The Overall Effects of Using the Balanced Epiphany© 21-day Ayurveda Program

According to Johns Hopkins, Ayurveda is a natural system of medicine, originated in India more than 3,000 years ago. The term Ayurveda is derived from the Sanskrit words ayur (life) and veda (science or knowledge). Thus, Ayurveda translates to knowledge of life. Ayurveda is based on the idea that disease is due to an imbalance or stress in a person’s consciousness. Ayurveda encourages certain lifestyle interventions and natural therapies to regain a balance between the body, mind, spirit, and the environment. Ayurveda treatment starts with an internal purification process, followed by a special diet, herbal remedies, massage therapy, yoga, and meditation.

According to the National Center for Complementary Health and Integrative Medicine, only about 240,000 American adults use Ayurvedic medicine. For 3,000 years Ayurveda has been widely used in the sub-continent of India and remains one of their traditional medical systems while America’s primary system is Western medicine. With the costs and overuse of pharmaceutical drugs a 21- day Ayurveda program can be an alternative for improving mind and body wellness.

There is a need for Ayurvedic practices to help reduce polypharmacy. Ayurvedic practices are effective in treating the mind and body and is proven to improve quality of life. When pharmacological efforts have failed Ayurvedic practice should be explored as a treatment option. Whether used alone or in combination with medication, Ayurvedic practices are proven to help with pain, anxiety, mood and other disease states. Ayurvedic practice has shown significant importance of being added to clinical practice so researchers are calling for future research. Recommendations include utilizing Ayurvedic practices alone or in addition to pharmacological therapy to treat the patient holistically.

According to Barlas [1], total hospital spending in 2017 reached $1.1 trillion, compared with $333 billion for prescription drugs, according to a new study by the Centers for Medicare and Medicaid Services. Prescription drug costs are outrageous, and many people are not compliant with their pharmaceutical therapy. Patients are plagued with hospital bills that put them in debt in addition to overwhelming stress. Rehabilitation care is often cut short due to the exhaustion of insurance claims and denials. Overall, hospitals represent 33% of U.S. healthcare costs, physician and clinical spending, 20%; and drugs, 10% [1]. Rioux [2], stated that the explicit discussion of context and process, as related to the intervention and participant response provided insights into the strengths of Ayurvedic medicine for treating a chronic lifestylerelated condition like obesity and the central role of the healing relationship as a stabilizing force for change anchored in increasing self-awareness.

According to Patil SB, et al. [3], with an increase in lifestylerelated disorders there is a worldwide resurgence of interest in holistic systems of health care, particularly with respect to the prevention and management of chronic, non-communicable and systemic diseases. Readmission rates soar due to a combination of hospital costs, pharmaceutical costs or minimization of the care to accommodate budgets. With the costs of Ayurveda therapies being minimal when compared to current healthcare costs this alternative could be utilized to treat patients without current pharmaceutical therapy or with current therapy.

The primary purpose of the project was to determine whether a 21-day program focused on Ayurveda implemented in a holistic medicine clinic can improve the self-concept, physical function, and mental health of women ages 18-80 years of age. Specific aims were to create increased awareness of, promote adoption of, and implement holistic options to treat and benefit voluntary participants.

The Iowa Model for Evidence-Based Practice Change served as a guideline for this project by using its problem-solving approach to aid clinical decision making [4]. The Iowa Model outlines a pragmatic multiphase change process with feedback loops [4]. The model phases are interprofessional team formation; evidence review, critique, and synthesis; change implementation through piloting; ongoing evaluation; and outcomes dissemination [5]. According to Brown [6], the Iowa Model can help nurses and other healthcare providers translate research findings into clinical practice while improving outcomes for patients. The Iowa Model provided grounded guidance for nurses and other providers/ clinicians to make evidence-based practice decisions about clinical and administrative practices that influence patient outcomes.

The Transtheoretical Model of Health Behavior Change provided theoretical underpinning to support the decision making of the participants and their willingness to change health behaviors. The model promotes intentional change motivated through interventions that push the individual though six phases of change. Health behavior change involves progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination [7]. The goal is to reach the termination phase and have the desire to maintain the new healthy behavior.

The team formed for this health promotion initiative consisted of the Clinic Director and the Doctor of Nursing Practice student. Both team members had interest in Ayurveda and the motivation to create increased awareness of the holistic treatments. The clinic director was an Ayurveda nurse practitioner with an established clinic and active patients who served as a convenience sample for the project.

Mills, et al. [8], discussed Ayurvedic practice centered on ayurvedic relationship imbalances and western measures of physical states in their qualitative exploratory study, they explored relationships among imbalances in the Vikruti which was reported via questionnaire and Western measures of psychological states. Data identified an imbalance association with physical and mental issues. Results included more anxiety, more rumination, less mindfulness, and lower overall quality of life. Pitta imbalance was associated with poorer mood and less mindfulness, more anxiety and stress. Kapha imbalance was associated with more stress, more rumination and less reflection. The authors suggest that symptoms of mind-body imbalances in Ayurveda are associated but far different with western assessments of psychological states. They suggest that Ayurvedic dosha assessment should be considered to assess physical as well as emotional wellbeing in research and clinical settings Muraleedharan, et al. [9] outlined in their case study the benefits of utilizing Ayurvedic practice for treatment of endometriosis. One 44-year-old woman underwent an established Ayurvedic treatment for 21 days and a second treatment for two months. They corrected her digestive system imbalance (digestive fire) and performed cleansing therapies known as “shodhana karma.” For two additional months she took an oral oil infused with anthem sowa. She reported a significant decrease in pain during her first, second and third menstrual after initiation of therapy identified by VASSCORE reporting. From menstrual three she continued to show a steady decline every month in her pain levels over a six-month period. There was also a significant reporting of improvement in the quality of life. The authors concluded that Ayurvedic management protocol is effective in managing chronic pain associated with endometriosis, especially when pharmacological methods have failed. According to Rioux (2018), explicit discussion of context and process, as related to the intervention and participant response, provided insights into the strengths of Ayurvedic medicine for treating a chronic lifestylerelated condition like obesity and the central role of the healing relationship as a stabilizing force for change anchored in increasing self-awareness.

Patil SB, et al. [3], reported that with an increase in lifestylerelated disorders there is a worldwide resurgence of interest in holistic systems of health care, particularly with respect to the prevention and management of chronic, non-communicable and systemic diseases. Ayurvedic therapies can give relief from stress and rejuvenating the body [3]. Some of the exercises Ayurveda promotes include mediation, tai chi, walking, swimming, and yoga which could be used by mental health, physical and occupational therapists [3] Activities as healthy community members are more productive and contribute to community and societal stabilization. In a single group pilot study focused on coronary heart disease done in the United States, the research team observed significant improvements in arterial pulse wave velocity, BMI, total cholesterol, LDL cholesterol, and triglycerides in the 22 patients enrolled in an Ayurvedic study [10]. Participation in Ayurvedic wellness courses that incorporate a mind–body–spirit approach to health improves multiple domains of psychosocial well-being, which persists even after course participation [11].

In this quasi-experimental pre and post participation survey health promotion project the participants targeted were a convenience sample of women 18-80 years of age recruited through a Toledo, Ohio based private Ayurveda clinic. The scope of the of the relationship with the clinic director was defined and both roles were established in this initiative. There were several meetings with the clinic director that focused on education, benefits, and appropriateness of Ayurveda. The Ayurveda health promotion program was marketed to established patients of the clinic by flyer and through conversation during appointments. The flyer and conversations highlighted what Ayurveda is and the three aims of the program and briefly identify some of the interventions that will be involved in achieving the desired goals. Participants were sent a flyer regarding the Balanced Epiphany © 21-day Ayurveda plan and voluntarily joined the program. Each participant was assessed to identify their dosha by the clinic’s nurse practitioner who administered a Prakriti and Vikriti quiz when they became established patients of the clinic. The identification of the participants dosha was pertinent to determine which program they were assigned.

Quasi-experimental design health promotion program was used to pilot and monitor the effects of Balanced Epiphany’s© 21- day Ayurveda Program and help voluntary participants improve health outcomes. This quasi-experimental design allowed for the collection of both quantitative and qualitative data.

The volunteer sample included women ages 25-64 years old (n = 10) who were familiar with Ayurveda Practices. The project was conducted in an online setting with optional communication via telephone, text message and email. The Doctor of Nursing Practice student sent individual text messages weekly to each participant with all survey links. No in-person activity occurred due to concerns with the active Covid-19 pandemic.

The Medical Outcomes Scales SF 36 was used to assess eight health concepts: limitations in physical activities because of health problems; limitations in social activities because of physical or emotional problems; (limitations in usual role activities because of physical health problems); bodily pain; general mental health (psychological distress and well-being); limitations in usual role activities because of emotional problems; vitality (energy and fatigue); and general health perceptions. The Medical Outcomes Scale SF 36 was given two days prior to the start of the program. Each week the participants responded to a two-question survey to assess progression and motivation to continue the program. The Medical Outcomes Scale SF 36 was then administered again to assess for improvement in self-concept, physical function, and mental health.

Project consistency and adherence to project guidelines was measured weekly via informal random audits until the project and the Balanced Epiphany© 21-day program was completed. Consistency with weekly check-ins for participation survey was evaluated by confirming receipt of the survey.

No costs were associated with the Medical Outcomes Scales SF 36 and the Balanced Epiphany© 21-Day Ayurveda program. Participation was free for volunteers in this project. The health promotion program had no more than minimal risk. An expedited review completed by a private university Institutional Review Board granted permission to conduct the project. Permissions were received from the clinic director to use copyrighted 21-day Ayurveda Program information from Balanced Epiphany©.

A statistician assisted in the evaluation and processing of the results. Evaluation was done utilizing the Medical Outcomes Scale SF-36 pre- and post-implementation results of the project the ages of the participants (n =10) that participated in the study ranged from 25-64 years of age. Areas assessed were age, ethnicity, work status, and participant dosha. Seventy-two percent of participants identified as Black or African American and 27% White. Seventythree identified as single and 27% married. Eighty-one percent reported working full-time, 0.09% as part-time and 0.09% as selfemployed/ freelance. Forty-five percent identified their dosha as kapha, 36% pitta, and 18% vata. 100% of participants started and fully completed the full 21 days.

The pre and post intervention comparative evaluation process focused on limitations of physical activity, social activity, bodily pain, physiological distress and well-being, vitality and general health perceptions before and after 21 days of the Ayurveda health promotion project. To analyze the pre- and post- surveys a paired 2-sample t test was used. Although there was not a statistically significant improvement (p value = < 0.05) between all categories physical function did reject the null hypothesis and was statistically significant. According to the mean of each category the participants scores increased from pre-survey to post-survey.

To assess barriers and motivation of participants a weekly survey was given to all participants (n = 10). Week one survey identified barriers to adhere to the plan due to work by participant and ability to adhere to food restrictions recommended by their dosha. All reported that they were motivated to continue with the program. Week two survey identified a social activity as a barrier to adhere to the program during week two and all reported being motivated to continue the plan. Week three survey identified time as a barrier by respondent and all reported being motivated to continue the plan.

Physical Functioning - Participants reported an increase in function according to the mean. Null hypothesis was rejected since the p-value is less than alpha. Role Functioning/Physical - Participants reported an increase in Role Functioning/Physical according to the mean. Null hypothesis cannot be rejected in this category. P-Value is greater than alpha. Role Functioning/Emotional- Participants reported an increase in Role Functioning/Emotional according to the mean. Null hypothesis cannot be rejected in this category. P-Value is greater than alpha. Energy/Fatigue - Participants reported an increase in Energy/Fatigue according to the mean. Null hypothesis cannot be rejected in this category. P-Value is greater than alpha. Emotional Well-being -Participants reported an increase in Emotional/Well-being according to the mean. Null hypothesis cannot be rejected in this category. P-Value is greater than alpha. Social Functioning - Participants reported an increase in Social Functioning according to the mean. Null hypothesis cannot be rejected in this category. P-Value is greater than alpha. Pain- Participants reported an increase in Pain according to the mean. Null hypothesis cannot be rejected in this category. P-Value is greater than alpha. General Health - Participants reported an increase in General Health according to the mean. Null hypothesis cannot be rejected in this category. P-Value is greater than alpha.

Limitations included a small sample size and the Covid-19 pandemic. The convenience sample utilized for this project was affiliated with Balanced Epiphany©. Expanding beyond the clinic could have increased statistical significance for the categories assessed on the pre and post-test. Beyond the 21-days required for the program follow-ups are needed to ensure maintenance which was not part of this initial study. Strengths of the program included strong support from the university and easy to read plans with educational information about Ayurveda and a brief overview of each dosha. The barriers of the project were minimal, and supportive facilitators were essential to ensure completion of the program. An effective program evaluation and follow up plan will ensure that the health promotion program will be sustainable and utilized in many areas of healthcare.

Theory supported the project led by nurse scientists who appropriately applied the Iowa Model for Evidence-Based Practice Change to organize the team to plan and formulate change. The Transtheoretical Model of Health Behavior Change was used by the leaders to predict, plan, and support necessary participant behavioral and lifestyle changes.

Beyond the pilot, there will be a need for Ayurveda providers to establish relationships with service providers in all fields. Key points to highlight for marketing purposes would be the objectives, partners budget, locations interventions, potential obstacles and challenges, outreach strategies, findings, and evaluation strategies from the pilot. It is also important to identify the motivation a patient has to change their health-related behaviors. This identification can assist in fostering a practitioner client relationship to collaborate and coordinate treatments as a team. Based on the positive correlations of the pilot, the authors believe Ayurveda treatment plans can assist in primary, secondary and tertiary prevention. Implementing the Balanced Epiphany© 21-day Ayurveda Program into practice promotes self-autonomy in making the decision to improve health related behaviors that can negatively impact health. When patients are included in making decisions regarding their treatment plans patient satisfaction and feeling of well-being can show significant improvement. The Balanced Epiphany© 21-day Ayurveda program has the capability of being offered in many different practice settings besides stand-alone Ayurveda Clinics which will be the focused work of this author to create sustainable health outcomes for future generations. Using this program will increase awareness of holistic options in treating patients instead of focusing on only Western medicine and help in the reduction of polypharmacy.

The introduction of an Ayurveda health promotion program to healthcare can be beneficial in many ways to patients, medical providers and therapists. An Ayurveda health promotion program can stand alone or be used in addition to pharmaceuticals and other therapies. With the increasing costs of healthcare and pharmaceuticals additional interventions with minimal costs are needed as an alternative. Project results identified several improvements. Balanced Epiphany© 21- Day Ayurveda program is effective in improving quality of life specifically, self-concept, physical function, and mental health [12-16].

The authors appreciate the statistical assistance provided by Beryl Stemens, MS for this project. This work posthumously honors the holistic nursing spirit and Ayurvedic work of the late Dr. Temeaka Gray-El.

The authors have no conflict of interest to disclose.