Tai Chi Interventions Promoting Social Support and Interaction Among Older Adults

Abstract

Tai chi is known to improve balance and reduce falls in older adults. Yet, little is known about the impact of group tai chi on perceived social support and its relationship with participant self-efficacy and adherence. The current systematic review, guided by Social Cognitive Theory and Successful Aging, includes an overview of tai chi interventions with and without enhancements (e.g., music, mentorship, group practice) that evaluated social support among their outcomes (N = 10). PubMed, CINAHL, and PsycINFO databases were searched for studies eligible under the inclusion criteria: sample population aged ≥60 years and published between 1999 and 2019. Four articles reported on tai chi interventions with specific enhancements to promote social interaction and reported increased perceived social support (p < 0.05). Six studies evaluated social support outcomes of tai chi programs without specific modifications to promote social engagement. Four of the six traditional tai chi intervention studies reported improved social support (p < 0.05). Group tai chi interventions for older adults may increase social support and therefore further increase health benefits of tai chi exercise among this population.

Loneliness and social isolation are major concerns, particularly for the older population. According to a recent national survey, 36% of adults aged >60 years are lonely and one in five older adults is affected by social isolation (Anderson & Thayer, 2018). Social isolation or limited socialization contributes to poor health outcomes and hospitalizations among older adults (Greysen et al., 2013; Mistry et al., 2001; Penninkilampi et al., 2018). In Berkman et al.’s (2000) seminal paper on socialization and health, the researchers described the impact of the multicomponent aspects of social networks and social integration on health in adults that is particularly evident during aging. Social support is important for a person’s mental and physical health and the ability to cope with the challenges of aging. One of the ways through which social support can promote health is as a motivator for engaging in healthy behaviors. As older adults are high users of health care services, nurses and other health care providers need to be aware of effective, low-cost interventions, such as engagement in exercise, to promote social connectedness and healthy behaviors. Identifying such interventions can impact the overall quality of life for older adults.

The association between social support and exercise/physical activity in older adults is well studied and there is a positive correlation between physical activity and increased quality of life, which may be partially explained by social support (Niedermeier et al., 2019). Social support is often a motivating factor in physical activity and incorporating socialization interventions can improve self-efficacy and participation in physical activity among older adults (Ory et al., 2018). Tai chi, a gentle mind–body exercise, is often recommended for older adults to improve balance and reduce fall risk (Wang et al., 2004). Although a number of health benefits have been studied, it is unclear whether social support and improved self-efficacy for exercise are factors in the benefits of tai chi practice. Recent community-based research found that tai chi was more effective than standard exercise-based fall prevention programming for reducing fall risk among vulnerable older adults (Li et al., 2018). Group exercise classes can create a sense of community and social support within the older adult population. Often practiced in a group setting, tai chi may contribute to social support within the classes with subsequent added benefits, including better adherence to the tai chi intervention.

We sought to determine whether tai chi interventions enhance social support and thereby contribute to self-efficacy for exercising. The current literature review is guided by the theoretical frameworks of Social Cognitive Theory and Successful Aging (Bandura, 1993; Rowe & Kahn, 2015). According to Bandura (1989), self-efficacy beliefs are essential for motivation and action, and through enhanced self-efficacy, or self-confidence, people will strive to achieve higher goals. In addition, based on Social Cognitive Theory, social support may be an important motivation, contributing to improved self-efficacy (Bandura, 1989). As older adults participate in exercise groups, the classroom environment may encourage social interaction, subsequently affecting their participation and thereby enhancing health benefits from group exercise. Tai chi is also said to improve self-efficacy, which may be impacted by instructor styles and social connectedness (Chan et al., 2017; Lo et al., 2020). Improved self-efficacy may give older adults confidence to tackle day-to-day self-care and management of chronic illnesses as well as encourage social interaction (Taylor-Piliae et al., 2006; Yeh et al., 2011). The MacArthur model of Successful Aging is based on three principles: “low risk of disease and disease-related disability; maintenance of high mental and physical function; and continued engagement with life” (Rowe & Kahn, 2015, p. 593). Engagement in life includes social relations with others and positive activity in the community. Therefore, social engagement benefits in addition to physiological benefits of exercise classes may positively contribute to successful aging.

The primary aim of the current systematic literature review is to examine current knowledge of the impact of tai chi exercise, including programs enhanced with additional interventions (e.g., music, mentorship, group practice) on social support for older adults. We hypothesized that (a) tai chi exercise could improve social support in older adults; and (b) enhancements to group tai chi interventions could contribute to greater benefits to social support, and to self-efficacy and adherence as well, in older adults.

METHOD

Search Strategy and Inclusion Criteria

A systematic literature review was conducted via searches of PubMed, CINAHL, and PsycINFO databases using the keywords, “tai chi” AND “social support” OR “social intervention” OR “social interaction.” The studies included had sample populations aged ≥60 years that evaluated group tai chi interventions (traditional and enhanced) for outcomes of social support. A comparison group was not required, and randomized controlled trials, quasi-experimental studies, and qualitative studies with tai chi interventions written in English and published from 1999 to 2019 were included. Qualitative studies were included to better understand themes in participants’ experiences related to group tai chi and social support. Initially, titles and abstracts were reviewed for eligibility and duplicates were excluded. After reviewing the abstracts, studies of other exercise interventions, younger age groups, and systematic reviews were also omitted. We conducted full text review of the articles that appeared relevant. We excluded studies that did not report on social support in their results. To find more relevant articles, we scanned reference lists of the included articles to identify additional studies. Articles were reviewed by two authors (Y.K., S.L.) to extract the relevant studies.

Quality Assessment

We used the Mixed Methods Appraisal Tool (MMAT), a validated critical appraisal tool designed for qualitative, quantitative, and mixed methods studies, to assess quality of the articles (Hong et al., 2018). The tool provides criteria to assess research studies according to their study design (i.e., qualitative, randomized controlled, non-randomized, quantitative descriptive, and mixed methods). Each study was assessed and scored by two authors (Y.K., S.L.) based on the five MMAT criteria; discordant scores were discussed, and agreement was reached by the assessors. Scores are calculated as a percent of quality criteria met within each article.

RESULTS

Database Search

Initially, 256 articles were found (Figure 1). After reviewing the titles and abstracts, 85 duplicates were removed and 56 were excluded based on their relevance to the review topic. Of the 65 full articles that were reviewed, 55 were excluded for not meeting various inclusion criteria. There were 10 articles identified for the review, including seven quantitative and three qualitative studies. Two articles were qualitative sub-studies based on quantitative parent studies (Lo et al., 2020; Yeh et al., 2016).

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) diagram of study selection.

The articles in this review reported mixed results regarding tai chi’s effect on social interaction. Four articles reported using enhancements to the tai chi intervention to promote social interaction (Chan et al., 2017; Ma et al., 2018; Roberts et al., 2017; Taylor-Piliae et al., 2006). Enhancements included mentorship, listening to music as a shared experience, and peer practice outside of class. Each of these four studies reported increased social interaction and social support in the tai chi groups. Among the 10 reports, there were six studies that evaluated social support outcomes of tai chi without program modifications specifically to promote social engagement. Four of these six studies reported improved social role function and social support among tai chi participants (Chou, 2008; Lo et al., 2020; Sun et al., 2014).

Quality Assessment Outcomes

Eight of the 10 studies reported adherence to the tai chi intervention and all of these studies reported moderate to high adherence (>64%). Of the 10 studies, there were a total of four randomized control studies; two quasi-experimental studies; one non-randomized, non-equivalent control group design; and three qualitative sub-studies of randomized control studies. The results of the MMAT quality evaluation ranged from 80% (4 of 5 quality criteria met) to 100% (5 of 5 quality criteria met) (Tables A-C, available in the online version of this article). The average MMAT score of the 10 articles was 96%. The qualitative studies were of the highest quality according to MMAT score (i.e., all scored 100%) (Table A).

Table A.

Quality Appraisal of Eligible Qualitative Studies Using the Mixed Methods Appraisal Tool, version 2018

	Yeh et al. (2016)	Lo et al. (2020)	Roberts et al. (2017)
1.1. Is the qualitative approach appropriate to answer the research question?	Yes	Yes	Yes
1.2. Are the qualitative data collection methods adequate to address the research question?	Yes	Yes	Yes
1.3. Are the findings adequately derived from the data?	Yes	Yes	Yes
1.4. Is the interpretation of results sufficiently substantiated by data?	Yes	Yes	Yes
1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation?	Yes	Yes	Yes
Conclusion	100%	100%	100%

Hong QN, Pluye P, Fabregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, Gagnon M-P, Griffiths F, Nicolau B, O’Cathain A, Rousseau M-C, Vedel I. Mixed Methods Appraisal Tool (MMAT), version 2018. Registration of Copyright (#1148552), Canadian Intellectual Property Office, Industry Canada.

From Hong et al. (2018, in the public domain; permission is not required).

Table C.

Quality Appraisal of Eligible Non-Randomized Trials Using the Mixed Methods Appraisal Tool, version 2018

	Taylor-Piliae et al. (2006)	Sun et al. (2014)	Lee et al. (2010)
3.1. Are the participants representative of the target population?	Yes	Yes	Yes
3.2. Are measurements appropriate regarding both the outcome and exposure/intervention?	Yes	Yes	Yes
3.3. Are there complete outcome data?	Yes	Yes	Yes
3.4. Are the confounders accounted for in the design and analysis?	No	Yes	Yes
3.5. During the study period, is the intervention/exposure administered as intended?	Yes	Yes	Yes
Conclusion	80%	100%	100%

Hong QN, Pluye P, Fabregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, Gagnon M-P, Griffiths F, Nicolau B, O’Cathain A, Rousseau M-C, Vedel I. Mixed Methods Appraisal Tool (MMAT), version 2018. Registration of Copyright (#1148552), Canadian Intellectual Property Office, Industry Canada.

From Hong et al. (2018, in the public domain; permission is not required).

Quantitative Synthesis

Sample sizes of the quantitative studies (n = 7) ranged from 14 to 206 participants. The tai chi programs varied in length from 12 to 26 weeks. Geographically, five studies took place in China, one study was in the United States, and one study was in Australia. Four studies did not have a clear or intentional intervention to promote social connection, yet they purposefully targeted isolated communities or communities experiencing chronic illnesses and thus provided a social component simply through conducting group-based tai chi programs (Chan et al., 2010; Chou, 2008; Lee et al., 2010; Sun et al., 2014). Social support was measured using a variety of instruments across studies (Table 1). Key findings from the tai chi interventions reported from the quantitative studies included improved social support and self-efficacy related to disease management (e.g., chronic obstructive pulmonary disease [COPD], chronic heart failure, depression), decreased loneliness, and improved quality of life.

TABLE 1.

Literature Search Results and Mixed Methods Appraisal Tool (MMAT) Quality Score

Authors (Year)	Design/Sample/Criteria	Intervention	Measurement of Social Support and Social Activity	Results	MMAT Score
Taylor-Piliae et al. (2006)	Quasi-experimental single group design N = 39 enrolled; 38 completed Inclusion: Chinese ethnicity; age ≥45 y; Cantonese or English speaker; ≥1 CVD risk factor; no regular tai chi practice past 12 mo Exclusion: cognitive impairment, unstable cardiac condition, and musculoskeletal disorders	Intervention: Yang-style 24 posture short form; classes 3x/wk, 12 wk Enhancement: verbal persuasion, social support, and encouragement from instructor during class; RNs present for monitoring and safety	Multidimensional Scale of Perceived Social Support (MSPSS)	Significant improvement in total and subscale scores of MSPSS (p < 0.05)	80%
Chan et al. (2017)	Single blind RCT N = 48, 24 per group; recruited at district older adult community center Inclusion: age ≥60 y, did not engage in social activities Exclusion: cognitive impairment, musculoskeletal disorders	Intervention: Tai chi qigong (TCQ), 18 forms; classes 2x/wk, 3 mo Enhancement: socially active trained volunteers from the neighborhood paired with participants during practice Control: usual care (monthly home visits by social workers and mailed information)	Luben Social Network Scale (LSNS) De Jong Gierveld Loneliness Scale Revised Social Support Questionnaire (RSSQ)	Group x time interaction not significant for primary outcomes; intervention group experienced significant pre-post improvement in De Jong Gierveld Loneliness Scale (p < 0.05) and RSSQ (p < 0.05)	100%
Ma et al. (2018)	RCT N = 158 randomized, 113 completed; intervention group: n = 55; control group: n = 58 Inclusion: age >60 y, hypertension, taking anti-hypertension medications, residing in Tianhe district Guangzhou, China Exclusion: musculoskeletal diseases limiting physical activity, secondary hypertension, current physical activity participation	Intervention: 24-form tai chi; training classes 2x/wk for 5 wk followed by ongoing peer-led classes (enhancement) 3-5x/wk for 24 wk Control: usual care for hypertension	Chinese Social Support Rating Scale (SSRS) Medical Outcomes Study SF-36	Group x time interactions showed intervention group improved in SSRS total and subscale scores	80%
Roberts et al. (2017)	Qualitative interview sub-study of pilot RCT N = 18 from older adult activity center; intervention group: n = 9, control group: n = 5 Inclusion: age >50 y, English speaking Exclusion: >2 falls in past 6 mo, dementia, debilitating medical condition	Intervention: Modified Yang-style 24-form tai chi with music (enhancement), 1x/wk, for 13 wk Control: Modified Yang-style 24-form tai chi in silence	Semi-structured interviews with modified grounded theory analysis	Intervention group themes of social interaction during class, enjoyment and laughter with peers, increased social support Intervention group had higher adherence than controls	100%
Studies Without Specific Enhancements
Chou (2008)	RCT N = 14 patients from a psychogeriatric outpatient clinic; intervention group: n = 7, control group: n = 7 Inclusion: DSM-IV depression, CES-D score >16, age >60 y, MMSE >25 Exclusion: regular exercise for the past 6 mo and specific medical contraindication for exercise (e.g., unstable cardiac condition, stroke)	Intervention: Yang-style 18-form tai chi 3x/wk, 3 mo, no enhancement Control: waitlist control group	LSNS	Intervention group: effect of intervention on CES-D scores diminished when social support was added to the model, indicating social support may mediate the effect of tai chi on depressive symptoms	100%
Sun et al. (2014)	Quasi-experimental study, single group design N = 41 Inclusion: 6 wk post heart failure surgery, no previous tai chi experience, able to participate Exclusion: severe mental health issues	Intervention: Tai chi classes 2x/wk for 6 mo; used variety of tai chi meditation techniques focused on breathing, balance, flexibility; no enhancements	Medical Outcomes Study SF-12 Health Related Quality of Life (HRQoL) subscales Resilience Scale with social activity and self-efficacy subscales	Improved social functioning subscale of HRQoL (p < 0.05) No effect of intervention on resilience subscales of family relationship, social skills, and friend support	100%
Chan et al. (2010)	Single blind three-group RCT N = 206 patients with COPD from five general outpatient clinics in Hong Kong; intervention group: n = 70, exercise control (EC) group: n = 69, usual care control group: n = 69 Inclusion: diagnosed with COPD, reduced expiratory ratios (FEV/FVC) of <70% (poorly reversible with bronchodilators), and able to walk independently Exclusion: severe sensory or cognitive impairment, symptomatic ischemic heart disease, and practiced TCQ within 1 y prior to commencement of the study	Intervention: TCQ 13 forms breathing regulated 2x/wk plus daily 1-hour practice at home for 3 mo; DVD and TCQ pictures given for home practice; no enhancement EC: breathing techniques combined with walking as exercise Usual care control: medication and encouraged to attend community activities	MSPSS	No group x time differences in MSPSS total and subscale scores	100%
Lee et al. (2010)	Non-randomized, non-equivalent control group design N = 139 residents living in six nursing homes; intervention: n = 66, control: n = 73 Inclusion: age ≥65 y, cognitively intact, walks without assistance Exclusion: acute medical problems, psychological disorder, previous tai chi experience	Intervention: Tai chi classes 3x/wk, 26 wk; no enhancement Control: usual care	Medical Outcome Study SF-12 (HRQoL); Social Support Questionnaire (SSFQ6)	No group x time interaction in HRQoL, social support, or social network satisfaction measures	100%
Yeh et al. (2016)	Qualitative interview sub-study of RCT random subsets N = 32; control: n = 17, intervention: n = 15 Inclusion: physician diagnosis of CHF, left ventricular EF <40%, stable medication regimen, NY Heart Association class I- III Exclusion: unstable angina or myocardial infarction/3 mo, cardiac rehab, peripartum cardiomyopathy, cognitive dysfunction, lower extremity amputation	Intervention: Yang-style short-form tai chi, classes 2x/wk, 12 weeks and encouraged to practice at home 3x/wk Control: HF education classes 2x/wk	Semi-structured interviews, grounded theory analysis	Emergent themes of social support for intervention and control groups: motivation from others, shared common experience, empathy Intervention group also experienced renewed social role	100%
Lo et al. (2020)	Qualitative focus group and interview sub-study of Mi-Wish RCT N = 41 tai chi intervention participant volunteers Inclusion: residents of low-income senior housing, aged ≥60 y, speak English Exclusion: plan to move, unstable terminal illness, mobility disability, currently practicing tai chi	Intervention:Tai chi classes 2x/wk, 1 year, home practice 3x/wk, no enhancement Control: not interviewed	Grounded theory analysis for emergent themes from focus groups and interviews	Tai chi led to perceived improvements in social support and self-efficacy, motivating tai chi engagement Aspects of mindfulness and social regulation positively affected social interactions	100%

Note. CVD = cardiovascular disease; RCT = randomized controlled trial; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.); CES-D = Center for Epidemiologic Studies-Depression Scale; MMSE = Mini-Mental State Examination; COPD = chronic obstructive pulmonary disease; CHF = chronic heart failure; EF = ejection fracture; FEV/FVC = forced expiratory volume/forced vital capacity.

Enhanced Group Tai Chi Intervention Studies

Three of the included quantitative studies used enhanced tai chi programs in their intervention and reported improved social support. A quasi-experimental study conducted by Taylor-Piliae et al. (2006) included RNs during the tai chi intervention classes who had exercise testing and supervision experience and monitored participants’ safety. In addition, the tai chi groups were limited to 20 participants per group so the instructor could provide individual attention, promoting safety and social support within the class environment. Improving social support was one aim of the single-group trial, which demonstrated positive results among participants, including increased perceived social support from baseline to follow up (p < 0.05) based on the Multidimensional Scale of Perceived Social Support (MSPSS). In addition, the authors reported good adherence to this modified tai chi intervention (87%).

A randomized controlled trial focused on the effectiveness of tai chi qigong on the “hidden elderly” in a community, referring to socially isolated older adults (Chan et al. 2017. Volunteers were paired to participants during the tai chi classes in which training focused on alleviating social isolation, building trust, establishing bonding, and increasing interpersonal skills. This study assessed loneliness (De Jong Gierveld Loneliness Scale) and social support (a revised social support questionnaire and Luben Social Network Scale [LSNS]). Scores improved in the first two scales among tai chi participants comparing their baseline to follow-up assessments (p < 0.05). Most participants (82%) reported that they would continue to go to tai chi classes, and nine (38%) of 24 participants said their network had broadened after joining the class.

In another randomized controlled trial (Ma et al., 2018, participants with hypertension were randomized to a 6-month tai chi group or a usual care control group. This study’s enhancement included additional outdoor group exercise classes led by a peer group leader from among participants in the tai chi intervention group. Participants met three to five times per week at a local park and attendance was monitored in a group log. Participants in the tai chi intervention had higher follow-up scores for social support compared to the control group (p < 0.05) according to the Chinese Social Support Rating Scale (SSRS).

Traditional Group Tai Chi Intervention Studies

Four quantitative tai chi studies had no specific enhancements to improve social support yet assessed the impact of the tai chi intervention on social support and self-efficacy. A 3-month randomized tai chi intervention was conducted by Chou (2008) with participants with depression at a psychogeriatric outpatient clinic in Hong Kong to evaluate whether improved depression symptoms were related to improved social support from the tai chi intervention. Social support was measured using the LSNS (Chou, 2008). Findings suggested that the benefits of tai chi in alleviating depression symptoms were in part related to the increased social support from the tai chi program. In the community-based tai chi intervention in Australia, Sun et al. (2014) evaluated the effect of tai chi on health outcomes in patients with heart failure over a 6-month period. The authors reported improved social functioning (p < 0.05) on the Short-Form 12 Health Survey (SF-12) and improved self-efficacy (p < 0.05) on the resilience scale in the tai chi participants comparing their pre- and post-intervention measurements (Sun et al., 2014).

Two studies (Chan et al., 2010; Lee et al., 2010) using traditional tai chi interventions did not show significant improvements in the group-by-time analysis of social support based on the MSPSS and Health-Related Quality of Life instrument, respectively.

Qualitative Synthesis

The three qualitative studies included in the current review focused on themes related to specific tai chi interventions. The studies used semi-structured interviews and focus groups post-intervention, performing analyses using grounded theory for emergent themes and subthemes (Lo et al., 2020; Roberts et al., 2017; Yeh et al., 2016). Two studies conducted semi-structured interviews (Roberts et al., 2017; Yeh et al., 2016), whereas Lo et al. (2020) conducted focus groups. The interviews and focus groups were conducted post-intervention for the three studies, and all took place in the United States. Common themes that emerged in the studies related to the group-based tai chi interventions included renewed social roles as well as continued motivation from others, togetherness, companionship, and commitment to the group.

The theme of renewed social roles was discussed in the study by Yeh et al. (2016), which qualitatively assessed the impact of tai chi exercise on participants’ level of self-efficacy, social support, and empowerment in older adults with heart failure. In semi-structured interviews, participants described the impact that tai chi had on previous and renewed social roles as well as continued relationships, noting a new sense of purpose and improvement in personal relationships (Yeh et al., 2016). A few participants in this study gave examples of this phenomenon, including their sharing tai chi practice with others, returning to prior hobbies, and spending time with family members (Yeh et al., 2016).

Participants in the tai chi intervention groups also shared the idea of listening to each other’s stories, learning empathy, and experiencing a sense of togetherness (Roberts et al., 2017; Yeh et al., 2016). The shared experience feeling was reported in the music-enhanced tai chi group in the randomized controlled trial by Roberts et al. (2017) in which participants were randomized to either the music-enhanced tai chi or the silent tai chi control group for the 15-week intervention. Participants reported increased social support and companionship through social interaction in the music-enhanced classes. One participant shared how interacting with others made them want to continue attending class. In addition, the tai chi music group participants had greater adherence (100%) than their peers in the traditional tai chi control group (44%) (Roberts et al., 2017).

Participants shared a similar experience of having fun as a group and laughing together in the quantitative sub-study of a randomized controlled trial conducted by Lo et al. (2020). The tai chi intervention group reported improved social support, self-efficacy, and psychosocial well-being (Lo et al., 2020). Psychosocial benefits, such as emotional regulation and mindfulness, were also noted and subjectively reported as improving social interactions with others. Examples include participant reports of feeling calmer and less angry and having fewer difficulties with a spouse since practicing tai chi (Lo et al., 2020). Participants in two studies expressed the feeling of commitment to the group and wanting to not let others down (Lo et al., 2020; Yeh et al., 2016).

These qualitative themes reveal enhanced social support and social interaction in group tai chi programs for older adults that also serve as a motivation for continuing tai chi practice.

Self-Efficacy and Reported Adherence

We examined self-efficacy and adherence as outcomes secondary to the impact of tai chi on social support. Improved self-efficacy was reported in each of the four studies that evaluated self-efficacy outcomes (Lo et al., 2020; Sun et al., 2014; Taylor-Piliae et al., 2006; Yeh et al., 2016). Sun et al. (2014) reported improvement in self-efficacy measured by the Resilience Scale, a 37-item inventory used to measure ability to manage challenges and difficulties. Taylor-Piliae et al. (2006) reported improved self-efficacy via the Tai Chi Self-Efficacy (TCSE) Performance Scale, which evaluated participants’ perceived self-efficacy to perform tai chi, and TCSE barriers, which evaluated perceived self-efficacy to overcome barriers; the intervention improved both self-efficacy measures in the pre-post analysis (p = 0.001). Lo et al.’s (2020) qualitative sub-study reported improved self-efficacy based on a focus group discussion with tai chi intervention participants. In addition, Yeh et al.’s (2016) qualitative sub-study reported improved self-efficacy in the tai chi and education groups from the semi-structured interviews. The tai chi group described increased confidence in their ability to exercise due to the nature of tai chi (Yeh et al., 2016). The authors also noted the findings from their parent study, which showed the tai chi intervention group compared to the control group had significant improvement in cardiac exercise self-efficacy (p < 0.05) (Yeh et al., 2016).

Overall, eight of the 10 studies reported adherence to the intervention, yet evidence was lacking to determine whether improvements in social support were associated with better adherence to the intervention (Table D, available in the online version of this article). The four studies with enhancements to the tai chi intervention, which also reported improved social support (Chan et al., 2017; Ma et al., 2018; Roberts et al., 2017; Taylor-Piliae et al., 2006) reported high adherence (>70% attendance). Of the four studies without tai chi enhancements that also reported improved social support, one reported high adherence (Chou, 2008). Of the other three studies, Lo et al. (2020) reported moderate adherence (64.3%), whereas the remaining two studies lacked information on adherence (Sun et al., 2014; Yeh et al., 2016). Both studies reporting no improvement in social support also reported high adherence to the intervention (Chan et al., 2010; Lee et al., 2010).

Table D.

Evaluation of Adherence, Attendance, and Self-Efficacy

Article	Enhanced tai chi intervention	Adherence	Attendance	Reported self-efficacy and measurement tool
Taylor-Piliae et al. 2006	Yes	Intervention (TC group): 87% adherence to intervention Control: none	No attendance reported	TC group: Significant improvement (p=0.001) on TCSE performance scale (both perceived self-efficacy and barriers sub-scale
Chan et al. (2017)	Yes	Intervention (TC group): 83.3% adherence, 16.7% attrition rate for 6 months follow up Control: 68.2 % adherence, 31.8% attrition rate for 6 months follow up	No attendance reported	No reported self-efficacy outcome
Ma et al. (2018)	Yes	Intervention (TC group): 69.60% adherence Control: 73.4% adherence	No attendance reported	No reported self-efficacy outcome
Roberts et al. (2017)	Yes	Intervention (TC group): 100% adherence to tai chi music Control: 44.4% adherence to tai chi silence	No attendance reported	No reported self-efficacy outcome
Chou (2008)	No	No adherence reported	Intervention (TC group): 95% attendance rate	No reported self-efficacy outcome
Sun et al. (2014)	No	No adherence reported	No attendance reported	TC group: Significant improvement (p <0.001) on Resilience Scale
Chan et al. (2010)	No	Intervention (TC group): 85.7% completed follow up Control: 81.7% completed follow up	No attendance reported	No reported self-efficacy outcome
Lee et al. (2010)	No	No adherence reported	Intervention (TC group): 85.5%	No reported self-efficacy outcome
Yeh et al. (2016)	No	No adherence reported	No attendance reported	TC group: Qualitative reports via semi-structured interviews of improved self-efficacy
Lo et al. (2020)	No	Intervention (TC group): 64.3% adherence *79% completed with high adherence >50%	No attendance reported	TC group: Qualitative reports via focus groups of improved self-efficacy post intervention

DISCUSSION

The findings from the current literature review suggest that tai chi may have a significant impact on social support as a result of the shared group experience and group motivation components, especially when the tai chi program includes enhancements. Findings of improved social support reported in eight of 10 studies suggest that further research on specific enhancements that promote social support and improved self-efficacy is warranted. Although the enhancements were not consistent, all four studies that included enhancements (Chan et al., 2017; Ma et al., 2018; Roberts et al., 2017; Taylor-Piliae et al., 2006) reported benefits to social support and high adherence to the intervention compared to the traditional tai chi interventions, with four of six reporting benefits to social support. These results suggest that a variety of enhancements to group tai chi interventions may yield positive results related to social support and adherence, but further research is needed to evaluate the content and quality of the specific interventions.

Our findings suggest a relationship between tai chi and benefits to psychosocial health that complement the physical health outcomes reported in other studies. Tai chi has been shown to improve neuromotor function and, in turn, improve mobility and reduce fall risk (Li et al., 2018, Wang et al., 2004). A recent review of 23 randomized controlled studies across a variety of exercise modalities did not find that physical activity interventions, in general, led to improved social support in older adults (Shvedko et al., 2018). Therefore, the physical aspects of tai chi alone may not be a strong contributor to the improvements in social support. The group exercise and mindfulness component of tai chi may be key aspects, improving mood, increasing social interaction, and, subsequently, contributing to improved self-efficacy and adherence. Improved self-efficacy in older adults and adherence to the tai chi intervention may yield further physical improvements noted with regular practice of tai chi. In addition, there is evidence of a positive impact of tai chi on cognitive function (Wayne et al., 2014). Based on recent evidence showing the paired benefits of exercise on cognitive and physical function (Levin et al., 2017), improved cognitive function may, in turn, contribute to more stable mobility and fall prevention in older adults who engage in tai chi practice.

It is important to consider the differences in tai chi styles used in the interventions, such as tai chi qigong, Yang-style tai chi, and modified versions of both styles. Yang-style 24 short form posture is similar in intensity to brisk walking, and older adults with chronic illness may practice it safely (Taylor-Piliae et al., 2006). Tai chi qigong focuses on gentle exercises, including healing postures, movements, and healing techniques. The combination of tai chi and qigong entrains the coordination of muscular movement and breathing and increases lung capacity (Chan et al., 2019). The difference in these practices may have affected results, as tai chi qigong has more meditative properties than Yang-style tai chi. In addition, some studies reported specific enhancements to promote socialization, whereas others did not, yet all studies included in the current review reported socialization outcomes.

Recognizing ways to improve self-efficacy and increase adherence in tai chi interventions is important. Tai chi instructors and their overall approach to teaching classes may influence social support benefits, self-efficacy, and adherence. A multiple case study conducted by Killingback et al. (2017) evaluating factors that affect long-term adherence to group exercise suggests that aside from individual motivators, factors relating to the instructor may play a role in group exercise adherence. Individual characteristics of the instructor that might have an effect may include personality traits and humanistic approaches to instruction (Killingback et al., 2017). Some tai chi instructors may embody friendlier and more welcoming mannerisms, creating an environment that promotes and welcomes social interactions among participants, as a result influencing adherence and attendance rates. According to Taylor-Piliae et al. (2006), self-efficacy beliefs may be influenced by tai chi instructors who provide encouragement and verbal persuasion during classes. The improved self-efficacy reported in four studies may have been impacted by social support within the tai chi group setting. Lo et al. (2020) indicate the importance of self-efficacy in maintaining exercise, which could contribute to upholding healthy behaviors and further health maintenance. Interventions that may contribute to enhancing self-efficacy and social support during class may include breaks to socialize and connect with peers and encouraging peer engagement and support in class group practice. Social interventions can be supported in the course of the classes while still maintaining the mindfulness aspect of tai chi. Further studies are needed to evaluate the effect of specific tai chi instructor interventions and approaches tailored for older adults to intentionally enhance social support and self-efficacy.

According to Sun et al. (2014) high levels of self-esteem and self-efficacy as a result of tai chi practice may be related to an open and supportive environment, which may enhance resilience and desire to engage in further practice to help manage chronic conditions. The positive impact that tai chi may have on self-efficacy can further improve symptoms in chronic illnesses such as COPD, heart failure, and depression (Wang et al., 2004). In addition, social support is a resource people may use to cope with problems and improve disease management, in turn, improving quality of life for older adults with chronic illnesses (Chan et al., 2010). Motivators, such as enhanced social support and improved self-efficacy, may contribute to adherence to tai chi and subsequent improved physical health outcomes (Farrance et al., 2016).

It is unclear what factors might have played a role in the two studies that did not show improvements in social support (Chan et al., 2010; Lee et al., 2010). The teaching style of specific tai chi instructors and the instructor’s level of priority to engage participants was not reported, which may have contributed to the studies’ social support outcomes as their style may deter or encourage social interaction among participants. In addition, the length of the intervention in the tai chi programs that did not report improved social support were 3 months and 26 weeks, respectively (Chan et al. 2010; Lee et al., 2010). Although the length of their interventions is similar to studies that resulted in improved social support (12 weeks to 1 year), longer interventions and more frequent meeting times may provide further opportunity to foster social connection. However, more research is needed to determine why some standard tai chi approaches with similarly timed interventions contributed to social support whereas others had no impact in this area.

LIMITATIONS

The current systematic review has several limitations. Overall, our review revealed a low strength of the existing evidence about the impact of tai chi on social support outcomes in older adults. In addition, the few studies that included enhancements to the tai chi intervention prevented us from determining the extent of benefits from the enhancements. The low strength of existing evidence was related to a number of limitations in the published literature. Many of the studies had small sample sizes and would be considered pilot studies; seven of 10 studies had <50 participants. These studies with small sample sizes may have biases that undermine the internal and external validity of their results. In addition, the two quasi-experimental studies have limited generalizability and lack comparison to a control group, making it difficult to discern if improvement is related to the intervention or other confounding factors (Sun et al., 2014; Taylor-Piliae et al., 2006). Not all of the studies reported adherence, making it difficult to draw overall conclusions on the impact of social support on adherence or attendance in tai chi interventions.

A number of other methodological issues limited the conclusions that could be drawn from this review. The overall length of studies and frequency of meeting times varied from 12 weeks to 1 year and 1 day per week to 3 days per week. Variations in frequency of meetings and overall length of studies may have affected the impact of tai chi on socialization, self-efficacy outcomes, and associated health benefits. Chan et al. (2010) suggest that their short-term 3-month study and evaluation period may have missed long-term effects of tai chi qigong on social support. Due to the short-term format of most of the tai chi intervention studies, participants’ perceived long-term social support needs further study. Another limitation of the literature review is the inconsistency of the ways that social interaction, social support, and self-efficacy were measured among the studies. In addition, although the MMAT evaluation indicates that the included studies were of good quality overall, the MMAT does not allow for a comparison across design types and sample sizes, thus it has limitations in the depth of the evaluation of quality across the various design approaches.

CONCLUSION AND IMPLICATIONS

Although tai chi practice requires individual focus, enhancements to tai chi classes can provide social benefits during and outside of classes to promote connections among older adults. Promoting social interaction may also improve self-efficacy and class attendance. Subsequent participant enjoyment in the classes could increase the accessibility of health benefits, such as balance, fall prevention, and psychosocial health, as a result of sustained tai chi practice among older adults. Nurses and health professionals can play an important role in understanding and explaining health benefits of tai chi and promoting social interaction and self-efficacy through tai chi, with a goal to improve mobility and other health outcomes among older adults. Our review shows that a number of studies suggest that tai chi may provide benefits to social support, yet the evidence is limited on this important issue. Further research with higher quality studies, such as large randomized controlled trials, is needed to determine which specific enhancements to tai chi programs may be most beneficial for promoting social interaction and social support among older adults.

Table B.

Quality Appraisal of Eligible Randomized Control Trials Using the Mixed Methods Appraisal Tool, version 2018

	Chan et al. (2017)	Ma et al. (2018)	Chou (2008)	Chan et al. (2010)
2.1. Is randomization appropriately performed?	Yes	Yes	Yes	Yes
2.2. Are the groups comparable at baseline?	Yes	Yes	Yes	Yes
2.3. Are there complete outcome data?	Yes	Yes	Yes	Yes
2.4. Are outcome assessors blinded to the intervention provided?	Yes	Yes	Yes	Yes
2.5 Did the participants adhere to the assigned intervention?	Yes	Unknown-not reported	Yes	Yes
Conclusion score	100%	80%	100%	100%

Hong QN, Pluye P, Fabregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, Gagnon M-P, Griffiths F, Nicolau B, O’Cathain A, Rousseau M-C, Vedel I. Mixed Methods Appraisal Tool (MMAT), version 2018. Registration of Copyright (#1148552), Canadian Intellectual Property Office, Industry Canada.

From Hong et al. (2018, in the public domain; permission is not required).