VALIDATION OF THE “EIGHT NATURAL REMEDIES QUESTIONNAIRE” – Q8RN – ADULT VERSION

The Eight Natural Remedies Questionnaire (Q8RN) comprises eight dimensions: nutrition, exercise, water, sunlight, temperance, pure air, rest, and trust in God. It is used to assess adherence to the healthy habits of the Adventist lifestyle. This article aims to analyze the attributes of validity 1 Nurse, PhD in Science. Professor in the Health Promotion Master Degree Program at the Adventist Univesity of São Paulo (Unasp-SP), Brazil. E-mail: gina.abdala@unasp.edu.br 2 Nurse, PhD in Science. Professor in the Health Promotion Master Degree Program at the Adventist Univesity of São Paulo (Unasp-SP), Brazil. E-mail: dyrcem@yahoo.com.br 3 Physical Therapist, PhD in Morphological Sciences (Neuroscience), Professor in Medical Science, Jundiaí, SP, Brazil. E-mail: ricardonoboro@hotmail.com 4 Engineer of CI&T Software, Campinas, SP, Brazil. E-mail: gabriel.tagliari93@gmail.com 5 Bacharelato in Law Science, Network Technology Computers and Systems for the Internet. Post-doctor Unicamp. PhD in Education, professor at the Adventist University of São Paulo (Unasp-SP). E-mail: roberto.sussumu@ucb.org.br 6 Physical Educator, Post doctor Unesp. PhD in Human Development and Technologies at Unesp. Professor at the Adventist University of São Paulo (Unasp-SP). E-mail: ivanwallan@gmail.com


Introduction
The Eight Natural Remedies (ENR), named since 1863 by Ellen G. White, consist of: Nutrition, Exercise, Water, Sunlight, Temperance, Pure Air, Rest, and Trust in God. Health practices related to ENR have been considered as healthy principles of life that can help to promote health, prevent disease and maintain quality of life (WHITE, 1905). 7 It is also reiterated that each one of these Natural Remedies has specific beneficial effects to promote and restore health. For a better understanding of its applicability, the concepts adopted in this study for each one of them will be described below.
Besides the internal use of water, it is important to use it as a therapeutic resource, applied externally. Hydrotherapy, in all forms of indication, is useful for calming nerves and balancing the circulation (WHITE, 2009, p. 267).

Sunlight
Sunlight has several benefits such as: helps in brain and cognitive biological functions (Bezerra et al., 2016); improves mood and fights depression (THOMAS; AL-ANOUTI, 2017); self-regulation of the body -influences the production of hormones and synthesizes and metabolizes vitamin D (OLIVEIRA et al., 2014;QUADROS, OLIVEIRA, 2016).

Temperance
Temperance, according to DeCS (2018), 11 means habitual moderation in the indulgence of a natural appetite, especially in relation to alcohol consumption. In the present study temperance was considered as "avoid everything that is harmful, and to use wisely what is wholesome and nourishing" (WHITE, 1877). 12

Pure air
Pure air is a mixture of gases present in the earth's atmosphere, consisting of oxygen, nitrogen, carbon dioxide, and small amounts of other gases. Pure air is considered to be free of contaminants or pollutants that interfere in the human health and well-being or cause harmful effects on the environment (DeCS, 2018). 13 individuals, regardless of age, gender and economic situation (BELLOC, BRESLOW, 1972).
Adventists residing in Loma Linda -California have been studied, being considered a special group of long-lived people seeking to live a healthy lifestyle based on healthy practices related to ENR. The researchers admitted that these habits bring benefits to the cardiovascular system and, consequently, lower mortality risks. They also affirm that religious involvement and activities in the church act as protective factors for mortality, when associated with healthy behavior and social and emotional support (KWOK et al., 2014;MORTON;LEE;MARTIN, 2017).
The National Policy for Health Promotion -PNPS, approved by the Minister of Health of Brazil through Administrative Rule no. 687 on March 30, 2006(BRASIL, 2006 proposes actions that aim at the coverage of "care" related to human needs for integral health. Within this scope, Health Promotion is defined as "a mechanism for strengthening and implementing a transversal, integrated and intersectoral policy […]" (BRAZIL, 2006, p. 18). 17 Thus, the Health Promotion seeks, based on the intersectoriality, involving the spheres of the private sector, government and society, to overcome the determinants of the health-disease process, implementing actions that aim to stimulate the systematic practice of physical exercise; the adoption of a healthy diet; measures to combat smoking and alcohol and other actions to promote active aging, which can be implemented in the Health Fairs (MEIRA et al., 2015).
In the axis of integral care, the PNPS proposes actions to strengthen the SUS and the expansion of actions for the prevention and Chronical Diseases Control at different levels of care, with a special focus on Primary Health Care (PHC) (MALTA, NETO; SILVA JR., 2011).
Regarding health-related lifestyle assessment, although it is possible to find instruments with reasonable psychometric properties and internal consistency, these instruments do not contemplate the eight components of the Adventist healthy lifestyle proposal (PÔRTO et al., 2015).
Some of them are too extensive to be applied effectively in events that associate research with educational and / or behavioral interventions, as in the case of "Health Fairs", and it was necessary to construct and validate an instrument that would measure this lifestyle as a whole issue (EXPO HEALTH MANUAL, 2018). 18 The construct of the "Eight Natural Remedies Questionnaire" (Q8RN) was analyzed by judges in all its extension with eight dimensions and 25 items (ABDALA et al., 2018) and considered validated as to the content, being applied to approximately 500 participants of Health Fairs held in the state of São Paulo.
Continuing the validation process of the instrument, this study aimed to analyze the attributes of validity and reliability of the "Eight Natural Remedies Questionnaire" (Q8RN), in the adult version, to investigate the adoption of the constitutive habits of the Adventist lifestyle.

Material and Method
This is a descriptive study, methodological type, involving 504 participants from "Health Fairs" offered in public spaces in the State of São Paulo, Brazil. The model of the fairs is described on the Seventh-day Adventist Church's (SDA), South American Division website (2018) 19 that provides practical guidance on the benefits of each addressed remedy.
The Q8RN was based on White (1905, p. 127) 20 and literally embraces the principles of a healthy life: "Nutrition, Exercise, Pure Water, Sunlight, Temperance, Pure Air, Rest, and Trust in God." In addition, the components of this instrument were based on some validated lifestyle tools in Brazil and in other countries. They are: FANTASTIC Questionnaire, validated by Rodriguez Añez, Reis, Petroski (2008), Ramírez-Vélez, Agredo (2012) and Silva, Brito and Amado (2014) and applicable to the population from 15 years of age; NAHAS Pentacle Questionnaire, validated by Nahas, Barros, Francalacci (2000); DUKE-DUREL Religious Questionnaire, validated by Taunay et al. (2012) and Lucchetti et al. (2012).
The data were collected in "Health Fairs" held in various places in São Paulo: schools, parks, blocks, streets, etc. Participants signed the Consent Form and responded to the questionnaire on a Tablet configured as an Applicative developed on the Android system.
Factorial Confirmatory Analysis (FCA) was performed in the R program, by a WLMSV (Weighted Least Squares Mean and Variance--adjusted) polychoric type, in which the categories of responses of the questionnaire evaluated were, for the most part, Likert (TELLO et al., 2010). For the results, Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) values greater than 0.92 and Root Mean Mean Square of Approximation (RMSEA) less than 0.07 were considered acceptable (HAIR et al., 2009).
The IFC means the comparative or incremental adjustment index. It measures a relative improvement in the adjustment of the researcher's model in relation to the standard model. The closer to one, the better. TLI indicates non-standard Tucker-Lewis index. There are aspects that compensate for the effects of the model's complexity. The value may fall outside the range of zero to one, but values close to one indicate a good fit. The RMSEA, also called the parsimonious adjustment index, estimates how well the parameters of the model reproduce the population covariance, being better equal to zero. Values close to 0.06 or smaller indicate reasonable adjustments to the model. The Standardized Root Mean Square Residual (SRMR) is based on the discrepancy between the correlations in the sample matrix and the correlations predicted by the model, that is, it is based on the differences between the predicted and observed covariance. The closer to zero the better (LEÓN, 2011;HAIR et al., 2009).
The Cronbach's alpha test was also evaluated as a measure of the internal consistency of the construct that varies from 0 to 1, with values from 0.60 to 0.70 considered as the lower limit of acceptability (HAIR et al., 2009). This study was approved by the Research Ethics Committee of the proposing institution, number 1,404,196, on 02/02/2016. Participants signed the Free and Informed Consent Term (TCLE) pursuant to resolution 466/12 of the National Health Council.
When applying the FCA, three questions were taken from the Dimensions: 1 -Nutrition: How many meals do you make per day? (breakfast, lunch, dinner, snack, etc); 5 -Temperance: Do you consider yourself balanced about time spent studying, working, internet, television, meals, friendships, According to the FCA, according to R Software, there was evidence of validity of the Q8RN instrument as the factorial load presented goodness of fit adjustment data: Comparative Fit Index (CFI) = 0.972, Tucker-Lewis Index (TLI) = 0.964, parsimonious -RMSEA = 0.044 and WRMR = 1.024, confirming the evidence of validity. The multivariate analysis allowed to maintain the eight dimensions, but indicated reducing from 25 to 22 questions of the original instrument, thus becoming a Q8RN with 22 items.
For the calculation of the classification of the lifestyle, it was followed the logic of proportion of the scores adopted by the FANTASTICO Questionnaire of Rodriguez-Añez et al. (2008).
Cronbach's Alpha was 0.72, indicating internal reliability of the instrument. The correlation matrix between the items showed that some loads factors are weak but with good adjustments in the model (Tables 2 and 3).  The standardized table of Q8RN items showed that most items (90.9%) had loads above 0.40 and all had statistical significance (p <0.05). In addition, there was a covariance between two variables of the "trust" dimension, where confidence in God or in a higher being positively influences people's way of living and vice versa (p <0.05) ( Table 4).

Discussion
Lifestyle has been a factor of great repercussion when it is associated with the prevalence of chronic diseases. Studying about its influence in promoting health linked to the practice of "Eight Natural Remedies" is of paramount importance. In order to improve the evaluation of adherence to these healthy principles of life, we opted to evaluate the validity evidence of a new instrument, whose validation of the construct has already been finalized and presented in the study by Abdala et al. (2018).
As it is a multidimensional, objective and pre-established dimensions' instrument based on the Adventist health philosophy (KWOK et al., 2014;Morton;Lee, Martine, 2017), a polychoric estimation analysis was used. This allows to correlate / covariate categorical items, which is possible to treat categorical variables as continuous variables (HOLGA et al., 2010).
When comparing the goodness adjustments of the present study with those applied in similar instrument validations on lifestyle, it was observed that similar values were found in a validation of an instrument called Health Promoting Lifestyle Profile-II (HPLP-II) in which the authors analyzed nutrition, good health habits and physical activity of 788 university students. The results of the goodness adjustments reached were: CFI 0.92, TLI = 0.90, RMSEA <0.045 and SRMR 0.055 (p <0.001). The internal consistency of this instrument was 0.70 (LIM et al., 2016).
The limitation of this study is that we did not find similar publications to compare the results found in the validation process of Q8RN, considering all the dimensions, estipulating them as gold standard.

Conclusion
The adult lifestyle, based on the Adventist health philosophy, could be assessed through the Q8RN which, after review process maintained the original eight dimensions and was reduced to 22 questions.
The measures of validity and reliability reached adequate indexes, being considered an instrument that presents evidences of validity and reliability, corresponding to the proposal of a healthy lifestyle, based and guided by Eat dairy and eggs more than once a month and fish and meat less than once a month Strict vegetarian: Consume milk, cheese, eggs, fish or meat   How to calculate the total Q8RN score: The total Q8RN score is the sum of the points assigned to each item, that is, each question scores from zero (0) to four (4), totaling a maximum of 88 points if all 22 questions are answered.
To classify Lifestyle based on the "Eight Natural Remedies", the following parameters must be considered: