This paper explores how the intersection of masculinity and religion shapes workplace well-being by focusing on Christianity and the social construction of masculinity among factory workers in a city in China. While existing work on public and occupational health has respectively acknowledged masculinity’s influences on health and the religious and spiritual dimensions of well-being, there have been limited efforts to examine how variegated, and especially religious, masculinities influence people’s well-being in the workplace. Drawing on ethnography and in-depth interviews with 52 factory workers and 8 church leaders and factory managers, we found that: (1) Variegated masculinities were integrated into the factory labor regime to produce docile and productive bodies of workers. In particular, the militarized and masculine cultures in China’s factories largely deprived workers of their dignity and undermined their well-being. These toxic masculinities were associated with workers’ depression and suicidal behavior. (2) Christianity not only provided social and spiritual support for vulnerable factory workers, but also enabled them to construct a morally superior Christian manhood that phytologically empowered them and enhanced their resilience to exploitation. This paper highlights not only the gender mechanism of well-being, but also the ways religion mediates the social-psychological construction of masculinity. Since 2010, more than 10 young male factory workers have committed suicide at an electronics manufacturing company located in China. These suicide events not only exposed the notoriously militaristic, masculine, and highly exploitative factory management system but also focused world-wide attention onto the psychological well-being of Chinese factory workers. Importantly, whilst the suicides frequently happened amongst men, the assembly line work was stereotypically considered a women’s job )Moreover, hegemonic masculinity is shown to be associated with men’s depression and therefore increases the risk of suicidal behaviors . ClinicaIt is noteworthy that these unhealthy gender practices are often reproduced by particular institutional structures  in which “unhealthy beliefs and behaviors among men”   contest and shape one another in the workplace, and how they could impact on people’s well-being differently, are still underexplored. Religion is one of the factors that may create alternative definitions of masculinity in the workplace, and therefore requires further analysis.Religion is largely absent from the literature exploring the intersections of masculinity and health. We argue that the lack of engagement in religion’s influences on masculinity and health leads to a failure to address not only the spiritual dimensions of health, but also the variegated forms of masculinity. This paper therefore attempts to bring masculinity, religion and health into conservation with one another in order to understand the mediating role of religion in the gender dynamics of health.On the one hand, some research has suggested that masculinity is often religiously constituted and mediated ,26,27,28On the other hand, research has shown that religion and spirituality play an important role in shaping people’s health practices and psychological well-being e.g., ,11,12). ,12. 11,1However, although religion’s influences on masculinity and health have been acknowledged, how the intersection of religion and masculinity can shape people’s well-being and resilience is still unclear. Above all, this paper fills the lacuna by examining: (1) the variegated and contested masculinities at the workplace and their impacts on workers’ well-being; and (2) how religion creates new masculinities, and how this religious masculinity influences well-being and the resilience of workers.We chose China’s factories and especially Company A as our research setting because of the vulnerability and poor well-being of China’s factory workers . One of On the other hand, over the past three decades or so, China has undergone a nationwide religious revival, one manifestation of which is the “Christianity fever”. According to a report conducted by the Pew Research Centre , there wThe materials of this paper are based on a project that explores the regulatory politics of migrant laborers, as well as the religious beliefs and practices of migrant workers in China. In general, the project aims to examine the relation between religion and labor in the context China’s neoliberal transformation. One of the concerns of this project is to explore the gender politics of factory workers and its influences on well-being. Our data come from ethnography conducted from September 2017 to March 2018. The methods utilized in this study included participant observation and in-depth interviews. First, we closely followed factory workers’ everyday life practices in the factories, church and living spaces. Participant observation was used to gain an intimate familiarity with Christian factory workers. In particular, we participated in their Christian fellowships with the church’s permission in order to comprehend their understanding of masculinity. Participant observation not only provided important sources of data for this paper but also helped situate the analysis of interview data within specific social contexts  see Sec.Second, we conducted interviews with various actors involved in China’s manufacturing factories (chief among them was Company A) and religious institutions. Interviews were conducted with 52 Christian factory workers and 8 church leaders. Among the 8 church leaders, 4 were senior and middle managers who were working or had worked at Company A. In total, the factory worker informants consisted of 32 males and 20 females, with ages varying from 16 to 60 see . It needIn this paper, we reconcile the Gioia Methodology  and HellThe interview data were coded with the qualitative data analysis tool NVivo 11 . As a result, we generated 126 codes relevant to “masculinity, religion and well-being” from the raw data. Based on these 126 codes, we conducted 1st-order analysis, which tried “to adhere faithfully to informant terms”  (p. 20).The whole management system was designed by [the CEO]. He used to serve the military. You know, his personality, he is aggressive and dominating. He also required his subordinates acted like him. [He] doesn’t like others to ask him the rationale behind his orders and just needs you to be obedient, to follow and execute. If you can’t execute efficiently or make mistakes, he will scold you without any reservation. So, the atmosphere of Company A actually evolved from his own management philosophy.At many manufacturing factories like Company A, a set of coercive and exploitative regulatory techniques, such as strict surveillance, standardized operations, monetary penalties, and even verbal abuse, are deployed to produce productive, docile workers on the factory floor. These governing techniques not only operate through “the modification of individual conduct” but also through processes of subjectivation that shape “how an individual acts upon himself”   or diaomao (屌毛), a form of verbal violence that is prevalent in the workshop. Diaoren is a verb that means using dirty words to sneer and curse at others, while diaomao is a noun to describe low-status people. The word diaomao is usually used by male assembly line workers to depreciate themselves and thus construct and reinforce a working-class identity amongst their fellow low-status workers, or to devalue their supervisors.If the coerciveness and verbal abuse become hegemonic masculinity among Company A’s managers, then many male assembly line workers attempt to construct a form of protested masculinity that resists managers’ control by rebellious and aggressive practices. While facing the abuse from their supervisors, many male workers overtly use verbal violence to fight back and therefore to defend their masculinity. In particular, they would use In Company A, it was common that the security guards abused workers with dirty language if the workers forgot to bring or swab the factory ID card. The security guard group do not belong to any [factory] floor or department, they are directly managed by the senior managers in Company A. So security guards and production workers are two confrontational groups in Company A. I remember there was even a group flight between workers and security guards at the canteen a few years ago. The cause of the conflict was that one worker insulted the security guards by calling them “watchdogs”. So they came to blows and many workers participated in. You know, there were just 4–5 security guards at the canteen and they were fiercely beaten up by the workers.Male production workers’ protested masculinity can also be illustrated by the frequent group conflicts between workers and Company A’s security guards. In order to enhance the militarized management, the CEO of Company A often recruited military veterans to be the factory’s security guards. In Company A, security guards were endowed with the rights to manage production workers in terms of enacting factory’s disciplines and rules. It is noteworthy that Company A’s first suicide was induced by the bullying and assault that the security guards inflicted on a young worker. Zhicheng, a 35-year-old worker explained to us how the conflicts occurred:However, although the protested masculinity performed by male workers could be understood as a strategy to resist Company A’s hierarchical and disciplinary power, it is also harmful to the well-being of workers themselves. In fact, both security guards and production workers are low-ranked workers at Company A but they were placed into two confrontational positions. As Kazmierczyk suggests, mobbing and bullying more likely occur within employees/workers at a similar level and this kind of non-hierarchical mobbing has even greater detrimental effects on workers’ well-being .Right after I was assigned to this assembly line, they asked me to assemble the phone screen, by just pressing the flexible printed circuit (FPC) into the phone model. I said: “OK, I have no objection”. But they asked me to do this every day, repeating the same action again and again with my two fingers. Other colleagues could switch to other operations but I wasn’t allowed to. So, I had pressed the FPCs for ten hours a day for one month and my fingers were injured already. After the first month, I talked to the line heads and asked them to let me shift to other positions, but they refused. The line head and assistant line head both asked me to continue. They  said: “You do a good job on this. If I change to another one who is unfamiliar with this, he is more likely to destroy the FPCs, so more products will become scrap.”Further, on the factory floor, the fear of being blamed and punished has created an unhealthy atmosphere of distrust among workers in which some workers tend to evade responsibility by passing the buck to each other once they are found to have made a mistake. It is common to see workers quarrelling with one another on the factory floor over the responsibility of the mistakes. In particular, women assembly line workers are the victims of both hierarchical and hegemonic masculinity from their supervisors and the protested masculinity from their male workmates. While many male production workers are verbally humiliated by their managers, they, in turn, construct their masculinity through claiming superiority over woman workers. As one female respondent recalled, it was common for male managers or production workers to overtly “talk dirty” and make sexual jokes and flirt with women workers in the workshops. In some cases, offensive language turned into sexual harassment, such as touching women’s bodies. However, this verbal violence and sexual harassment was viewed as natural by men. If the women tried to complain and resist, they would be viewed by male workers or managers as “too serious” and as someone who “can’t take a joke”. On the factory floor, there are therefore two forms of contested masculinities: the hierarchical masculinity among managers that encourages the exercise of power to control lower-ranking workers, and the protest masculinity  among maAs we show in In this section, we elaborate on the moderating effects of Christianity on masculinity and workplace well-being. We suggest that Christianity can produce a Christian and morally superior manhood that enables factory workers to fend off and negotiate with the hierarchical and protested masculinities on the factory floor. This Christian masculinity therefore psychologically empowers them and enhances their resilience in the face of adversity and exploitation.In Company A, it is very easy to use abusive language to treat others. Gradually, we lost the ability to respect the colleagues and workmates around you. However, I don’t want to be that kind of supervisor, and I don’t want to be assimilated by this culture. This is against God’s teachings. When my subordinates made mistakes, I usually taught them what lessons can be learned rather than scolding them.It is noteworthy that within Company A’s management system, a certain proportion of middle and senior managers appointed by its headquarters are Christians. Although these Christian managers would not overtly challenge the CEO’s masculine and militarized workplace culture, they normally refuse to accept coerciveness and aggressiveness as their own management philosophies, and attempt to blend them into a more humanist form in their “actually existing” management practices. Long and Liao were two of these Christian managers. For example, Long, a 40-year-old manager who used to work at Company A, offered his account of how a Christian manager should be:Different from Long who attempted to prevent himself from being assimilated by Company A’s culture, another 60-year-old manager, Liao, was more ambitious to transform Company A’s atmosphere and to revitalize the long-repressed humanism by introducing the Christian ethics of love and care into workers. In response to the suicide event, Liao established a house church right next to a factory plant of Company A in order to provide social and spiritual support for workers. In 2018, Liao’s Protestant church had more than 200 church members, most of whom were workers of Company A. The church provides these workers various forms of communal life  through which they can temporarily escape from their oppressive social realities. For example, Duo, a 35-year-old worker mentioned that the Christian fellowship offered him a comfort zone to confide in about his distress, even though he was ashamed to share his feelings of vulnerability elsewhere. This is particularly the case within Company A, where sharing the feelings of depression to workmates is at odds with the protested masculinity amongst working-class men. As Liao remarked, the lack of channels through which factory workers can pour out their troubles was one of the crucial factors that caused the suicide event. Instead, the church carves out an equal space built upon Christian ethics of brotherhood and love. It is common to see assembly-line workers and managers alike chat harmoniously with one another during the same congregation, which contrasts with the hierarchical and masculine culture of the factories.laohaoren (one who tries to never offend anybody), you aren’t able to manage the workers”. I was thinking, if I acted coercively, it went against Bible’s teachings. The Bible teaches us to be benevolent and considerate of others.A girl (worker) said to me that she wanted to go to the toilet. We normally had a ten-minute break at 3:00 p.m. and now it was 2:45. So I politely responded, “It’s nearly 3 o’clock, you can take a break 15 min later”. The girl suddenly became extremely angry. It scared me, out of my expectation. I froze there, not knowing what I should say. Our line leader witnessed this scene… He said, “You shouldn’t let your workers deter you, you shouldn’t let her go to the toilet, it’s just 15 min”. I thought a while, said, “She is a girl, perhaps she was on her period and felt mood swings”. The line leader replied, “You shouldn’t act like that—consider the workers’ feelings. If you continue acting like this, being a For Liao, the Christian workers were an important force in transforming Company A’s masculine and abusive culture. Liao encouraged Christian workers to exhibit Christian virtues, such as caring for others and being helpful and trustworthy, so that non-Christian workers could feel the positive influence of Christianity. For male Christian workers, they have a different definition of masculinity beyond the hegemonic masculinity on the factory floor characterized by aggressiveness and verbal abuse. For example, Zhicheng was a 32-year-old Christian worker who had worked in Company A for 7 years. Zhicheng was promoted to a sub-line leader in 2017 because of his diligence and experience on the assembly line. In one fellowship, he shared his struggles of being a Christian rank-and-file manager, which was incompatible with Company A’s dominant culture of coercive management:In Company A, if a worker is often abused by his supervisors, he must have accumulated a lot of despair and hate. So, some workers chose to transferring their hate to others by abusing those who are weaker than them. For a Christian man, you should understand others’ sufferings. If a Christian is bullied by his supervisors, he should take the sufferings by himself rather than imposing your sufferings to others. It’s all God’s test on you.Zhicheng offered an interpretation of what is Christian manhood: a Christian man should be considerate and caring of others, especially female colleagues. Zhicheng’s account of Christian masculinity was also influenced by the Christian teaching of male headship in the Bible. However, instead of interpreting male headship as men’s domination over women, Zhicheng told us that male headship meant men should take primary and more responsibilities in family and the workplace in comparison to women. Therefore, it is common to see that Christian male workers often voluntarily cover other workers’ shifts when their workmates are ill or exhausted, or undertake greater workloads to reduce the pressure on their workmates. Likewise, another 28-year-old Christian worker, Dong, understood Christian manhood as taking the sufferings by himself rather than transferring them to others:Now, I don’t need to care about any rules and regulations any longer, because I am working for God, not for the boss. The purpose of work is to glorify God. If you have such spiritual state, you can be peaceful regardless of how they treat you.In the above quotations, both Zhicheng and Dong pursued a Christian and moral manhood characterized by being benevolent, considerate and responsible. Although, this form of masculinity cannot challenge the hierarchical power from above, it nevertheless opens an alternative moral order within factory workers beyond the hegemonic and protested masculinities that encourage workers to turn against with each other. It is also noteworthy that Christian male workers exhibit stronger tolerance and resilience to exploitation and verbal abuse, given that the ontological conditions of social inequalities cannot be altered. For example, Dong considered the verbal abuse as “God’s test on you”. Many male Christian workers consider themselves as “God’s workers”, which means that they are working for God, not for the factory. It is through this alternative interpretation of work that the problem was deflected from this worldly labor relation per se. For example, a 27-year-old worker, Lijun, told us how he overcame the trouble of depression by converting to Christianity:waibangren  often do”. Similarly, another 28-year-old male worker Jinlong considered self-discipline and obligations as valuable assets that distinguished him from other non-Christian male workers:Because you are a Christian, your behaviors must be more civil than them (non-Christian workers). Your inner life has changed, you have to live out the image of Jesus—manage your temper and control your emotional impulse. I used to often argue with the line leaders when I was unhappy. But after I converted to Christianity, I started to follow God’s teachings and I tried not to complain. It is my duty to do the work that I should do. Once you realised this, you can attain inner peace.In this sense, by constituting an alternative and transcendent manhood, Christian male workers’ masculinity and dignity therefore detaches from the logics of winners and losers under the “Dog-Eat-Dog” culture at Company A. Moreover, this psychological self-empowerment also manifests in Christian migrant workers’ construction of a civil and morally superior manhood, which distinguishes them from rebellious and aggressive non-Christian workers. For example, many Christian workers believe that they are more civil and self-disciplined than non-Christian workers, who often engage in gambling and drinking. As Lijun further explained: “Because I believe in Jesus, I am different from them (non-Christian workers). I will never talk dirty or gamble, in contrast to what wen (literary) and wu  are considered two normative models of Chinese masculinity [Both Lijun and Jinlong actually assumed a higher ground in which they felt morally superior to non-Christians. In Chinese tradition, culinity . The forWe have identified three forms of masculinities on the factory floor of Company A: (1) the hierarchical and hegemonic masculinity performed by managers who use verbal and physical violence to control workers; (2) the protested masculinity that male assembly workers utilize with rebellious and aggressive practices to defend their deprived dignity and masculinity; (3) Christian masculinity where Christian workers attempt to constitute a morally superior subject to fend off both hierarchical and protested masculinities and to reframe their experience of exploitation. A model of how these variegated masculinities influence workplace well-being is presented below in As we see in On the other hand, religious institutions and values provide a way to moderate and ameliorate workers’ psychological vulnerability inflicted by the coercive and masculine management. Religion’s moderating effects on well-being operate through creating a Christian masculinity and increasing workers endurance and resilience in the face of exploitation. Furthermore, Christianity provides the social and emotional supports for both male and female factory workers by offering them a relaxing and equal space to moderate the sense of unhappiness. These Christian spaces also foster a more equal and harmonious gender relationship that cuts against the patriarchal and heretical masculinity on the factory floor. However, this kind of self-empowerment cannot alter the material base of labor exploitation per se but rather reframes the ways factory workers make sense of exploitation. In this sense, the moderating effects of religion on workers’ well-being are conditioned by specific cultural and power relations.This paper has explored the social construction of masculinities in the workplace, and its impacts on factory workers’ psychological well-being. Then, we explored the moderating effects of religion on the constructions of masculinity and well-being. This paper has two contributions to research on masculinity and health. First, we have developed Courtenay’s theory of masculinity and health  by bringHowever, the limitations of this paper are also noticeable. First, the paper primarily focuses on male factory workers’ experiences of male leadership, and women workers’ agency and coping strategies under the militarized and masculine management have not been fully examined. Second, it cannot reflect the dramatic transformations of China’s global factories  in the past four years and how these changes impact on workers’ well-being. Third, this paper cannot cover masculinities’ influence on well-being in other industry sectors and management models. Accordingly, future research can provide quantitative and comparative studies to understand how different models of management/leadership influence workers’ health and well-being. Further, research can also extend to examining more complex intersectional identities  and their relation to health.


Dementia diseases, especially Alzheimer’s disease (AD), are of considerable importance in terms of social policy and health economics. Moreover, against the background of the current Karlsruhe judgement on the legalisation of assisted suicide, there are also questions to be asked about medical humanities in AD.Relevant literature on complementary forms of therapy and prognosis was included and discussed.Creative sociotherapeutic approaches  and validating psychotherapeutic approaches show promise for suitability and efficiency in the treatment of dementia, but in some cases still need to be scientifically tested. Biomarker-based early diagnosis of dementia diseases is increasingly becoming a subject of debate against the background of the Karlsruhe ruling.Needs-oriented and resource-enhancing approaches can make a significant contribution to improving the quality of life of people with dementia. The discussion on the issue of “assisted suicide” should include questions of the dignity and value of a life with dementia.The integrative dementia therapy model can be complemented by a religion- and spirituality-based approach. Appropriate forms of psychotherapy should be scientifically evaluated. More than five million people across Europe are affected by dementia –3, AlbatAlthough in the broader field, words such as “self-determined death” and “death with dignity” have become popular, we use the term “assisted suicide” throughout the text because its equivalent “assistierter Suizid” is the term most commonly used in Germany, whereas the concept of “euthanasia” may induce associations with Nationalsocialist murders as described below.In mid-June, four university professors presented a draft law to clearly regulate assisted suicide. In it, the legal responsibility for assisting suicide was assigned to medical decision-making. The medical ethicist Urban Wiesing says “Our proposal is appropriate for a modern, pluralist society, because it does not explicitly express any defining ethics of successful living and successful dying” .In this context, questions about medical humanities in AD arise, making it necessary to take medical-historical and ethical aspects into account.Division of Medical Humanities and Bioethics - University of Rochester Medical Center) - a development tending to restrict the essential holistic approach towards the sick individual. The integrated medical humanities have to be enhanced because “health is more than the absence of disease. It is also more than a biological phenomenon. It is inherently social, psychological, cultural and historical”  more persistent, more faithful, smell and taste still remain for a long time, like souls, remembering, waiting, hoping [...]” . This acThe more the individual living with dementia is deprived of core functions of his or her personality– beginning with orientation– the more painfully he or she is exposed to the danger of a practical loss of dignity. Basic affective-motivational and attentional systems, including positive affect/approach, fear, frustration/anger, and effortful control  represenHonor and dignity are the essential ethical and psychological attributes of an individual as a subject of highly moral behavior and creative activities for the production of material and spiritual values, including his/her self as the supreme value . Dignity is one of the most important dimensions of a human being, dignity is the result of the interaction between 3 different internal representations: „the Self, the others’ perception about the Self and the perception one’s Self with others in a social context “ . It has Art, dance and music therapy enable a healing approach to the “borderline experience” of fully recognisable human dignity  describes his grandmother, her “deranged soul”, and her patriotically moved singing of French revolutionary anthems . Music tValidation  means “strengthening”, “affirmation”, “substantiation”; the verb “validate” can also mean “to value” . The valin the arms” as in music therapy, but the “being taken by the arm” that Lind seems to favour, with such methods as simulation of reality in his “dementia villages”. However, even in advanced stages of the disease, those affected often still have a feeling for the authenticity of the person speaking to them. Three years before Sven Lind’s strategy of creating an illusory world, the medical ethicist Maartje Schermer presented a reality-based approach to people with dementia [In contrast to the German-American gerontologist Naomi Feil, whose validating approach emphasizes the dignity of the dementia patient , the psydementia , in whicdementia  of relatHowever, an up-to-date systematic review is unable to give a categorical statement on the effectiveness of SPT in treating behavioural and other psychological factors. Further valid studies are needed for this purpose . The samAnother way to alleviate loneliness and pain is to have robots, such as the lifelike interactive seal “Paro” ), read oJust like anyone else, people with dementia need interaction with their social environment as a key element of quality of life. Dementia researcher Martin Dichter et al. list family, social contacts, relationships, living environment, religious beliefs, security and enjoyment of activities as essential individual dimensions .The nursing scientist Annette Riedel emphasises the “subjectivity of the phenomenon of pain”  when assParticularly promising in this context is the world’s first “experiment in comparative ethics advice in real time”, which enables anonymous comparative analyses by ethics committees throughout Germany . This stSocially creative and psychotherapeutically validating approaches in dementia therapy should be further researched and used especially with reference to their ethical aspects. For the social and medical treatment of people suffering from dementia, the recent Karlsruhe judgement on assisted suicide could trigger developments that require scientific and medical-ethical discussion.On Ash Wednesday, 26 February, 2020 the federal constitutional court of Karlsruhe has enacted a fundamental judgment: The paragraph 217 of the penal code whereupon a person who businesslike supports the suicidal intention of another person will be punished by imprisonment up to 3 years was declared as unconstitutional.According to the President of the German Medical Association, Dr. Klaus Reinhard, the “bombshell” decision from Karlsruhe  of 26 FeIn view of the genetic tests available, this equation becomes particularly controversial. Before testing for genetic risk factors, the patient is informed about possible consequences of the medical findings. This is the case, for example, with the gene for apolipoprotein E, which can be analysed from blood serum and whose allelic variant E4 is expressed as the strongest genetic risk factor in more than half of AD patients , 52. StaIndeed it may not appropriately measure the item of concern: the international standardised registration shows a low rate of pure AD pathology; it is the combination of vascular dementia and AD that is more often present . Up to nDeutsche Huntington-Hilfe e.V. and member of the International Huntington Association (IHA), emphasises: “The doubts about the gene status no longer exist, but they are replaced by other questions” [Referring to the predictive genetic diagnosis of Huntington’s disease, which also leads to dementia, Christiane Lohkamp, member of the German National Ethics Council, former chairwoman of the charity estions” – namely The fact that – even from the medico-ethical point of view – the compass only goes in one direction, namely that of plurality, like described in the introduction, does not seem helpful. One of the tasks of medical ethics is to work out basic ideas about “successful” living and dying in our modern society. The more a society moves away from religious, pastoral and philosophical positions on the question of what is good living and dying, the more it needs concrete and differentiated guidance from the medical-ethical side. A basic problem of anticipatory provisions should also be taken into account, as the case of Walter Jens (1923–2013) notably demonstrates: The rhetoric professor had consistently advocated a self-determined death and the legalisation of “assisted suicide”, but distanced himself from his former positions by his living will after the onset of his dementia in 2004 . AccordiFine arts, music and physical movement, especially dance, can be used in many ways with personal caregivers as well as psychotherapeutically to improve the quality of life of people with dementia. Validating procedures in communicating with people with dementia require high levels of empathy, patience and specialist training. The staging of “illusory worlds” can contribute to better the quality of life of gerontopsychiatric patients, but it requires great skill and critical attention from an ethical perspective. Robot-supported help against loneliness and for pain relief is well accepted by patients, according to previous findings . SensoryIn order to find individually appropriate answers to the “other questions” mentioned above , an int


Yoga is becoming an increasingly popular holistic approach in the West to manage long-term health conditions. This study presents the evaluation of a pilot yoga intervention, Yoga4Health, that was developed for the NHS to be socially prescribed to patients at risk of developing specific health conditions . The aim of this qualitative study was to explore service users’ experiences of Yoga4Health and the acceptability of the programme.n = 22); 3. interviews with yoga teachers delivering Yoga4Health (n = 7). Each data source was analysed thematically, then findings were combined.Qualitative data were collected from three sources: 1. Open-ended questions on questionnaires completed by services users at three different time-points ; 2. Interviews and focus groups with a subset of participants (n = 240), 82.5% were female, 50% White, with a mean age of 53 (range 23–82) years. Baseline questionnaires revealed key motivations to attend Yoga4Health were to improve psychological and physical health, and believing Yoga4Health would be accessible for people with their health condition. Post-intervention, participants reported a range of benefits across psychological, physical and social domains from Yoga4Health. Increased confidence in self-management of health was also reported, and a number of participants described making positive lifestyle changes after attending the programme. Unanticipated benefits of yoga emerged for participants, such as enjoyment and social connectedness, which facilitated ongoing attendance and practice. Also key to facilitating practice (during and after the intervention) were suitability of the classes for those with health conditions, practising with a group and qualities of the yoga teacher. Home practice was supported by course materials , as well as the teaching of techniques for everyday application that offered immediate benefits, such as breathing practices. Follow-up questionnaires revealed a key challenge was continuation of practice once the intervention had finished, with the structure of a class important in supporting practice.Of participants completing baseline questionnaires (Yoga4Health was a highly acceptable intervention to services users, which brought a range of biopsychosocial improvements, suggesting yoga is an appropriate intervention to offer on social prescription.The online version contains supplementary material available at 10.1186/s12906-022-03514-3. Social prescribing is a means of enabling general practitioners and other primary healthcare professionals to formally refer patients to a range of non-clinical community services. Its aim is to support people in a holistic way, recognising that health is influenced by a range of social, economic and environmental factors . PioneerYoga is a holistic mind-body practice originating from India but increasingly recognized as a therapeutic intervention to prevent and manage health conditions . It has Systematic reviews have reported the potential effects of yoga interventions on cardiovascular risk factors in the general population and high risk groups  , 14. ComYoga has been found to have robust effects on poor mental wellbeing – notably, by decreasing anxiety and depression , 22, as As well as offering physical and mental health benefits, yoga has been associated with increased social connectedness and has been advocated for populations at risk of social isolation, such as the elderly, or those who are bereaved or have depression , 28. A sYoga interventions, which typically include weekly or bi-weekly instructor led group classes for 8–12 weeks, have been found to be acceptable for a range of populations, including those with depression , type 2 This study reports on qualitative evaluation findings exploring participants’ experiences of a pilot yoga intervention, called Yoga4Health. Yoga4Health was developed for the NHS to be socially prescribed to patients at risk of developing specific health conditions, including those at risk of cardiovascular disease or pre-diabetes, with mild to moderate anxiety or depression, or who are socially isolated. It is important to conduct early phase qualitative studies of interventions to assess acceptability to services users, optimise their experiences and support uptake upon implementation in the community . Whilst Frameworks to guide the development of complex interventions in healthcare advocate a mixed-methods approach to evaluate the feasibility and acceptability of an intervention during its pilot phase , 37. HerIn total, 365 service users were booked onto the Yoga4Health programme and 279 (76%) attended at least one session with 240 (86%) completing a baseline questionnaire. The programme was advertised with leaflets through general practice, community organisations  and outreach. The main method of referral was from mass text message campaigns inviting targeted patients who met the eligibility criteria, which were sent by the provider (Thrive Tribe) from general practices across the clinical commission group area. Patients either self-referred to the programme or were referred by their general practitioner. Each interested patient received a telephone call to discuss the intervention and evaluation and to book a place on a course if they met the intervention inclusion criteria, which included: mild to moderate anxiety or depression (self-reported), social isolation (self-reported), risk factors for cardiovascular disease (Q risk over 10%) or pre-diabetes,  to invite to interview/focus groups Other participants said that they had little interest in exercise, but thought yoga might be an enjoyable way to be active. For others, the appeal related to the mind-body approach of yoga, or the belief that Yoga4Health would teach yoga ‘properly’, as opposed to the perceptions of gym-based yoga.n = 171), virtually all participants provided responses regarding benefits they had experienced and provided examples of tangible and concrete lifestyle changes they had made. These benefits were echoed in interviews/focus groups and by participants who completed the 3-month follow up questionnaire. Responses regarding benefits were organised into four sub-themes: 1) psychological benefits, 2) physical health benefits, 3) social benefits, and 4) self-management of health and well-being.Of those who completed the post-intervention questionnaire  and thinking such things as, actually, what a lovely group of people.” Yoga teachers also observed social changes in the group. For example, they told how the groups became more comfortable with one another at each class, by becoming more talkative and sharing their personal experiences. One yoga teacher described how relationships began to form between the members of the group, as well as between the service users and the teacher:“At the beginning the first week everyone is very quiet, no one wants to share much … but then you see that they open up so much and they like to share and so it’s wonderful to see this social bit of this yoga programme, how people get more and more comfortable.” [Yoga teacher 1]Participants reported feeling more knowledgeable and in control of their health, with greater confidence and skills to manage their health and wellbeing. For example, one participant described dealing with medical issues that she had previously put off, others discussed making more “positive choices” regarding their health. Health was therefore given greater priority, with some discussing how yoga made them realise the importance of self-care and described how it felt good to do something for themselves, especially for those who spent so much time caring for others, such as children or relatives. The Yoga4Health programme encouraged participants to take “time out” or “make time” for themselves. Consequently, after the course, some participants felt more able and confident to prioritise their own health.“What it made me do was reassess my life and how important actually I am, and how I need to give myself something … I reassessed my life basically, and how important it was for me to find time for me to do stuff. To be a bit more autonomous in my own healthcare. Things that I’ve been niggling, like I’ve had a pain in my hip for quite a long time and I’ve never gone to the doctor with it because I can’t face the battle … ” “The main benefit has been the recognition that I can improve my health and mostly my mental health by using mindfulness, yoga, and meditation to keep me away from the GP.” Many participants described changes they had made to their lifestyle as a result of yoga. These lifestyle changes overlapped and interacted with the sub-themes above of improved physical and psychological health, and are indicative of improved self-management and agency over health. For example, nearly a quarter of participants who responded to the post-intervention questionnaire described the positive effects of the Yoga4Health programme on their diet and eating habits, which was further elaborated on within the interviews. Participants described an improved awareness of their bodies as a result of yoga, which in turn, drew their attention to their health and consequently, their diet and related habits.“There’s no point in going to yoga and then going and having spaghetti bolognese and three cakes and so it made you more aware of your body and what you were eating and how you were living. I genuinely believe that.” Participants talked about how they became more aware of their eating habits and were able to change to healthier habits by reducing consumption of unhealthy food and increasing fruit and vegetable intake. Since practising yoga was seen as beneficial for health, unhealthy eating was seen to undermine practice.“I'm conscious of the food I consume, and am eating more fruit and vegetables in my diet”. Other participants described an overall increase in their levels of physical activity, including increases in yoga, walking, or running; where participants were “more active than before” or “more willing to go out jogging”. Some described how they had continued to practice yoga to maintain the physical health benefits experienced:“I’ve exercised more and now look forward to it. I’m also walking more”. How much services users enjoyed the intervention was key to engagement, where users did not enjoy the course or yoga, they were less likely to undertake home practice or continue to practise once the course was completed. However, the majority reported high levels of enjoyment, describing the programme as “enjoyable”, “useful” and even “life-changing”. Enjoyment appeared to be influenced by a number of factors including group dynamics, yoga teacher qualities, inclusivity of the class and practical issues, which are described in more detail below.“I have found the course to be a unique and powerful experience. I was really surprised at how much I enjoyed it and looked forward to the sessions.” Experiencing benefits of yoga practice  was key to engagement, particularly participants’ continued practice of yoga once the course had finished. Participants wanted to sustain the improvements to their “mood”, “energy levels”, “body shape” and the “sense of calm” they had experienced.“I know how beneficial practicing yoga has been/is for me so that motivates me to continue to practice.” In some cases, class venue was found to negatively impact on enjoyment of the programme; several participants complained that the community venues were too cold to practice, especially for those who suffered with pain and related ailments. For example, one service user told how she was in “great pain … which was dreadful” during the classes due to the low temperature of the venue caused by “a window that was open that wouldn’t close” [focus group 2]. This issue deterred some from attending.How well the class aligned with participants needs was key to engagement. A few participants felt that the classes were not a ‘good fit’ for them, some reported finding yoga “demanding” or “difficult”. In contrast, one participant found it repetitive and unchallenging (with a few others reporting they felt this way towards the end of the course), others did not enjoy the relaxation at the end of the class. The vast majority, however, felt that the course was for people of their ability, which had been a key motivator for attending the course. The provision of modifications and alternative practices were important enablers, and meant that participants felt able to try even challenging postures, with teachers making “everyone feel included”.“The teachers made real good efforts to be very inclusive of everybody and bend over backwards to fit into everybody’s needs” Timing and location of class were also important. Yoga4Health organisers arranged classes in local community venues and at times that they thought would be most accessible for participants. Nevertheless, a small number of participants could not attend due to scheduling constraints, for example not being able to get time off work to attend. Some recommended having a break in the middle of the course, whilst others suggested a second weekly session or a class recording for those who needed to miss a session. Others, highlighted the sheer time commitment needed from them as challenging in comparison to other methods for managing health and wellbeing:“The time commitment compared to popping a pill is a challenge and it is very hard to commit so much time in an already busy life.” Participants highlighted their enjoyment of the group dynamic both for its practical and social encouragement. The vast majority of participants reported a preference for practising yoga in a group compared to practising alone at home. Classes provided several advantages over home practice: participants valued the protected time to practice yoga without distractions, often feeling that they lacked the discipline and time to practise alone at home. Others felt motivated by wanting to ‘keep up’ with others in class. Unlike home practice, the class provided the opportunity to ask questions and have yoga postures corrected whilst receiving encouragement from the teacher. Moreover, participants enjoyed hearing about others’ experiences of yoga, as well as getting to know their peers on a personal level.“It was nice to sit around and just hear people’s experiences and share that, yeah. And I have a tendency to want to talk a lot, and I found myself just sitting back and listening, but that was the effect of being in the yoga class. It was interesting to hear people’s different experiences … and to get to know them a little bit better.” Losing the structure provided by a group class at the end of the programme therefore created challenges for the continuation of yoga practice. In addition to the above factors, some participants felt that without regular classes they simply “fell out of the habit” of practising yoga. However, for others the course kick started a habit which they were able to continue. In addition, the relationships formed within the Yoga4Health course encouraged continuation of practice within their already established social networks. For instance, some participants found new classes to go to together, whilst others practiced yoga at home together.“The enthusiasm of class members- we now meet every Tuesday evening and practice yoga together.” Our findings highlight that being able to find another suitable class was an important factor for whether or not participants continued to practice once Yoga4Health had finished. Classes needed to be at an accessible location, time and cost, as well as suiting the participants’ ability; there was a perception that local classes would not meet the needs of individuals with complex needs. Recommendations for improvement included additional Yoga4Health sessions and one teacher said they would have liked the ability to provide GPs with feedback regarding participant needs.“[I] found it difficult to find a class appropriate to my needs. I have a knee injury. Most classes don’t cater for people with mobility problems.” Having skilled yoga teachers providing Yoga4Health was key to achieving the enjoyment, adaptations, inclusivity and positive social environments described above. Participants valued and praised the skills and qualities of their teacher, describing teachers as “supportive”, “caring”, “dedicated”, “encouraging”, and “knowledgeable”, these qualities also appeared to facilitate adherence to the programme:“It was very easy to follow, because the instruction was so good … There are people who can teach and there are people who can’t, and she just had that outgoing, friendly, interested in her class, concerned, good at demonstrations. Yeah, just good teaching is really important, and I think she created that atmosphere of togetherness … While we were there together, I had a feeling of it was quite a unit. And that was teacher creating that.” .Yoga teachers acknowledged that building a relationship with the group was important for both their own and participants’ enjoyment. Rapport was built in various ways, for example, one teacher talked about using humour in the class when participants struggled to achieve certain postures. Communication with participants and being available were also identified as strategies to build the teacher-practitioner relationship. This also helped yoga teachers to adapt the script and/or postures and exercises to suit the individual needs of the group. This skill appeared important in engendering an inclusive approach within classes.Participants often reported the course materials  to be a facilitating factor for home practice and subsequent maintenance of practice post-intervention. Irrespective of resource preferences, each offered the benefit of enabling participants to recap what they had learned in class, progress in their yoga postures outside of class, and enabled them to catch up if they missed a class. Although some felt that the quality of presentation of these resources could be improved e.g. sound quality on videos.Participant A: Yes, because the video’s OK. And you could pause it and have another look, so that video was really, I think that was the best thing, having those videos.Interviewer: Did anyone else use the videos or manuals in the evening to recap what they learned?Participant B: I choose the manual, just because I wanted to, because I was doing the stretching and that, I wanted to make sure, like, I was doing my warriors properly. This is the first study to report on patient experiences, feasibility and acceptability of a novel multi-component yoga intervention on social prescription for several high-risk patient groups. The biopsychosocial benefits reported by participants and high levels of enjoyment, highlight the potential of this type of programme on social prescription for supporting at-risk groups in the community. Perceived benefits spanned psychological, physical and social domains, with participants continuing to report benefits at 3 months post intervention. Improved self-management skills, along with a greater awareness and prioritisation of self-care were also notable, with a number of participants reporting positive lifestyle changes after attending classes. Whilst motivation to initially attend often centred around a desire to improve physical or mental health, unanticipated benefits emerged for participants, such as enjoyment and a sense of social connection, which further supported ongoing attendance and practice. The qualities of the yoga teacher, access to a suitable class, and other practical considerations were also important for ongoing engagement and practice (during and after the intervention). Home practice was supported by Yoga4Health course materials, as well as learning practical techniques (such as breathing exercises) that could be easily applied in everyday life with immediate benefit. A key challenge was continuation of practice once the support and structure of the group classes had finished, highlighting the importance of finding suitable classes for these patient groups in terms of cost, location, timing, and ability level.The improved mental and physical health reported by study participants are consistent with the significant literature citing these benefits for our patient groups , 22, 46.The social benefits reported in the current study are supported by a small but growing number of studies that have investigated the effects of yoga on social connection, in both the general population and patient groups. Practising yoga with a group can provide opportunities to meet  others and engender a sense of social connectedness , 28, 50,Of key importance for this study was the finding that participants reported improved self-management skills including the knowledge, skills and confidence needed to manage one’s health, suggesting improved patient activation among our participants . PatientFor those promoting yoga interventions, it is worth noting that studies of yoga and complementary therapies have demonstrated that reasons for continuing practice often differ from, or expand on, reasons for initiating it , 31, 57.Our findings showed that Yoga4Health appeared to be acceptable to the majority of patients; the ‘enjoyability’ of yoga was important here, and this finding is reflected by other research , 58, 59.Participants reported very few negative reactions or problems related to practice, however, it is important to note that a small number of participants reported triggering of anxiety-related symptoms. The complex needs and abilities of this patient group suggest the importance of highly trained yoga teachers with experience of working with patient populations. Indeed, the Yoga4Health programme was designed by yoga therapists, and delivered by experienced teachers who underwent specific training and received ongoing support. In acknowledgement of the importance of the teacher’s role in managing patients’ complex needs, the Yoga4Health teacher training course has now been increased from 35 to 60 h and has been accredited by the Personalised Care Institute.Finding time for a 2-h class did act as a barrier to attendance for some. Time barriers are common for lifestyle interventions , neverthFor some participants attending Yoga4Health kickstarted a practice or ‘habit’ that they were able to continue after the intervention ended: some found new classes to attend, others used the social connections they had formed and practised at home or attended new classes together. Whilst some participants used their home practice materials to continue their practice, our findings indicated that many participants benefitted from attending a class to develop and support regular ongoing practice. As well as the aforementioned benefits of classes, attending a class also meant that there was protected time for practice, supporting habit formation . When soThe diverse sample and triangulation of three qualitative methods plus both participant’s and yoga teacher’s perspectives are strengths of the current study , 68. AddYoga4Health was an acceptable intervention to patients, which was perceived to bring a wide range of biopsychosocial improvements, including physical and mental health benefits, social connectedness, patient activation and positive lifestyle changes. Taken together these factors suggest that yoga is an appropriate intervention to offer on social prescription, given that social prescribing aims to support patients (particularly those with long-term conditions) in a holistic way. Quantitative studies including clinical trials, should now be used to explore this intervention further, our findings can be used to guide the design of such research. Future research may also wish to examine this model of delivering yoga as a health intervention for other conditions, as well as how to support patients to continue their practice in order to promote ongoing self-management of health and wellbeing.Additional file 1.Additional file 2.Additional file 3.Additional file 4.