Effects of an ICT-Based Chinese Qigong Baduanjin Exercise Support Program on Self-Efficacy and Motivation to Promote Long-Term Practice for Hypertension Prevention in Adults

According to the 2018 Revised Chinese Guidelines for the Prevention and Management of Hypertension, the prevalence of hypertension in the Chinese population continues to rise. The guidelines emphasize the necessity of integrating exercise into daily life as part of healthy lifestyle interventions through communication technologies such as media and websites [1]. Furthermore, the Healthy China 2030 Plan highlights that compared to other industries, the medical sector demonstrates a particularly strong fundamental demand for artificial intelligence applications and encourages the development of scientific exercise programs [2]. In this context, self-managed exercise as a lifestyle intervention plays an increasingly important role in controlling hypertension. With rapid economic development, technological advancement, and population aging, attention has been growing toward convenient and efficient telemedicine solutions. 

Baduanjin, a traditional Chinese qigong exercise, is a full-body routine that combines slow movements and breathing techniques. Its health benefits have been substantiated by numerous studies, particularly among groups who practiced continuously for more than eight weeks. These studies have shown significant reductions in blood pressure, improvements in psychological well-being, and enhanced physical flexibility and balance [3]. However, these benefits are not achievable through short-term practice; a sustained period of engagement is required. Therefore, the continued practice of Baduanjin is essential to maximize its health benefits. Psychological factors, especially motivation and self-efficacy, are considered critical to sustaining engagement [4]. When individuals perceive value in Baduanjin (motivation) and believe in their ability to practice it (self-efficacy), they are more likely to incorporate it into daily life and form a lasting habit. For lifestyle-related diseases such as hypertension—where preventive behavior tends to be postponed—establishing easy-to-maintain and sustainable exercise habits is particularly important. Thus, intervention programs that aim to enhance motivation and self-efficacy are expected to produce public health benefits by contributing to hypertension prevention. 

To date, several exercise support programs utilizing information technologies (such as internet and digital tools) have been developed to promote physical activity. However, there is still a lack of empirical evidence demonstrating the effectiveness of ICT-based exercise support programs, and their nationwide implementation remains limited. According to Suzuki, e-learning materials based on the ARCS motivation model and Gagné’s Nine Events of Instruction—educational design theories supporting the human information processing process—can be developed to be efficient, effective, and engaging, thus promoting learners’ motivation to adopt physical activity [5,6]. In addition, Ding Dong proposed that to improve the quality of social medical services in telemedicine, the medical industry should actively promote telehealth education based on e-learning [7]. To address these challenges, in June 2021, developed an ICT-based Baduanjin exercise support program incorporating the principles of andragogy, the theory of adult learning [8]. 

Based on this, a quasi-experimental study was launched in July 2021 to evaluate whether the ICT-based Baduanjin Exercise Support Program effectively supports the integration of exercise into the daily lives of adults.

The effectiveness of an ICT-based Baduanjin Exercise Support Program was evaluated in this study.

An overview of the ICT-based Baduanjin Exercise Support Program was presented in figure 1. The key features of this program included the use of EDEN Corporation’s e-learning platform, through which ease of management was facilitated and personalized information was provided. In addition, group learning—characteristic of adults. 

 Figure 1: Overview of the ICT-Based Baduanjin Exercise Support Program.

Participants

In this study, participants were divided into two groups—an ICT-based intervention group and a paper-based intervention group—to compare the effects of the intervention. The methods and procedures for group allocation are described below. 

Recruitment and preliminary survey 

To select study participants, community groups in China were chosen, and approval was obtained from the district office and community group administrators. Through WeChat, community administrators were asked to introduce the researchers to potential participants in advance. Additionally, adults aged 18 and older who were interested in health promotion through Baduanjin were recruited via local health centers and online bulletin boards. Prior to participation, informed consent was obtained, and basic demographic information (such as gender, health status, and experience with smartphones or digital devices) was collected. 

Eligibility criteria 

Participants were included if they met the following criteria:

• Adults aged 18 years or older.
• No regular exercise habits within the past six months, aside from residential community activities.
• Ability to communicate verbally.
• Independence in activities of daily living.
• Absence of physical disabilities affecting exercise.
• Ability to operate a smartphone, tablet, or computer. 

Group allocation procedure 

Based on the collected demographic information, stratified randomization was used to allocate participants into groups in a balanced manner. Specifically, stratification factors such as gender and other relevant characteristics were used to randomly assign participants to the ICT-based intervention group: 41; paper-based intervention group: 40. 

Study period

The study was conducted from June 2021 to July 2021. 

Flow of the Baduanjin Exercise Support Program Intervention

• Pre-intervention Guidance for the Baduanjin Exercise Support Program

The following steps were carried out prior to the intervention:

• The effectiveness of Baduanjin in preventing hypertension was explained.
• The benefits of exercise for hypertension prevention were outlined.
• Instruction on how to use the e-learning exercise support system was provided.
• Personal goals were set.
• Guidance on how to learn and perform Baduanjin exercises was offered.

Implementation of the Baduanjin Exercise Support Program 

For the ICT-based intervention group (as shown in figure 2):

• Participants recorded daily exercise impressions, physical conditions, and blood pressure on a designated sheet. Based on this information, necessary messages were sent by researchers, and relevant information was shared with all participants when appropriate.
• Mid-term and final reflections were conducted. Group discussions were held to promote peer learning and enhance motivation. Researchers facilitated these sessions and provided support for future exercise planning.
• Upon completion of the program, certificates of completion were automatically distributed to participants. 

For the paper-based intervention group (as shown in figure 3):

• Exercise support videos and daily recording sheets were distributed via WeChat. Participants recorded their impressions, activity status, and blood pressure, and submitted photos of the completed sheets weekly.
• One-on-one reflection sessions were conducted at the Midterm and final stages. During these sessions, impressions, activity status, and blood pressure data were discussed, and possible solutions for future exercise challenges were considered.

 Figure 2: Flow Diagram of the ICT Intervention Group. 

Figure 3: Flow Diagram of the Paper Intervention Group.

Survey Content

• Before and after the program, participants were assessed using the Chinese version of the GSES. This scale, originally developed by Schwarzer et al., in 1981 and translated by Zhang Jianxin and Schwarzer in 1995, has been widely used in China with confirmed reliability and validity [9].
• Following the program, participants were evaluated using the ARCS Motivation Mode, developed by Guo Dejun in 2000 based on Keller’s ARCS motivation model. This questionnaire has also demonstrated reliability and validity [10].
• In addition, participants’ free-text responses were collected and organized at the Initial, Midterm, and Final.

Ethical Considerations 

This study was approved by the Ethics Committee of the Graduate School of Nursing at Kyoto Koka Women’s University (Approval No. 20MM3). The purpose, methodology, voluntary nature of participation, the right to withdraw, privacy protection, data handling and management, potential benefits and risks, and publication of results were explained both in writing and verbally. Written informed consent was obtained from all participants prior to the commencement of the study.

Basic Characteristics of the Study Participants

The basic characteristics of the participants were presented in table 1. Among the 81 total participants, the ICT-based intervention group consisted of 41 individuals whose average age was in their 40s (±12.945). This group included 8 males (19.5%) and 33 females (80.5%). The paper-based intervention group, which consisted of 40 individuals, had an average age in the 20s (±10.952), with 12 males (30%) and 28 females (70%).

Table 1: Basic Characteristics of Study Participants. 

Relationship between GSES and the Four Factors of the ARCS Motivation Model After the Implementation of the Exercise Support Program

1) A Mann–Whitney U test was conducted to compare ARCS motivation model scores between participants with low and high post-intervention GSES scores. It was found that the mean rank of the low-GSES group was 15.79, while that of the high-GSES group was 23.22, indicating a significant difference between the two groups (p = 0.038). However, no significant differences were observed between the low- and high-GSES groups for the following 26 ARCS items: A2, A21, A24, A27, A34, R11, R23, R28, R35, R38, R44, R49, C1, C22, C30, C37, C39, C42, C45, C48, S14, S18, S25, S29, S40, and S43 (p > 0.05). Aside from these items, significant differences were found in the overall ARCS motivation model scores and the remaining individual items between the low- and high-GSES groups (p < 0.05). The detailed results were provided in table 2. The increase in GSES and ARCS scores does not directly indicate differences between groups; however, the development of a positive attitude toward exercise and a willingness to continue suggests the potential for strengthening future hypertension prevention behaviors.

Table 2: Post-Intervention GSES Low and High Groups and Their Scores on Each ARCS Motivation Model Component.

• A Kruskal–Wallis H test was applied to examine differences in ARCS motivation model factor scores among four subgroups within the ICT-based intervention group, categorized by changes in GSES scores before and after the intervention. Significant differences (p < 0.05) were observed in the following three items: R44: "When I had a question, the instructor did not immediately answer it but encouraged me to think or discuss it first. This stimulated my interest in learning." The mean ranks were Group 1 = 19.45, Group 2 = 24.67, Group 3 = 29.25, and Group 4 = 13.43.C45: "The instructor encouraged us to incorporate exercise into our daily lives on our own, which increased my interest in learning." The mean ranks were Group 1 = 19.71, Group 2 = 24.28, Group 3 = 29.00, and Group 4 = 13.43.C48: "When I failed to successfully integrate exercise into my daily life, the instructor asked me to consider whether I had made enough effort, which stimulated my learning interest." The mean ranks were Group 1 = 21.39, Group 2 = 19.56, Group 3 = 31.00, and Group 4 = 13.21.

No significant differences were found in the total ARCS motivation model score or in the other individual items among the four groups (p > 0.05). These results were presented in table 3. 

To further identify specific group differences among the three significant items, a post-hoc multiple comparison was conducted using the Tukey (T) method. For items R44, C45, and C48, significant differences were found between Group 3 and Group 4 (p < 0.05). The post-hoc results were presented in table 4.

Table 3: Differences in ARCS Motivation Model Component and Item Scores Among Four Groups Based on GSES Score Change (Post–Pre) in the Intervention Group.

Table 4: Multiple Comparisons of ARCS Motivation Model Component and Item Scores Across Four Groups Based on GSES Score Change (Post-Intervention) in the ICT Intervention Group.

Free-Text Responses from Participants 

Change in GSES: According to Bandura, the maintenance of physiological states—defined as stabilizing both mind and body—is closely associated with GSES. To assess changes in GSES, participants’ free-text responses Initial, Midterm, and Final were analyzed for references to maintaining physiological states. These responses were categorized under "psychological health maintenance" and "physical health maintenance," and classified based on evident improvement or decline. The results were shown in tables 5 & 6. 

 Table 5: Changes in self-efficacy in the Intervention Group Classified from Open-Ended Responses.

 Table 6: Changes in self-efficacy in the Non-Intervention Group Classified from Open-Ended Responses.

Change in Motivation

To evaluate changes in motivation—particularly in relation to incorporating exercise into daily life—free-text responses from Initial, Midterm, and Final were examined. Content was extracted according to the four components of the ARCS motivation model, and the responses were categorized based on whether a clear improvement or decline was indicated. The results were presented in tables 7 & 8.

 Table 7: Changes in "Motivation" in the Intervention Group Classified from Free Descriptions.

 Table 8: Changes in "Motivation" in the paper-based intervention group Classified from Free Descriptions.

This study was conducted to examine the effectiveness of an ICT-Based Baduanjin Exercise Support Program, focusing on self-efficacy and motivation. Based on the results obtained, this section discusses the implications for nursing practice, the limitations of the study, and suggestions for future research. 

Participant Demographics

A response rate of 100% was achieved, suggesting that a strong interest in health and physical activity was held by the participants. Among them, 75.3% were female and 24.7% were male. According to a report on physical activity published in The Lancet, the rate of physical inactivity in China was reported to exceed 16% for men and 12.2% for women. In alignment with these trends, a greater number of women than men expressed a desire to participate in this study.

Effectiveness of the Baduanjin Exercise Support Program Based on GSES and the ARCS Interest Questionnaire 

Relationship Between GSES and the Four Factors of the ARCS Motivation Model: As shown in table 2, higher scores on the GSES were associated with higher total scores on the ARCS motivation model. This relationship suggested that motivation levels, as measured by the ARCS model, were influenced by GSES. It has been reported by Suzuki that GSES was beneficial for maintaining and continuing learning or when providing support for such activities, indicating a close connection between GSES and motivation [11]. Moreover, the activity control theory proposed by Kohl (1984) and the concept of GSES were foundational elements of the ARCS model, thereby reinforcing the strong relationship between these two constructs [11]. The increase in GSES suggests that participants are more likely to continue exercising even when faced with difficulties, which is a key element of behavior change in hypertension prevention. Furthermore, maintaining interest and motivation toward exercise supports the sustainability of behavior, so the improvement in motivation through this program is likely to lead to the implementation of hypertension prevention behaviors. 

Relationship Between Changes in GSES Scores and the ARCS Motivation Model in the ICT-based intervention group: As indicated in table 3, changes in GSES scores among participants in the ICT-based intervention group were found to be associated with three specific items within the ARCS motivation model (R44, C45, and C48). These changes were shown to influence two ARCS components: Relevance (R) and Confidence (C). Through multiple comparisons, significant differences were observed between Group 3 and Group 4 in terms of GSES score changes, indicating that greater improvements in GSES were accompanied by more favorable outcomes in the Relevance and Confidence domains. 

Yang’s findings further supported this result, having demonstrated that the ARCS motivation model—compared to conventional instructional approaches—was associated with enhanced GSES, a greater sense of achievement, increased enjoyment of physical activity, and a more positive attitude toward exercise [12]. In the present study, it was shown that the Baduanjin Exercise Support Program was linked to improvements in GSES and in two components of the ARCS model: Relevance and Confidence. Given that higher GSES was found to promote greater motivation, it was considered essential to implement strategies that enhanced GSES, especially in individuals who initially displayed low exercise motivation for daily life integration. Therefore, it was inferred that this exercise support program had the potential to enhance motivation by improving GSES. 

Regarding Free-Text Responses from Participants 

Self-efficacy: Maintaining a Healthy Condition: In the ICT-based intervention group, continuous positive feedback and advice were provided by instructors via WeChat. This interaction was considered to have functioned as immediate feedback. As both the ICT and paper-based intervention groups demonstrated more improvements than declines in self-efficacy, it was inferred that the program had a positive effect on enhancing self-efficacy. A high number of comments related to physical health maintenance were observed in both groups, suggesting that the benefits of Baduanjin exercise were recognized. In the ICT-based intervention group, the constant accessibility of video content was believed to have contributed to this outcome. Moreover, participants’ awareness of specific physical changes, such as improvements in blood pressure, was likely influenced by the individualized daily feedback that was provided by instructors, indicating that personalized guidance affected participants’ awareness of their physical condition. 

Motivation to Incorporate Healthy Habits into Daily Life: In Terms of the ARCS Model: Participants’ motivation was examined using the four elements of the ARCS motivation model: Attention (A), Relevance (R), Confidence (C), and Satisfaction (S). Compared to the paper-based intervention group, the ICT-based intervention group demonstrated clearer expressions of motivation across all four factors. Throughout the course of the program—from the beginning to the Midterm and then to Final, an increasing trend in exercise motivation for daily life integration was observed in the ICT-based intervention group, whereas both self-efficacy and motivation declined in the paper-based intervention group. From the Midterm to Final of the intervention, satisfaction was reported to have improved. Reflections conducted at these points were believed to have contributed to this improvement. Additionally, comments expressing a desire to emulate peers suggested the influence of group reflection. As both groups provided more specific free-text responses at the Midterm and Final, it was inferred that feedback during these periods had a positive effect. 

Regarding "A: Attention": Changes in “Attention” were observed over time—from the beginning to the Midterm, and post-intervention. At the beginning, comments such as “I’m not good at it, so I’ll practice more” and “I’ll keep working hard every day” were made by the ICT-based intervention group, suggesting an increase in attention. At the Midterm, declines in attention were noted in the paper-based intervention group, with statements like “It’s a bit boring, tiring, and not very interesting.” By the Final, this downward trend continued in the paper-based intervention group, whereas the ICT-based intervention group demonstrated improvement. The component of “Attention,” expressed through initial interest or novelty such as “This looks fun” or “I want to try it,” appeared to diminish over time. In the ICT-based intervention group, sustained attention was likely facilitated by the ease of engaging with the video content. Regular reminders were also presumed to have been effective in maintaining engagement. In contrast, the motivation in the paper-based intervention group seemed to rely more on intrinsic interest. Additionally, requests for instructor feedback indicated that ongoing communication with instructors significantly affected motivation. 

Regarding “R: Relevance”: In the ICT-based intervention group, motivational changes were evident at the beginning, Midterm, and post-intervention stages, with comments such as “It seems likely to lead to good results” and “It seems worthwhile” indicating increased relevance. In contrast, no comments suggesting improved relevance were found in the paper-based intervention group. “Relevance” referred to the extent to which the activity was perceived as personally meaningful. In the ICT-based intervention group, improvements in relevance were believed to have resulted from ongoing feedback, instructor encouragement, and communication with peers. Although these comments reflected some improvement, the overall low frequency of relevance-related statements in both groups suggested that the activity might have lacked elements that clearly conveyed personal significance or value. 

Regarding “C: Confidence”: In the ICT-based intervention group, a gradual increase in expressions indicating enhanced confidence and satisfaction was observed over time, while expressions of decline decreased. Conversely, in the paper-based intervention group, comments reflecting improved confidence and satisfaction were fewer and declined over time, while negative expressions increased. In the ARCS motivation model, “Confidence” referred to the expected likelihood of success in various activities. Strategies to enhance this expectation and support beliefs such as “I can do it if I try” were considered essential. In the ICT group, confidence appeared to have been influenced by participants perceived progress in learning Baduanjin. Comments such as “I was encouraged by the instructor’s message” suggested that instructor feedback messages delivered daily had a positive impact on participants’ confidence. 

Regarding “S: Satisfaction”: In the ICT-based intervention group, an increase in satisfaction was observed from the beginning through to the Final, with a decline in negative expressions over time. In contrast, the paper-based intervention group showed fewer expressions of satisfaction, and the frequency of negative comments increased. “Satisfaction,” which referred to the joy of achieving something challenging and valuable, was considered a crucial factor in sustaining motivation. In the ICT-based intervention group, it was inferred that tailored instructor feedback messages of encouragement and advice, designed to support participants’ sense of accomplishment, had reinforced both confidence and satisfaction. Satisfaction was particularly noted to have improved from the Midterm to the Final, possibly because of structured reflections. Comments indicating that participants learned from peers further underscored the impact of group reflections. In the paper-based intervention group, improvements noted at the Midterm and Final were also attributed to instructor feedback.

Based on the discussion above, participants’ free-text responses suggested that the immediacy of feedback from instructors, recognition from others (instructors and peers), communication among participants, and mid-program reflections in the ICT-based Baduanjin exercise support program had positively influenced and appeared to have enhanced both self-efficacy and motivation. 

Limitations and Future Directions of the Study 

In this study, a convenience sampling method was employed for participant allocation, which resulted in an imbalance between the ICT-based intervention group and the paper-based intervention group. Consequently, a pre-post comparison design was adopted within each group. Therefore, the validity of participant allocation should be examined in future research through more rigorous sampling strategies. 

In addition, the short duration of the study introduced considerable individual differences among participants (e.g., age, occupation, and place of residence), which may have limited the clarity of results when comparing the GSES and the ARCS Motivation Mode. Thus, future studies should consider extending the intervention period and employing strategies to minimize the influence of individual variability. 

This study, which implemented an ICT-based Baduanjin exercise support program as a lifestyle intervention, indicated a positive effect on exercise motivation for daily life integration and a tendency toward increased willingness to engage in physical activity. Based on these findings, it was suggested that ICT-based exercise support programs could be utilized in other contexts to enhance individuals’ self-care ability related to physical activity. 

Moreover, in Japan, no prior intervention studies were identified that incorporated Baduanjin into an ICT-based exercise support program. In view of the current results, it was considered necessary to develop a culturally adapted program that could be applied to Japanese society with the aim of improving adults’ self-care abilities related to physical activity. 

Due to environmental restrictions caused by the spread of COVID-19, in-person instruction for the initial introduction of the program could not be implemented. Although the non-intervention group had originally been scheduled to receive all instructions face-to-face and conduct the program using printed materials, instructor feedback messages, midterm and final reflections, and surveys were all conducted through synchronous online communication. As a result, the study could not be characterized as a pure comparison between face-to-face instruction and ICT-based instruction. Therefore, it was recommended that future studies clearly define implementation conditions to allow for more accurate and meaningful comparisons. 

Baduanjin is a form of health-promoting Qigong exercise rooted in traditional Chinese medicine, with a history spanning several centuries. In recent years, multiple studies have reported its effectiveness in preventing and improving hypertension among adults. However, to achieve the benefits of Baduanjin, it is essential to engage in the practice continuously as part of daily life, rather than through one-time efforts. Sustaining behavioral changes for hypertension prevention requires ongoing motivation and practical support; without this, even effective exercise methods may fail to yield results. In this regard, this program offers regular guidance and encouragement through videos and messages, visualizes progress, promotes interaction with other participants, and incorporates self-monitoring and feedback functions. These features help enhance participants’ sustained motivation and self-efficacy, thereby contributing to the habituation of health-promoting behaviors. Thus, by combining traditional health practices such as Baduanjin with ICT-based support, it becomes possible to implement such practices in a way that fits modern lifestyles, facilitating more effective and sustainable engagement in hypertension prevention behaviors.

This study was conducted to enhance self-care ability through a lifestyle intervention that was implemented using an ICT-based Baduanjin exercise support program. Based on the findings, it was suggested that the ICT-based Baduanjin exercise support program tended to improve self-efficacy and exercise motivation for daily life integration. Furthermore, the results indicated that ICT-based exercise support contributed to improvements in the Relevance (R) and Confidence (C) components of exercise motivation for daily life integration. These outcomes underscored the importance of developing intervention strategies that were aimed at enhancing self-efficacy. In the future, it will be necessary to specifically examine the impact of continued exercise on hypertension prevention and improvements in blood pressure values through long-term follow-up studies. The motivational effects of this program have the potential to promote long-term behavior change and serve as practical support for the prevention of lifestyle-related diseases.

Sincere gratitude was extended to all the research participants and their families for the cooperation that was provided during the conduct of this study.

The authors declare no conflicts of interest.

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