LIFESTYLE CHANGE AND NON-COMMUNICABLE DISEASES: A STUDY ON THE PARTICIPANTS OF CRANBERRY HEALTH
PROJECT
Emmanuel Okwara Kalu Master`s Thesis Public Health Nutrition University of Eastern Finland Faculty of Health Sciences School of Medicine August 2019
KALU, EMMANUEL OKWARA: Lifestyle change and non-communicable diseases: A study on the participants of Cranberry health project
Master's thesis, 161 pages, 2 appendixes (3 pages)
Supervisors: Arja Erkkilä, Adjunct Professor; Sohaib Khan, Assistant Professor August 2019
Key words: Non-communicable diseases, Intervention, Diet and other lifestyles, Change, Cranberry health project
The annual mortality associated with Non communicable diseases (NCDs) has been on the rise, and now stands at 71% (40.5 million). Thus, increased global efforts are being made to prevent and control them. Finland has a long history of war against NCDs her hallmark was North Karelia Project (NKP) (1972 to 1997) which led to significant drop in CVD prevalence. In 2012 a privately managed intervention body known as Cranberry Health Project (CHP) emerged, and she uses Adventist Health Principles (AHPs) for her interventions in a 5+35+2- day residence-home-residence intervention programmes, and her clients served as subjects for this study.
Using phenomenographic approach, the study explored and described the meanings the 26th batch of CHP intervention programme clients give to their experiences with the intervention.
Out of the twenty-two clients that attended a 2-day closing session of the intervention in Pieksämäki [between 06.06.2016 and 07.06.2016], twenty volunteered to participate in the study, and the data was collected through a questionnaire in Finnish and was translated into English before being analysed.
Ten main ‘Categories of Description’ emerged from the study showing 1) that prior to the intervention the participants’ diet and other lifestyles were largely unhealthy, 2) that the participants were largely motivated by their illnesses to participate in the intervention, 3) that the participants are quite impressed with the contents and impacts of the intervention programme, 4) that through the intervention the participants gained substantial health knowledge and skills, 5) that the participants have been making many changes in their diet and other lifestyles, 6) that the changes are claimed to have been making a lot of positive impacts on their health, 7) that the participants are also largely motivated to continue with the new diet and other lifestyles by their illnesses and believed health improvements witnessed thus far, 8) that the participants' adherences to CHP recommendations have remained incomplete, 9) that the incomplete adherences are due to challenges beyond their control , and 10) that despite all the challenges the participants have high hopes and anticipations for a better health.
The outcomes thus show that the participants’ health knowledge, diet and other lifestyles, health, and other aspects of their lives are being positively influenced by the intervention programme.
My gratitude goes first to Almighty God for His grace. To the Finnish society who opened her door for education aspiring individuals like me. To the University of Eastern Finland who admitted me into this MSc programme in ‘Public Health Nutrition’ (MPHN). To the teaching and non-teaching staffs of UEF who are associated with MPHN programme for their supports.
And to my supervisors – [Adjunct Professor Arja Erkkilä; Assistant Professor Sohaib Khan]
who have been very supportive.
I am also grateful to Cranberry Health Project management who did not just give me access to the participants, but also allowed me to use her intervention programme as a platform for my data collection. My gratitude also goes to the participant for volunteering to participate in this study and as well for providing rich data for the study. I will not forget to thank my wife and kids for their supports and permission that part of the time I should have spent with them be devoted to this study. I am also thankful to my colleagues for their motivational roles, and then to my family members in Nigeria who have not been too demanding because they are aware that my primary goal in Finland is academic pursuit.
Kalu, Emmanuel Okwara August 2019
Kuopio, Finland
Contents
1 INTRODUCTION... 12
2 THEORETICAL AND CONCEPTUAL BACKGROUND ... 14
2.1 Non-communicable Diseases (NCDs) ... 14
2.1.1 NCDs overviews ... 14
2.1.2 Who is at risk of NCDs?... 15
2.1.3 The WHO 2015 NCDs country profile: Finland ... 15
2.1.4 Global action plan for the prevention and control of NCDs ... 16
2.1.5 The nine WHO voluntary global NCDs targets ... 16
2.1.6 Global monitory framework ... 17
2.2 Intervention for lifestyle change ... 18
2.2.1 Health intervention overview ... 18
2.2.2 Meaning of intervention ... 18
2.2.3 Meaning of lifestyle ... 19
2.2.4 Lifestyle change ... 20
2.2.5 Lifestyle Medicine ... 21
2.2.6 Lifestyle intervention programme ... 22
2.2.7 Intervention participants and their experiences ... 22
2.3 Intervention studies in Finland... 24
2.3.1 Earlier Finnish intervention studies ... 24
2.3.2 The North Karelia Project (NKP) ... 25
2.4 Cranberry Health Project and the principles on which it is based ... 29
2.4.1 The Cranberry Health Project (CHP) ... 30
2.4.2 Adventist Health Principles (AHPs) ... 32
3 AIMS ... 35
3.1 General aim of the study ... 35
3.2 Specific aims of the study ... 35
4 METHODS AND MATERIALS ... 36
4.1 Phenomenography... 36
4.1.1 Phenomenography versus phenomenology ... 37
4.1.2 How phenomenography was used in this study ... 38
4.2 The study participants ... 38
4.3 Ethical considerations ... 41
4.4 Data collection ... 41
4.5 Data analysis ... 42
5 RESULTS ... 44
5.1 Diet and other lifestyles of the participants prior to the intervention ... 46
5.1.1 Diet/ nutrition... 46
5.1.2 Exercise ... 47
5.1.3 Temperance ... 47
5.1.4 Rest/ sleep ... 48
5.1.5 Others ... 48
5.2 Participants’ motivations to participate in the intervention ... 50
5.2.1 Health related motivations to participate ... 51
5.2.2 Illness related motivations to participate ... 51
5.2.3 Individual(s) related motivations to participate ... 52
5.2.4 TV programme motivations and quest for new inspiration motivations ... 52
5.3 Intervention programme assessment ... 54
5.4 Gained Health Knowledge and Skills ... 59
5.4.1 Diet/ nutrition gained knowledge and skills ... 60
5.4.2 Exercise gained knowledge and skills... 61
5.4.3 Rest/ sleep gained knowledge and skills ... 62
5.4.4 Temperance and other gained knowledge and skills ... 62
5.5 Changes in the participants’ diet and other lifestyles ... 64
5.5.1 Changes in diet/ nutrition ... 65
5.5.2 Changes in exercise ... 66
5.5.3 Changes in water intake... 67
5.5.4 Changes in temperance ... 67
5.5.5 Changes in rest/ sleep ... 67
5.6 Impacts of the diet and other lifestyle changes ... 70
5.6.1 Physical health impacts ... 70
5.6.2 Physiological health impacts ... 72
5.6.3 Mental/ emotional health impacts ... 73
5.7 Motivations to continue with the new diet and other lifestyles ... 77
5.7.1 Health knowledge related motivations... 78
5.7.2 Religious knowledge related motivations ... 79
5.7.3 Personal experience related motivations ... 79
5.7.4 Individuals’ support related motivations ... 79
5.7.5 Illness related motivations ... 79
5.7.6 Good diet related motivations ... 80
5.7.7 Hope related motivations ... 80
5.8 Participants’ Conceptions on Adherences ... 81
5.8.1 Diet/ nutrition adherences ... 82
5.8.2 Exercise adherences... 83
5.8.3 Rest/ sleep adherences ... 83
5.8.4 General adherences ... 84
5.9 Participants’ challenges with implementing changes ... 87
5.9.1 Diet/ nutrition challenges ... 87
5.9.2 Exercise challenges ... 89
5.9.3 Temperance challenges ... 89
5.9.4 Rest/ sleep challenges ... 89
5.9.5 Other challenges ... 90
5.10 Participants’ hopes and anticipations ... 92
5.10.1 Diet/ nutrition hopes and anticipations ... 93
5.10.2 Exercise hopes and anticipations ... 93
5.10.3 Rest/ sleep hopes and anticipations ... 93
5.10.4 Other hopes and anticipations ... 93
6 DISCUSSIONS ... 96
6.1 Categorical discussion of main outcomes ... 96
6.1.1 Lifestyles of the participants prior to the intervention... 96
6.1.2 Motivations to participate in the intervention ... 97
6.1.3 Intervention programme assessments ... 99
6.1.4 Gained health knowledge and skills ... 100
6.1.5 Change in the participants’ diet and other lifestyles ... 102
6.1.6 Impacts of the diet and other lifestyles changes ... 105
6.1.7 Motivation to continue with the new diet and other lifestyles ... 106
6.1.8 Participants’ conceptions on adherences ... 108
6.1.9 Participants’ challenges with implementation ... 109
6.1.10 Participants’ hopes and anticipations ... 111
6.2 Strength and limitations of the study ... 113
6.3 Implications of the study ... 113
7 CONCLUSIONS ... 115
8 REFERENCES ... 116
9 APPENDIXES ... 159
9.1 Appendix one (Letter of consent) ... 159
9.2 Appendix two (Finnish version of the questionnaire)... 160
Figures
Figure 1. The ten main categories of description of the study ... 45
Figure 2. Sub-categories for the participants’ initial lifestyles ... 46
Figure 3. Sub-categories for the motivations to participate in the intervention... 50
Figure 4. Sub-categories for the gained health knowledge and skills ... 60
Figure 5. Sub-categories on changes in diet and other lifestyles ... 65
Figure 6. Sub-categories showing the impacts of the diet and other lifestyle changes ... 70
Figure 7. Sub-categories on motivations to continue ... 78
Figure 8. Participants’ conceptions on adherences ... 82
Figure 9. Conceptions on participants’ challenges with implementing changes ... 87
Figure 10. Conceptions on participants’ hopes and anticipations... 92
Tables
Table 1. Participants' basic information ... 39
Table 2. The participants’ different kinds of NCDs ... 40
Table 3. Conceptions on the prior diet and other lifestyles of the participants ... 48
Table 4. Participants’ conceptions on their motivations to enrol for the intervention ... 53
Table 5. Participants’ conceptions on the intervention programme assessment ... 57
Table 6. Conceptions on the gained health knowledge and skills ... 62
Table 7. Changes in the participants’ diet and lifestyles ... 68
Table 8. Conceptions on the impacts of the diet and other lifestyle changes ... 74
Table 9. Participants’ conceptions on the Motivation to Continue ... 80
Table 10. Participants’ conceptions on adherence ... 85
Table 11. The conceptions on challenges with implementation ... 90
Table 12. Participants’ conceptions on hope and anticipations ... 94
Abbreviations
AHPs: Adventist Health Principles
CDC: Center for Disease Control [and Prevention]
CDs: Communicable Diseases CHD: Coronary Heart Disease CHIP: Health Improvement Program CHP: Cranberry Health Project CRP: C-reactive protein
CV: Cardiovascular
CVDs: Cardiovascular diseases GBD: Global Burden of Diseases
hs-CRP: high-sensitivity C-reactive protein LDL: Low Density Lipoprotein
MONICA: Multinational Monitoring of Trends and Determinants in Cardiovascular Disease MPHN: Master’s Public Health Nutrition
MS: Metabolic Syndrome
NCDs: Non-communicable diseases
NEW START: Nutrition, Exercise, Water, Sun, Temperance, Air, Rest, Trust NKP: North Karelia Project
SD: Sustainable Development SDA: Seventh-day Adventist
SDG: Sustainable Development Goals
THL: Finnish National Institute of Health and Welfare TV: Television
UEF: University of Eastern Finland UN: United Nations
WHO: World Health Organisation
1 INTRODUCTION
Human history has always been characterised with diseases and health interventions therein (Tishkoff & Verrelli 2003, Molyneux 2006). The diseases are many, and for easy identification they are classified into ‘communicable diseases (CDs)’ and ‘non-communicable diseases (NCDs)’. The main difference between the two is that while the CDs are often acute and transmitted through pathogens (Heymann 2008), the NCDs are often chronic in nature and mostly attributed to unhealthy diet and other lifestyles (Kelishadi et al.2008).
Up till few centuries ago (particularly before industrialisation) humans’ greatest health challenges were bent towards CDs (Lederberg 2000), but now improved nutrition, good hygiene, better housing plus modern medicine seems to have contributed greatly to taming many of the pathogens responsible for CDs (UN 1987). Thus, humans should have been somewhat relieved from diseases; but unfortunately, the global rapid increase [to epidemic proportions] of different NCDs seems to be making mockery of past CDs related health gains and achievements (WHO 2017). In fact, the recent World Health Organisation (WHO) data show that NCDs now account for about 71% of the global cause of death (WHO 2018b).
Although the burden of NCDs is rising disproportionately among middle- and lower-income countries and populations (WHO 2017) nevertheless, NCDs remain the most important cause of death in the developed countries (WHO 2018b). In Finland, the high prevalence data of NCDs dates back to the 19th century when cardiovascular (CV) mortality was already a common occurrence (Karvonen 2009). The scenario led to different intervention studies (Keys 1952, Key et al 1958, Roine et al 1958, Turpeinen et al 1960, Karvonen et al 1970, Turpeinen et al 1979, Keys & Aravanis 1980, Miettinen et al 1983, Kromhout & Blackburn 1994) the most popular of which is the North Karelia Project (NKP) which began in 1972 and ended in 1995 (Puska 2009b). Although it was very successful, the Finnish recent WHO NCDs country profile seems not to be very promising (WHO 2014) despite recent Finnish improved health care services and the strengthening of legislations against certain NCDs risk factor related products (Österberg 2007, Reijula et al. 2012).
Studies have repeatedly proven that NCDs are mainly due to unhealthy diet and other lifestyles (Hecht 1999, Roberts & Barnard 2005, Hu 2011, Carrero et al. 2013), and thus lifestyle change has remained the most important tool for preventing and controlling NCDs (Arena et al. 2015) and it is believed to be cheap when compared with the cost of healthcare (Van Baal et al. 2008), Thus this study is centred on lifestyle change (Walsh 2011). Lifestyle change involves a person making some number of transitions in the individual’s lifestyles (Cobb et al. 2006); from the ones harmful to health (Hassan & Killick 2004) to the healthy ones (Verheijden et al. 2007).
But because lifestyle change is a difficult task (Aspinwall & MacNamara 2005), it often requires intervention programmes (Fishbein & Yzer 2003) which are mostly aimed at reducing NCDs’ risk factors (Nissinen 2001, WHO 2013). The intervention programmes are often conducted by health institutions and bodies of health experts who plan (Puska 2009b), execute (Muuttoranta et al. 2009), and evaluate (Puska 2009c) the programme. The programmes often target dietary lifestyle change (Pietinen et al. 2009), improvement in physical activities (Muuttoranta et al. 2009), reduction of or total quitting from substance use (Vartiainen et al.
2009), and so forth. However, in practice the need to make dietary changes often dominate others (Puska 2009b, Laatikainen 2016).
So, in view of the present Finnish NCDs scenario and need for lifestyle changes, an intervention body known as Cranberry Health Project (CHP) emerged in 2012 and she uses ‘Adventist health principles (AHPs)’ known as ‘NEW START’ for her lifestyle interventions. Like relative intervention bodies in other parts of the glove, her goal is primarily to change her clients’ diet and other lifestyles in order for their health to improve. Being a newly emerged lifestyle change intervention body, this is a pioneer study on CHP and it comprehensively explored and described the conceptions of a batch of the intervention participants and explicitly shows the meanings the participants give to their experiences with the intervention.
2 THEORETICAL AND CONCEPTUAL BACKGROUND
In this chapter, literatures which informed the theoretical and conceptual framework upon which the empirical data analysis of this study is built are reviewed. The chapter is divided into four sections; section one gives brief review on NCDs’ recent facts and figures, section two discusses lifestyle intervention for preventing and controlling NCDs, section three gives a brief history of NCDs intervention studies in Finland with emphasis on NKP, and section four gives brief insights on CHP and the AHPs ideology upon which it is built.
2.1 Non-communicable Diseases (NCDs)
This section gives NCDs overviews and outlined the facts that show the need for health intervention. The section as well made explicit who is at risk of NCDs, and Finland’s stand in the WHO recent NCDs country profile was also described. Efforts in tackling the surge of NCDs was also reviewed along with WHO’s global action plan for the prevention and control of NCDs. Then the section ended with the illumination of the nine WHO voluntary global NCDs targets along with insights on the WHO initiated global monitory framework.
2.1.1 NCDs overviews
As the name foretells, NCDs are diseases which are not infectious or transmitted inter- personally. The WHO (2016) data show that there were 56.9 million death in that year, and out of that 40.5 million were associated with NCDs. Furthermore, nearly half of the NCDs mortalities are termed premature death because they occur between the ages of 30 to 69 years, and although about 80% of the NCDs mortality (31 million) occur in the middle and low income countries, nevertheless, NCDs accounts for most morbidity and mortality in the high income countries (Global Burden of Diseases 2015).
There are different kinds of NCDs; they include: cardiovascular disease (CVD), cancers, diabetes and chronic lung diseases, Alzheimer's, Asthma, Cataracts, Chronic Kidney Disease, Fibromyalgia, and so forth. However, four main NCDs account for about 80% of their mortality (WHO 2017), and about a decade ago the mortality was projected to increase by 17% over the
next 10 years (Puska et.al 2009). The four are CVDs (17.7 million), cancers (8.8 million), respiratory diseases (3.9 million), and diabetes (1.6 million) (WHO 2017), and as the above WHO data show, CVDs is by far the leading cause of death followed by cancer.
As the global burden of NCDs has continued to grow, the socioeconomic implications therein have continued to constitute major hindrances to development especially in the twenty-first century. Ala Alwan (Assistant Director General, WHO) argued in Puska et.al (2009) that NCDs are not only closely related to poverty, but also contribute to it, and if left unchecked, may impede development and derail efforts to reduce poverty. Furthermore, the 2030 agenda for Sustainable Development (SD) captured NCDs as a major challenge for SD, which is probably why the Sustainable Development Goal (SDG) target 3.4 is aimed at reducing [by a third]
premature mortality from NCDs through prevention and treatment (WHO 2017).
2.1.2 Who is at risk of NCDs?
NCDs use to be much associated with the elderly people. Nowadays, the trend seems to be changing as increasing proportion of NCDs morbidity and mortality is found among individuals in their middle and young ages; as such it may be logically out of place to continue to view NCDs as diseases of the elderly, instead it should be seen as disease that affect people of all ages (GBD 2015). But despite the changing trend, larger proportion of individuals affected by NCDs remain those who are advanced in age (Strandberg &, Pitkälä 2007).
Furthermore, despite the changing trend, certain NCDs (e.g. CVD), are largely associated with gender (Warren et al. 2010). In addition, there are socio-economic related factors associated with who is more at risk of NCDs; this is largely manifested in NCDs dichotomy between the developed and developing countries (WHO 2018).
2.1.3 The WHO 2015 NCDs country profile: Finland
The WHO has a frequently updated NCDs country mortality profile data for every country, which shows that NCDs account for 92% death in Finland, and the chances of dying between ages 30 to 70 years from any of the four major NCDs (CVDs, cancers, respiratory diseases, and diabetes) is 11% (WHO 2014). In view of the figures, it seems that NCDs remain a call
for concern in Finland (just like in other Western countries) despite the past Finnish public health interventions and their successes. As such, there may be need for the revival of a countrywide public health intervention programme in Finland like the NKP.
2.1.4 Global action plan for the prevention and control of NCDs
Preventing and controlling NCDs have been very challenging (Wagner & Brath 2012). At first studies largely identified NCDs with genes leaving little or no hope for the affected persons to fight back (Vineis et al. 2014), but lately increasing number of epigenetic studies in concord with the Finnish Twin Cohort Study (Kaprio & Koskenvuo 2002) are increasingly suggesting that there is a lot that can be done to switch ON or OFF the genes associated with the surge of NCDs because it is actually the interaction between the genes and the changing human environment that is responsible for the NCDs surge (Halusková 2010, Vineis et al. 2014), so there are now strong optimism to fight back (Roura & Arulkumaran 2015).
Thus, in view of the urgent need to broadly tackle the global surge of NCDs, the WHO has recently formulated action plan focused on reducing the proportion of the four main NCDs through their shared behavioural risk factors. The four most discussed shared behavioural risk factors for NCDs are: tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol (WHO 2013). The action plan provides United Nations (UN) Member States and other stakeholders with road map and policy menu options for taking coordinated and coherent action at all levels in order to attain a set of nine voluntary global targets (WHO 2013).
2.1.5 The nine WHO voluntary global NCDs targets
The nine WHO voluntary global NCDs targets are well pictured in a WHO global monitoring framework table where the nine targets are grouped into mortality and morbidity (1 target), behavioural risk factors (4 targets), biological risk factors (2 targets), and national system response (2 targets), and their twenty five corresponding indicators are also grouped accordingly ( WHO 2018b). As the nine are outlined in WHO (2018b) the targets are: 1) a 25% relative reduction in the overall mortality from CVDs, cancer, diabetes, or chronic respiratory diseases; 2) at least 10% relative reduction in the harmful use of alcohol, as
appropriate within national contexts; 3) a 10% relative reduction in prevalence of insufficient physical activity; 4) a 30% relative reduction in mean population intake of salt/sodium; 5) a 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years; 6) a 25% relative reduction in the prevalence of raised blood pressure or tame the prevalence of raised blood pressure, according to national circumstances; 7) halt the rise in diabetes and obesity; 8) at least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes; and 9) an 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major NCDs in both public and private facilities
2.1.6 Global monitory framework
For the obvious need of explicit evaluation of progresses on the nine targets, the WHO has invented a global monitoring framework which is based on the four groups of the nine targets (mortality and morbidity, behavioural risk facts, biological risk factors, and national system response) (WHO 2018a). While the mortality and morbidity framework monitors the unconditional probability of dying between ages thirty to seventy years from the four main NCDs, the behavioural risk factors framework monitors the harmful use of alcohol, low fruit and vegetable consumption, physical inactivity, salt intake, saturated fat intake, and tobacco use. The biological risk factors framework monitors raised blood glucose/ diabetes, raised blood pressure, overweight and obesity, and raised total cholesterol. Then the national system response framework monitors cervical cancer screening, drug therapy and counselling, essential NCDs medicines and technologies, hepatitis B vaccine, human papilloma virus vaccine, marketing to children, access to palliative care, policies to limit saturated fats and virtually eliminate trans-fats (WHO 2018a).
The framework is being used to track the implementation of the NCDs global action plan by monitoring and reporting attainments on the nine global targets till 2025 against a baseline in 2010. The framework is also designed to urge governments to set national NCDs targets based on national circumstances, develop multisectoral national NCDs plans that will help reduce risk factors exposure coupled with enabled health systems response in order to reach a national
targets by 2025 and then measure results against the Global Action Plan benchmark (WHO 2018a). The next section further gives insight on actions against NCDs with emphasis on positive lifestyle change through health intervention,
2.2 Intervention for lifestyle change
This section began with overview on health intervention, followed by the meaning of intervention in the context of NCDs. Next to that is the meaning of lifestyle and lifestyle change. Then the newly emerged lifestyle medicine was also explored, and the section is concluded with insights on health intervention and its meanings based on experiences.
2.2.1 Health intervention overview
It is becoming clearer that negative lifestyles are closely associated with NCDs. For example, smoking causes lung cancer (Hecht 1999), and constant consumption of fast food coupled with little or no exercise increases the risk of metabolic diseases (Roberts & Barnard 2005, Hu 2011, Carrero et al. 2013) one of the most popular of which is metabolic syndrome (MS) (Kaur 2014).
Furthermore, as there have been alterations in humans’ lifestyles in food consumption, physical exercise, sleeping pattern and duration, and so forth in the last few decades the alterations are believed to be largely responsible for the sharp increase in the prevalence of NCDs (Hu 2011), so modifying the lifestyles through health interventions are therefore believed to be key tool for preventing and controlling NCDs (Arena et al. 2015). Health interventions are mostly aimed at reducing NCDs risk factors (Nissinen et al. 2001) which include unhealthy diet, physical inactivity, tobacco use, and harmful use of alcohol (WHO 2013).
2.2.2 Meaning of intervention
Singling out the word ‘intervention’, the Cambridge Dictionary (2019) defines it as “to become involved intentionally in a difficult situation in order to change it or improve it or prevent it from getting worse”. This definition in the context of NCDs may connote getting intentionally involved in a given group of subjects’ exposures to risk factors for NCDs in order to change or improve the subjects’ health conditions or prevent their ill health conditions from getting
worse. This intervention is often referred to as ‘lifestyle change intervention’ because it involves making certain lifestyle transitions (Cobb et al. 2006).
The aim of health intervention is often to improve health and thereby increase longevity (Gremeaux et al, 2012). Many literatures have also referred this as ‘positive lifestyle change’
which borne the idea that the actual lifestyles which require the intervention are the negative ones which are also harmful to health (Hassan & Killick 2004). In the light of this argument, many literatures have also referred the lifestyles anticipated for and pursued by the subjects of the intervention as ‘healthy lifestyle’ (Verheijden et al. 2007). Beside the WHO (Kickbusch 2003) and other health institutions and bodies, nation-states directly or indirectly contribute to health interventions (Chen et al. 2015) most likely because ‘health is wealth’ not only for individuals but also for nation-states (Roemer 1989, Bloom 2000). It is also worth noting that using the intervention to prevent NCDs is cheap both for individuals and their nation-states (Van Baal et al. 2008). But what actually is the meaning of lifestyle?
2.2.3 Meaning of lifestyle
The word ‘lifestyle’ is a broad term which encompasses different aspects of human lives. It is made up of two English words (life + style). As a specific term, the word was first used by an Austrian psychologist (Alfre Adler: 1870-1937) to express a person's basic character as established from childhood’ or better still it connotes ‘a person’s style of living’ (Online Etymology Dictionary 2010). In a more elaborative way, BusinessDictionary (2018) defines lifestyle as “a way of living of individuals, families, and societies, which they manifest in coping with their physical, psychological, social, and economic environments on a day-to-day basis”. The dictionary as well captures the fact that lifestyle could mean a person’s ‘living identity’ which is expressed in work and leisure behaviour patterns reflecting a person's self- image or self-concept. The dictionary as well captures the fact that lifestyle connotes a person’s attitudes, interests, opinions, values, and allocation of income, and thus it is a conglomerate of motivations, needs, and wants which is influenced by factors such as culture, family, reference groups, and social class (BusinessDictionary 2018). As such, either the healthy or unhealthy lifestyles are transmittable from a generation to another (Case et al. 2002). Therefore, to save
human posterity, the importance of making eminent necessary lifestyle changes or modifications cannot be over emphasised (Walsh 2011).
2.2.4 Lifestyle change
As illustrated earlier, since many of the NCDs emerge due to health adverse way of living, lifestyle change seems to stand out as the most authentic tool for many NCDs prevention and control. Nevertheless, while change is believed to be the most constant thing in life (Doemer 2000), change in lifestyle seems to be a very difficult task, which is why it often requires intervention (Fishbein & Yzer 2003). In that vein, after different options would have been explored, many of the health intervention participants often see the intervention as one of their last hopes for health recovery (Fowler 1997). Furthermore, lifestyle change could idea be partial or absolute; that is, while some aspects of human lifestyles only need modifications, others require complete change. For example, some health experts advocate for complete quit from smoking, while they promote moderate consumption of alcohol (Kahler et al. 2008).
Furthermore, there are psychological challenges with making deliberate and positive lifestyle transitions (Aspinwall & MacNamara 2005). APA (2019) argues that to improve one’s chances of successful positive lifestyle transition, it is essential to focus on ‘one change at a time’. The APA also argues that since negative lifestyles pattern are developed over a certain period of time, it is also essential not to rush the changes, because many have had setbacks with accomplishing their targeted lifestyle change because they try to change too much too fast.
For instance, if a smoker suddenly decides to quit, it is very likely the individual will develops
‘withdrawal syndrome’ (Hughes et al. 1984), in such case the individual will develop difference irregular signs of illness that may last for days, or may not go away until the smoker light up some sticks. This is because the smoker’s system has become used to cigarettes. A similar example is the case where a person who has been very inactive chooses to begin strenuous physical exercise, such intense sudden change may not only be unsustainable, but may be adverse to the person’s health (Kenny & Markou 2001).
So, in view of the importance of making positive lifestyle changes and sticking to them, some health experts recommend using SMART objectives (Bjerke 2017). The known first use of SMART objectives was in Doran (1981) and its use has evolved over time. As illuminated in Bjerke (2017), individuals determined to make and stick to positive lifestyle change would need to set SPECIFIC goals for themselves (e.g. target losing certain amount of weight), MEASURE their progress (e.g. login daily efforts on a calendar) which are predesigned to be ACHIEVABLE (e.g. exercise not too far from what is within one’s capacity), and REALISTIC (e.g. a satisfactory amount of change that is sufficient for realising the targeted result), and accompanied with a set TIME commitment (e.g. specific time to start a routine exercise and targeted time to achieve the goal). Taking this lifestyle change phenomenon steps further may usher in ‘lifestyle medicine’, so what is it about?
2.2.5 Lifestyle Medicine
Lifestyle medicine is defined as “the application of environmental, behavioural, medical and motivational principles to the management of lifestyle-related health problems in a clinical setting” (Egger et al.2009). This is a field of health care which is based on change in personal lifestyle where doctors may need to cooperate with other health care experts like nutritionist, psychologists, and so forth, and in such case rather than being passive, patients get actively involved in their health matters (Sarris & O’Neil 2014). The term is increasingly been used in the twenty first century probably because the importance of the new medical paradigm is becoming popular, and in view of the recent changes in disease pattern this could be the future of medicine (Egger et al.2009). The term was first use as the title of a symposium in 1989 (Yeh
& Kong 2013), and it became the title of an article the following year (Urbanek 1990), and about a decade late it became the title of a book (Rippe 2013).
In one Adventist medical institutions (Loma Linda University in California, U.S.A.) lifestyle medicine paradigm shift was recently introduced as ‘whole person care’. The whole person care is also part of her academic courses designed to equip the institute`s medical students with skills on administering medical treatments beyond the use of drugs. That is – training health care professionals to spend additional time with their patients in talking about their
relationships, addictions, and every other aspects of their personal and professional life which is in contrast with the predominant paradigm (Loma Linda University 2011). But besides health institutions like that, health intervention bodies are increasingly conducting lifestyle intervention programmes.
2.2.6 Lifestyle intervention programme
Principally, intervention programmes involve planning (Puska 2009b), execution (Muuttoranta et al. 2009), and evaluation (Puska 2009c). While the planning stands out as the foundation upon which the success of an intervention programme depends, the execution is mostly characterised with health education and skill trainings, and the evaluation requires careful monitoring of documented experiences especially for progressive improvement of subsequent intervention programmes.
There seems to be no specific model for health intervention programmes, so individual intervention bodies plan and carry out their intervention programmes based on what they deem fit. Thus, interventions are tailored to meet the presumed needs of groups of targeted subjects.
Although health intervention programmes are mostly attended by the aged, it is also useful for the youths. The programme often targets group of individuals who share NCDs risk factors.
Since lifestyle change is central to intervention programmes, it is essential that a body organising intervention programmes should have sound understanding of their subjects and the psychological factors motivating the targeted behaviours for change (Puska 2009b). To further increase the chances of an intervention programme success, the programme ought to be flexible enough to suit most of the intervention participants (Muuttoranta et al. 2009), because it is the very individual experiences with the intervention that determine the extent of its impacts.
2.2.7 Intervention participants and their experiences
There seems to be no (or better still, the researcher could not find) earlier literature on a study like ‘this one’ (which primarily targets the conceptual meanings of health intervention participants based on their experiences), rather there are pockets of available different literature reflecting related intervention experiences. Starting with the health education aspect, Hemming
& Langille (2006) argue that knowledge in health are built upon an existing one. So, because necessity is the mother of invention (Gasper 2003), many health intervention participants tends to build upon their existing knowledge during an intervention programme in making up for some of their health knowledge deficiencies. The intervention health education therein is often centred on teaching participants to refrain from unhealthy lifestyles like smoking (van Osch et al. 2008), to improve healthy lifestyles like physical exercise, to increased consumption of fruits and vegetables (Smith-Warner et al. 2000, Albright et al. 2005), and so forth.
Furthermore, certain health factors motivate participants’ interest to partake in an intervention, and also propel them to continue to adhere to recommendations of the health intervention experts (Damush et al. 2005). Such factors are mostly associated with their past lifestyle related NCDs (Roberts & Bailey 2011). In addition, because the education aspect of health intervention programmes are also characterised with good number of skills trainings, intervention participants tend to acquire satisfactory health knowledge mostly during the period of the intervention (Muuttoranta et al. 2009), and the acquisition of the health knowledge is largely responsible for the possible lifestyle changes therein (Osborne et al. 2007) which in return may improve the participants’ health and lower their healthcare costs (Koyama 2000). Then though participants’ assessments of an intervention programme start right from the beginning of an intervention programme (Eldredge et al. 2016), how the programme influence individual participants’ health is often central to their assessment of the programme (Koyama 2000). In addition, though there are many challenges with changing lifestyles (Brawley et al. 2003), the participants’ health improvements need may continue to keep them motivated to uphold their hopes and anticipating for a better health (Sargeant et al. 2008).
It is also worth noting that beside the main intervention subjects, standard lifestyle change plan should also target other individuals around the immediate social environment of the person (s) pursuing lifestyle changes, because changes are often not apparent in participants’ social community, as such, making the major changes may seem difficult because lifestyle has both cultural and practical dimensions (Muuttoranta et al. 2009). In addition, as much as it is possible, subjects of lifestyle change intervention may better still change their social
environment soon after the intervention programme (Bandura 2003, Rieker et al. 2013) to avoid distracting factors. The next section is narrowed down to intervention studies in Finland.
2.3 Intervention studies in Finland.
Finland is known for her excellent actions against NCDs, this section gives broad and deep- rooted insights on meaningful intervention actions against NCDs in Finland prior to the emergence of CHP. The section is presented in a historic manner with emphasis on the NKP.
2.3.1 Earlier Finnish intervention studies
NCDs mortality being already a common phenomenon in Finland in the nineteenth century (particularly CVD mortality) was not limited to men and the elderly (Karvonen 2009) and thus propelled the necessary intervention studies. In 1947, VäinöKannisto’s demographic doctoral thesis pointed out that higher mortality was taking place in the eastern Finland when compared with other parts, and it was mainly due to higher coronary heart disease (CHD) rate in the east (Puska et al. 2016), which was even the highest in the world (Karvonen 2009). This seemed ironical because forestry, which is physically demanding, and health rewarding was the main occupation in the eastern Finland, and thus should have contributed to the people’s better health and longevity (Karvonen 2009). However, subsequent studies demonstrated links between dietary and other lifestyle factors with CVDs mortality. Keys (1952) was among the first published hypothesis on diet related chain of causation which include: dietary fat, high blood plasma cholesterol, atherosclerosis, and its clinical manifestation in the (CV) system.
The above insight sparked the Finnish first East-Southwest cross-sectional study on coronary risk factors in 1956 which subjected family habitual diets into intense study (Karvonen 2009).
Supporting Keys (1952) cholesterol hypothesis, the results showed that dietary intakes of saturated fats and serum cholesterol values exceeded international standards in the eastern part of Finland (Keys et al 1958; Roine et al 1958). In 1959, time dimension was added to the east and southwest longitudinal study of two contrasting population using 40 to 59 years aged men, and the study was also a component of a ‘Seven Country Study’. Five- and ten-year follow-ups
of the Finnish cohort further confirmed the already established east-west disparity in coronary risk and mortality (Karvonen 2009).
In the cause of the follow-ups, different potential contributing factors to CVDs risk were explored in addition to the existing ones in Keys (1952) hypothesis they include dietary fat, high blood plasma cholesterol, atherosclerosis, and its clinical manifestation in the CV system.
The contributory factors were also explored which include blood pressure, smoking habits, salt intake, trace elements in water, habitual physical activity, thyroid antibodies, childhood environment, war experience, and recent life changes (Kromhout et al 1994). All these led to a preliminary 12 years cross-over dietary intervention that started in 1960 in two Finnish hospitals. The intervention involved introducing soybean oil as substitute for the diary fat in milk and substituting butter with soft margarine which has high polyunsaturated fatty acid content (Karvonen 2009). The investigators observed that as the poly-unsaturated/ saturated fatty acids ratio of the hospitals diet changed (from 0.25 to 1.48 on average), serum cholesterol levels also changed in the participants. In men the serum cholesterol levels changed from 267 to 226 mg/dl, and in women it changed from 275 to 249 mg/dl over the study period, and there were drops in the incidence of CHD in both sexes (Miettinen et al 1983, Turpeinen 1979). The Finnish Heart Association was founded in 1955, and her coming on board coupled with the broad support she received enabled further relative intervention studies (Karvonen 2009).
2.3.2 The North Karelia Project (NKP)
The most outstanding of all Finnish public health interventions is the NKP. It emerged as the world’s first major community-based intervention and preventive study in the area of CVDs which did set a pace for other nation-state (Puska 2009a). The WHO sees the project as a logical step towards the realisation of shared ideas and opportunity for practical testing of prevention in a community setting (Puska et al. 2009). The tremendous success of the project is argued by Puska (2009a) as a ‘proof that a country can significantly halt or reverse the advancement of her NCDs rate through intervention’ (Global burden of Diseases 2015).
The project commenced in 1972 and continued till 1997; thus, lasting for 25 years (Puska 2009b). Initially it served as a pilot project for the nation, and later (from 1977) it went
nationwide (Solomaa et al. 2016). It received thorough and in-depth evaluations and contributed meaningfully to transforming CVDs prevalence in the entire Finland (Puska 2009a). It also contributed to transforming the state of other NCDs and their risk factor profiles (Puska 2009b).
The risk factors responsible for the high CVDs rates in the North Karelia were discovered to be closely linked to the community lifestyles. The most outstanding of which were the community-wide unhealthy eating and tobacco smoking habits. As such, the project was designed to employ a community-based intervention strategy that will shift the risk factor profile of the entire North Karelia population through a number of community actions (Puska 2009b). The project was originally planned for five years (1972 to 1977), but as it was deemed necessary, its five-year interval renewal continued for the next twenty-five years. Then while a large baseline survey population samples was drawn from the North Karelia area, a reference was drawn from the neighbouring province of Kuopio, and Kuopio remained the reference until after 1977 when the project evolved into a nationwide project and other monitoring areas were gradually included (Puska 2009c).
The general aim of the project was to perform a community-based intervention for the benefits of the North Karelia habitants, and to generate novel knowledge that will benefit the entire Finland and other nation-states (Puska 2009b). At first, the main objective was to reduce CVD mortality in the North Karelia local population. But this objective was expanded after the first ten years of the project to include ‘major NCDs mortality reduction’ and ‘local population health promotion’ (Puska 2009a). Then the intermediate objective was ‘to reduce the levels of the risk factors in the local population and to promote secondary prevention’, the main targeted risk factors were smoking, elevated serum low-density lipoprotein (LDL) cholesterol and elevated blood pressure. The working-class individuals within the community were the main targeted population – especially the men (Puska et al.1981). This choice was likely because of the remarkable excess CVDs mortality rate among the middle-aged men in North Karelia (Puska 2009a).
The project contributed to bridging the gaps between medical knowledge and real-life situation (Puska 2009b). The elements of the project include planning, intervention, and evaluation, and while the general aim of the project remained concrete, its objectives were left to operate in a flexible manner in order to adjust to any unforeseen situation (Puska 2009a). Then the main tools employed in the intervention were primary prevention, treatment, rehabilitation and other secondary prevention models (Jousilahti et al. 2016).
As a means of narrowing down the intervention activities in order to get more promising results, certain special sub-projects were initiated in the 1990s, they include: Cholesterol Project, the Smoke-free Campaign, My Choice/ School Health Programme, the Work Site Health Programme, the Health Fair, the Berry and Vegetable Project (Puska 2009d), and youth programmes (Vartiainen et al. 2009), and the project is said to have followed the WHO MONICA protocol model (Kuulasmaa & Tolonen 2016).
The media’s role was focused on advising people on how to change their lifestyles which took different dimensions including sharing of leaflets, health books, strategic pasting of stickers and posters, newspaper editorial reports, radio and television (TV) campaigns, and so forth (Muuttoranta et al. 2009). Then as their contribution to the environmental change, supermarkets offered their environment for health education campaigns and healthier plant-based food alternatives promotion (Muuttoranta et al. 2009). In addition, competitions were used as useful tool to motivate people’s interest towards positive lifestyles (Mäki & Jukola 2009).
The evaluations of the project were divided into formative/ internal and summative/ external evaluations (Puska 2009c). The former was carried out during the programme by the internal personnel to provide quick feedback to the workers and management. While the later gave a summed-up evaluation carried out by the personnel of institutions outside the immediate project team. Since the project was originally planned for 5 years, the first summative evaluation covered the first five years of the project (1972 to 1977). The evaluation assessed the feasibility/ performance, effect, process, cost, and other impacts of the project (Puska 2009c).
The survey results could be divided into behavioural and biological risk factor changes, and morbidity and mortality trend changes. Starting with the former; results on dietary habits show that the consumption of butter and high fat milk drastically decreased. For while the high fat milk was largely replaced with low fat milk, butter use became largely limited to bread spread.
In addition, the intervention drastically increased the consumption of vegetables on one hand and decreased the consumption of sugar and salt (Helakorpi et al. 2009). On diet in general, there were decrease in animal-based foods consumption on one hand and increase in plant- based foods consumption on the other (Pietinen et al. 2009, Vartiainen et al. 2016).
On tobacco smoking, within the first ten years of NKP, there was also a significant drop in the smoking prevalence in the North Karelia when compared with the reference, and the trend continued afterward. For instance, the proportion of men smokers in the North Karelia was 52% in 1972; it dropped to 30% in the mid-1990s (Pietinen et al. 2009, Heloma & Puska 2016).
It is believed that the decline was not only due to the large proportion of quitters, but also because of increased proportion of never-smoked (Heloma & Puska 2016). However, the proportion of women smokers instead of being decreased by the intervention increased instead from about 10% in 1972 to 22% in 2000s (Pietinen et al. 2009). So though the intervention significantly decreased the proportion of men smokers, it did not make the expected impacts on women’s smoking habits, then though subsequent tobacco legislations have been having some effects on smokers and also minimising the chances of second-hand smoke exposure, the ultimate goal is the realisation of a smoke-free Finland, and as suggested by a Finnish formal Prime Minister (Paavo Lipponen) 2040 is the projected time for the smoke-free Finland (Savuton Suomi 2040) goal (Kalu 2010).
Alcohol consumption is reported to have increased over the years (Pietinen et al. 2009). Could it be that the project [like in the case of women smoking habit] had no positive impacts on alcohol consumption? However, the report on physical activity shows that the proportion of Finns who partake in leisure physical activity, walking, and cycling increased (Pietinen et al.
2009).
Then on biological risk factor changes, the risk factors that were surveyed and compared are,
‘serum total cholesterol, blood pressure, and body mass index (BMI)’. The results show that serum total cholesterol declined by 21% in men and 23% in women (Pietinen et al. 2009).
Systolic and diastolic blood pressure measured during the first five years of the project declined faster in both men and women in the North Karelia than in the reference area (Vartiainen et al.
2016). Another positive report on the subject matters is that increased number of people moved from not knowing the importance of serum cholesterol and blood pressure measurements to measuring them at least once in the last six months (Pietinen et al. 2009).
On BMI results, there has been continued increase in men in the North Karelia and other parts of Finland from about 26kg/m2 in 1972 to 27.2kg/m2 in 2007 and in women within the same period, the increase has not been that significant although there are slight variations in different provinces (Pietinen et al. 2009). However, the prevalence of obesity (BMI 30 and above) has constantly increased since 1972 among men and women (Vartiainen et al. 2016).
The decrease in salt consumption contributed to the decrease in the trend of hypertension (Nissinen & Tuomilehto 2009), and the dietary and other lifestyle changes contributed to improvement of functional capacity (Sainio et al 2009), the prevention of type two diabetes (Peltonen et al. 2009), better heart and brain health (Kivipelto & Nigandu 2016), and the NCDs mortality trend in general got better (Jousilahti et al 2016). But undoubtedly, the most outstanding achievement of the NKP is the drastic reduction of CVDs (Jousilahti et al 2016).
2.4 Cranberry Health Project and the principles on which it is based
This is the fourth section of this chapter; it briefly gives some insights on CHP and the AHPs on which it is based. The section began by introducing CHP, her personnel structure and services. Then since the intervention programmes are based on AHPs, an overview of the Adventists health principles (NEW START) was given.
2.4.1 The Cranberry Health Project (CHP)
CHP is a Finnish health intervention service provider which emerged in 2012, and it is privately managed. Its Finnish name is ‘Terveysprojekti Karpalo ry’ and she has a five-person board membership. Since 11.01.2012 she has conducted different batches of partial residence dietary and other lifestyle health intervention programmes in Finland, and over 800 individuals have so far participated (some of the clients have participated more than once). The clients of CHP are mostly individuals over 50 years of age many of whom have been diagnosed with one NCDs or another.
The main aim of CHP is to improving health and well-being of participants, while her main objectives are to offer theoretical and practical skills and training for reducing the main risk factors for NCDs, improve metabolic markers, and generate novel epidemiological knowledge and experience for broader purposes. Her main targeted NCDs risk factors are overweight and obesity, high blood pressure, high serum cholesterol, high blood sugar, tobacco smoking, and alcohol consumption, and the outlined targeted risk factors are in line with what we already know which fall within the WHO identified behavioural and biological risk factors (WHO 2018b)
The CHP programmes start with a five-day diet, exercise and health education programme.
After the first five days of a given intervention batch, the clients are allowed to return home for about five weeks to continue what they have learnt during the first part of the residence programme. After the five weeks, they return for a two-day closing session which is identified with the formula: 5+35+2. During the residence, the participants receive in-depth theoretical and practical training on diet and other lifestyles based on ‘AHPs known as ‘NEW START’
through host or guest health professional lecturer (mostly on voluntary basis).
In the basic training part of the intervention, the clients are made to become familiar with heart- healthy vegetarian foods served to them three times per day. Also, the clients are advised to minimise or avoid refined foods, animal flesh and animal products consumption, eat more fibre rich foods and on regular basis (e.g. vegetables, domestic berries, fresh fruit, nuts, legumes, and whole grain products), and to supplement with Vitamin D and B12 daily. In addition, the
participants who smoke cigarette or drink alcohol are advised to quit them along with caffeinated drinks which may serve as a gateway to other dependant drugs (Reissig et al. 2009).
Furthermore, a daily brisk walking and muscular training exercises are carried out. Although each individual is encouraged to take between 5,500 to 10,000 steps per day (Schneider et al.
2006), the exercises are allowed to be on each individual`s motivation and capacity basis. The clients are also encouraged to participate in classes that strengthen team spirit which tries to keep them on the right tract even after the residency. Separate open lectures and trainings [like seminars where health experts are invited to give health lectures and two-day healthy cooking training] are also organised for the past clients irrespective of their batch.
Before participating in the programme, each client is advised to conduct blood sample tests, and they are advised to repeat the tests at the end of the five-week home intervention follow- up programme to enable assessment of changes in selected biomarkers and health outcomes. The blood-tests analyse the participants` fasting glucose, total LDL and high- density lipoprotein (HDL) cholesterol, triglycerides, and high-sensitivity C-reactive protein (hs-CRP). In addition, they do anthropometric measurements such as height, weight, and waist- to-hip ratio along with blood pressure and pulse examination. Afterward a lifestyle assessment is done by the project doctor or nurse. The entire assessments give the management the opportunity to compare different health outcomes attributable to the intervention. In the first sixteen residence programmes, the above data were collected from the clients, compiled and compared, but due to constrains that include availability of the personnel for compiling and comparing the data, the management could not continue the exercise. But now with the advent of the opportunity to scientifically explore their data, the management has resumed collecting, compiling, and comparing the data.
Puska (2009c) argues that there are already in accumulation abundant wealth of knowledge, as such the question is no longer ‘what should be done’, but ‘how should it be done’. CHP is now bringing to the table novel elements on the ‘how it should be done’, and what difference it will make in the epidemiological literature remain to be seen.
CHP’s main strategies are 1) to offer a unique diet and other lifestyle programme that targets improving diet, exercise, sleep, and stress control. The strategy also include using increased health knowledge, creation of positive attitude, and improvement of participants’ skills to enable them quit alcohol consumption and tobacco smoking, 2) ask participants to take blood tests and anthropometric measurements before and after attending the programme, 3) form and uphold support groups and alumni, and 4) to conduct evidence-based research. CHP uses AHPs like many other organisations in the U.S.A. and other parts of the world. So, she is guided by the Adventist laid down health principles and intervention mechanism. More also, that CHP personnel are Adventists show that her services are largely Adventist centred. Therefore, it seems wise to take some insights on the Adventist health principles.
2.4.2 Adventist Health Principles (AHPs)
Seventh-day Adventist (SDA) is a global religious organisation whose many health literatures include: ‘Counsels on Diet and Foods’, ‘Counsels on Health’, ‘The Health Food Ministry’,
‘Healthful Living’, ‘Medical Ministry’, ‘The Ministry of Healing’, ‘Temperance’, ‘Testimony Studies on Diet and Foods’, ‘A call to Medical Evangelism and Health Education’, ‘Christian Temperance and Bible Hygiene’, ‘Welfare Ministry’, and so forth. The health teachings in them all are either in part or in full consistent with the AHPs - ‘NEW START’.
NEW START is an acronym depicting Nutrition (proper), Exercise, Water (potable), Sunlight, Temperance, Air (fresh), Rest, and Trust in Divine Power. The term seems to have emerged from White (1905, p127) which was written by one of the SDA pioneers - Ellen Gould White.
In the text, she recommends that individual members should use, “pure air, sunlight, abstemiousness, rest, exercise, proper diet, the use of water, trust in divine power….” as natural remedies to heal and prevent diseases instead of depending on medications. This acronym has become the health trademark, emblem and framework upon which the Adventist health philosophies and practices are built. Although each of the natural remedies that constitute the NEW START has always been used long before SDA began to exist in the latter half of the 19th century, the trademark claim for NEW START may probably be limited to the holistic use of the eight principles which she also calls ‘the eight laws of health’ (White 1905).
Besides the many SDA members whose lives are regularly guided by the NEW START, SDA health institutions, health-oriented resorts (sanitariums), privately managed affiliated health organisations, and so forth, differently use the principles to treat and prevent NCDs. For instance, one of the present-day Adventist sanitariums (Weimar Center of Health & Education) in California uses an 18-day NEW START health recovery programme to help individuals prevent or reverse NCDs (Weimar Institute 2015). In view of the order of the principles in White (1905, p27), the acronym should have been ASAREDWT (air, sunlight, abstemiousness, rest, exercise, diet, water, trust), but it is believed that the NEW START acronym emerged when one of the institute`s pioneer health guests arranged the principles in the order which he can easily memorise them, and ever since NEW START has become globally recognised as SDA health emblem (Weimar Institute 2013, Adventist News 2013).
As Comstock (2011) argues, NEW START principles are tools for energy boosting, immune system enhancement, prevention of premature aging, and stopping of the progression of degenerative diseases. This is probably because the principles enable choosing proper diet, avoiding sedentary lifestyle, making proper usage of water, benefiting wisely from sunshine, practicing self-control (which includes complete avoidance of harmful substances), spending quality time in natural environments (the best place to breathe pure and fresh air full of negative ions), avoidance of overwork plus spending quality time resting/ sleeping, and upholding a faith based trust.
Few of the organisations that use AHPs in their intervention programmes are Weimar Center of Health & Education’ in the U.S.A. (headed by Nelson Nedley), ‘Complete Health Improvement Program’ (CHIP) in the U.S.A. (headed by Hans Dehl) Misty Mountain Health Retreats in Australia (headed by Barbara O’Neil), and so forth. For instance, comparing the intervention practices of the three, the differences are obvious, and most likely tailored to fit the environment and the targeted audiences; for while CHIP uses NEW START guided 30-day non-residential intervention lectures (CHIP 2019), Center of Health & Education runs a 18-day residential programme (Health & Wellness 2018), and Misty Mountain Health Retreat uses 8- day/ 7-night residential programme (Misty Mountain Health Retreat 2019). However, unlike the three and other NEW START guided intervention bodies, the newly emerged AHPs
informed Finnish health intervention body (CHP) uses both residence and non-residence intervention approaches in a 5+35+2-day residence-home-residence intervention format.
3 AIMS
3.1 General aim of the study
The general aim is to systematically and comprehensively explore and describe the meanings a group of CHP clients give to their experiences with participating in a health intervention programme.
3.2 Specific aims of the study The specific aims of the study are:
1) To explore the diet and other lifestyles of the participants prior to the intervention and identify their gained knowledge and skills
2) To identify the different factors that motivated the participants to attend the intervention and to continue with the new diet and other lifestyles despite their challenges
3) To explore the participants’ assessments of the intervention programme
4) To identify the changes that have taken place in the participants' diet and other lifestyles and the impacts of the changes
5) To find out the participants' conceptions on adherence to the intervention instructions 6) To identify what the participants’ challenges with the new lifestyle implementations
are, and their hopes and anticipations
4 METHODS AND MATERIALS
For decades studies have either been classed as qualitative or quantitative, and the differences between the two are well established (Fenstermacher 1986, Siljo 1988, Martin & Gaskell 2000, Morse & Richards 2002, Creswell 2003, Wheeldon and Åhlberg 2012). Experts and users of each have always argued in favour of one or the other. However, it is becoming clearer that they are equally useful, and should be chosen based on research goals and objectives. But because quantitative methods are predominantly used in health science studies, experts are increasingly arguing that the less usage of qualitative methods has been creating some knowledge vacuum in the field of health sciences such as sound insights on the behavioural rationale behind some quantitative studies outcomes (Woodside et al. 2015). To fill such gaps, mixed method (combination of quantitative and qualitative methods) is increasingly being used (Creswell 2007). Nevertheless, this health science study is limited to qualitative methods with the intention of understanding the meanings of participating in CHP intervention. As such, emphasis is led on ‘words’ rather than ‘numbers’ (Bryman 2004), and thus it gives in-depth and detailed insights on the phenomenon being studied (Patton 2002). There are different qualitative methods, but the two that are chiefly interested in human experiences are phenomenology and phenomenography. The main qualitative approach chosen for this study is phenomenography because it will meet the main goal of exploring and describing the meanings CHP clients give to their experiences with the health intervention.
4.1 Phenomenography
As a qualitative approach, phenomenography provided the philosophical foundation upon which the empirical data of this study was analysed. Phenomenography is an approach within the interpretivist paradigm (Marton & Booth 1997) which is very descriptive (Marton 1986).
From the phenomenographic viewpoint, experiences are the only reality that exist (Siljo 1996, Uljens 1996), and phenomenography strives to describe the relationships between individuals and their world based on conceptual thoughts and immediate experiences (Marton 1986).
In using phenomenographic approach, it is essential that the researcher reflects on the variation within the population in terms of range of meanings, and not necessarily the frequency of ways
