Acceptability and feasibility of a tai chi/qigong intervention for older people living with HIV

Abstract

Tai chi/qigong (TCQ) is a low impact, meditative movement with breathwork that may benefit people with HIV (PWH) over 50 years old. This study is a feasibility clinical trial of a remote TCQ intervention for older PWH. Participants (n=48) were recruited via clinic sites and social media and randomized to a TCQ, sham qigong, or wait-list control group. The 12-week intervention included fourteen 45–60-minute sessions. Acceptability (satisfaction, attitudes, practice, attendance) and feasibility (retention rate, adverse events, remote delivery) data were surveyed. Overall retention rate was 72.9%, but 81.2% for the TCQ group. Most TCQ participants attended at least 10 sessions (62.5%) and were practicing TCQ after 2 weeks (72.7%). Over 92% of TCQ participants reported satisfaction and positive attitudes and preferred remote versus in person delivery (63.6%). Two mild intervention related adverse events occurred. Findings suggest that a remote TCQ intervention is acceptable, feasible, and safe among older PWH.

Introduction

Due to several factors, including effective anti-retroviral medications, testing, and early diagnosis, HIV has become a chronic illness rather than the terminal disease seen in the 1980s. At present, over half of people with HIV (PWH) in the United States are over 50 years of age [1], with some studies projecting this number to reach 70% by 2030 [2]. The largest age group living with HIV are those that are over the age of 55 (39%), followed by those who are 45–55 (24%) [1]. Racial minorities also account for the majority of PWH (71%), with African American/Blacks (40%) and Hispanic/Latinos (24%) the most affected [1]. As PWH age, they are more likely to experience HIV-related symptoms and other comorbidities [3]. For example, older PWH report more depressive symptoms than those not living with HIV [4], are more likely to have current pain than younger PWH or older adults in the general population [5], have a higher prevalence of frailty and prefrailty compared to older adults in the general population [6], and list fatigue as their most common physical symptom (78%) [7]. Despite the growing number of people aging with HIV, there are limited interventions tailored specifically for older PWH and that may also be beneficial in addressing multiple co-morbidities. A recent review found only 9 psychosocial interventions specifically tailored to older PWH, all focused on either mental health or cognitive functioning [8]. To the author’s knowledge, there are no interventions that concurrently address both psychological and physical symptoms for older PWH. The present study assesses the acceptability and feasibility of a remotely delivered tai chi/qigong intervention that may improve both mental and physical health for older PWH.

Tai Chi/Qigong Intervention

Tai chi and qigong are meditative movement practices with roots and similar principles based on concepts derived from traditional Chinese medicine [9]. Both are slow, low-impact series of movements that focus on the breath and meditative states to promote health and wellness [10]. Often in practice and in research, tai chi and qigong are combined into simplified sets of movements and referred to as tai chi/qigong (TCQ). Research in TCQ as an intervention has increased in recent years, showing that TCQ improves mental health [11–13] as well as physical health [14–15]. Most of the research on TCQ focuses on community dwelling older adults [16] or populations with specific clinical conditions such as cancer [17], cardiovascular disease [18–21], and cognitive disorders [22–25]. However, research is limited on the use of TCQ interventions among PWH with only one pilot study on older PWH in the last 10 years [26]. This pilot study examined the acceptability and feasibility of an intervention that combined tai chi, cognitive behavioral therapy, and text messaging to reduce substance use and pain among older PWH [26]. The study found the intervention to have adequate acceptability and preliminary evidence that tai chi plus cognitive behavioral therapy may be beneficial in reducing substance use and pain. However, this intervention was delivered in person and did not focus on the benefits of tai chi alone. There are also only a handful of studies that examine a remotely delivered TCQ intervention that focused on populations other than PWH [14, 16, 27]. These studies have found that a remotely delivered TCQ intervention was generally feasible and safe in community dwelling older adults [16], cancer patients [14], and older adults with pain [27]. However, to the author’s knowledge, the acceptability and feasibility of a remotely delivered TCQ intervention in older PWH is lacking. Interventions delivered remotely can address some of the known barriers to care for older PWH such as transportation challenges, flexibility with scheduled appointments, and privacy for those who may not want to attend a clinic due to HIV-related stigma [28]. For these reasons, the remote delivery of a TCQ intervention for older PWH is critical for the health and well-being of this population.

The Gentle Empowering Movement (GEM) Study was a feasibility clinical trial of a remotely delivered TCQ intervention conducted in South Florida and tailored to older PWH (i.e., over 50 years of age). The primary outcomes of the larger clinical trial were the acceptability and feasibility of the TCQ intervention; and the secondary outcomes were mental health (i.e., depression, anxiety, stress) and physical health (i.e., fatigue, HIV-related physical symptoms, pain). The present study is the outcome paper for the two main aims, which focuses on acceptability and feasibility. Specifically, the present study poses the following research questions: 1) will a remotely delivered TCQ intervention be acceptable among a diverse sample of older PWH; 2) and will a remotely delivered TCQ intervention be feasible to implement with older PWH?

Methods

Study Overview

The GEM Study was a 3-arm randomized feasibility clinical trial, designed to primarily examine the acceptability and feasibility of a 12-week TCQ intervention for older adult PWH. The intervention utilized the Tai Chi Easy curriculum that was developed and standardized by the Institute of Integral Qigong and Tai Chi (www.instituteofintegralqigongandtaichi.org). This curriculum has been broadly disseminated by certified practice leaders with participant evaluations indicating reductions in stress [29] and has been found efficacious in improving fatigue and mental health among breast cancer survivors [15, 30]. The trial was conducted in South Florida and in collaboration with federally qualified health centers (FQHC) and HIV community-based organizations, which served as recruitment sites. Recruitment was also conducted via on-line social media sites by a professional recruiting service (see www.trialfacts.com) with research experience. The study was approved by both the Florida International University and the Arizona State University institutional review boards and registered with clinicaltrials.gov (NCT#03840525).

Study Preparation and training.

The Tai Chi Easy curriculum includes its own training and intervention manuals (see www.instituteofintegralqigongandtaichi.org). A certified senior instructor of the Institute of Integral Qigong and Tai Chi (Larkey) trained facilitators for both the TCQ and sham qigong (SQG) control group. For the Tai Chi Easy facilitators, training lasted approximately 25 hours in total, and weekly/monthly meetings were scheduled during the project to discuss any issues. Each instructor was required to teach a class to the certified trainer successfully, demonstrating key skills and practice components, prior to beginning to lead intervention participants. For the SQG groups, training was approximately 4–6 hours in duration, and each instructor was also required to teach a class to the trainer before leading the groups. Professionally produced videos, consisting of the movements performed in class, were created for both the TCQ and the SQG control group. This video was then used by both the participants and facilitators to aid in their at-home practice. Practice and ‘dry runs’ of the intervention, including instructor feedback and correction, were further performed before the feasibility clinical trial was initiated.

Intervention.

The intervention consisted of 12-weeks of TCQ sessions. In the first two weeks, participants attended two remotely delivered classes per week, followed by remotely delivered weekly group sessions for a total of 14 classes. The SQG control group had the same frequency of classes and were also remotely delivered. Classes for both the TCQ and SQG groups were conducted via the Zoom platform and were live and not asynchronous. The instructors led the class by modeling the movements and doing the movements along with the class. Instructors would verbally explain how to do the movements, but this was kept at a minimum. Although participants could ask questions of the instructor, they normally did not ask questions or interact with other participants during the class. Still, there may be incidental social support provided by the instructor and/or other class members at the end of the class. The wait-list control group did not attend any groups and, along with SQG participants, were offered the TCQ classes after the study was completed. The wait-list control group did not receive any services from the study; they only received the TCQ course if they requested it after they completed the study. The TCQ classes consisted of a series of meditative movements based on simplified Tai Chi and Qigong, the Tai Chi Easy curriculum, and included a focus on taking deep slow breaths in conjunction with the movements. TCQ participants were also taught to maintain a meditative state which included clarity of mind, focus on the breath and movements, visualization of nature, and general relaxation .While the SQG is a set of movements very similar to Tai Chi Easy movements, it was devoid of coordination between the breath and movements, relaxation into a meditative state using the movements, and visualization of connections to nature (aspects that were all present in the TCQ intervention). Both the TCQ and SQG sessions lasted approximately 45–60 minutes each. Every class was recorded so that the trainer and/or the principal investigator could review a set of classes (approximately 10%) to confirm intervention fidelity (see Table 1).

Table 1.

Descriptive characteristics of the TCQ intervention and control conditions

	TCQ Intervention	SQG Control	Standard of Care Group
Intervention Features	Low impact physical activity Focus on breath Meditative State Incidental Social Support	Low impact physical activity with same/similar movements as TCQ intervention Incidental Social Support	No exercise or activity program
Dose/Frequency	12-weeks, 1/week 60 min class (2x per week in first 2 weeks) Approx. 2 ½ hours home practice/week	12-weeks, 1/week 60 min class (2x per week in first 2 weeks) Approx. 2 ½ hours home practice/week	n/a
Controls for	Unique focus; breath and meditative state	Low impact physical activity	n/a

TCQ= Tai chi/qigong; SQG=sham qigong; n/a=not applicable

Participants

Potential participants were recruited via flyers and presentations distributed at federally qualified health centers (FQHC), at community organizations that provide social services to PWH, by word of mouth, and online through social media posts (i.e., Facebook). Recruited and screened eligible individuals completed a baseline assessment followed by randomization into one of three study conditions: a TCQ group, a SQG control group, or a wait-list control group (random allocation was 1:1:1). Figure 1 displays the study design flowchart.

Fig. 1.

The Study Design Flowchart

Eligibility criteria were defined as participants who are 50 or older, are living with HIV, can provide consent, have reliable access to internet, and agree to participate for the length of the intervention (12 weeks). Exclusion criteria consisted of participants who were cognitively impaired or had prior substantial experiences with other mind-body practices defined as practicing once a week for 3 consecutive months in the past year.

Procedure

Interested participants contacted the study phone line, and screening was conducted to determine eligibility through phone call assessments. Eligible participants were scheduled for a baseline assessment that lasted approximately 40 minutes. All assessments were done either in-person or by telephone. Participants were provided with $30 cash for completing the baseline assessment. After the baseline, the participant was randomly assigned to one of the three study conditions based on a block randomization scheme produced by the Plan Procedure in SAS 9.4. If participants did not have a computer or tablet, the study provided a tablet with Zoom already uploaded for their use. Before every class, participants were called to complete a pre-survey about the previous class and about the weekly home practice; and they were also called after class to do a post-survey about the class that they just attended. Two weeks after the last class, participants were called and asked to complete a 2-week follow-up assessment, which lasted about 45 minutes. Participants were provided $30 for the completion of the 2-week follow-up assessment, and if they had completed 80% of the group classes, they earned an additional $20. Three month follow up assessments were also conducted, and all participants earned $50 for completing these assessments. Participants enrolled in the wait list and SQG control groups were offered the chance to participate in the TCQ intervention at the end of the study.

Measures

Acceptability.

Based on Bowen et al. [31], acceptability was defined as direct measures of satisfaction and indirectly assessed via adherence to the intervention which included home practice and group attendance. Benchmarks were set to claim acceptability if at least 80% of participants responded agree-to-strongly agree or yes on all acceptability items. Borderline acceptability was set for all indicators at a level of 70% to 79% of participants responding agree-to-strongly agree or yes on these questions. The exception was attendance with the acceptability benchmark for attendance set at 70% of participants attending at least 75% of classes. Attendance was based on cumulative number of times being present in the classes. Attendance was considered 100% if the participants attended a total of 14 classes including the make-up classes. A comparable make-up class was scheduled weekly for those participants who could not make the regularly scheduled class.

Satisfaction with the TCQ and SQG groups were assessed via weekly surveys that asked participants the following items: ‘I really enjoyed today’s class’ (1=strongly disagree to 5=strongly agree); ‘Today’s class met my expectations’ (1=strongly disagree to 5=strongly agree); ‘I felt the instructor was engaging during today’s class’ (1=strongly disagree to 5=strongly agree); ‘Are you practicing at home?’ (1=yes, 0=no). At the two week follow up assessment, participants were also asked the following ‘Overall, being part of this group was a positive experience’ (0=strongly agree to 4=strongly disagree); ‘Overall I feel these classes have helped me feel healthier’ (0=strongly agree to 4=strongly disagree); ‘Have you practiced any of the movements in the last 2 weeks’ (0=no, 1=yes); ‘If yes, how often did you practice the movements’ [1 = very frequently (everyday), 2 = frequently (a few times a week), 3 = infrequent (once a week), or 4 = very infrequent (less than once a week)]; ‘I would be willing to participate in the group again’ (0=strongly disagree to 4=strongly agree); and ‘I plan to continue the movement practice’ (0=strongly disagree to 4=strongly agree). Group attendance in both the TCQ and SQG groups was also assessed.

Feasibility.

Feasibility was defined by assessing whether it was feasible for participants to perform the intervention; whether delivering remotely was feasible, and whether study completion was feasible (i.e., retention rate). Benchmarks were set to claim feasibility if at least 80% of participants responded agree-to-strongly agree or no on these questions; and study retention rate was at least 80%. The exception was soreness. For soreness, the feasibility benchmark was if at least 90% of participants did not report any soreness during the intervention.

Feasibility of movement items are as follows: ‘Did you have any difficulty understanding or following the presented movements?’ (0=no, 1=yes); ‘Were any of the movements difficult to perform due to physical symptoms such as pain, limited mobility or range or motion?’ (0=no, 1=yes); ‘Did you experience physical soreness after the last class you attended because of the movements?’ (1=yes, 2=no); The feasibility of delivering the intervention remotely was assessed by the following items: ‘Did you have any difficulties with internet connectivity, using the Zoom application, or trouble hearing/seeing the class?’ (0=no, 1=yes). The intervention’s feasibility of movement and remote delivery were both evaluated via weekly surveys. In the two week follow up assessments, participants were asked the following items: ‘Overall, I found doing the class on Zoom was easy’ (0=strongly agree to 4=strongly disagree); ‘I prefer doing the classes on Zoom rather than face to face’ (0=strongly agree to 4=strongly disagree); and ‘Did you have any difficulties with internet connectivity, using the Zoom application, or trouble hearing/seeing the class?’ (0=no, 1=yes).

Demographics.

Age, gender (male, female, transgender/other), ethnicity (Hispanic/Latinx, Non-Hispanic/Latinx, Other), race (White, Black), education (high school or less, some college or more), employment (employed, unemployed/retired, on disability), and weekly income were assessed at baseline assessment.

Data analysis plan

Descriptive statistics were used including mean and standard deviation for continuous variables and frequency and percentage for categorical variables. Acceptability was assessed by a) attendance in the intervention sessions, b) the proportion of intervention participants with higher level of satisfaction, c) the proportion of participants with higher level of positive experience after intervention, d) the proportion of participants practicing the movements after classes ended, and f) the proportion of participants who were willing to participate in the program again and planning to continue performing the movements. Feasibility was assessed by a) the proportion of intervention participants without soreness or difficulties understanding the movements, b) the proportion of participants that reported having difficulties with internet connectivity, using the Zoom application, and/or hearing/seeing the classes, and c) the proportion of individuals retained after randomization.

Results

Sample characteristics

Descriptive statistics are reported in Table 2. The mean age for the sample is 60.1 years of age. Most of the sample was male (55.3%), non-Hispanic (55.3%), Black (48.9%), had a high school or less level of education (53.2%), and was receiving disability benefits (42.6%). There were no group differences by these demographic variables.

Table 2.

Sample characteristics of the total sample and by study conditions

Characteristics	Total (N=47)*	TCQ (N=16)	SQG (N=16)	Control (N=16)
Age a	60 (5)	59 (6)	61 (6)	61 (4)
Gender, n (%)
Male	26 (55.3)	8 (50.0)	9 (60.0)	9 (56.2)
Female	19 (40.4)	6 (37.5)	6 (40.0)	7 (43.8)
Transgender/Other	2 (4.3)	2 (12.5)	-	-
Ethnicity n (%)
Hispanic/Latino	17 (36.2)	8 (50.0)	5 (33.3)	4 (25.0)
Non-Hispanic/Latino	26 (55.3)	5 (31.2)	10 (66.7)	11 (68.8)
Other	4 (8.5)	3 (18.8)	-	1 (6.2)
Race n (%)
White	24 (51.1)	9 (56.2)	7 (46.7)	8 (50.0)
Black	23 (48.9)	7 (43.8)	8 (53.3)	8 (50.0)
Education n (%)
High School or less	25 (53.2)	7 (43.8)	9 (60.0)	9 (56.2)
College or above	22 (46.8)	9 (56.2)	6 (40.0)	7 (43.8)
Employment n (%)
Employed	12 (25.5)	4 (25.0)	4 (26.7)	4 (25.0)
Unemployed/Retired	15 (31.9)	5 (31.2)	8 (53.3)	2 (12.5)
On disability	20 (42.6)	7 (43.8)	3 (20.0)	10 (62.5)
Income per week a	389 (429)	498 (608)	247 (152)	404 (363)

^amean (SD)

^*One baseline interview was invalid and considered missing data.

TCQ = tai chi/qigong; SQG = sham qigong

Acceptability and Feasibility

Recruitment and retention.

135 individuals were screened and 77 were found eligible. Of those found eligible, 48 were enrolled for a 62.3% recruitment rate. Reasons individuals were eligible but not enrolled are the following: lost contact (n=19), unknown (n=5), not interested/no show (n=3), sample size already met (n=1), and participant had a family emergency (n=1). The recruitment rate for those who were recruited only online via social media (i.e., Facebook) was higher at 70.6% (12/17). Overall study retention rate (i.e., completed the final follow up assessment at 3-month post intervention) across all groups combined was 72.9%. For each of the groups separately, retention rate was the following: TCQ group (13/16; 81.3%), SQG group (12/16; 75.0%), and the wait-list control group (10/16; 62.5%).

Adherence to the intervention.

In the TCQ group, 62.5% of participants (10/16) attended 10 or more sessions (over 70% of the classes), with 6 participants attending all sessions and 3 participants not attending any class. Among TCQ participants that attended at least one session, 76.9% (10/13) attended 10 or more classes. As for the SQG group, 56.3% of SQG group participants (9/16) attended 10 or more classes, with 3 participants attending all sessions and 5 participants not attending any classes. Of those who attended at least one SQG session, 82% (9/11) attended at least 10 classes.

Satisfaction/attitudes toward the intervention.

Among TCQ participants that attended at least one session, all (13/13; 100%) reported that they enjoyed the sessions, that they found the instructor engaging, and that it was a positive experience. Almost all participants stated that the TCQ group met their expectations (12/13; 92.3%). During the intervention, home practice was reported by 76.9% (10/13) of the TCQ participants; at two-week post intervention, most TCQ participants (8/11; 72.7%) continued to report home practice with participants reporting the frequency of their practice as ‘frequently’ or ‘very frequently’ (M=1.88, SD=0.83). At the 2 week follow up assessment, over 90% (10/11) of the TCQ participants reported that they felt healthier after the intervention. Lastly, most TCQ participants (7/11; 63.6%) stated that they would be willing to participate in the intervention again; and that they planned to continue practicing the movements (9/11; 81.8%).

Feasibility.

Among TCQ participants that attended at least one session, most (10/13; 76.9%) reported no soreness doing the movements, with 23.1% (3/13) reporting soreness 3–4 times throughout the intervention. Less than half of the TQG participants reported having difficulties in understanding or following the movement (5/13; 38.5%), with participants experiencing difficulties in understanding the movements an average of 1.38 (SD=1.76) classes during the intervention. Almost half of TQG participants reported difficulty doing the movements at some point during the intervention (6/13; 46.2%), with participants having difficulty doing the movements an average of 1.77 (SD= 2.74) classes during the duration of the intervention. Lastly, TQG participants reported having ‘any technical difficulties such as loss of internet connectivity, not understanding the features in the Zoom application, or trouble hearing/seeing the instructor’ in 31.3% of the classes; however, at the 2 week follow up assessment, all reported that Zoom was easy to use (11/11; 100%) and most preferred Zoom over in person delivery (7/11; 63.6%).

Adverse events.

Only two adverse events were deemed intervention-related but were considered mild. These included two events in which the same participant reported soreness as ‘somewhat severe’ after a TCQ class, however, the participant did not report soreness again and was able to complete the study. An additional adverse event was reported but it was not related to the intervention and considered mild.

Discussion

Summary of findings

This is the first study to examine the acceptability and feasibility of a remotely delivered TCQ-only intervention tailored for older PWH. The remotely delivered TCQ intervention either “met” or “borderline met” most acceptability and feasibility indicators. Only two acceptability indicators (preference for Zoom over face-to-face delivery; and willingness to participate again) and two feasibility indicators (difficulty with doing the movements; and difficulty understanding the movements) did not meet our criteria. However, participants reported good attendance and adherence and strong satisfaction and positive attitudes toward the intervention. Although the proportion of participants that preferred Zoom over face-to-face delivery did not meet our benchmark, most participants still reported a preference for Zoom and all participants reported Zoom was easy to use. More than half of the participants were willing to participate again in the TCQ group, but this also did not meet our benchmark. It is unclear why this would be; future delivery of this intervention should include qualitative interviews at the end of the intervention to learn more about reasons for not wanting to participate again. Although a bit more than half of the participants reported difficulties performing the movements, it was on average only for a class. This could be because of the co-morbidities experienced by this population, their age, and/or a lack of physical activity in this population. It is encouraging to note that most participants did not experience any soreness, and for those who did experience soreness, it was for a minimal number of classes. Overall, our findings suggest that a TCQ intervention is an appropriate and acceptable form of physical activity and wellness promotion for older PWH, which is congruent with Moore et al.’s, study [26] on older PWH.

Regarding adherence, the TCQ participants reported good attendance and frequent home practice. Moreover, if participants attended at least one session, they were likely to stay adherent to the intervention. Most of the intervention dropouts occurred before attending any group sessions. Although our staff were trained to emphasize the importance of being able to commit to the entire study during the screening and consenting process, participants may have been more interested in the monetary incentives of the baseline assessment or perhaps did not feel comfortable withdrawing from the study prior to enrollment due to social desirability issues. Future studies should focus on strategies to encourage attendance to the first session such as providing an added incentive for the first session.

The overall retention rate (i.e., the proportion of participants in the overall sample that completed the 3-month follow up assessment; 73%) was lower than expected (80% was expected). This could be because this population experiences multiple health conditions including fatigue [32–33], which may affect motivation to complete the study. The trial was also on-going during the COVID-19 pandemic, which may have also affected participation. Retention may increase if the intervention is of shorter duration (e.g., 8 weeks vs. 12 weeks) as reported in other studies [26]. However, most participants who dropped out did so before attending any class or within the first 1–2 weeks. Future TCQ intervention studies should focus on strategies to improve recruiting of participants to prevent early dropout. Information on retention rates for recent remotely delivered TCQ interventions is limited and mixed with one study on healthy community-dwelling older adults at 93% [16], another study on older cancer patients at 55% [14], and a third study on older adults experiencing pain at 75% [27]. Perhaps physical activity interventions such as TCQ, with older participants who also are experiencing a chronic condition, may naturally experience more attrition than the general population. Although our overall retention rate (i.e., the proportion of participants in the overall sample that completed the 3-month follow up assessment) was lower than expected, a higher proportion of participants in the TCQ group were retained and completed the 3-month follow up assessments (81%) than either of the control groups. The retention rate for TCQ group participants did meet our benchmark, and it is comparable to the retention rate for TCQ groups in previous studies [26–27]. Lower retention rate among the wait list control group (63%) could be explained by the high proportion of participants that reported receiving disability benefits compared to either the TCQ or the SQG groups, although post hoc analysis found no significant group difference regarding disability. The intervention also had minimal side effects with two study-related adverse events that were considered mild, with one event related to study procedures rather than the intervention. Most TCQ studies do not report information on serious adverse events [34, 26]; however, our findings are congruent with a recent TCQ intervention for healthy community dwelling older adults that reported only a few mild events [16].

The present TCQ intervention is unique in that it was delivered via Zoom rather than face to face. Remotely delivered TCQ and other mind-body classes are more common in a post-COVID-19 world, yet information on how best to conduct virtually delivered mind body interventions is not well understood. Our findings show participants found the TCQ groups delivered remotely either acceptable or borderline acceptable. There is little research on the acceptability of remotely delivered TCQ interventions. However, three recent studies assessing remotely delivered TCQ interventions with populations other than PWH also found that delivering TCQ virtually was acceptable and feasible [14, 16, 27]. More research is needed to determine whether remotely delivered TCQ interventions is acceptable to other subgroups of PWH, whether they are as efficacious as in-person TCQ interventions, and what are the best practices and strategies for delivering TCQ remotely.

Limitations and strengths

There are a few notable limitations of the study. First, results may not be generalizable due to the sample size and because only participants with reliable internet access were eligible. However, this was a feasibility study, which often includes small sample sizes, and for which generalizability is not the main aim. Second, data were self-reported which may lead to recall or social desirability bias. Although assessors were blind to group assignments at baseline, they were not blind for the follow up assessments. Lastly, the wait list control group participants tended to be on disability which may have affected their retention rate. However, there are also some noteworthy strengths of the study. The sample was a racially/ethnically diverse sample; it had a strong study design including randomization of participants, multiple follow up assessments, an attention control group as well as a wait list control group, and at least the TCQ and SQG participants were blinded to group assignment. In fact, a recent scoping review found that only two TCQ studies were blind to participants [35]. The study also focuses on a population that needs more tailored and remotely delivered interventions, older PWH.

Conclusion

Despite effective medication, HIV-related symptoms and co-morbidities persist, affecting the quality of life for older PWH. This study provides preliminary evidence of the acceptability and feasibility of a remotely delivered TCQ intervention for this population that may promote wellness. It also encourages further exploration on how best to deliver TCQ remotely to a racially/ethnically diverse sample of older PWH. Future studies are warranted including larger RCT studies to determine the efficacy and health benefits of a remotely delivered TCQ intervention for older PWH.

Table 3.

Proportion of participants who met the acceptability and feasibility benchmarks for both the TCQ and SQG groups.^*

Acceptability/Feasibility Indicator	Group	N	N %	Acceptability/Feasibility Benchmark**
No Soreness experienced	TCQ	13	10 (76.9)	Borderline feasible
	SQG	13	6 (46.2)
Difficulty understanding or following the presented movements	TCQ	13	5 (38.5)	Did not meet feasibility criteria
	SQG	13	8 (61.5)
Movements difficult due to physical symptoms	TCQ	13	6 (46.2)	Did not meet feasibility criteria
	SQG	13	8 (61.5)
Enjoy1	TCQ	13	13 (100)	Acceptable
	SQG	13	13 (92.3)
Expect1	TCQ	13	12 (92.3)	Acceptable
	SQG	13	13 (100)
Engage1	TCQ	13	13 (100)	Acceptable
	SQG	13	11 (92.3)
Positive Experience2	TCQ	11	11 (100)	Acceptable
	SQG	9	9 (100)
Feel healthier2	TCQ	11	10 (90.9)	Acceptable
	SQG	9	9 (100)
Zoom Easy2	TCQ	11	11 (100)	Acceptable
	SQG	9	9 (100)
Preferer Zoom over Face to Face2	TCQ	11	7 (63.6)	Did not meet acceptability criteria
	SQG	9	4 (44.4)
Practice movement	TCQ	11	8 (72.7)	Borderline acceptable
	SQG	9	6 (66.7)
Frequency of Practice3	TCQ	8	6 (75.0)	Borderline acceptable
	SQG	6	4 (66.7)
Willing to Participate4	TCQ	11	7 (63.6)	Did not meet acceptability criteria
	SQG	8	8 (100)
Continue Movement4	TCQ	11	9 (81.8)	Acceptable
	SQG	9	6 (66.7)

^*This is based on participants who attended at least 1 group session.

^**Acceptable was set at 80% or greater; Borderline acceptable was set at between 70% to 79%; and not acceptable less than 70%.

¹Those who responded to agree/strongly agree in a 5-point Likert type response 1-Strongly Disagree 5-Strongly Agree

²Those who responded to agree/strongly agree in a 5-point Likert type response 0-Strongly agree to 4-Strongly Disagree

³Those who responded to practice movement Very frequent (every day) or Frequent (a few times a week

⁴Those who responded to agree or strongly agree in a 5-point Likert type response 0-Strongly Disagree to 4-Strongly Agree