A safe and just operating space for human identity: a systems perspective.

A safe and just operating space for socioecological systems is a powerful bridging concept in sustainability science. It integrates biophysical earth-system tipping points (ie, thresholds at which small changes can lead to amplifying effects) with social science considerations of distributional equity and justice. Often neglected, however, are the multiple feedback loops between self-identity and planetary boundaries. Environmental degradation can reduce self-identification with nature, leading to decreased pro-environmental behaviours and decreased cooperation with out-groups, further increasing the likelihood of transgressing planetary boundaries. This vicious cycle competes with a virtuous one, where improving environmental quality enhances the integration of nature into self-identity and improves health, thereby facilitating prosocial and pro-environmental behaviour. These behavioural changes can also cascade up to influence social and economic institutions. Given a possible minimum degree of individual self-care to maintain health and prosperity, there would seem to exist an analogous safe and just operating space for self-identity, for which system stewardship for planetary health is crucial.

Evidence-based healthcare in practice: a study of clinician resistance, professional de-skilling, and inter-specialty differentiation in oncology.

Evidence-based medicine (EBM) is strongly shaping the nature and direction of biomedical practice and organisational culture. Clinicians are now expected to adopt the principles of EBM and evidence-based practice (EBP) whilst also maintaining such things as professional autonomy, clinical judgement and therapeutic integrity. Little sociological work has been done on the implications of EBM in oncology contexts. Drawing on in-depth interviews with 13 oncology consultants and 12 oncology nurses in Australia, in this paper we explore how oncology clinicians utilise and/or critique types of evidence and statistical probabilities; the organisational systematisation of care; and, wider policies of EBM. The results illustrate significant variation in perception of EBM between the oncology sub-specialties examined, and the central role of organisational structures and intra-professional hierarchies in how evidence is viewed and utilised in practice. The interviews also capture the ways in which oncology specialists are negotiating the systematisation of care under the rubric of EBM, and the contradictory effects of professional de-skilling vis-à-vis the reinforcement of biomedical objectivity/power. Finally, we examine the experiences and perceptions of oncology nurses in relation to evidence and EBM, exploring the interplay of processes of professionalisation and distinction in shaping the evidence-based trajectories of nursing. We contrast these results with previous sociological writings on EBM, reflecting on the applicability and limitations of these theoretical positions when applied to the experiences of oncology clinicians.

Exploring the temporal dimension in cancer patients' experiences of nonbiomedical therapeutics.

To date, research on complementary and alternative medicine (CAM) use by cancer patients has tended to provide a "snapshot" of experience, with little attention given to the evolution of experience over time. Drawing on data from solicited diaries, this article examines individual cancer patients' temporal experiences of CAM. Our findings suggest that experiences of CAM are variable over time and space, and furthermore, that the everyday act of "doing CAM" is considerably more problematic than is often reported in face-to-face interview or survey studies. This is explored in relation to the tension between the perceived need for restrictive self-discipline alongside a sense of the emancipatory potential of CAM; the role of CAM therapists in reconceptualizing disease; and the complex interplay between CAM-derived notions of self-healing and acceptance of individual mortality. We argue that an emphasis on the temporality of cancer patients' CAM engagement is necessary to access a more nuanced understanding of the lived experiences of cancer patients.

The role of the Internet in cancer patients' engagement with complementary and alternative treatments.

This article draws on a study of 80 National Health Service cancer patients and their experiences of using the Internet within disease and treatment processes. It focuses on the role the Internet plays in the context of potential or actual engagement with complementary and alternative medicine (CAM). The results depart from previous conceptualizations of the Internet as a major source of CAM knowledge, and second, as a major pathway to patient CAM usage. Moreover, the results highlight significant anxiety as patients attempt to process vast amounts of complex biomedical diagnostic and prognostic information online. For patients attempting to embrace alternative therapeutic models of cancer care, exposure to prognostic data may pose considerable risks to individual well-being and engagement with healing practices. On the basis of these results we problematize social theorizations of the Internet as contributing to such things as: the democratization of knowledge; the deprofessionalization of medicine; and patient empowerment. We emphasize, instead, the potential role of the Internet in reinforcing biomedicine's paradigmatic dominance in cancer care.

Cancer patients' negotiation of therapeutic options in Pakistan.

Cancer is the second leading cause of death in Pakistan. There is increasing evidence that patients are using a range of (biomedical and nonbiomedical) therapeutic options for cancer treatment. To date there has been no sociologically informed research into the engagement of cancer patients in Pakistan with available modalities. In this article, the authors present findings from the first such study. They purposively sampled 46 cancer patients from four hospitals in Lahore and conducted semistructured interviews with them. They argue that individuals are actively mediating therapeutic possibilities by drawing on, and at times being constrained by, personal, social, and cultural resources. It is the authors' contention that this can be conceptualized by an appreciation of individuals' active engagement with three temporally and spatially specific dimensions: structural and practical constraint; pragmatic experimentation; and cultural and religious affiliation. The negotiation (and varying power) of these dimensions is crucial to the process.

[Complementary and alternative therapeutics teaching in nursing schools]. / O ensino das terapias alternativas e complementares em escolas de enfermagem.

There is an increasing interest on Alternative and Complementary Therapies (ACT) both by patients and health professionals and managers. This article explores ACT teaching in five nursing schools in the state of São Paulo, Brazil. Detailed interviews were carried out with the people responsible for these courses as to their sociological characteristics, format, justification, and strategies to start and to maintain the courses. This debate is essential for health in general, and for nursing in particular, as there is a growing international trend to include these ACT in health training and practice.

Use of traditional medicine and globalized complementary and alternative medicine among low-income cancer service users in Brazil.

BACKGROUND: Complementary and alternative medicine (CAM) has become increasingly high profile in prosperous countries over the past 2 decades. Alongside this has been a renewed interest in the use of traditional medicine (TM) in poorer countries. Academic attention has tended to focus on either CAM in rich countries or indigenous TM in poorer ones. However, such a differentiation leads to a potential to gloss over global complexities, such as the study of countries where both CAM and TM are a potentially significant part of health options. Brazil is just such a country. Brazil is marked by massive socioeconomic inequalities; cancer is its second highest cause of death. To date, there has been little research on CAM/TM in cancer care in Brazil. PURPOSE: The purpose of this study is to provide the first exploratory data on the proportion of the use of CAM and/or TM among low-income cancer service users in Brazil. METHOD: A survey of cancer patients was conducted in November 2004 in a public-sector hospital in a major city in Brazil. A random sample (n = 92) was generated from a list of all appointments scheduled during that month (n = 570). Eighty-nine of the 92 patients contacted (97%) completed the questionnaire. RESULTS: Of the sample, 62.9% had used at least 1 form of CAM or TM. However, this headline figure is potentially misleading. The data reveal an almost total absence of use of non-indigenous international CAM; it also shows prayer to be a major contributor to the relatively high use rate. DISCUSSION: On the basis of this small-scale exploratory study, there is no evidence that those international CAMs ubiquitous in the West are spreading to low-income cancer service users in Brazil (despite anecdotal evidence of its increasing presence in the country generally). Moreover, when excluding prayer, use of indigenous traditional medicine was found to be relatively low. Further research is needed to examine these findings on a larger scale and to explore the relative importance of social, cultural, and economic factors behind them.

Toward an understanding of decision making on complementary and alternative medicine use in poorer countries: the case of cancer care in Pakistan.

During the past 2 decades, the study of complementary and alternative medicine (CAM) in general, and the sociological study of CAM in particular, have developed apace in richer countries. In addition to data on use levels and the nature of provision, there is now increasing research on issues such as motivation for use, decision-making processes, and so on. The integration of nonorthodox therapies into cancer care has been an important focus for such work. However, this interest has yet to be matched by work in poorer countries. While the nature of traditional medicine (TM) has long been of interest to anthropologists, the new context (marked by the globalized nature of CAMs existing alongside TM and allopathic treatment) has yet to be examined in any depth. In this article, the authors discuss the structural and cultural context of the first sociological research to be conducted into the role ofCAMandTMin cancer care in Pakistan. They identify some potentially important processes (ie, those identified in the limited existing literature and in anecdotal commentary), which are being tested by the new empirical study. The specific foci of the work are outlined. It is argued that research in poorer countries is essential both to ensure that an existing academic imbalance is addressed and to underpin more informed policy making in complex medically pluralistic (poorer) countries.

Patient assessment of effectiveness and satisfaction with traditional medicine, globalized complementary and alternative medicines, and allopathic medicines for cancer in Pakistan.

BACKGROUND: Virtually no research has been conducted on patient assessments of traditional medicines and allopathic medicines for cancer care in poorer countries marked by pluralistic medical environments. Pakistan represents an excellent case for such a study because of the coexistence of culturally and historically specific indigenous traditional medicine, the strong presence of allopathic medicine, and, to a lesser extent, the availability of some globalized complementary and alternative medicines. AIM: To gain a preliminary understanding of cancer patients' perceptions of effectiveness and satisfaction with traditional medicine, globalized complementary and alternative medicine, and allopathy in the context of a pluralistic medical environment. STUDY DESIGN: Structured survey of 362 cancer patients, from diverse regions in the Punjab province and Northwest Frontier province, who were being treated in 4 different hospitals in Lahore, Pakistan. RESULTS: Use of traditional medicine remains high among cancer patients, with traditional healers used by the majority of those surveyed. Although patients' perceptions of the overall effectiveness of traditional medicines for treating cancer are low, those patients who do use traditional medicines still have high levels of satisfaction with these modalities. This is distinct from levels of satisfaction with, and perceptions of effectiveness of, Western cancer treatments, which were synonymous in this group of patients. Important differences in patient perceptions were found within groups (eg, between different forms of traditional healers) as well as between them. CONCLUSION: This study showed considerable support for complementary and alternative medicine/traditional medicine but also significant variation in usage of and perceptions of local traditional medicines. More research needs to be done to explore the social processes underlying this variation in cancer patients' preferences for particular traditional medicines.

Use of traditional, complementary and allopathic medicines in Pakistan by cancer patients.

INTRODUCTION: The healthcare systems of developing countries are complex in that they often accommodate a range of disparate and often competing paradigms of care. This is the case in Pakistan where Indigenous traditional medicine (TM) co-exists with Western allopathic medicine and, in theory at least, with 'globalised' complementary and alternative medicines (CAM). To date we know little about what treatments are being chosen and why in this still predominantly rural country. AIM: To gain a preliminary understanding of patterns of usage of traditional medicine and globalised complementary and alternative medicine by cancer patients in Pakistan. METHOD: Structured survey of 362 cancer patients, from diverse regions in the Punjab and North-west Frontier Province provinces, who were being treated in four different hospitals in Lahore, Pakistan. RESULTS: Use of traditional medicine is high amongst cancer patients, with many patients using a combination of different therapeutic modalities. Unlike studies in Western contexts, this study indicated no relationship between cancer type or sex and use of CAM/TM. However level of education was influential in determining usage of particular TM. There is, however, no uniformity in patterns of use of different TM. CONCLUSION: There is less differentiation between social groups in usage of CAM and TM in Pakistan than has been reported in studies of western cancer patients. Differing levels of use for specific TM highlight the need to get beyond monolithic categorizations (such as TM) to understand use patterns for specific indigenous practices (in their social and cultural context).

Nostalgic and nostophobic referencing and the authentication of nurses' use of complementary therapies.

In recent years what can loosely be described as a sociology of complementary and alternative medicine (CAM) has begun to emerge. Although work has been conducted with lay therapists, orthodox practitioners, and consumers, overall, research in this area remains patchy and underdeveloped. Despite its role at the forefront of integration, the sociological study of the apparent affinity between nursing and CAM is virtually non-existent. This paper provides an exploratory analysis of how writers within the CAM nursing sub-world adopt a recourse to history (nostalgic and nostophobic referencing) as a strategy to authenticate the relationship between nursing and CAM and so facilitate continuing integration. A text analysis, of articles written on CAM in four nursing journals, was conducted. Eighty papers satisfied the inclusion criteria. Evidence is presented of the way in which writers attempt to authenticate integration of CAM through reference to its apparent interconnectedness with the historically grounded core of nursing values, and more specifically, with the key historical figure of the nurse Florence Nightingale (1820-1910). It is argued that these rhetorical strategies can be understood in the context of the need to engage in (primarily) intra-professional persuasion: to protect and develop the values of their nursing sub-world over alternatives. The findings are preliminary. Themes identified are illustrative of the potential offered by an analysis of nostalgic and nostophobic referencing in this context, and not a definitive account of it. Further research should examine individually produced texts from other sources, and documents produced by relevant professional bodies.

A single-blind trial of reflexology for irritable bowel syndrome.

BACKGROUND: Irritable bowel syndrome (IBS) is a significant problem for primary care, as treatment options are limited and it can frequently develop into a chronic condition. Complementary and alternative medicine, including reflexology, is being turned to increasingly in an attempt to manage symptoms. There are currently no studies which address the effectiveness of reflexology for IBS. Despite this, it continues to be advocated and used. AIM: To provide the first evidence on the effectiveness of reflexology in the management of the core defining symptoms of IBS. DESIGN OF STUDY: A single-blind trial carried out in primary care settings. SETTING: Thirty-four participants diagnosed with IBS on the basis of the Rome Criteria. METHOD: Participants were allocated to receive either a reflexology foot massage or a non-reflexology foot massage control group. RESULTS: On none of the three symptoms monitored--abdominal pain, constipation/diarrhoea, and abdominal distention--was there a statistically or clinically significant difference between reflexology and control groups. CONCLUSION: On the basis of these results there is nothing to suggest that reflexology produces any specific benefit for patients with IBS. There is currently no evidence to support its use. However this was one (relatively) small scale study; further research that, for example, assesses the impact of therapist (professional and lay) versus therapy, is still needed.

Introduction to the research methods in CAM series.

There is increasing awareness of a need for rigorous research into complementary and alternative medicine, but as yet, limited guidance has been given to researchers, practitioners and students as to the range and scope of the various methodologies available and how existing methods can be modified for CAM research. This research methods series provides an outline of the main methods for researching CAM-related issues, including clinical trials, cross-sectional studies and qualitative methodologies. Drawing on the experiences of a range of experts in CAM research, each article in this series addresses the scope and strengths of a particular methodological approach. This series aims to convey the basis and objectives of particular methodologies within the context of CAM research, and thus, each paper will draw on actual examples of CAM research. It is intended to be of value both to inexperienced researchers and to those who are more experienced but are looking to broaden their range of knowledge. In this introduction, we outline some of the fundamental concepts for researching CAM, providing an overall sense of where each methodological approach outlined in this series fits in the 'order of things'. We outline different design strategies, the philosophical differences underpinning particular approaches to collecting data, and the issue of bias in research design and analysis.

Story teller or story analyst? How useful is the storied narrative for a critical sociology of CAM and nursing?

Despite recent developments in the sociology of complementary and alternative medicine (CAM), a critical analysis of the apparent affinity between CAM and nursing has, to date, remained essentially undeveloped. An empirical project is currently being conducted as an initial step to address the absence of such important critical research. A total of 30 written life history narratives were obtained from nurses working with and using CAM to explore such matters as professional boundaries and nurses' authentication strategies and conceptualisation and operationalisation of CAM. This paper addresses questions and conflicts that arose as the analytical tools were considered for these narrative accounts. Specifically, the paper explores whether the storied narrative sits easily with a critically oriented sociology of CAM; the differences between the role of "storyteller" or "story analyst"; and ask whether there is potential for developing a critical sociology of CAM nursing that retains the essence of personal stories.

[Complementary and Alternative Medicines: a meta-synthesis]. / Medicinas Alternativas e Complementares: uma metassíntese.

The growing use of Complementary and Alternative Medicines (CAM) has led to an increase in the number of qualitative studies on the subject, thus justifying a meta-synthesis of the resulting material. The current article presents a systematic review of qualitative studies on CAM published in international journals. The review was conducted according to the meta-synthesis methodology. A search was performed in journals through the Periodicals Periodical of CAPES, the National Agency for the Evaluation of Graduate Studies, and 32 articles were selected for analysis. The reviewed studies raise questions focusing on: patients, their therapeutic experiences, and their social and cultural contexts; professionals, professional relations, and the process of professionalization of CAM; and CAM and their relationship to biomedicine. The article concludes that qualitative studies on CAM call for an exploratory view of the theme, seeking to identify the experiences of patients and professionals with these therapies and discussing the impact of their use on conventional medicine or biomedicine.

The inequalities of medical pluralism: Hierarchies of health, the politics of tradition and the economies of care in Indian oncology.

India has an eclectic health system that incorporates biomedical as well as traditional, complementary and alternative medicine (TCAM). Our understanding of the co-existence of these therapeutic modalities in this diverse, postcolonial and developing nation is extremely limited, and in the context of cancer care, to our knowledge no sociological work has been carried out. Contemporary Indian oncology represents a fascinating site for examining the interplay and articulation of forms of tradition/modernity, economic progress/structural constraint and individual beliefs/cultural norms. In a context of an increase in the prevalence and impact of cancer in an ageing Indian population, this paper reports on a qualitative investigation of a group of oncology clinicians' accounts of 'pluralism' in India. The results illustrate the embeddedness of patient disease and therapeutic trajectories in vast social inequalities and, indeed, the intermingling of therapeutic pluralism and the politics of social value. We conclude that notions of pluralism, so often espoused by global health organisations, may conceal important forms of social inequality and cultural divides, and that sociologists should play a critical role in highlighting these issues.

Indian Cancer Patients' use of Traditional, Complementary and Alternative Medicine (TCAM) and delays in presentation to Hospital.

OBJECTIVES: A majority of Indian cancer patients are often presented with incurable diseases at the latest phase of disease progression. The use of traditional, complementary and alternative medicine (TCAM) has been identified by Indian oncologists as a potential factor for the delay in seeking health from medical practitioners but no research has been conducted to verify such claims. The aim of this study is to identify socio-demographic and disease status differences between TCAM and non-TCAM users among cancer patients in India and associated patterns of seeking professional medical help. METHODS: A random survey of 825 cancer patients in one public and one private hospital was conducted in Delhi, India. Using four interviewers, a list sampling technique was used to interview every patient over a four month period, with a response rate of 80%. RESULTS: The results showed that 34.3% of cancer patients had used TCAM. The results also demonstrated a statistically significant relationship between the use of TCAM and reported delay in seeking help from clinical medicine (p<0.001). On the other hand, 35.2% of TCAM users reported seeking help immediately after onset of symptoms, whereas 50% of non-users immediately sought help from conventional medicine. Furthermore, 11.5% of TCAM users reported waiting for six months or more after noticing cancer-related symptoms, while only 2.1% of non-users waited this long. CONCLUSION: Overall, early diagnosis and intervention is critical for effective treatment of many malignancies. Delays in presentation related to the use of TCAM may be an important factor relating to the high rates of advanced disease on presentation and low survival rates in the care of Indian cancer patients. Further research is needed to explore the reasons for using TCAM and to ensure existing issues of delays in help seeking are addressed.

Therapeutic pluralism? Evidence, power and legitimacy in UK cancer services.

The integration of complementary and alternative medicine (CAM) into cancer services is increasingly discussed as a potential part of UK health policy but as yet there has been little sociological research examining this process. This paper examines the results of a study on the provision of CAM to cancer patients in two distinct organisational contexts: the hospice and the hospital. It is based on interviews with medical specialists, nursing staff and CAM therapists. This paper focuses on how integration is managed in each organisation, examining professional boundary disputes and inter-professional dynamics. Discussion focuses on the rhetorical and practical strategies that are employed by a variety of differently positioned interviewees to negotiate the complexities of the interface of CAM and biomedicine. The results show significant differentiation in how differently positioned cancer clinicians view and utilise the biomedical hierarchy of evidence. We argue that the integration of CAM should not be conceptualised as a mere challenge to biomedicine, or, as resulting in a linear process of de-professionalization. Rather, it should be seen as producing a complex array of processes, including strategic adaptation on the part of medical specialists and NHS organisations.

Evidências produzidas por pesquisas qualitativas sobre diabetes tipo 2: revisão da literatura / Evidence produced by qualitative investigations on type 2 diabetes: a review of the literature / Evidencias producidas por investigaciones cualitativas sobre diabetes tipo 2: revisión de literatura

O diabetes tipo 2 produz um grande impacto sobre a vida dos pacientes e a rede assistencial. Diante do crescimento de informações qualitativas sobre diabetes, torna-se importante a sistematização desse conhecimento. Foi realizado um metaestudo sobre diabetes, por meio da análise de 42 artigos disponibilizados em revistas do portal de periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes). Identificamos bom grau de teorização nos estudos revisados, os quais abordaram: gerenciamento do cuidado, concepções saúde-doença, relação profissional-paciente, práticas profissionais e adesão ao tratamento. Os artigos descreveram claramente os procedimentos metodológicos adotados. Houve predomínio do uso de entrevistas e grupos focais para a coleta de dados, buscando explorar diferentes visões dos sujeitos investigados. Afirma-se a importância dos profissionais de saúde e gestores implementarem políticas, programas e modelos de atenção adequados às especificidades do adoecimento crônico, orientados pelo eixo da integralidade e corresponsabilização pelo cuidado.

Type 2 diabetes has a major impact on patients lives and the healthcare network. Given the growth in qualitative information on diabetes, it becomes important to systematize this knowledge. A meta-study on diabetes was conducted through analysis on 42 articles that were made in journals at the periodicals portal of the Coordination Office for Advancement of Higher-level Personnel (Capes). We found that the studies reviewed had a good theoretical basis, which included: care management, health-disease concepts, professional-patient relationships, professional practices and treatment compliance. The articles clearly described the methodological procedures used. The use of interviews and focal groups for data gathering predominated, and it was sought to explore different views of the individuals investigated. It was reaffirmed that it was important for health professionals and managers to implement healthcare policies, programs and models that are appropriate for the specific features of chronic illness, guided by comprehensive care and co-responsibility.

La diabetes tipo 2 produce un gran impacto sobre la vida de los pacientes y la red asistencial. Ante el crecimiento de informaciones cualitativas sobre diabetes, llega a ser importante la sistematización de este conocimiento. Se ha realizado un meta-estudio sobre diabetes por medio del análisis de 42 artículos disponibles en revistas del portal de periódicos de la Coordinación de Perfeccionamiento de Personal de Nivel Superior (Capes). Identificamos un buen grado de teorización en los estudios revisados que tratan de la dirección del cuidado, concepciones de salud-enfermedad, relación profesional-paciente, prácticas profesionales y adhesión al tratamiento. Los artículos describen claramente los procedimientos metodológicos adoptados. Ha predominado el uso de entrevistas y grupos focales para la colecta de datos buscando explorar diferentes visiones de los sujetos investigados. Se afirma la importancia de los profesionales de salud y gestores que implementan políticas, programas y modelos de atención adecuados a las especificidades del enfermo crónico orientados por el eje de la integralidad y co-responsabilización por el cuidado.