions, and may be an important factor hindering the integration
of EBP into clinical practice.5,18,20,23,36 The provision of appropriate
and effective EBP education/training programs may assist in chang-
ing these misperceptions of EBP; indeed, yoga therapists, and allied
health and other CIH practitioners, have reported an interest in and
need for better education on EBP.1,2,5–14,20,23,36
4.5. Skill and engagement with EBP
The self-reported skill level of yoga therapists across thirteen
EBP-related areas was assessed overall as moderate to moderately
high. This is comparable to US chiropractors and herbalists, who
have reported similar EBASE skill subscores (median of 47 for yoga
therapists, 47 for herbalists and 44 for chiropractors).20,23 The per-
ceived skill level for each of the thirteen EBP-related areas was
also similar across the three CIH professions, with all three groups
reporting moderate to high skill ratings for problem identification
and evidence acquisition, and lower skill ratings for the conduct of
systematic reviews and clinical research.5,20,23 While skill devel-
opment may be achieved through EBP education/training, the data
suggest that increased engagement in research may be helpful,
with a weak but significant association evident between thera-
pist skill and participation in research. Evidence from other studies
supports this association, with involvement in research and EBP
training connected to increased EBP skill and use in allied health
and CIH.4,5,11,13–15,18,22–24,29,36,39–41 The development of initiatives
that foster yoga therapists involvement in research and EBP may be
an important next step in improving yoga therapist skill and uptake
of EBP.23,32,42
While yoga therapists reported engaging in EBP at a moder-
ately low level, their level of engagement was slightly higher than
that reported by US chiropractors and herbalists (i.e. median EBASE
use subscore of 13 for yoga therapists, 12 for herbalists and 8
for chiropractors).20,23 This level of EBP uptake is encouraging
given that traditional knowledge was identified as the number one
source informing clinical decision making. Although this is not dis-
similar to other CIH practitioners,5,23 there are some important
distinctions – for instance, yoga therapists relied more heavily on
personal intuition (2nd most frequently used information source
for yoga therapist clinical decision making vs. 6th for other CIH
practitioners) and less so on published clinical evidence than other
CIH practitioners (5th most frequently used information source
for yoga therapists vs. 2nd for herbalists vs. 4th for other CIH
practitioners).5,23 The greater reliance on personal intuition over
published clinical evidence among yoga therapists may be due
to the evolving nature of the discipline; in particular, the rela-
tively recent growth in research publications in the field.32,43 To
this point, the most cited and only major barrier to EBP uptake
expressed by yoga therapists in this study was the lack of clinical
evidence – a concern also shared by practitioners in other fields of
CIH.5,20,23
Another important feature of this population was that over half
of the respondents had been practicing for six or more years while
the yoga therapist educational standards have only been published
for four years, accreditation of schools for two years and certifica-
tion for under one year.32 This study did not explore the quality
or content of yoga therapist education, nor did it find a significant
association between EBP use and years practiced in yoga therapy.
Examining the impact of these new yoga therapist accreditation
and certification standards on EBP uptake in yoga therapy would
be an important focus of future research in this field.
4.6. Use of EBP
Although yoga therapists demonstrate positive attitudes toward
EBP, and report moderate to moderately high levels of EBP skill,
most were engaging in EBP activities less than six times per month.
While this level of activity is similar to that reported by other CIH
practitioners, it is far lower than that described by allied health
professionals, such as physical therapists, who reportedly engage
in EBP activities four or more times a week.5,20,23,40 Improving
access to EBP training and resources have been recommended in
both occupational and physical therapy as ways of facilitating the
 M. Sullivan et al. / Complementary Therapies in Medicine 32 (2017) 11–18
uptake of EBP.22,28,40 Yoga therapists similarly identified (like other
CIH practitioners)5 access to online educational materials, full text
articles and free online databases as important enablers of EBP util-
isation. However, what is not clear is whether the provision of such
training and resources would translate into greater EBP uptake in
yoga therapy; this should be a focus of further work on EBP in yoga
therapy.
4.7. EBP education
The study found a weak but significant correlation between
the highest qualification held and a yoga therapist’s use and skill
in EBP. This corroborates the findings of earlier research, which
have shown higher levels of educational attainment to be cor-
related with greater use of EBP among CAM practitioners and
physical therapists.4,5 At present, the IAYT competencies for school
accreditation do not include topics such as research literacy and
EBP. This creates significant variability in the extent to which EBP
is addressed or taught in yoga therapy schools, and in turn, the
degree to which EBP in practiced by yoga therapists. Evidence-
based practice is critical to the professionalization, credibility and
acceptance of yoga therapy as a healthcare profession as it rep-
resents a movement within healthcare in general. An important
next step in advancing the professionalization of yoga therapy
would be to incorporate EBP and research training in yoga ther-
apy education. Of course, if such training is to have a meaningful
impact on yoga therapy practice, the industry needs to consider
new and innovative ways to deliver this education. Strategies that
have been shown to have a positive impact on CAM academic cul-
ture and behaviors relating to EBP (that may be transferable to
yoga therapy education), include the embedding of EBP content in
assessments and across curricula, including clinical training; and
complementing/reinforcing skill development through the provi-
sion of EBP-related extra-curricular activities (e.g. journal clubs),
supplementary learning materials (e.g. online learning resources),
and microskills modules.41
4.8. Limitations
Although the study had achieved the required sample size, and
a validated instrument was used, there were some limitations.
As is inherent in most surveys, self-reporting and self-selection
bias may mean that those completing the survey could have been
more experienced and/or interested in EBP, resulting in skewing
towards higher values. The use of the IAYT mailing list as the
sampling frame may not have reached all eligible yoga therapists
across North America. Furthermore, there was limited represen-
tation from Canada and none from other countries; as such, the
findings may be generalizable only to US yoga therapists. The sur-
vey also required people to self-identify as a yoga therapist at a time
when the credentialing of yoga therapists had not yet commenced;
this may have limited the number of people that responded to the
survey. This low response rate, while meeting the required sample
size, may limit the generalizability of the findings as the sample
might not accurately reflect the views/experiences of all of those
who identify as a yoga therapist. Lastly, asking participants to dis-
tinguish the practice of yoga therapy from the teaching of general
yoga classes may have presented a challenge in an emerging profes-
sion where the discipline continues to evolve; this is acknowledged
as a limitation of this study, as well as the development of the field
in general.
17
5. Conclusion
This study reveals that, although yoga therapy is an emerging
discipline, yoga therapists view EBP positively, are moderately pre-
pared to engage in EBP (reporting a moderate to moderately high
level of perceived skill in EBP), and are participating in EBP at a mod-
erately low level; this puts them in line with other CIH and allied
health practitioners. These findings are encouraging and suggest
readiness of the field to deliver best practice care, to advance their
professional standing, and to be integrated into the mainstream
healthcare environment. Of course, some improvements can be
made, particularly in relation to the development of EBP-related
skills and EBP uptake. The findings of the study indicate that the lat-
ter could be addressed through greater investment in yoga therapy
research and improved practitioner access to research literature,
and indirectly by addressing the former through innovative EBP
training and education.
Conflict of interest
No competing financial interests exist for ML and JS. MS and
SM report personal fees from yoga teacher and yoga therapy train-
ings outside the submitted work and trains yoga professionals in
academic and continuing education settings.
Author contributions
MS and SM were responsible for drafting the introduction and
discussion. ML was responsible for conducting the analysis, writing
up the results and co-writing the methods. JS was responsible for
co-writing the methods. All authors were involved in the editing of
the manuscript.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
Acknowledgements
The authors would like to thank the yoga therapists who par-
ticipated in this study. They would also like to acknowledge the
support of IAYT in disseminating the study information to their
membership.
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