Chronic obstructive pulmonary disease (COPD) is associated with multiple psychosocial and behavioral factors. Prior research suggests that mind-body interventions may support the development and maintenance of healthy behaviors and improve health-related quality-of-life in such patients. We sought to qualitatively explore cognitive, psychosocial, and behavioral changes in patients with COPD who participated in two different mind-body interventions compared to an education control.
We analyzed semi-structured qualitative exit interviews from a prospective, randomized pilot trial (N = 123) investigating 12-weeks of Tai Chi (TC) vs. mind-body breathing (MBB) vs. education (EDU) control in patients with moderate-severe COPD. TC involved traditional movements, that integrate meditative breathing, while MBB focused mainly on meditative breathing techniques alone. Interviews were audio-recorded and transcribed verbatim. Qualitative analysis of randomly selected transcripts was performed by two independent reviewers using an iterative process to identify emergent themes informed by grounded theory methods until thematic saturation was reached.
A total of 66 transcripts were reviewed (N = 22 TC, N = 22 MBB, N = 22 EDU). Participants were mean age = 68.1 years, GOLD Stage = 2.3, baseline FEV11 percent predicted mean (SD): 58% (13.4), 42.4% female. We identified six frequently mentioned themes: 1) overall awareness and understanding, 2) self-care knowledge, skills and behaviors, 3) behavior-related neurocognitive concepts, 4) physical function, 5) psychological well-being, and 6) social support/social function. Compared to EDU, more participants in TC and MBB noted improvements in awareness of self and the mind-body connection (e.g., body and breath awareness), knowledge of breathing techniques and integration of self-care skills with daily activities, self-efficacy for symptom management (particularly managing anxiety and dyspnea), acceptance of disease, physical function improvements (e.g., endurance, dyspnea, fatigue), and psychological well-being (particularly relaxation, emotion regulation and decreased reactivity). Compared to MBB, those in TC shared more intention to continue with self-care behaviors, physical activity self-efficacy, and improved flexibility. All three groups, including EDU, noted increased social support and knowledge of disease. Those in EDU, however, had fewer mentions of processes related to behavior change, and less concrete changes in neurocognitive, psychological, and physical function domains.
Mind-body interventions including meditative breathing may impact behavior-related neurocognitive and emotional factors that improve self-care management and support positive behavioral changes in patients with COPD.
This trial is registered in Clinical Trials.gov, ID number NCT01551953.
Citation: Gilliam EA, Cheung T, Kraemer K, Litrownik D, Wayne PM, Moy ML, et al. (2021) The impact of Tai Chi and mind-body breathing in COPD: Insights from a qualitative sub-study of a randomized controlled trial. PLoS ONE 16(4): e0249263. https://doi.org/10.1371/journal.pone.0249263
Editor: Adam T. Perzynski, The MetroHealth System and Case Western Reserve University, UNITED STATES
Received: June 17, 2020; Accepted: March 12, 2021; Published: April 8, 2021
This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Data Availability: Data cannot be shared publicly due to potentially identifying information and restrictions imposed by the Deaconess Medical Center Committee on Clinical Investigation (IRB). Reasonable requests for access to de-identified transcript data can be directed to the Principal Investigator, Dr. Gloria Yeh (617-754-1419), the Beth Israel Deaconess Medical Center Committee on Clinical Investigation (IRB) at 617-975-8511, or Angela Lavoie, RN, CIP, CCRP is the Director of the Human Research Protection Program (CCI/IRB) at email@example.com.
Funding: This study was supported by an award (R01AT005436) from the National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health (NIH) (https://www.nccih.nih.gov/). Dr. Yeh was supported by K24AT009465 from the National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health (NIH) (https://www.nccih.nih.gov/). Dr. Wayne was supported by K24AT009282 from the National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health (NIH) (https://www.nccih.nih.gov/). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Chronic obstructive pulmonary disease (COPD) is a syndrome of progressive airflow limitation  resulting in breathlessness and limitations in physical function [1, 2] and is a major cause of morbidity and mortality both in the US and worldwide. As COPD is a complex chronic illness, the importance of the biopsychosocial model is increasingly recognized, and current management guidelines emphasize a multimodal approach that holistically addresses the patient experience. It is well-known that psychosocial factors such as anxiety, depression, fatigue, and social isolation have an important role in clinical functioning and well-being [3–8]. Prior research suggests that mind-body interventions may support the development and maintenance of healthy behaviors and improve health related quality of life (HRQL).
Integrative mind-body programs, such as Tai Chi, have been explored for COPD management as they may impact relevant physiological and psychosocial pathways. Tai Chi incorporates aerobic, strength, and balance training with breathing techniques, mindfulness, and focused internal awareness [9–11]. Previous research [12–16] has suggested that Tai Chi and similar mind-body behavioral interventions may have beneficial effects in COPD patients on HRQL, symptoms of anxiety and depression, and physiological measures like pulmonary function and exercise capacity [17–21].
There has also been a growing literature supporting mind-body interventions and positive behavior change. Mind-body interventions, including Tai Chi, have been shown to improve key processes implicated in health behavior change, such as self-efficacy, emotion regulation, and executive functioning [22–24]. Improvements in these processes may, in turn, lead to downstream improvements in health behavior change . Indeed, although there is limited work in Tai Chi specifically, extant work suggests that mind-body interventions (e.g., mindfulness interventions) may improve healthy behaviors, such as physical activity, smoking cessation, and adherence to medical regimens .
One component of Tai Chi with particular relevance for the COPD population is mind-body breathing. Mind-body breathing strategies foster an interoceptive  awareness of somatic and psychological processes associated with breath, and provide a tool for focused mindful attention [28, 29]. Often, mind-body breathing can also include a purposeful slow, deep breathing that encourages utilization of full lung capacity and complete exhalation. Slow breathing patterns can positively impact both physiological and psychological health outcomes, including heart rate variability, blood pressure, mood, and disease related quality of life [30–33] in both COPD and non-COPD populations . The extent to which mind-body breathing is beneficial, in isolation from the multimodal Tai Chi intervention, is not well understood. Similarly, the impact of Tai Chi and mind-body breathing on behavior change is understudied.
Mixed method approaches that utilize qualitative in addition to traditional quantitative analysis are increasingly recognized as valuable for exploring the complexities of patient experiences and behaviors and contextualizing quantitative outcomes [35, 36]. Qualitative research, which can descriptively describe the experiences of a sample and capture themes not found by quantitative instruments, are often used to compliment and inform quantitative results and generate hypotheses. We conducted a pilot  feasibility randomized controlled trial examining the effects of Tai Chi and a mind-body breathing intervention (adapted from the Tai Chi protocol) on exercise capacity and HRQL in individuals with COPD. In the context of this trial, we sought to qualitatively characterize patient experiences, better understand emergent patient-centered outcomes, and explore behavioral changes in the two intervention groups compared to an education control group.
Quantitative parent study
The parent study  (trial registration number NCT01551953) was a prospective, randomized controlled trial investigating 12-weeks of Tai Chi (TC) vs. education (EDU) control vs. a third exploratory arm of mind-body breathing (MBB). This study was approved by the Beth Israel Deaconess Medical Center Institutional Review Board (protocol #1020P-000412). Written informed consent was obtained from all participants. In brief, we randomized 123 participants with moderate to severe COPD recruited from outpatient academic medical clinics in the Boston area in a 2:1:1 ratio to 12 weeks of twice weekly TC (N = 61), EDU (N = 31), or MBB (N = 31). See S1 Appendix for the Consort Flow Diagram. We included participants with moderate-severe COPD as defined by (1) GOLD (Global Obstructive Lung Disease) stage 2 or 3 or 4 with symptoms of dyspnea (either FEV1 ≤ 80% and FEV1/FVC <0.70, or CT evidence of emphysema) and (2) age ≥ 40 years. We excluded those with: 1) respiratory failure or GOLD stage 4 who were unable to perform a 6 minute walk test (6MWT); 2) COPD exacerbation requiring steroids, antibiotics, ED visit or hospitalization within the past 2 weeks; 3) planned thoracic surgery within the next 3 months; 4) hypoxemia on 6MWT or cardiopulmonary exercise test (oxygen saturation < 88% on supplemental oxygen); 5) inability to ambulate due to vascular or other neuromuscular conditions that would preclude a 6MWT; 6) clinical signs of unstable cardiovascular disease (i.e., chest pain on walk test or EKG changes on cardiopulmonary exercise test); 7) severe cognitive dysfunction (Mini-Mental Status Exam ≤ 24); 8) non-English speaking; 9) current active participation in pulmonary rehabilitation program or current regular practice of Tai Chi. The first study enrollment was 8/29/2011 and the last data collection date was 3/2/2016.
The TC intervention, previously designed for an older, physically limited population, consisted of five Tai Chi movements based on the traditional Cheng Man-Ch’ing’s Yang-style short form [9, 38, 39]. Four breathing techniques were also integrated: 1) “Renewing the body with breath”, which emphasizes relaxation, body and breath awareness, and imagery to systematically scan the whole body and release tension; 2) “Mindful Breathing,” which emphasizes mental focus, interoception, awareness of the mechanics of breathing; 3) “Dan Tien Breathing” or “Ocean Breathing”, which combines diaphragmatic breathing with arm movements and mental imagery; 4) 4) “Balloon Breathing,” which extends the previous practice by extending the period of exhalation. Each class began with a series of warm-ups.
The MBB intervention was designed to emphasize the mind-body breathing component of the TC group but exclude the traditional movements. The same five breathing techniques as taught in TC made up the main portion of each MBB class. Practice of the breathing techniques was integrated into simulated activities of daily living (e.g., walking, folding laundry, washing dishes).
The education EDU control was designed to replicate the social interaction of the intervention arms, but without any physical activity, breathing exercise, or mind-body components. Classes for this group focused on the presentation and discussion of educational material from the American College of Chest Physicians, the American Thoracic Society, and the Global Obstructive Lung Disease Patient Guide. Educational modules included: anatomy of the lungs, COPD, managing COPD symptoms, smoking cessation, diagnostic tests, understanding COPD meds, managing acute exacerbations, managing stress, exercise, nutrition, sleep, mental health, oxygen therapy, surgical options, pulmonary rehabilitation, and advance care planning. Time was spent with both didactic as well as informal group discussion moderated by the instructor.
This education content (printed slides) was also provided to patients in TC and MBB groups, although not presented and discussed as in EDU.
Semi-structured interviews were conducted with all participants at the end of the 12-week intervention. Open ended questions focused on the participant’s experience with the intervention and any perceived changes in physical and mental wellbeing or functioning as a result of the study (S2 Appendix). The same study member (DL), who was experienced with qualitative methods, performed all interviews. Interviews were audio recorded and transcribed verbatim. Our goal in analyzing these transcripts was to provide qualitative insight and generate hypotheses regarding pathways by which mind-body therapies may impact people with COPD.
Qualitative analysis was performed on a randomly selected subset of transcripts from each study group by two independent reviewers (EG, TC) using an iterative process to identify and explore emergent themes informed by grounded theory methods . An initial sample of 15 transcripts, 5 from each of the three study groups, was analyzed and discussed among the authors, leading to the development of a preliminary list of themes and subthemes. This list was expanded and revised when coding subsequent transcripts, with analysis continuing in batches of 5–6 per group to the point of thematic saturation .
Extracted information included broad themes that were identified de novo, nuanced details or sub-themes that emerged, and relevant, representative quotes pertaining to each theme. The number of participants within each group who mentioned a given theme during their interview was also noted. Categories were not meant to be completely mutually exclusive. When a specific statement fit into more than one category, it was assigned by consensus to the single theme it most specifically represented. A single quote could contain multiple statements. Categorization of themes, and further synthesis and analysis proceeded through multiple collaborative discussions.
We then qualitatively described, compared, and contrasted the groups with respect to the occurrence of themes and number of participants endorsing each theme. Bias and validity were addressed through random selection of transcripts for analysis, having each transcript independently coded by two authors who had not taken part in the original interviews, having a third author (GY) act as arbiter in cases where there was disagreement, utilizing a multi-disciplinary analysis team, and documenting all analysis and decision points in detail.
A total of 66 qualitative transcripts, 22 from each group, underwent review, coding, and analysis before thematic saturation was reached. The qualitative sample represented 76% of the total transcripts from the parent study. Baseline characteristics of this sub-population (N = 66) included 42.4% female, mean age = 68.1 years, GOLD Stage = 2.3, baseline FEV1 percent predicted = 58% and were generally representative of the overall study population. Additional demographic data of the total sample is published elsewhere .
Six broad themes emerged from the qualitative interviews: 1) overall awareness and understanding, 2) self-care knowledge, skills, and behaviors, 3) behavior-related neurocognitive concepts, 4) physical function, 5) psychological wellbeing, and 6) social support/social function. Within each domain, several related themes or sub-themes emerged. To aid in qualitative comparison Table 1 shows the percentage of individuals within each group who endorsed a given theme at least once during their interview. Boxes 1–6 provide representative quotes from each of the main domains.
Box 1. Representative quotes related to ‘overall awareness and understanding’
Box 2. Representative quotes related to specific self-care knowledge, skills, and behaviors
Box 3. Representative quotes related to behavior-related neurocognitive/psychological concepts
Box 4. Representative quotes related to physical function
Box 5. Representative quotes related to psychological wellbeing
Box 6. Representative quotes related to social support and social function
Overall awareness and understanding
Participants expressed being more conscious of, thinking more often about, or having an improved understanding of themselves, their body, their disease, and the mind-body connection. In the TC and MBB intervention groups a majority of participants expressed increased awareness Of Self, a theme which including expressing attention to their body, breathing patterns, movement and posture, and the relationship of these to other symptoms.
Across all three groups participants expressed a new or greater understanding Of Disease. This included an improved understanding basic respiratory physiology and function, the effects of COPD on the lungs, and the disease’s long-term prognosis.
Not surprisingly, only those patients in the TC and MBB intervention groups spoke about the mind-body connection and how it might help COPD symptoms. Both the TC and MBB groups commonly expressed this as an understanding of the integration of mind and body, that this was an important principle of the mind-body interventions taught that is different from other exercise, and that mental health and emotions are linked to and can impact physical well-being.
Specific self-care knowledge, skills, and behaviors
Across all groups participants commonly discussed how the interventions influenced their knowledge, beliefs, and behaviors around self-care management. In particular, knowledge of breathing techniques and utilization and integration of self-care skills into daily life was more often reported in the intervention groups than the EDU control. Not surprisingly, those in MBB mentioned breathing most often, followed by TC. Another commonly mentioned disease management or self-care strategy was learning how to pace oneself to increase stamina over time.
Beyond knowledge of various self-care strategies, participants discussed specific situations in their daily lives where they were able to utilize behavioral skills learned in class, call upon these skills as needed, and began to incorporate them into their everyday lives. This theme was more prevalent in the two intervention groups.
Participants in all groups mentioned doing physical activities, such as walking, more often than previously. Some participants, primarily in TC and MBB, discussed increased awareness and engagement in healthy behaviors such as smoking less, eating healthier, and improved medication compliance.
Behavior-related neurocognitive/psychological concepts
Within this domain, locus of control and self-efficacy were common themes that notably occurred more often among TC and MBB participants. Locus of control is the degree in which one perceives control over the outcome of events in one’s life, as opposed to external forces beyond one’s control . Participants in the TC and MBB groups expressed having an internal locus of control for management of their COPD, including control over health-related outcomes. Participants often used similar language in describing increased locus of control and this centered around gaining a new “tool,” they could use to manage symptoms.
Related to locus of control, patients in TC and MBB also expressed increased self-efficacy, or self-confidence or belief in one’s capabilities for specific tasks. We noted mentions of self-efficacy specifically around symptom management, managing anxiety and breathlessness, and engaging in physical activity. In particular, those in TC and MBB mentioned confidence in intervening on anxiety should they feel shortness of breath so that further anxiety/breathlessness did not escalate and further worsen symptoms. Self-efficacy for physical activity was also mentioned slightly more than other groups.
Patients also shared a range of themes related to acceptance of their disease and the limitations or challenges it created, with such expressions occurring most often in TC. Patients often shared that they felt such acceptance helped them adapt, or let go of negative feelings about having COPD.
Another theme that was most prevalent among TC participants was explicit expression of intention to continue physical activity or other management of their disease. Many statements expressed the intention to continue with Tai Chi.
Patients in the TC and MBB intervention groups shared a variety of perceived improvements in their physical wellbeing, especially ease in performing specific activities, more energy, improved breathing, and a reduced need for rescue medications to manage their symptoms.
Participants in both intervention groups reported a range of emotional improvements as a result of the study. One prominent theme was characterized by emotion regulation, and being less emotionally reactive or volatile, and more able to manage strong emotions in perspective. Participants provided specific examples of stressful events they felt they had handled more successfully than they might have in the past.
Both intervention groups also reported experiencing less emotional distress—including feelings of stress, sadness, and anxiety, and an improved outlook on the future. Expressions of appreciation for oneself, for others, and for nature, emerged more often in TC. Increased relaxation was mentioned by a significant majority of intervention participants. Intervention participants spoke of relaxation both during and immediately after classes, and of a general sense of greater relaxation in their lives.
Social support and social function
Patients shared a variety of social benefits from their participation, both during the classes themselves and more broadly. These themes were seen across all three groups. Participants mentioned a benefit from seeing others with the same disease, either as motivation to be more active in their self-care, or because it let them see the way others coped. Participants also expressed the value of sharing a difficult experience with their classmates or experiencing improved social engagement outside of class. Those in all groups, especially EDU, reported having shared knowledge and information about COPD together with their classmates. Feelings of increased social support were primarily connected to time spent in the classes. However, some patients mentioned feeling more socially engaged outside of class, or more able to fulfill important social and familial roles, such as husband or grandparent, often tied to positive changes in other areas, such as increased energy or improved emotional regulation.
The aim of the current study was to qualitatively assess the impact of Tai Chi, mind-body breathing, and an education control in a pilot RCT among individuals with COPD. Several important domains emerged, including 1) overall awareness and understanding of oneself and disease, 2) self-care knowledge, skills, and behaviors, 3) behavior-related neurocognitive concepts, 4) physical function, 5) psychological well-being, and 6) social support and function. Participants in both the TC and MBB interventions, but not the education control group, endorsed many themes within each domain at similar rates, including improved internal locus of control and self-efficacy towards managing anxiety and dyspnea, greater emotion regulation and decreased reactivity, less emotional distress, improved physical function, and valuing social interactions within the program and in their personal network. However, compared to the MBB group, more participants in the TC group reported greater intentions to engage in self-care behaviors, particularly physical activity, and greater self-efficacy for physical activity. Those in education only endorsed increased knowledge and management of disease. Taken together, these findings highlight 1) the impact of mind-body interventions on key health behavior change processes, and 2) the need to better understand the effects of different mind-body interventions for COPD, including the potential added benefits of integrating physical activity.
Recently, the Science of Behavior Change, a NIH Common Fund, identified three higher-order mechanistic pathways for behavior change, including self-regulation, stress reactivity/resilience, and interpersonal/social processes [25, 43]. These themes emerged in both the TC and MBB groups, with some important distinctions, but not the education group. For example, intention, or specific plans about how behavior change will occur, has been identified as a necessary self-regulatory process in health behavior change models, such as the theory of planned behavior and the transtheoretical model [16, 44, 45]. In our study, half of the participants in TC, compared to few in the MBB group, endorsed an intention to continue self-care behaviors, particularly physical activity. This finding supports a hypothesis that a multimodal intervention, which combines mind-body breathing and physical movement (i.e., Tai Chi), may offer advantages over mind-body breathing alone (i.e., a single component of Tai Chi) in regards to increasing physical activity and other self-care behaviors.
Self-efficacy is another important self-regulatory health behavior change process that was frequently endorsed by both the TC and MBB groups. Intervention participants expressed similar improvements for self-efficacy related to symptom and anxiety management. However, more participants in the TC group endorsed increased self-efficacy for engaging in physical activity, specifically. Given the similar levels of improvement between the intervention groups for self-efficacy in other areas, it seems possible that the integration of meditation, breathing, and physical activity, which is central to the practice of Tai Chi, may increase confidence in one’s ability to engage in physical activity. These findings support prior studies of Tai Chi in other chronic cardiopulmonary conditions that suggest a favorable impact on exercise self-efficacy [46, 47].
Emotion regulation, or one’s ability to modulate affective states, has also been implicated as a self-regulatory process key to health behavior change . Strikingly, more than half of participants in the TC and MBB groups reported improvements in emotion regulation, while this theme was entirely absent among the EDU group. At least one prior study in COPD found that Tai Chi may have a positive effect on emotional regulation . Together, these findings suggest that both TC and MBB alone enhance one’s ability to modulate difficult emotional states, which may produce downstream improvements in healthy behaviors and psychosocial functioning. More rigorous research is needed to examine whether MBB alone is sufficient to improve emotion regulation, or whether multimodal mind-body interventions, such as Tai Chi, add benefits above and beyond this specific component.
Acceptance has been increasingly recognized as a potential health behavior change process . Around a third of TC and MBB participants expressed acceptance of their disease or limitations, with many explicitly linking this acceptance to an improved ability to engage in behaviors to better manage their COPD. Limited prior research in this area suggests that acceptance of COPD is associated with improved quality of life  and fewer depression symptoms . Additionally, acceptance has been correlated with improved medication adherence , greater self-management of exacerbations , and positive behavioral changes during pulmonary rehabilitation programs . Overall, these findings suggest that acceptance may be an important factor in behavior change for COPD patients and that Tai Chi and MBB may be well-suited for targeting this process.
Results from the current study suggest that more rigorous research is needed to better understand the effects of different mind-body interventions for COPD, including the potential added benefits of integrating physical activity and the implications for promoting positive behaviors. Indeed, participants in the MBB and TC groups equally endorsed most qualitative themes related to emotional and physical functioning. Both groups also reported an increase in self and interoceptive body awareness, which is one important aspect of mind-body therapies [27, 55]. However, one major distinction between the two groups was that those in the TC group (which integrates MBB with physical activity) more frequently endorsed themes related to self-efficacy for physical activity and intentions to engage in physical activity. Indeed, prior literature has suggested that Tai Chi may promote physical activity and increase exercise capacity in diverse cardiopulmonary populations [56, 57]. Our current findings support the hypothesis that body/breath awareness and mindful physical activity may interact in multimodal Tai Chi interventions to provide benefits above and beyond mind-body interventions with no physical activity component (e.g., MBB) [27, 58, 59]. Quantitative comparison between the TC and Edu group, published in full elsewhere , provide preliminary support for improved self-efficacy, especially towards positive self-care behaviors and physical activity, and decreased psychological distress among intervention participants.
While traditional pulmonary rehabilitation programs for COPD do improve patient’s physical function [60, 61], self-efficacy , and quality of life , these benefits tend to diminish within six months of completing the program [60, 62]. Supervised and home-based exercise programs designed to support long-term maintenance of physical activity and prolong benefits have had mixed results [63–65]. These qualitative results support the consideration of mind-body exercises in in the development of novel programs to address physical activity maintenance in this population.
Our findings also highlight the value of assessing patient-centered outcomes consistent with biopsychosocial model among patients with COPD. For example, while critically important diagnostically, FEV1 often fails to capture the breadth of the disease’s impact on patients and therefore correlates only modestly with health status and satisfaction . Patient-centered outcomes such as self-efficacy towards symptom management and self-care, the ability to address anxiety and breathlessness, or overall psychological well-being were significantly meaningful to patients with COPD and may be equally important to care as results of radiographic imaging or pulmonary function tests.
There are several limitations to this study that are important to acknowledge. First, the interviewer who conducted the qualitative interviews was a member of the study team, and participants may have offered more positive statements to please the investigators. Second, we recognize theoretical overlap in some of the themes and sub-themes such that coding decisions may be subjective. Third, due to the open-ended nature of the interview, theme separation or number of endorsements of a single theme within an individual’s interview was not always clear. To reduce bias in these areas, we randomly selected transcripts for analysis, had independent coding and theme extraction by two authors, and used triangulation where a third arbiter was used in case of any discrepancies. Our descriptive comparisons and conclusions are exploratory and should be replicated or confirmed using quantitative methods.
Despite these limitations, these findings generate valuable hypotheses regarding pathways by which mind-body therapies may impact behavior change for patients with COPD. These findings also suggest that there may be specific advantages associated with a multimodal Tai Chi intervention (i.e., that combines MBB and physical movement), particularly for promoting physical activity engagement and this should be further studied.
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