We and they in the house of healing: debate among Arab complementary medicine practitioners on an integrative versus alternative approach to supportive cancer care

Barriers to Applying Integrative Oncology from the Perspective of the Care Providers in Iran: A Mixed-Methods Study

OBJECTIVE

The present study aims to explain and determine the use of integrative oncology from the perspective of the care providers in Iran.

DATA SOURCES

This mixed-methods study is a convergent type of study with quantitative and qualitative phases that have been performed simultaneously. The quantitative phase was a descriptive study that was conducted through convenience sampling. With the use of a psychometrically evaluated questionnaire with 10 items, 202 nurses and physicians were included in the study to assess their views on the integration of traditional and complementary medicine (TCM) within supportive cancer care. The qualitative part of the study was conducted through semistructured interviews with 11 care providers. The interviews were analyzed through conventional content analysis and the method proposed by Graneheim and Lundman with the use of MaxQDA software.

CONCLUSION

After the quantitative and the qualitative data were combined, we identified four main categories as the important dimensions of using TCM: patients' main expectations of TCM services, reasons for using these services, existing challenges and barriers, and recommendations and strategies to improve the interaction between physicians and patients to facilitate the use of integrative oncology .

IMPLICATION FOR NURSING PRACTICE

Although cancer patients use TCM due to a wide range of expectations, there are many barriers to integrative oncology in Iran. Therefore, it is necessary to pay attention to the benefits of conventional medical and TCM treatments, conceptualize integrative oncology, and try to meet the existing challenges.

Medicinal plants in the treatment of urinary tract malignancies during the Araboislamic period (7th- 14th century AD)

Arabic medicine, or Arab-Islamic, mainly refers to all developments achieved in the Age of Khalifs, or the Golden Age of the Arab-Islamic civilization (ca 7^th-14^th centuries AD). Arab scholars adopted ancient Greek medicine and soon understood the essence of the fatal disease known as cancer. They introduced various new types of cancer, distinguishing other entities like infection and proposed new methods of treatment, both surgical and non-invasive. Herbal medicine after Dioscurides and Galen bloomed in the Arabic world. Malignancy of the urinary tract was identified and a plethora of herbs were used to slow down its expansion. Moreover, herbal drugs were introduced to alleviate cancerous symptomatology. Avicenna introduced Hindiba, while known scholars like Abulcasis and Rhazes noted the benefits of garlic, onion, black seeds, pomegranate, olive oil as well as leaf and bread wheat. Arabian herbal medicine may still be beneficial in anticancer fight and mainly in the palliative medicine. It should be emphasized that almost 50% of the drugs administered today have their point of origin in the plants used in antiquity.

The Intersection Between Models of Health and How Healing Transpires: A Metaethnographic Synthesis of Complementary Medicine Practitioners' Perceptions

Introduction: This metaethnography provides an interpretative synthesis of complementary medicine (CM) practitioners' perceptions toward their health model and the healing process. CM is commonly described on the basis of its distinction from biomedicine with limited research available on CM practitioners' understanding of what the essence of their practice is and how healing transpires as a result. This is despite the significant patronage of CM and high rates of couse with biomedical services. Materials and Methods: An extensive and systematic search of the literature was conducted across seven databases (AMED, SINAHL, Medline, PsycINFO, PUBMED, Science Direct, and Scopus) with no date, language, or region restrictions applied. The basis for the search was MeSH terms and keywords relating to (1) CM practitioners, (2) perceptions, and (3) healing. A screening process was conducted and articles were identified for inclusion based on their addressing the research question. These articles were then quality appraised. A seven-stage metaethnographic framework was utilized to assist with identifying and interpreting the themes within the data. Results: Following the screening process, merely 10 qualitative studies were identified, which represented practitioner views across 22 CM professions. CM practitioners believe they provide a distinct model of care informed by a traditional shared holistic and vitalistic philosophy. Nonspecific factors, such as an augmented therapeutic relationship, empathy, and patient empowerment, are actively and deliberately incorporated into the treatment process alongside specific interventions and afforded equal valued. Conclusions: This metaethnographic synthesis brings together the perceptions of CM practitioners on how healing transpires within the CM clinical setting. In a context of medical pluralism and aspirational integrative health care, this synthesis highlights the understanding and approach CM practitioners bring to health management and may assist in further defining CM philosophy and practice, and the positioning of CM in the contemporary health care landscape.

Integrating Complementary and Traditional Practices in Middle-Eastern Supportive Cancer Care

The Middle East is a promising arena in which researchers can explore the interchange between cross-cultural traditional medicine and supportive cancer care, as provided within an integrative oncology setting. Integrative oncology research and clinical practice in this part of the world have been focusing, for the most part, on the use of herbal medicine and mind-body-spiritual modalities, both of which are deeply rooted in traditional medical care. A regional, multinational, and interdisciplinary collaboration is currently being undertaken as part of the academic activities of the Middle-East Research Group in Integrative Oncology (MERGIO). This group is part of the Middle-East Cancer Consortium, a body supported by the National Cancer Institute. MERGIO currently facilitates a number of innovative educational, basic science, and clinical research projects that are investigating the effectiveness and safety of traditional herbal remedies. In order to create a structured, pragmatic "bedside-to-bench" and subsequent "back-to-bedside" approach, MERGIO has designed a patient-tailored integrative oncology model of supportive-palliative care. This approach addresses both patients' individual health belief models and the larger social-cultural-religious context, as defined by the health-related values of the patient's community.

Crossing the death threshold: experiencing multi-disciplinary end-of-life integrative oncology training

OBJECTIVE

Complementary and integrative medicine (CIM) is acknowledged in more and more oncology-care centers as part of supportive and palliative cancer care. However, only limited research is available on medical training of CIM practitioners regarding end-of-life (EOL) care. In this study, we assess the impact of multi-disciplinary EOL training on cultural-diverse groups of CIM-trained healthcare practitioners (HCPs) working in integrative oncology care settings in Germany and Israel.

METHODS

The authors co-designed an evidence-based patient-centered EOL-training curriculum incorporating palliative and CIM concepts of care. Afterwards, a 3-day course was designed for 25 HCPs working in three anthroposophic-medicine-oriented medical centers in Germany and 14 CIM-trained HCPs from one oncology center in Israel. Qualitative assessment of the EOL-training impact on trainees was assessed 4-month post-intervention. Narratives were analyzed using ATLAS.ti software for systematic coding.

RESULTS

Post-training narrative assessment was reported by 18 German and 14 Israeli HCPs comprising 10 physicians, 12 nurses and paramedical practitioners, and 10 CIM therapists and spiritual care-providers. Content analysis of post-training outcomes suggested participants' attitude-change regarding their professional role in EOL care as individuals and as members of a team. Participants acquired practical clinical tools to enhance EOL care and to better communicate with patients about death, implementing a patient-centered, cultural-sensitive approach.

CONCLUSIONS

EOL training of CIM-trained HCPs enhances communication and palliative clinical skills. Multidisciplinary and international training settings emphasize a cross-cultural perspective and enrich the bio-psycho-social-spiritual model of palliative care.

Integrated care in cancer: What is it, how is it used and where are the gaps? A textual narrative literature synthesis

Integrated care is an underpinning concept of contemporary health care policy proffered as a strategy to overcome the fragmentations in care encountered by people with complex care needs (Shaw et al. [2011] What is Integrated Care? An Overview of Integrated Care in the NHS). Cancer patients have potential to benefit from such policy, often having needs that extend beyond cancer. This paper seeks to understand how the concept of integrated care is used in the cancer literature. A search of leading databases was conducted for original research relating to integrated care or an integration intervention aiming to improve outcomes of cancer patients, and analysed using textual narrative synthesis. 38 papers were included, each with a focus on improving cancer-specific aspects of care enhancing the capabilities of the cancer multidisciplinary team. Of the eight studies involving integration between the cancer service and other care providers, all focused on utilising the external provider to deliver aspects of cancer care or placed them in a passive role, as survey participant, a recipient of cancer-related clinical information or as the comparator "usual care" arm. Within the cancer literature, integration is predominantly used to describe initiatives to improve cancer-related aspects of care. Less attention is given to integration initiatives that enhance coordination across levels of the healthcare system or service providers.

Perception of risk and communication among conventional and complementary health care providers involving cancer patients' use of complementary therapies: a literature review

BACKGROUND

Communication between different health care providers (conventional and complementary) and cancer patients about their use of complementary therapies affects the health and safety of the patients. The aim of this study was to examine the qualitative research literature on the perception of and communication about the risk of complementary therapies between different health care providers and cancer patients.

METHODS

Systematic searches in six medical databases covering literature from 2000 to 2015 were performed. The studies were accessed according to the level of evidence and summarized into different risk situations. Qualitative content analysis was used to analyze the text data, and the codes were defined before and during the data analysis.

RESULTS

Twenty-nine papers were included in the primary analysis and five main themes were identified and discussed. The main risk situations identified were 1. Differences in treatment concepts and philosophical values among complementary and conventional health care providers. 2. Adverse effects from complementary products and herbs due to their contamination/toxicity and interactions with conventional cancer treatment. 3. Health care physicians and oncologists find it difficult to recommend many complementary modalities due to the lack of scientific evidence for their effect. 4. Lack of knowledge and information about complementary and conventional cancer treatments among different health care providers.

CONCLUSION

The risk of consuming herbs and products containing high level of toxins is a considerable threat to patient safety (direct risk). At the same time, the lack of scientific evidence of effect for many complementary therapies and differences in treatment philosophy among complementary and conventional health care providers potentially hinder effective communication about these threats with mutual patients (indirect risk). As such, indirect risk may pose an additional risk to patients who want to combine complementary therapies with conventional treatment in cancer care. Health care providers who care for cancer patients should be aware of these risks.

Perceptions of complementary medicine integration in supportive cancer care of Arabs and Jews in Israel: a cross-cultural study

CONTEXT

There is a dearth of studies on how cultural background influences patients' attitudes and choices regarding complementary and traditional medicine (CTM) integration.

OBJECTIVES

To explore Arab and Jewish patients' perspectives regarding CTM use and its possible integration within conventional cancer care.

METHODS

This was a cross-cultural study. We developed a 27-item questionnaire that evaluates patients' perceptions regarding CTM integration in supportive cancer care. The questionnaire was administered to a convenience sample of patients receiving cancer care in community and hospital oncology centers.

RESULTS

Of the 770 respondents (response rate 88%), 324 defined their religion as Muslim, Christian, or Druze (henceforth, regarded as Arabs) and 446 were Jews. Respondents in the two groups differed significantly in terms of age, gender, marital status, number of children, education, religiosity, and prevalence of cancer types (excluding breast cancer). Although Arab respondents reported less use of CTM for cancer-related outcomes (39.6% vs. 52.1%; P = 0.001), they expressed greater support than Jewish respondents for optional CTM consultation if provided within conventional oncology care (P < 0.0001). Respondents in both groups stated that their primary expectation from the oncologist concerning CTM was to participate in formulating a CTM treatment plan to be provided within the oncology department. Compared with Arab respondents, Jews expected CTM consultations to focus on improving daily functioning and coping, reducing chemotherapy side effects, and providing spiritual support.

CONCLUSION

Although quality of life-related expectations are more pronounced among Jewish respondents, both groups share the expectation from their health care providers to be actively involved in construction of a tailored integrative CTM treatment plan.

Religious/spiritual characteristics of indian and indonesian physicians and their acceptance of spirituality in health care: a cross-cultural comparison

Religious/spiritual (r/s) characteristics of physicians influence their attitude toward integrative medicine and spiritual care. Indonesia physicians collaborate with traditional, complementary, and alternative medicine (TCAM) professionals within modern healthcare system, while Indian physicians are not reported to do so. The aim of the study was to understand the r/s characteristics and their influence on Indian and Indonesian physicians' acceptance of TCAM/spirituality in modern healthcare system. An exploratory, pilot, cross-cultural, cross-sectional study, using Religion and Spirituality in Medicine, and Physician Perspectives (RSMPP) survey questionnaire, compared r/s characteristics and perspectives on integrative medicine of 169 physicians from two allopathic, Sweekar-Osmania University (Sweekar-OU), India, University of Airlanga (UNAIR), Indonesia, and a TCAM/Central Research Institute of Unani Medicine (CRIUM) institute from India. More physicians from UNAIR and CRIUM (89.1 %) described themselves as "very"/"moderately" religious, compared to 63.5 % Sweekar-OU (p = 0.0000). Greater number of (84.6 %) UNAIR physicians described themselves as "very" spiritual and also significantly high (p < 0.05) in intrinsic religiosity as compared to Sweekar-OU and TCAM physicians; 38.6 % of UNAIR and 32.6 % of CRIUM participants reported life-changing spiritual experiences in clinical settings as against 19.7 % of Sweekar-OU; 92.3 % of UNAIR, compared to CRIUM (78.3 %) and Sweekar-OU (62 %), felt comfortable attending to patients' spiritual needs, (p = 0.0001). Clinical comfort and not r/s characteristics of participants was the significant (p = 0.05) variable in full regression models, predictive of primary outcome criteria; "TCAM or r/s healing as complementary to allopathic treatment." In conclusion, mainstreaming TCAM into healthcare system may be an initial step toward both integrative medicine and also improving r/s care interventions by allopathic physicians.

Women supporting patients, men curing cancer: gender-related variations among Israeli Arab practitioners of traditional medicine in their treatment of patients with cancer

The use of complementary traditional medicine (CTM) is prevalent among patients with cancer. An understanding of cultural and religious values is needed to design an effective patient-centered supportive treatment program. To examine gender-related demographic and professional characteristics; treatment goals and approaches; and attitudes toward integration among Arab practitioners of CTM. Male and female Arab CTM practitioners treating patients with cancer were located by snowballing through practitioner and clientele networks. Participants underwent semi-structured, in-depth interviews which were analyzed thematically, with a focus on gender-related issues. A total of 27 Arab CTM practitioners participated in the study (17 males, 10 females). Female practitioners were found to be treating women exclusively, with male practitioners treating both genders. Female practitioners tend to be younger, unmarried, urban-based and non-Muslim. Male practitioners set out to "cure" the cancer, while female practitioners focus on symptoms and quality of life. Male practitioners employ a more schematic and structured therapeutic approach; female practitioners a more eclectic and practical one. Male practitioners employ a collectivist approach, involving family members, while female practitioners interact exclusively with the patient. Finally, male CTM practitioners see integration as a means for recognition, increasing their power base. In contrast, female practitioners perceive integration as a foothold in fields from which they have previously been shut out. A number of gender-related issues can have a significant impact on CTM therapy among Arab patients. Further research is needed in order to understand the implications of these differences.

Integrative health care in Israel and traditional arab herbal medicine: when health care interfaces with culture and politics

This article contributes to contemporary critical debate in medical anthropology concerning medical pluralism and integrative medicine by highlighting the issue of exclusion of traditional medicine (TM) and presenting attempts at border crossing. Although complementary medicine (CM) modalities are integrated into most Israeli mainstream health care organizations, local indigenous TM modalities are not. Ethnographic fieldwork focused on a group of Israeli dual-trained integrative physicians that has recently begun to integrate traditional herbal medicine preferred by the Arab minority, using it as a boundary object to bridge professional gaps between biomedicine, CM, and TM. This article highlights the relevance of political tensions, ethnicity, and medical inequality to the field of integrative health care. It shows that using herbal medicine as a boundary object can overcome barriers and provide opportunities for dialog and reciprocal learning.