The challenges in promoting integrative oncology nursing research in Iran: Lessons for the international community.

In recent years, with the growing incidence of cancer in Iran, attention to traditional and complementary medicine (TCM) has increased among patients.

Traditional medicine (TM) refers to the whole knowledge, skill, and practice based on the theories, beliefs, and experiences endemic to different cultures, comprehensible or not. While complementary medicine (CM) refers to a wide range of health care practices that do not belong to a country's own tradition or conventional medicine, and are not fully blended with the leading healthcare system. The amalgam of the above-mentioned terms is used broadly and is substitutable with TCM in many countries.

Because of the long history of this type of medicine, Iranians have a positive attitude towards these methods, especially traditional medicine, and the demand for such treatments is increasing. Numerous studies in Iran show that most patients either use complementary therapies for cancer, or have used them in the past.

Among the various methods, the two common methods in Iran, which are based on traditional medicine, are the use of medicinal herbs and nutritional advice to select the correct type of food and cooking methods. In contrast, homeopathy is used less often and anthroposophic medicine and nature therapy are not used at all. The prevalence of using at least one of the complementary medicine methods is 42% in Iran, 34% in the United States, and 20–30% in Germany,, and the most common CM treatments used in the United States are prayer therapy and phytotherapy.,

Patients use these approaches in order to relieve pain or manage treatment-related side effects, improve the quality of life, and reduce symptoms such as anxiety and fatigue, mainly due to concerns about the complications of drugs and believing that therapeutic approaches are ineffective. Additionally, as a result of increased patients' survival rate, the needs of cancer survivors, which go beyond physical needs and symptom relief, have become more important to caregivers, as many complementary therapies aim to provide comprehensive care. By applying these methods, more attention is paid to the patient's psychological and spiritual needs.

Ideally, it is expected that these treatments will be combined with conventional medicine approaches to increase safety and effectiveness, and services will be provided using a single care team in order to achieve the best possible results for addressing patients’ needs. This approach is called integrative oncology (IO).

While integrating evidence-based complementary therapies with conventional care, IO provides physical, mental, and spiritual health by taking into account the values and priorities of each patient, and aims to maintain and improve health, and quality of life besides improving clinical outcomes across the cancer care chain, and empowering individuals to prevent cancer and to have active participation before, during, and after cancer treatment.

In Iran, using these TCM approaches is accepted among cancer patients and most patients believe that if doctors introduce them as part of cancer treatment services, they will accept and use these methods.

However, due to the background of this type of medicine in Iran, there are both credible writings and non-written medical knowledge and experiences.

Owing to the antiquity of this type of medicine in Iran, oral traditional medicine includes experiences and information that are passed down from generation to generation by word of mouth, and contains various hygiene and treatment methods. The use of these medical experiences and therapeutic methods has been considered as an inextricable part of people's lives, and it has been vital and essential to correctly distinguish between sound and unsound, and to transfer experiences to the next generation. Some exaggerate about the effects of traditional medicine to the extent that will make every sane person ponder; on the other hand, the degree of irreparable damage and misuse of this medicine is considerable, too.

Therefore, in order to integrate these interventions into the cancer care and treatment cycle in the country and doctors’ recommendation for using these methods, research should be conducted and evidence needs to be produced in order to perform evidence-based practice (EBP). Obviously, in order to improve EBP and, consequently, to enhance the quality of services, it is necessary to identify the barriers against conducting research, with the aim of producing the required evidence.

More than half of health workers in Iran are nurses who seem to have a good position for providing complementary medicine services. Studies also show that Iranian nurses have a positive attitude towards using these approaches. On the other hand, a high percentage of the research conducted by nurses and the articles published in Iran focus on this topic. Therefore, a good opportunity exists to produce evidence in this field. However, due to some challenges, research development in this area is progressing slowly. These challenges are divided into the following three categories: challenges in providing services, challenges in accessing resources, and nurse-related challenges.

Obviously, some of these challenges are general and are considered a barrier to research in any field. While some others are specifically related to research in the field of integrative medicine.

Challenges in providing services

The variety of regulations and policies, the multiplicity of institutions, and decision-making authorities in the field of TCM, and not being officially recognized as a branch of medicine are among the most important challenges, because until a consensus is reached on the acceptance of this type of medicine, every action will be merely institutional and local and cannot be extended to other sectors.

Given the legal challenges mentioned, it is obvious that the provision of traditional and complementary medicine services in the form of integrated IO services is face limitations, too.

Obviously, to conduct research in a field, a place is needed to do the practice. Due to the lack of this type of medicine in Iranian healthcare system, there is a shortage of specific settings to access to research samples. On the other hand, since in the related studies, the subjects consist of non-patient individuals, patients and their family caregivers, and in general, the society, people lack of knowledge causes them to refuse to participate in the study in many cases.

On the other hand, for the same reasons, these services are provided at a tariff rate, which is not affordable for everyone. The lack of insurance coverage makes it difficult and costly to use a product or service, even in a study.

Considering Iranian cancer patients’ tendency to consume herbal compounds, the lack of adequate registration systems for herbal medicine, insufficient knowledge of medicinal plants, and inaccessibility to these plants can be some of the challenges of conducting research in this field.

One of the necessities to carry out intervention studies is the existence of therapeutic and care protocols and guidelines, the development of which requires research. It is not possible to develop a guideline until a research is done.

Concerns about potential complications and legal outcomes are also challenges of nursing research in the field of IO. One of the misconceptions among people in regard with traditional medicine is the belief that herbal medicinal plants naturally cause no complications. This leads people to use any medicinal plants relentlessly. Most patients who use this type of treatment have limited knowledge about it and are unaware of its possible complications. Therefore, researchers are concerned about patients' not following the instructions provided in research interventions and suffering the subsequent outcomes. Some ambiguities regarding the safety, effectiveness, and quality of these interventions, which is in turn due to the lack of research and evidence in this field, results in nurses and patients’ reluctance to participate in such studies.

Challenges in accessing resources

The lack of research centers in the field of IO, as well as the lack of journals in this field in Iran, causes researchers to face limitations in writing and publishing articles. There are several international journals that focus on this field generally or professionally. However, due to the fact that some Iranian researchers have no proper knowledge of English, writing an article in Farsi for submission to foreign journals requires translation by a translator professionally familiar with the topic, which has its own problems. Therefore, many researchers prefer to publish Farsi articles in domestic journals.

Another challenge is not regarding these topics as one of the research priorities of organizations and research centers, which consequently, leads to insufficient funding of these studies.

Access to Internet, the required software and translation services in some parts of Iran is accompanied with many challenges, which can reduce nurses’ general interest in research in any field.

The lack of access to available evidence and background due to the difficulties in accessing the full text of articles and journals is another problem. This is a result of the sanctions imposed on Iran, which causes limited access to references.

The lack of access to research oncologists is another challenge that nurses face due to oncologists’ negative attitude towards TCM.

Nurse-related challenges

In this category of challenges, nurses' lack of training and insufficient knowledge is very important. Most nurses are unfamiliar with IO because it is not included in the bachelor's curriculum and is only mentioned in few disciplines of master's programs. Therefore, nurses will not be able to manage the research process, especially during sample selection and interventions.

On the other hand, due to the fact that such measures are not included in nurses' job description and as in many cases it is not possible to perform the related clinical techniques due to legal issues or patients’ hesitation, there is little desire to do research in this area.

Nurses spend all their time providing care for their patients and have no sufficient time to perform research due to the shortage of nursing workforce, which is considered another challenge in Iranian health system.

Conclusions

Since TCM is a part of people's culture, it has many advantages over other medical systems. Today, integrative oncology is considered as an important topic in cancer management.

However, in Iran, despite the existence of traditional medicine schools and PhD programs in these disciplines and the activities of traditional medicine office at the Ministry of Health and Medical Education, this field is still unknown. One of the most important reasons behind this is the lack of sufficient evidence for evidence-based practices. Nurses, as one of the groups competent in providing these services, have the potential to produce evidence. However, they face legal and regulatory challenges, challenges in accessing resources, and personal challenges. To address these issues, in addition to carrying out structural reforms regarding laws and regulations in education, research, health care and treatment at the level of Ministry of Health and medical universities, it is recommended to introduce IO to medical students and promote public awareness for the development of IO services, increase access to articles, empower nurses in research through training courses and workshops at national, regional, and international levels in the form of TOT, use mentorship, and conduct multi-center research with foreign professors.

Funding

Nil.

Declaration of competing interest

None declared.