Abstract
Background:
Acquired brain injury (ABI) is associated with chronic physical, cognitive, emotional, and social impairments requiring long-term rehabilitation. Adaptive yoga is an evidence-based intervention that may address these needs; however, implementation remains limited. Thus, determinants of engagement must be translated into actionable, theory-informed implementation strategies. This study aimed to (1) identify determinants of engagement in adaptive yoga for individuals with ABI using the Theoretical Domains Framework (TDF), and (2) operationalize these determinants into mechanisms and implementation strategies.
Methods:
We conducted an implementation mapping study using qualitative data from participants (n = 9) who completed an 8-week adaptive yoga randomized controlled trial. Data were collected through focus groups and semi-structured interviews and analyzed using the framework method. Inductive in-vivo coding was followed by deductive mapping to TDF domains. Determinants were aligned to the Capability, Opportunity, Motivation–Behavior model to specify mechanisms of action and mapped to implementation strategies using the Expert Recommendations for Implementing Change (ERIC) taxonomy. Strategies were further specified by actor, action, target, temporality, and dose.
Results:
Qualitative data mapped to 12 TDF domains. Knowledge and Environmental Context and Resources represented barriers related to communication, scheduling, and navigation. Skills, Social Influences, Emotion, and Beliefs about Capabilities facilitated engagement. Determinants influenced engagement through three inter-related mechanisms: (1) adequately trained personnel, (2) adaptable yet structured program delivery, and (3) socially driven group processes. These mechanisms reflect capability, opportunity, and motivation-related processes through which 12 ERIC implementation strategies are expected to act.
Conclusions:
Engagement in adaptive yoga for individuals with ABI is shaped by inter-related mechanisms rather than isolated determinants. Linking determinants, mechanisms, and strategies provides a theory-informed pathway for intervention refinement and future hybrid effectiveness-implementation testing.
Introduction
Traumatic and non-traumatic brain injuries [i.e., acquired brain injuries (ABI)] are associated with chronic physical, cognitive, emotional, and social impairments that often require long-term rehabilitation (–). Although adaptive yoga has facilitated improvements in participants' balance, mobility, self-efficacy, and quality of life following ABI, access to these programs remains limited (–). Individuals with ABI encounter numerous barriers to participating in community-based rehabilitation, including depression, fatigue, concerns about safety, physical limitations, reduced confidence to exercise, transportation challenges, and inaccessible environments (, ). Understanding the determinants (i.e., barriers and facilitators) that influence engagement in adaptive yoga is an important step towards improving participation and informing future implementation efforts.
Adaptive yoga has demonstrated promising clinical outcomes across several pilot and feasibility studies (–, ). However, little research has examined the determinants of participant engagement needed to inform the next stage of intervention testing (–). As rehabilitation research increasingly emphasizes progression from feasibility studies to hybrid effectiveness-implementation trials, understanding the determinants that influence participant engagement has become essential for selecting and tailoring implementation strategies (, ).
Theory-informed approaches are needed to move beyond descriptive lists of barriers toward actionable implementation strategies. The Theoretical Domains Framework (TDF) identifies behavioral determinants influencing implementation (, ), the Capability, Opportunity, Motivation–Behavior (COM-B) model specifies mechanisms through which these determinants influence behavior (–), and the Expert Recommendations for Implementing Change (ERIC) taxonomy provides implementation strategies that target these mechanisms (). Together, these complementary frameworks offer a systematic approach to translating qualitative findings into testable implementation strategies for future hybrid effectiveness-implementation trials (). Accordingly, the primary aim of this study was to use the TDF to identify determinants influencing engagement in adaptive yoga among adults with ABI. A secondary aim was to link these determinants to COM-B mechanisms and ERIC implementation strategies (, ) to inform a future hybrid effectiveness-implementation trial.
Methods
Study design
We conducted an implementation mapping study (, , ) using the framework method (, 27) to examine qualitative data collected during the final two weeks of an 8-week pilot randomized controlled trial (RCT) (28, 29). The target behavior of interest was participant engagement in adaptive yoga. We examined engagement qualitatively and considered how participant-reported determinants may inform future implementation outcomes, including acceptability, adoption, appropriateness, feasibility, fidelity, and sustainability (). Because we aimed to identify implementation strategies, we followed the recommendations for specifying and reporting implementation strategies () and the Consolidated criteria for reporting qualitative research (30).
Recruitment & enrollment of participants
Participants were drawn from the adaptive yoga arm of the parent RCT (28, 29). Eligible RCT participants were adults with chronic ABI ≥6 months and self-reported balance problems of moderate or greater severity. We used criterion-based sampling (31, 32) and invited the 12 participants who completed the yoga intervention to participate in interviews or focus groups during the final two weeks of the trial. To encourage participation, dinner was provided. Given the focused study aim, use of an established theoretical framework, and relatively homogeneous sample of participants who completed the intervention, the sample size was considered sufficient (33).
Intervention
The adaptive yoga intervention was delivered in person for 1 h, twice weekly, for 8 weeks (28, 29). The intervention was developed for adults with ABI and included physical postures, breathwork, and meditation. Sessions were led by an experienced adaptive yoga instructor and supported by trained intervention assistants who provided environmental setup, safety monitoring, physical support, and posture modifications.
Data collection & management
Demographic information including age, sex, time since injury, and mechanism of injury were collected by a trained research assistant and reviewed for accuracy by the study PI (JAS) at time of enrollment into the RCT.
Interview guides were developed to explore their experiences, barriers, and facilitators that influenced their engagement in the adaptive yoga intervention. The semi-structured interview guide was designed to elicit determinants influencing engagement and was informed by implementation science and behavioral theory (, 34). Interview questions were structured to capture influences consistent with TDF domains, while allowing flexibility for participants to introduce unanticipated factors ().
We completed focus groups and to maximize participation, we also conducted individual interviews based on participant preference and availability. Interviews were conducted either virtually or in-person in a private room by the first author (JAW) or study personnel trained by the first author. Focus groups and interviews were audio-recorded, transcribed, de-identified using pseudonyms, and checked for accuracy. We documented transcript changes in an audit log.
Trustworthiness strategies
Trustworthiness was supported through transcript review, memo-writing, team-based coding, consensus meetings, reflexive discussions, and documentation of analytic decisions in an audit trail (35). The interdisciplinary team included occupational (JAW, JP, JAS, AAS) and physical therapists (JABE, AMG), implementation science experts (JAW, JP), an intervention researcher (AAS), and qualitative research experts (JAW, JP), all of whom have prior experience working with individuals with ABI.
Data analysis
We used descriptive analysis for all demographic data. Qualitative data were analyzed using the framework method, which supports both inductive and deductive analysis (27). Qualitative analyses were completed using NVivo 14 software (Version 14, https://lumivero.com/products/nvivo/). The first author led the analysis with two primary analysts, who met weekly to review codes, refine the codebook, and resolve coding discrepancies through consensus (36). Transcripts were independently coded until agreement exceeded 80% (32). Coding decisions, code definitions, and TDF domain alignment were documented in an analytic audit trail (35). Representative quotes are presented in the tables.
Identifying barriers and facilitators using the theoretical domains framework
Data were first coded using inductive in-vivo coding (36) and then deductively mapped to the 14 TDF domains (, ). New categories were generated when participant statements did not align with a TDF domain. We then examined whether each determinant functioned primarily as a barrier or facilitator to participant engagement in yoga (, 34). TDF domain importance was determined based on the frequency, richness of coded data, strength of expressed perceptions, and relevance to the development of actionable implementation strategies ().
Specifying implementation strategies to support implementation outcomes
Prioritized TDF domains were mapped to COM-B components to identify capability, opportunity, and motivation-related mechanisms influencing engagement. We then selected ERIC implementation strategies most likely to address identified barriers and strengthen facilitators (, , , 37). Strategies were conceptually clustered (38) and specified by actor, action, target, temporality, dose, and candidate outcome () affected to support future testing in a hybrid effectiveness-implementation study.
Results
Participants
Nine of the 12 adaptive yoga participants completed interviews. Participants ranged in age from 29 to 82 years, with time since injury ranging from 6 months to 59 years. We completed two focus groups and two interviews. Participant characteristics are summarized in Table 1.
Table 1
| Characteristics | n (%) or mean (SD) |
|---|---|
| Sample Size, n | 9 |
| Age, mean(SD), years | 61.6 (15.5) |
| Time Since Injury, mean (SD), years | 16.4 (19.3) |
| Sex, n (%) | |
| Female | 6 (67) |
| Male | 3 (33) |
| Education Level, n (%) | |
| Associates | 1 (11) |
| Bachelor's | 4 (45) |
| High School | 0 (0) |
| Master's | 1 (11) |
| PhD | 2 (22) |
| Vocation | 1 (11) |
| Etiology, n (%) | |
| Non-Traumatic Brain Injury | 5 (56) |
| TBI | 4 (44) |
| Race, n (%) | |
| White | 9 (100) |
Yoga participant characteristics.
Identifying barriers and facilitators using the theoretical domains framework
Qualitative statements mapped to 9 TDF domains and one additional category, “Recommendations.” Knowledge and Environmental Context and Resources were the most prominent barriers, reflecting challenges with communication, scheduling, and navigation (Table 2). Skills, Social Influences, Emotion, Beliefs about Capabilities primarily functioned as facilitators, reflecting participants' perceived ability, social support, enjoyment, and confidence. These domains mapped across COM-B components, with capability shaped by Skills and Beliefs about Capabilities, opportunity shaped by Knowledge and Environmental Context and Resources, and motivation shaped by Social Influences and Emotion.
Table 2
| Barrier/facilitator exemplary quote | Theoretical domain framework as a qualitative category defined by Cane et al. (2012) () | ERIC implementation strategy & definition (Powell et al., 2015) () |
|---|---|---|
| Key barriers and facilitators that mapped to implementation strategies clustered around “Train and Educate stakeholders” | ||
| Barrier: “It would be easier if there was just one person helping me the whole time, the same person texting me. They changed by several people, and that was really hard. It was like who am I talking to? And why? Where am I going? What time? Wait, you told me I didn't have to fast but that person told me I had to fast but I didn't fast. I mean, it was very confusing” (Sheryl) | Environmental Context and Resources: Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behavior. | Develop Education Training Materials: “Develop and format manuals, toolkits, and other supporting materials in ways that make it easier for stakeholders to learn about the innovation and for clinicians to learn how to deliver the clinical innovation.” |
| Barrier: “If it's not written, it doesn't exist” (Kevin) | *Recommendation: Comments and recommendations for changes in intervention/program | |
| Facilitator: “I had things where I was extremely challenged, but it was allowed that I couldn't do this, and then there were other things, what I could do well.” (Denise) | Knowledge: An awareness of the existence of something | Make Training Dynamic: “Vary the information delivery methods to cater to different learning styles and work contexts, and shape the training in the innovation to be interactive” |
| Barrier: “My challenge was I couldn't remember all of the assistants' names…that was a huge stress for me…It would have been helpful to have name tags” (Anna) | Environmental Context and Resources: Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behavior | Distribute Educational Materials: “Distribute educational materials (including guidelines, manuals, and toolkits) in person, by mail, and/or electronically” |
| Barrier: “Well, and I have tons to say about this. Because I had some bad experience with directions with time with fasting without fasting. And that was incredibly frustrating for me. It's hard enough for me. But when that kind of stuff when that kind of thing happens. It's brutal for me, and it made me very frustrated. And even my last test of my heart rate. I received an incorrect address. And I ended up somewhere else. And I didn't even report that to anybody because I was so exhausted by the whole process… I know, they get a handout sheet of dates and times, maybe, you know, a map of the building and where you go, or turn, where you should park?” (Sheryl) | *Recommendation: Comments and recommendations for changes in intervention/program | |
| Barrier: “He [the MRI tech] made…teenager jokes. I remember how difficult it was for me to deal with that. It took my safety away because after the stroke, I am not so confident. I needed the safety that somebody says, “Don't worry about this. We take care of you.” (Denise) | Emotion: A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event | Use train-the-trainer strategies: “Train designated clinicians or organizations to train others in the clinical innovation” |
| Facilitator: “Yeah… honoring my body… we started out and move through it, it built… I really pushed myself… and it was really good.” (Anna) | Skills: An ability or proficiency acquired through practice | |
| Facilitator: “When I couldn't get up, they would help you.” (Jim) | Skills: An ability or proficiency acquired through practice | |
| Facilitator: “I liked the positive attitude that's throughout the session. I've been pleased with that” (Kevin) | Skills: An ability or proficiency acquired through practice | |
| Facilitator: “there was no judgment, no guilt, no disqualification…no critical comments or anything…I really appreciated that…I think that was the best part of adaptive yoga” (Anna) | Social influences: Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviors | |
| Facilitator: “I thought, ‘Oh. I can do it. No problem at all.’” (Denise) | Optimism: The confidence that things will happen for the best or that desired goals will be attained | Conduct ongoing training: Plan for and conduct training in the clinical innovation in an ongoing way |
| Facilitator: “I prefer to be in a group… there were like, eight of us… and that's perfect.” (Patricia) | Social influences: Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviors | |
| Barrier: “I didn't realize that it was adaptive yoga until we started.” (Patricia) | Knowledge: An awareness of the existence of something | Conduct educational meetings: “Hold meetings targeted toward different stakeholder groups (e.g., providers, administrators, other organizational stakeholders, and community, patient/consumer, and family stakeholders) to teach them about the clinical innovation” |
| Key barriers and facilitators that mapped to implementation strategies clustered around “Evaluate and Use Iterative Strategies” | ||
| Facilitator: “The challenge with having a brain injury is finding accessible, affordable resources.” (Anna) | Social influences: Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviors | Conduct local needs assessment: “Collect and analyze data related to the need for the innovation” |
| Facilitator: “ …the consistency, like you having it on specific days at specific times. I liked that. That helped me. Like keep a routine. It was super helpful” (Miranda) | Knowledge: An awareness of the existence of something | Obtain and use patient/consumer feedback: “Develop strategies to increase patient/consumer and family feedback on the implementation effort” |
| Facilitator: “Yoga is movement and movement with intention…the whole thing is that it has moved me into making the movements and everything habit, which is good.” (Anna) | Intentions: A conscious decision to perform a behavior or a resolve to act in a certain way | |
| Barrier: “Like what Jackie does, how she texts us every morning. Maybe they could do that. Because I'm with you, I was confused [re: pre-assessment directions]. I luckily, was trying to stay consistent, and I'm just checking my email. But I kept getting confused on the day that I was supposed to fast and not fast…I really need text message reminders” (Miranda) | Knowledge: An awareness of the existence of something | |
| Barrier: “I was confused by that instruction initially. I asked [in the second session], ‘Can we get handouts so we could practice in between sessions?’ She said, ‘No, I prefer we just do it in class.’ About two sessions later, she started talking about what have you been practicing that you enjoy.” (Kevin) | Environmental Context and Resources: Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behavior. | Develop and organize quality monitoring systems: “Develop and organize systems and procedures that monitor clinical processes and/or outcomes for the purpose of quality assurance and improvement” |
| Key barriers and facilitators that mapped to implementation strategies clustered around “Adapt and Tailor Content” | ||
| Barrier: “And if I have to make a commitment for 10 weeks-it's easy to sign up for the first 8” (Denise) | Knowledge: An awareness of the existence of something | Promote Adaptability: “Identify the ways a clinical innovation can be tailored to meet local needs and clarify which elements of the innovation must be maintained to preserve fidelity” |
| Barrier: “I think it would be a good system if you would say we have groups from six weeks and then there's two weeks off, and then there's another group.” (Jim) | Knowledge: An awareness of the existence of something | |
| Facilitator: “It's really awesome. To observe the changes and development in my life. It was wonderful to see.” (Anna) | Knowledge: An awareness of the existence of something | |
| Facilitator: “It was a safe place here. I thought before maybe I start with yoga, this will help me to improve, but I didn't feel safe and I didn't really want to go to my gym and then to say, ‘Oh, I had a stroke or something.’ I was really looking forward to coming here because I felt safe. You couldn't fail. You could just improve.” (Denise) | Beliefs About Consequences: Acceptance of the truth, reality, or validity about outcomes of a behavior in a given situation | |
| Facilitator: “I was very surprised that I…I said, ‘Oh, you can do this?’…I could allow myself not to be perfect.” (Denise) | Beliefs about Capabilities: Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use | |
| Facilitator: “The energy from participants really makes a difference. Everyone in there is brain injured, and we're all in there to get some type of help with that.” (Barbara) | Emotion: A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event | |
| Facilitator: “I felt really safe and I could be a fragile person… that had so big impact on my emotions.” (Denise) | Emotion: A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event | |
| Facilitator: “I've really benefited a lot from this…let's take it slow. Let's do it on your pace. I liked that.” (Patricia) | Skills: An ability or proficiency acquired through practice | |
| Facilitator: “There was some familiarity and consistency with the people that were here and how it was structured.” (Anna) | Environmental Context & Resources: Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behavior. | |
| Key barriers and facilitators that mapped to implementation strategies clustered around “Engage Consumers” | ||
| Barrier: “I need more consistency, a longer time period. I was starting to get some strength back, and that felt really good.” (Barbara) | *Recommendation: Comments and recommendations for changes in intervention/program | Intervene with patients/consumers to enhance uptake and adherence: “Develop strategies with patients to encourage and problem solve around adherence” |
| Barrier: “I really need text message reminders” (Miranda) | *Recommendation: Comments and recommendations for changes in intervention/program | |
| Facilitator: “I'm going to add some yoga routines… and work with my wife… and we'll work out some things.” (Kevin) | Intentions: A conscious decision to perform a behavior or a resolve to act in a certain way | |
| Facilitator: “I like the consistency of the routine” (Anna) | Knowledge: An awareness of the existence of something | Obtain and use patients/consumers and family feedback: “Develop strategies to increase patient/consumer and family feedback on the implementation effort” |
| Key barriers and facilitators that mapped to implementation strategies clustered around “Change Infrastructure” | ||
| Barrier: “I had the same problem. My wife and I… GPS… we ended up where they were storing horses and goats… realizing that we were in the backside of it, and not the front.” (Kevin) | Environmental Context & Resources: Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behavior. | Change Record Systems: Change records systems to allow better assessment of implementation or clinical outcomes |
| Facilitator: “but I liked about it is the… consistency like you having it on specific days at specific times. Yep. I liked that. Okay, that helped me. Like keep a routine. It was super helpful.” (Miranda) | ||
| Barrier: “The [MRI] room was horrible. I mean, there were stacks of stuff. And I was like, there's a big door there. Like it's a refrigerator. Oh my god. Get me outta here. The sheet was dirty. Oh, it was horrible.” (Sheryl) | *Recommendation: Comments and recommendations for changes in intervention/program | |
| Barrier: “The have room with a body scan. [It] was like they threw it in a closet or something. It didn't seem professional at all and I thought what am I getting into? For seven years I've been in hospital rooms, and they were clean. I just I'd lost my confidence… it just it did not seem professional” (Kevin) | Emotion: A complex reaction pattern, involving experiential, behavioral, and physiological elements, by which the individual attempts to deal with a personally significant matter or event | |
Key barriers and facilitators mapped to ERIC implementation strategies.
Specifying implementation strategies
We mapped the facilitators and barriers to 12 of the 73 distinct ERIC implementation strategies. We organized the 12 strategies into 5 of the 9 pre-existing clusters (38). The five clusters that our data mapped to were: “Train and Educate Stakeholders,” “Evaluate and Use Iterative Strategies,” “Adapt and Tailor Content,” “Engage Consumers,” and “Change Infrastructure” (Table 2).
Inter-related mechanisms
We used interpretive analysis to move beyond TDF domain-level categorization and examined how identified determinants, aligned to COM-B components, and informed the mechanisms through which ERIC implementation strategies were expected to influence behavior. Determinants did not act independently. We identified three inter-related mechanisms, that influenced participant engagement in adaptive yoga, reflecting capability, opportunity, and motivation related processes through which implementation strategies were expected to act. These three inter-related mechanisms were: (1) adequately trained personnel, (2) an adaptable yet structured program delivery, and (3) socially driven group processes (Figure 1 and Table 3). These mechanisms reflect capability, opportunity, and motivation-related determinants that collectively positively shaped engagement in adaptive yoga.
Figure 1
Table 3
| Participant quote | TDF domain | ERIC strategy | Specified implementation strategy | Mechanism of action | Proposed outcome | Proctor's implementation outcome |
|---|---|---|---|---|---|---|
| Mechanism 1: The need for adequately trained personnel to provide physical and cognitive support | ||||||
| Denise: “I thought, ‘Oh. I can do it. No problem at all.’” | Optimism | Conduct ongoing training | Actor: Yoga instructor/team Action: Reinforce positive expectations Target: Outlook Temporality: Ongoing Dose: Repeated Outcome affected: Engagement Justification: Builds hope | Positive expectations increase engagement. | Increased participation | Acceptability |
| Adherence | ||||||
| Denise: “I felt really safe and I could be a fragile person… that had so big impact on my emotions.” | Emotion | Promote adaptability | Actor: Yoga instructor Action: Trauma-informed delivery Target: Emotional safety Temporality: Continuous Dose: Every session Outcome affected: Retention Justification: Reduces anxiety | Safety reduces threat and supports engagement. | Increased retention | Acceptability |
| Provide ongoing consultation | ||||||
| Anna: “Yeah… honoring my body… we started out and move through it, it built… I really pushed myself… and it was really good.” | Skills | Use train-the-trainer strategies | Actor: Yoga instructor Action: Train yoga instructors in graded adaptive delivery Target: Instructor behavior Temporality: Pre-implementation Dose: Initial + booster Outcome affected: Fidelity Justification: Ensures proper progression | Graded delivery improves skill match and reduces participants' anxiety. | Improved participation | Fidelity |
| Kevin: “I liked the positive attitude that's throughout the session. I've been pleased with that” | Skills | Use train-the-trainer strategies | Actor: Yoga instructor Action: Provide coaching and encouragement Target: Participant performance Temporality: Each session Dose: Continuous Outcome affected: Engagement Justification: Builds competence | Encouragement increases confidence and participation. | Increased engagement | Fidelity |
| Denise: “I was very surprised that I… I said, ‘Oh, you can do this?’… I could allow myself not to be perfect.” | Beliefs about Capabilities | Provide ongoing consultation | Actor: Yoga instructor Action: Prompt reflection on success Target: Self-efficacy Temporality: During sessions Dose: Repeated Outcome affected: Engagement Justification: Reframes ability | Reframing increases willingness to engage & self-efficacy. | Increased sense of self-efficacy | Participant outcome |
| Promote Adaptability | ||||||
| Denise: “Yeah. You couldn't fail. You could just improve.” | Beliefs about Consequences | Promote Adaptability | Actor: Yoga instructor Action: Emphasize non-judgmental improvement Target: Outcome expectations Temporality: Each session Dose: Repeated messaging Outcome affected: Engagement Justification: Reduces fear of failure | Reduced fear increases participation & self-efficacy. | Increased sense of self-efficacy | Participant outcome |
| Mechanism 2: The need for an adaptable yet structured program delivery | ||||||
| Miranda: “but I liked about it is the… consistency like you having it on specific days at specific times. Yep. I liked that. Okay, that helped me. Like keep a routine. It was super helpful.” | Environmental Context & Resources | Change record systems | Actor: Program coordinator Action: Assign single contact & standardized reminders Target: Patient communication Temporality: Enrollment → program end Dose: Each session reminder Outcome affected: Attendance/adherence Justification: Supports routine formation | Consistent cues reduce cognitive load and support routine formation. | Improved attendance | Adoption |
| Adherence | ||||||
| Anna: “There was some familiarity and consistency with the people that were here and how it was structured.” | Environmental Context & Resources | Promote adaptability | Actor: Intervention team Action: Maintain consistent staff/structure Target: Delivery environment Temporality: Every session Dose: Continuous Outcome affected: Retention Justification: Enhances predictability | Predictability reduces uncertainty. | Increased retention | Acceptability |
| Adherence | ||||||
| Kevin: “I had the same problem. My wife and I… GPS… we ended up where they were storing horses and goats… realizing that we were in the backside of it, and not the front.” | Environmental Context & Resources | Change physical structure and equipment | Actor: Study staff Action: Provide navigation instructions/signage Target: Access Temporality: Pre-session Dose: One-time + reminder Outcome affected: Attendance Justification: Removes barriers | Reduced navigation burden increases attendance. | Improved attendance | Feasibility |
| Change service sites | ||||||
| Denise: “And if I have to make a commitment for 10 weeks-it's easy to sign up for the first 8” | Knowledge | Promote adaptability | Actor: Intervention team Action: Explain intervention rolling scheduling options Target: Participant expectations Temporality: Onboarding Dose: One session + materials Outcome affected: Enrollment Justification: Aligns expectations with capacity | Clarifying expectations reduces uncertainty and increases feasibility. | Increased enrollment | Reach |
| Conduct educational meetings | Adoption | |||||
| Jim: “I think it would be a good system if you would say we have groups from six weeks and then there's two weeks off, and then there's another group.” | Knowledge | Promote Adaptability | Actor: Intervention team Action: Provide structured program format Target: Understanding of program design Temporality: Recruitment Dose: One explanation Outcome affected: Enrollment/retention Justification: Improves clarity | Improved understanding increases participation. | Increased enrollment and retention | Acceptability |
| Mechanism 3: The need for socially driven group processes to foster engagement and adherence | ||||||
| Patricia: “I prefer to be in a group… there were like, eight of us… and that's perfect.” | Social Influence | Conduct ongoing training | Actor: Study team Action: Maintain optimal group size Target: Social dynamics Temporality: Program design Dose: Fixed groups & specific social connection integration Outcome affected: Engagement/retention & peer connection Justification: Supports belonging | Optimal group size enhances connection and participation. | Increased retention & connectedness with other participants | Acceptability |
| Participant satisfaction | ||||||
| Kevin: “I'm going to add some yoga routines… and work with my wife… and we'll work out some things.” | Intentions | Intervene with consumers | Actor: Yoga instructor Action: Encourage carryover of skills Target: Behavior outside sessions Temporality: End of program Dose: Reinforcement discussions Outcome affected: Behavior change Justification: Promotes continuation | Planning increases likelihood of sustained behavior. | Sustained activity | Sustainability as noted by maintained patient outcomes related to balance |
| Barbara: “The energy from participants really makes a difference. Everyone in there is brain injured, and we’re all in there to get some type of help with that.” | Social Influences | Intervene with patients/consumers | Actor: Yoga instructor/study team Action: Foster shared identity and peer interaction Target: Group dynamics Temporality: Each session Dose: Continuous facilitation of interaction Outcome affected: Engagement/adherence Justification: Builds shared experience | Shared identity and peer interaction increase motivation and engagement. | Increased engagement and attendance | Acceptability |
| Adherence | ||||||
| Patient Outcome: Sense of Belonging | ||||||
| Anna: “There was no judgment, no guilt, no disqualification… no critical comments or anything… I really appreciated that.” | Social Influences | Provide ongoing consultation | Actor: Yoga instructor Action: Facilitate a non-judgmental group environment Target: Psychological safety within group Temporality: Each session Dose: Continuous reinforcement Outcome affected: Engagement/retention Justification: Supports emotional safety in group setting | Psychological safety reduces fear and increases willingness to participate. | Increased retention and participation | Acceptability |
| Patient satisfaction | ||||||
| Participant Outcome: Sense of Belonging | ||||||
| Anna: “The challenge with having a brain injury is finding accessible, affordable resources.” | Social Influences | Conduct local needs assessment | Actor: Study team Action: Identify need for group-based, accessible programming Target: Community context Temporality: Pre-implementation Dose: One-time assessment with ongoing refinement Outcome affected: Reach/engagement Justification: Aligns program with community needs | Addressing community need increases relevance and participation. | Increased enrollment and engagement | Reach |
| Adoption | ||||||
Specifying and reporting identified implementation strategies.
Strategies addressing the need for, and the mechanism of adequately trained personnel emphasized the role of the instructor in shaping participant experience through trauma-informed delivery, graded progression, and ongoing coaching. These strategies functioned as mechanisms of adaptive support, enabling the yoga instructor to dynamically respond to participants' physical, cognitive, and emotional needs. Participants described feelings of safety, confidence, and capability, suggesting that the adaptive yoga instructor's and assistants' behaviors directly influenced participant engagement throughout the study (Table 3).
Strategies related to the mechanism of adaptable, yet structured program delivery highlighted the importance of balancing structure with flexibility, including a standardized yoga program with modifications to meet individual abilities, consistent scheduling, clear communication, navigation supports, and flexible enrollment options. These implementation strategy elements may operate in the future as mechanisms of cognitive scaffolding, reducing confusion and cognitive burden while increasing predictability. Participants described their improved ability to plan, attend, and engage in adaptive yoga sessions because the expectations and routine were the same each week. However, when participants completed the pre- and post-assessments, they noted that the expectations were unclear and it was challenging to navigate to new locations (Table 3).
Finally, strategies targeting the mechanism of socially driven group processes underscored the value and role of in-person group-based mechanisms, including shared identity, psychological safety, and peer connection. Participants emphasized the importance of being part of a group with others who shared similar experiences, describing increased motivation and comfort in a non-judgmental environment. Our findings suggest that social processes functioned as mechanisms of action that fostered engagement, reinforcing participation and adherence through a sense of belonging and collective experience. Thus, while these social intervention elements were identified facilitators, they were not intentionally embedded or captured in the original RCT's participant outcomes. Thus, this was an important mechanism to capture because it suggests an additional participant-level outcome and highlighted a necessary intervention component, sense of belonging, to refine for a future study (Figure 1 and Table 3).
Collectively, our findings suggest that successful implementation may not be driven by any single strategy, but rather by inter-related mechanisms related to adequately trained personnel, adaptable yet structured program delivery, and socially driven group processes that together shape engagement and sustained adherence (Figure 1).
Discussion
This study used implementation mapping to identify determinants of engagement in adaptive yoga for individuals with ABI and translate those findings into theory-informed implementation strategies. Our findings suggest that engagement is shaped by three inter-related mechanisms: (1) adequately trained personnel, (2) adaptable yet structured program delivery, and (3) socially driven group processes. Linking participant-reported determinants to TDF domains, COM-B mechanisms, and ERIC implementation strategies provides an actionable framework to inform future hybrid effectiveness-implementation trials (39).
The first mechanism of adequately trained personnel highlights the importance of hiring a yoga teacher or therapist with advanced training in delivery of yoga for people with neurological disabilities. It also underscores the importance of training each intervention assistant to address and anticipate the participant's needs by providing posture modification, physical support, and environmental setup. Across multiple TDF domains, including Skills, Emotion, and Beliefs about Capabilities, participants emphasized the importance of personnel who could provide real-time modifications, ensure physical safety, and foster psychological safety (40, 41). Implementation strategies such as train-the-trainer approaches and ongoing consultation operationalize this need by equipping personnel with the skills required to tailor intervention delivery dynamically. These findings are consistent with self-efficacy theory, suggesting that participants engaged more readily when they felt supported, safe, and capable within the intervention context (42, 43).
The second mechanism, adaptable yet structured program delivery, highlights the importance of balancing predictability with flexibility. Participants described challenges related to communication, scheduling, and navigation, which map to the TDF domains of Knowledge and Environmental Context and Resources (). Implementation strategies such as reminder systems, clear communication materials, and flexible enrollment structures were identified to address these challenges (, 44). These strategies may function by reducing cognitive load, increasing predictability, and aligning participant expectations with program demands. Our finding aligns with best practices for adaptive yoga for people with brain injury include “the facilitation of consistent instruction with a manual that allows for flexibility” (45). From a theoretical perspective, our findings suggest that structured delivery provides a form of cognitive scaffolding that is particularly important for individuals with ABI (44). A future hybrid design should evaluate the dose of the adaptive yoga intervention, as multiple participants reported that the initial 8-week duration felt manageable and supported enrollment, but also expressed a desire for opportunities to continue participating beyond the initial commitment.
The third mechanism of socially driven group processes appeared to foster engagement through psychological safety, shared identity, and a sense of belonging. Participants consistently emphasized the value of practicing adaptive yoga alongside others living with ABI, suggesting that social connection functioned as an implementation mechanism that reinforced motivation and sustained participation rather than simply representing a participant outcome. These findings are consistent with previous qualitative studies of adaptive yoga after ABI (, 46–48) but extend the literature by identifying social connection as a mechanism that can be intentionally supported through implementation strategies, including peer interaction, optimal group size, and non-judgmental group environments (49, 50).
As illustrated in Figure 1, socially driven group processes interact dynamically with trained personnel and an adaptable yet structured delivery, reinforcing engagement through both relational and contextual pathways. Our findings are consistent with theories of social identity and belonging (50), suggesting that engagement in interventions is shaped not only by individual capability, but also by the extent to which participants feel connected to others with shared experiences (51–53). These findings suggest that implementation strategies should be designed and evaluated as integrated components rather than isolated actions. By operationalizing strategies according to actor, action, target, temporality, and dose, we provide sufficient detail to support replication and future hybrid effectiveness-implementation trials (). Linking implementation strategies to candidate implementation outcomes (e.g., acceptability, adoption, appropriateness, feasibility, fidelity, sustainability) (54) further advances current recommendations for specifying implementation mechanisms and contextual fit (, ).
Limitations
This study was conducted as part of a pilot RCT with a small, self-selected sample recruited from a single geographic region, which may limit the transferability of findings. Because only intervention completers were interviewed, determinants influencing early withdrawal or poor attendance were not fully captured. Similarly, the absence of perspectives from the yoga interventionist, intervention assistants, study personnel, care partners, and participants who discontinued the intervention may have limited the comprehensiveness of the identified implementation strategies. Although the proposed implementation strategies and mechanisms of engagement may have broader applicability, they remain untested beyond this study. Finally, the primary deductive analysis guided by the TDF may have constrained the identification of determinants beyond the framework.
Implications for implementation science and future research
These findings inform the design of future hybrid effectiveness-implementation trials evaluating adaptive yoga for individuals with ABI. Future studies should test whether the identified implementation strategies improve participant engagement and implementation outcomes while incorporating perspectives from interventionists, care partners, study personnel, and participants who discontinue interventions. Evaluating these mechanisms across different rehabilitation settings and stages of recovery will further refine implementation strategies and improve scalability.
Conclusions
Findings from this study demonstrate that engagement in adaptive yoga for individuals with acquired brain injury is shaped by dynamic, inter-related mechanisms rather than discrete determinants. By linking participant-reported experiences to TDF domains, COM-B mechanisms, and ERIC implementation strategies, we provide a theory-informed approach to translating qualitative data into actionable strategies. The three identified mechanisms: (1) trained personnel, (2) adaptable yet structured delivery, and (3) socially driven group processes, highlight critical components for optimizing participant engagement and sustained participation. These insights inform the design of a future hybrid trial and underscore the importance of explicitly specifying mechanisms of action to enhance implementation success in adaptive yoga interventions.
Statements
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics statement
We obtained ethical approval from Colorado State University Institutional Review Board #1799. We obtained consent from all participants in the study. The randomized controlled trial was registered on ClinicalTrials.gov: NCT05793827. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.
Author contributions
JAW: Conceptualization, Data curation, Formal analysis, Methodology, Resources, Software, Supervision, Visualization, Writing – original draft, Writing – review & editing, Project administration, Funding acquisition. JB-E: Formal analysis, Project administration, Software, Writing – original draft, Writing – review & editing. JP: Methodology, Writing – original draft, Writing – review & editing. AG: Formal analysis, Software, Writing – original draft, Writing – review & editing. JAS: Funding acquisition, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing. AAS: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Visualization, Writing – original draft, Writing – review & editing.
Funding
The author(s) declared that financial support was received for this work and/or its publication. This study was funded by a Boettcher Webb-Waring Biomedical Research Award issued to authors JAS and AAS. This study was funded by CSU OVPR Spur funds for the Translational Neurological Lab issued to authors AAS, JAS, and JAW.
Acknowledgments
We thank all study participants for sharing their experiences with the study team.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that generative AI was used in the creation of this manuscript. During the preparation of this work, the authors used ChatGPT to refine paragraph structure and grammar. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the publication's content.
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Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Abbreviations
ABI, acquired brain injury; COM-B, capability, opportunity, motivation–behavior model; ERIC, expert recommendations for implementing change; RCT, randomized controlled trial; TDF, theoretical domains framework.
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Summary
Keywords
brain injury, implementation science, qualitative, theoretical domains framework, yoga
Citation
Weaver JA, Bombino-Elliott J, Pisegna J, Grove AM, Stephens JA and Schmid AA (2026) Inter-related mechanisms of engagement in adaptive yoga for acquired brain injury: a qualitative implementation mapping study. Front. Health Serv. 6:1879725. doi: 10.3389/frhs.2026.1879725
Received
12 May 2026
Revised
09 July 2026
Accepted
20 July 2026
Published
06 August 2026
Volume
6 - 2026
Edited by
Claudia Fetter, Institute of Cardiology of Rio Grande do Sul, Brazil
Reviewed by
Janice Luisa Luisa Lukrafka, Federal University of Health Sciences of Porto Alegre, Brazil
Patricia Caetano De Oliveira, Institute of Cardiology of Rio Grande do Sul, Brazil
Updates
Copyright
© 2026 Weaver, Bombino-Elliott, Pisegna, Grove, Stephens and Schmid.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Jennifer A. Weaver weaverj8@vcu.edu
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.