Research Design and Participants

It has been noted that there is a dearth of qualitative approaches in understanding the RE-AIM dimensions.^20,21,26 This is rather unfortunate considering that qualitative and mixed methods provide a “rigorous and efficient way” in answering the hows and whys underlying the settings and contexts within which implementation takes place.²⁷ Our research employed a mixed-methods design in dissecting the various RE-AIM dimensions in the context of TJQ practice in China, paying particular attention to pragmatic issues (that are important to stakeholders), measures (that are assessed in heterogeneous, real-world settings), and perspectives (from those characteristic of typical practitioners) as highlighted by pragmatic approaches in implementation research.²⁸ Our design followed the general guidance as recommended by Holtrop et al²⁶ in their programmatic call for qualitative and mixed-methods approaches as they pertain to RE-AIM investigations. Both the quantitative and qualitative research protocol received approval by the ethics committee of Minjiang University. Informants were asked to read and sign an informed consent form prior to embarking on the research activities.

Our quantitative method consisted of an online cross-sectional survey featuring an array of questions on participants’ real-world experiences as well as their perceptions and health outcomes of TJQ (see Supplementary Material [available online]). We utilized a multistage snowball sampling strategy via social media and email in recruiting participants in the survey, which was distributed in July and August 2019 on Wenjuanxing (wjx.cn), a popular online survey administering platform in China. We developed a list of 55 “survey facilitators” representing a broad range of sociodemographics and sent them an invitation to circulate the online survey through their WeChat Moments or email accounts to recruit respondents. Forty-two (15 college faculty members and 27 nonfaculty individuals) agreed to participate. Potential participants, 18 years or older, were invited to complete a survey on public health practices without specifically mentioning TJQ. The qualitative portion comprised 2 components: focus groups and in-depth interviews completed in September and October 2019.

Measures and Data Collection

Survey questions were developed by focusing on the various aspects of the RE-AIM framework concerning individual experiences with TJQ, perceived barriers and motivators, and self-assessment in health, spiritual, and cognitive outcomes. An initial draft of the questionnaire was distributed to peer researchers for feedback and was administered to a pool of 30 college students in a pilot test. Revisions were made by modifying the content, wording, and length of the survey in accordance with suggestions and recommendations. The minimum amount of time (as automatically generated in the survey report) it took a student who had no TJQ experience to complete the survey in our pilot test was 135 seconds. In the final survey, we, therefore, eliminated 4 questionnaires (2 students and 2 nonstudents) that were completed in less than 2 minutes and received a total of 737 valid responses spanning a total of 30 provincial regions from across the country. The college student cohort comprised 18 college campuses. Demographics and other characteristics of the survey sample are reported in Table 1. In terms of gender, respondents were predominantly women (66.5%). The main reason contributing to this gap was due to the skewness in favor of female college students as college participants mostly came from humanities, social sciences, and marketing disciplines—which generally attract more female than male students. As shown in Table 1, the gender distribution among the other demographics was more balanced (56.9% women vs 43.1% men).

Four focus groups, consisting of 9 college students each, were conducted in person on college campuses. Students voluntarily signed up and were assigned to different sessions so that each group had a mixture of TJQ practitioners and nonpractitioners. Group discussions followed an identical set of semistructured open-ended questions pertaining to students’ personal experience (or lack thereof) with TJQ and the underlying reasons. A total of 23 informants were recruited from organizational/community leaders, TJQ masters, college physical education (PE) instructors, and on-the-ground training coaches for the semistructured in-depth interviews, which were completed in person at sites of the informants’ choice. The interview questions (identical for all interviewees) were focused on individual experiences of training practitioners and institutional settings intended to facilitate TJQ dissemination to various practicing communities. All focus group and individual interviews were audio recorded and transcribed for subsequent analysis.

Statistical Analysis

The quantitative data were analyzed using IBM SPSS Statistics for Windows (version 28). Descriptive statistics were run for all variables of interest to detect general patterns of variability and central tendency. TJQ experience was divided into 4 types: nonlearners (never learned TJQ), current learners (learning to practice at the time), quitters (learned before but quit now), and retainers (learned and continued to practice). We compared personal TJQ experience along the lines of occupation and gender, and where possible, comparisons were made between college students and the general public. Ordinal regression analysis was run to detect differences in individual perceptions of TJQ with the 5 ranked responses (from strongly disagree to strongly agree) in terms of its cultural, fitness, artistic, and other benefits using TJQ history, gender, and occupation as the predictor variables. Moreover, TJQ history was also adopted as an explanatory variable in accounting for variations in self-perceived health outcomes.

Qualitative data from focus groups and in-depth interviews were manually coded to pinpoint thematic patterns and alignments, revealing persistent barriers and facilitators in implementing TJQ through the conceptual lens of RE-AIM. We followed the established analytical procedure of data reduction, reorganization, and representation in thematic analysis to ascertain prominent patterns and recurring themes.²⁹

Reach

Reach has been typically presented as the number or proportion of individuals who were willing to participate in a program (most commonly in a 6-mo period). The nature of our data offered us the vantage point of examining a much more protracted period from a diverse population. TJQ still maintains a conspicuous reach among the Chinese general populace as it was ranked third in the types of activities that survey respondents did on a regular basis (often or almost daily): 14.2% chose TJQ versus walking (56.7%) and jogging (16.6%). Our conceptualization of reach of TJQ was divided into 3 categories of engagement: retainers, quitters, and current learners. In total, the reach of TJQ aggregated at 43.4%, meaning that close to half of the respondents had some type of prior or current engagement. For those who had attempted to learn TJQ, the rate of attrition was high—64.2% had forsaken the practice at the time of being surveyed, whereas 23.4% had persisted.

Table 2 reports the breakdown of diverse TJQ history within the various occupation groups. Chi-square test of TJQ history versus occupation pointed to significant variations among the distributions. Compared with other groups, college students were among the most unlikely to learn TJQ (along with corporate employees and self-employed individuals), the most likely to quit after practicing (with educators), and the most unlikely to sustain (with corporate and self-employed workers). Conversely, as might be expected, retirees reported the highest tendency to pick up TJQ and to persist. We also investigated male/female differences in TJQ history, comparing college students and the general public. Pearson chi-square test of independence cross-tabulating gender and TJQ history was nonsignificant for the nonstudent sample, χ²(3, N = 422) = 4.83, P = .19, whereas the same test performed on the college student sample confirmed a significant male/female difference in their TJQ experience, χ²(3, N = 315) = 15.17, P < .01. Groupwise comparison suggested that female students were less inclined to start learning (2.4% vs 4.6%) and to retain TJQ (2% vs 10.8%) than their male counterparts, and they also exhibited a much higher tendency to quit (35.2% vs 20%).

Along the dimension of educational achievement, people with the lowest level of education (high school or below) showed the highest rate of current learning and retention and had the lowest rate of attrition. By contrast, at-school college students displayed the highest rate of nonlearning and quitting, and they had the lowest rate of retention and current learning. This pattern of TJQ experience is revealed in Figure 1.

—TJQ experience by education level. χ²(9, 737) = 79.34, P < .0001. TJQ indicates Tai Ji Quan.

Citation: Journal of Physical Activity and Health 20, 3; 10.1123/jpah.2022-0354

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—TJQ experience by education level. χ²(9, 737) = 79.34, P < .0001. TJQ indicates Tai Ji Quan.

Citation: Journal of Physical Activity and Health 20, 3; 10.1123/jpah.2022-0354

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• Download figure as PowerPoint slide

—TJQ experience by education level. χ²(9, 737) = 79.34, P < .0001. TJQ indicates Tai Ji Quan.

Citation: Journal of Physical Activity and Health 20, 3; 10.1123/jpah.2022-0354

• Download Figure
• Download figure as PowerPoint slide

Participants from the focus groups indicated that TJQ had limited appeal to most students because it was considered “too slow” in pace, and the pedagogy in teaching TJQ was perceived to be “boring.” Even though TJQ was offered as an elective in the college curriculum, most students opted to sign up for these classes either for an “easy pass” or when other physical education courses were not available. The very few students who expressed an active volition attributed this to the influence of their practicing grandparents. Major barriers cited as detrimental to maximizing reach included unwarranted exaggeration of the combat effects of TJQ by charlatan masters in misleading the public, glamorizing of TJQ for its fist fight and action theatrics at the expense of ignoring its health benefits, lack of professionally trained coaching staff in guiding the general public, and ineffective and inefficient strategies in reaching out to young people.

Effectiveness

Accruing desired outcomes is an important motivator driving physical activities. In response to personal goals of undertaking TJQ, survey participants (N = 321) chose physical fitness (66%), relishing TJQ as an asset of traditional Chinese culture (42.1%), spiritual cultivation (40.2%), stress reduction (31.2%), and mindfulness meditation (30.2%) as the top-ranked categories. Notably, even though TJQ originated mainly as an art of self-defense, this was only mentioned by 15.9% of the respondents as a main goal in their pursuit.

Our survey included an assortment of statements about the diverse attributes and perceived values of TJQ. As perception was measured with a ranked Likert scale, ordinal regression was the ideal procedure in statistically dissecting the main effects of TJQ history, gender, and occupation on individual perceptions as the response variable. We followed the reporting procedures and interpretation routines as recommended in Heck et al³⁰ with regard to the results in Table 3. The reference category for the ordinal outcomes was 5 (strongly agree) in a 5-item Likert scale, and the odds ratio (OR) represented the odds of the higher category compared with the combined lower categories. Regarding the predictor variables of gender and occupation, a value larger than 1 indicated an increased tendency to agree with the TJQ statement compared with the reference categories of male or noncollege students. We performed a test against the assumption of parallel regression lines (slopes) for each statement, with the P values ranging from .07 (statement 6) to .26 (statement 9) in Table 3, making it feasible to pursue ordinal regression analysis on these statements.³⁰ None of the goodness-of-fit tests gave enough evidence of lack of fit (at the P > .05 level), and the model fitting data were all statistically significant (P < .01).

One lone statement (mean = 3.42; SD = 1.12) that tested to be in violation of the assumption of parallel slopes (P < .01) for ordinal regression analysis was the claim that “TJQ fails to appeal to young people.” Multinomial logistical regression was, instead, performed, with neutral being the reference category. Pattern of difference was found with regard to the strongly disagree scale, with current learners (OR = 5.94, P = .017) and retainers (OR =3.63, P = .049) more likely to strongly disagree than quitters. College students also tended to strongly disagree with nonstudents (OR = 4.27, P = .005) on this statement.

In response to the perceived merits and values of TJQ, current learners and retainers consistently displayed a positive tendency to agree with 8 of the 9 statements in comparison with nonlearners. The statement (S8) with the opposite trend was attributable to its reversely stated nature. In other words, current learners and retainers tended to disagree with nonlearners in that TJQ was a thing of the past. In terms of gender, women tended to agree more than men in attributing value to 5 of the 9 statements in Table 3. Compared with the general public, college students saw less value in TJQ being worthy of promotion for all (S2) and thought less of TJQ as an art of self-defense (S4).

Enhancing physical and spiritual well-being has been widely recognized as a major outcome of practicing TJQ. In analyzing responses to the question “How satisfied are you with your current health status?” (mean = 3.16; SD = 0.75), ordinal regression results showed that retainers were more likely to show satisfaction with their health status (OR = 2.25) (see Table 4). No significant difference existed between quitters, current learners, and nonlearners in their health satisfaction status. Gender and student/nonstudent status did not significantly predict one’s assessment of personal health; neither did age. In another measurement item (mean = 3.63; SD = 1.06), we asked participants with TJQ experience (ie, new learners, retainers, and quitters) their level of satisfaction with the role of TJQ in improving their physical and mental health outcomes. TJQ history, again, was an important predictor, with retainers (OR = 3.82) and current learners (OR = 2.79) displaying an increased tendency of being satisfied compared with quitters, as reported in Table 5. Difference among gender and (non)student status dimensions did not reach statistical significance. Worthy of note was that older demographics tended to be more satisfied with TJQ’s health outcomes (OR = 1.14).

Focus group discussions reflected quite a bit on the ineffectiveness of existing pedagogical approaches in teaching TJQ at college campuses. Many students complained about the lack of enthusiasm of college coaching staff, which, in turn, reduced their interest in learning TJQ in related classes. Class size, which typically ran at about 30 to 40 students, was invariably perceived to be a hindrance because this made it hard to get one-on-one coaching. The one-class-fits-all modality was also mentioned as an impediment to satisfy individual needs, thus failing to evoke personal interest and long-term engagement. Lack of practicing venues was also cited as a major barrier: Many other sports (eg, swimming, tennis, basketball, and soccer) had their own dedicated practicing ground, but there was no allocated venue for college students to do TJQ. Although public venues, such as community centers and parks, routinely witness TJQ practitioners, college students felt strange and out of place to be with these older populations.

Major issues mentioned in the in-depth interviews with TJQ professionals pertained to the (in)effectiveness of intervention programs rather than that of TJQ itself. Many TJQ masters emphasized that, instead of just focusing on the technical skills while teaching TJQ, a more holistic approach incorporating TJQ’s cultural, philosophical, historical, and physical aspects was desired to attract more followers from the general public. It was also suggested that TJQ training and coaching should create tiered, customized programs to cater to the specific physical-health conditions of diverse constituents.

Adoption

Adoption related to the role and nature of settings and agents in the dissemination of TJQ in society. Among the top 4 responses to the question “Why did you withdraw from TJQ?” 2 related to settings, namely lack of appropriate practicing settings (52.9%) and no appropriate practicing venues (17.5%). This offered solid evidence that environmental factors played an important role in shaping individual TJQ decisions. Our survey also queried those who had practiced TJQ (new learners, quitters, and retainers) on the question “Where did you learn TJQ?” The top 4 venues were as follows: work places (including schools) (27.4%), city parks (15.3%), residential communities (10.6%), and local training centers and academies (8.7%).

At the settings level, most college campuses have incorporated TJQ as part of the regular curriculum. For the vast majority of the students who had TJQ experience, they did this through enrolling in college classes, but this was largely due to the need to take electives rather than driven by personal interest. A couple of students mentioned that they started TJQ thanks to doctors’ recommendations as a therapeutic solution to certain physical conditions. Even though city parks provide an easy site for TJQ practitioners, a dearth of other amenable venues came up repeatedly as an issue. Some interviewees pointed out that collaboration between the government and residential builders in adding dedicated TJQ spaces would be highly desirable. TJQ professionals also suggested that community and other institutional bodies could be more proactive in investing in the infrastructure and training programs. A few interviewees mentioned their own success in teaching TJQ in local fitness centers through adapting to the needs of specific demographics. Another recurring point of discussion was that local and national government agencies could be more involved in incentivizing TJQ through policy initiatives and program funding.

Implementation

We asked survey participants what they would like to see more of in TJQ teaching materials. Four topical areas that were mentioned the most were easy-to-follow instructions for starters (75.3%), historical and cultural foundations (70.1%), step-by-step movement video tutorials (68.5%), and practical applications of TJQ moves (58.9%). A consistent theme we noted across focus groups and in-depth interviews was the call for systematic emphases on the aforementioned areas in teaching TJQ. Another issue that was prominently highlighted in the qualitative data was the lack of consistency in instructional activities from instructor to instructor: What one coach does in coaching TJQ may contradict what is taught by another coach. Especially for college students, this was a major source of confusion and was cited as a disincentive to continue beyond the course domain. Seasoned TJQ trainers and college coaching staff among the interviewees suggested that formally recognizing TJQ in the college curriculum (like track and field events, basketball, soccer, swimming) with rigorous assessment and evaluation would boost TJQ teaching and practicing across college campuses. Relatedly, TJQ masters in the interviewees deplored the current state of professional teaching staff and urged the establishment of a streamlined, effective “training the trainer” mechanism to provide college campuses and communal training centers with highly qualified TJQ leaders and coaches.

Many interviewees suggested that a more proactive involvement by social organizations and institutions could be a game changer in boosting public participation. The role of professional organizations and associations was also often noted in the interviews. Interviewees mentioned that TJQ has enormously benefited from being a major sport in international and regional tournaments and games events in recent decades, which has, in turn, amplified public recognition and galvanized popular participation. One example is the World Kungfu Championships tournament (iwuf.org), which, jointly sponsored by the International Wushu Federation and the Chinese Wushu Association, has been held once every 4 years since 2004. Two other contributing developments are the expanding list of specialized martial arts colleges in China and the establishment of thousands of TJQ centers and schools in the past 3 decades across the country.

Maintenance

Extant RE-AIM research often defines maintenance as 6 months or more after treatment. In the case of TJQ, the most common understanding among TJQ professionals puts learning at the stage when the guidance of coaching (either in person or aided by video tutorial) is essential in practicing, whereas retaining is the stage when one can practice movements independently. Our research considered maintenance to be the stage in which TJQ has been habitualized into routine lifestyle through regular independent practice. Our sample demonstrated a retention rate of 23.3% (people who learned and continued to practice) versus an attrition rate of 64.2% (quitting after initial practice). The contrast was stark, however, when the sample was split between college students and nonstudents. For the former, retention rate fell down to 9.8% (vs 38.7% nonstudents), and the attrition went to 82.8% (vs 52.8% nonstudents), clearly pointing to the challenge of converting college students into TJQ followers. Those who quit after having tried (N = 206) were asked the major reasons for withdrawal. Besides the lack of amenable practicing venues as mentioned before, the main triggering factors included forgetting important movements due to lapse in practicing (45.1%), lack of time (33.5%), and TJQ not being the right fit (16.5%).

Of particular note was the role of family networks in the initiation and retention of TJQ. About a quarter (25.9%, 191 out of 737) of the respondents indicated that they had family members practicing TJQ. Across all demographics, those who had family members doing TJQ were much more disposed to initiate and retain their TJQ practice, whereas they were more unlikely to be nonlearners and quitters, χ²(3, N = 737) = 56.59, P < .0001. As a matter of fact, 56% of retainers reported having family members practicing TJQ, whereas 72.8% of those without practicing family members quit TJQ after initialization.

As reported in Table 6, age was an important predictor for TJQ history. An interesting pattern emerged that for the demographics 20 years and older, attrition rate steadily went down, whereas retention rate continually rose. The under 20 demographic marked a clear deviation from this pattern in that its attrition rate stayed lower than only the 60 and older cohort, whereas its retention rate ranked higher than all except the demographics reaching 50 and beyond. This was not simply a college student effect because 13.3% of the participants in the under 20 group and 20.9% of the 20 to 29 cohort were noncollege students.

A few students in the focus groups indicated that their engagement at an earlier age gave them the impetus to continue. A couple mentioned that the influence of their grandfathers motivated them to stick to TJQ. On the opposite side, some students mentioned that they gave up because it was hard to find practicing companions. A few said that they quit because they felt embarrassed to do TJQ in public as they were not sure whether they were doing the moves the right way. In the in-depth interviews, coaching experts pointed out from personal experience that a sophisticated knowledge base of TJQ is commonly found among hardcore practitioners. Others advised from personal experience that sustainability of the practice is viable through setting long-term, not short-term, health goals. At the settings level, a few interviewees with extensive experience working with government agencies called for stability in strategic goal setting by the government and suggested that frequent changes in government policy orientations are detrimental to TJQ promotional efforts.