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.

The Experience of Complementary Alternative Medicine Use among People with Multiple Sclerosis

People with multiple sclerosis (MS) are increasingly using complementary and alternative medicine (CAM) for symptom management, despite the absence of an evidence base. This exploratory qualitative study ( n = 10) examined the experiences of CAM use among people with MS. Results suggest disillusionment with current medical treatments and a desperate search for something to relieve symptoms. Participants had an open attitude toward various approaches to health care, liked to be actively involved in their care, and viewed CAM as a “healthier” choice. Further research is needed to develop the preliminary findings, using more heterogeneous samples embracing the complexities of gender, ethnicity, and socioeconomic status.

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.

Medicinas Alternativas e Complementares: uma metassíntese

O aumento do uso de Medicinas Alternativas e Complementares (MAC) motivou o crescimento do número de estudos qualitativos sobre o tema, justificando a realização de sínteses sobre esse material. Este artigo apresenta uma revisão sistemática de pesquisas qualitativas sobre MAC publicadas em periódicos internacionais. Esta revisão se orientou pela metodologia dos metaestudos. Foi realizada busca em revistas do Portal Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior e foram selecionados 32 artigos para análise. Os estudos revisados apresentam questões que têm como foco: o paciente, suas experiências terapêuticas e seus contextos sociais e culturais; o profissional, as relações profissionais e o processo de profissionalização das MAC; a MAC e sua relação com a biomedicina. Conclui-se que as pesquisas qualitativas sobre as MAC ensejam um olhar exploratório sobre o tema, procurando identificar as experiências de pacientes e profissionais com essas terapêuticas, assim como buscam discutir as conseqüências desse uso para a Medicina Convencional ou biomedicina.

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.

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.

Oncologists’ and specialist cancer nurses’ approaches to complementary and alternative medicine and their impact on patient action

High levels of use of complementary and alternative medicine (CAM) have been consistently reported amongst cancer patients over recent years. This is occurring in the context of an apparent increase in sources of information on therapeutic alternatives and a growth in the range of those claiming professional expertise in the field. To date there has been little research on patient experience of discussions about CAM with biomedical cancer specialists in this increasingly complex social environment. This paper addresses three issues: patient experience with cancer specialists; the significance of that experience for patient engagement with CAM; and the nature and significance of inter-professional dynamics. It draws on the results of a qualitative study with cancer patients in the UK. In-depth interviews with 80 purposively sampled patients, incorporating a range of disease types and stages, were conducted. Patients reported three main types of approach by oncologists: explicit or implicit negativity; supportive ambivalence; and, pragmatic acceptance. Crucially, patients' accounts suggest that the type of approach adopted influences (though does not determine) patient action. Specialist cancer nurses emerged as potentially powerful mediators between oncologists and patients. Despite the apparent potential for influence from multiple information sources and 'experts', on the basis of this study we would argue that oncologists remain crucial to patient engagement with CAM. However, this is not to argue that the influence is a simplistic one. Where patient and medical perspectives diverge, strategic alignment with specialist nurses may help patients make choices which conflict with perceived advice.

[Complementary and alternative therapeutics teaching in nursing schools]

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.

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.

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.

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.

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.

Involving South Asian patients in clinical trials

OBJECTIVES

To investigate how South Asian patients conceptualise the notion of clinical trials and to identify key processes that impact on trial participation and the extent to which communication difficulties, perceptions of risk and attitudes to authority influence these decisions. Also to identify whether 'South Asian' patients are homogeneous in these issues, and which factors differ between different South Asian subgroups and finally how professionals regard the involvement of South Asian patients and their views on strategies to increase participation.

DATA SOURCES

A review of the literature on minority ethnic participation in clinical trials was followed by three qualitative interview studies. Interviews were taped and transcribed (and translated if required) and subjected to framework analysis. Face-to-face interviews were conducted with 25 health professionals; 60 South Asian lay people who had not taken part in a trial and 15 South Asian trial participants.

RESULTS

Motivations for trial participation were identified as follows: to help society, to improve own health or that of family and friends, out of obligation to the doctor and to increase scientific knowledge. Deterrents were concerns about drug side-effects, busy lifestyles, language, previous bad experiences, mistrust and feelings of not belonging to British society. There was no evidence of antipathy amongst South Asians to the concept of clinical trials and, overall, the younger respondents were more knowledgeable than the older ones. Problems are more likely to be associated with service delivery. Lack of being approached was a common response. Lay-reported factors that might affect South Asian participation in clinical trials include age, language, social class, feeling of not belonging/mistrust, culture and religion. Awareness of clinical trials varied between each group. There are more similarities than differences in attitudes towards clinical trial participation between the South Asian and the general population. Important decisions, such as participation in clinical trials, are likely to be made by those family members who are fluent in English and younger. Social class appears to be more important than ethnicity, and older South Asian people and those from working class backgrounds appear to be more mistrustful. Approachable patients (of the same gender, social class and fluent in English) tend to be 'cherry picked' to clinical trials. This practice was justified because of a lack of time and resources and inadequate support. South Asian patients might be systematically excluded from trials owing to the increased cost and time associated with their inclusion, particularly in relation to the language barrier. Under-representation might also be due to passive exclusion associated with cultural stereotypes. Other characteristics such as gender, age, educational level and social class can also affect trial inclusion.

CONCLUSIONS

Effective strategies for South Asian recruitment to clinical trials include: using multi-recruitment strategies; defining the demographic and social profiles of the population to be included; using focus groups to identify any potential barriers; consulting representative community members to provide assistance in the study; ensuring eligibility criteria are set as wide as possible; developing educational and recruitment approaches to attract ethnic minority health professionals; ensuring health professionals are adequately trained in culturally and ethnically orientated service provision; determining the most effective mass media to use in study promotion and recruitment; and targeting inner-city, single-handed practices likely to have high ethnic minority populations. Future research should consider: responses when invited to participate; the role of methodological and organisational barriers to recruitment; the complexities of recruitment from a health professional perspective; developing culturally sensitive research methods; the magnitude of the problem of under-recruitment; strategies to encourage inner-city, single-handed GP participation; and other factors affecting trial inclusion, such as age, gender, educational level and socio-cultural background.

Story teller or story analyst?

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 medicine (CAM), cancer and group-based action: a critical review of the literature

Interest in complementary and alternative medicine (CAM) continues to grow at an exponential rate despite the advances made by conventional medicine. Complementary and alternative medicine use is increasingly manifest across a wide range of health care settings, and is particularly prevalent in cancer and palliative care. In these arenas, patient groups and self-help organizations play a significant supportive role. There is evidence that they are a key informative and pragmatic resource in the provision of CAM services to patients. However, there is a significant paucity of research dealing with the functional aspects of these groups and the way in which they advocate, promote and supply CAM. In this paper we provide a critical review of the literature pertaining to themes around CAM provision and cancer care, and suggest that for a more complete picture of the field, the impact of group mediation of CAM needs to be addressed, and attention focused on the social and interactional dynamics that underpin these groups and organizations.

Improving management of obesity in primary care: cluster randomised trial

OBJECTIVE

To evaluate a training programme intended to improve the management of obesity, delivered to general practice teams.

DESIGN

Cluster randomised trial.

SETTING

Northern and Yorkshire region of England.

PARTICIPANTS

44 general practices invited consecutively attending obese adults to participate; 843 patients attended for collection of baseline data and were subsequently randomised.

INTERVENTION

4.5 hour training programme promoting an obesity management model.

MAIN OUTCOME MEASURES

Difference in weight between patients in intervention and control groups at 12 months (main outcome measure) and at 3 months and 18 months; change in practitioners' knowledge and behaviour in obesity management consultations.

RESULTS

Twelve months after training the patients in the intervention group were 1 (95% confidence interval--1.9 to 3.9) kg heavier than controls (P = 0.5). Some evidence indicated that practitioners' knowledge had improved. Some aspects of the management model, including recording weight, target weight, and dietary targets, occurred more frequently in intervention practices after the training, but in absolute terms levels of implementation were low.

CONCLUSION

A training package promoting a brief, prescriptive approach to the treatment of obesity through lifestyle modification, intended to be incorporated into routine clinical practice, did not ultimately affect the weight of this motivated and at risk cohort of patients.

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.

Cultural competency: professional action and South Asian carers

Inequality and exclusion are characteristic of the experience of UK South Asian communities. In health care, community needs are often not addressed by health and social welfare services. An increase in cultural competency is now part of identified policy. The aim of this paper is to examine the extent to which there is evidence of cultural competency amongst professionals concerning South Asian parents caring for a person with cerebral palsy. Semi-structured interviews were conducted with respondents from 19 service organisations. Results are presented on perceptions of service delivery and on the dynamics of service development: evidence is found that inadequate service delivery continues despite professional knowledge that it exists. Conditions necessary for the achievement of cultural competence are discussed. We suggest that service development to meet the needs of South Asian carers must form part of an overall strategy geared to change at different levels within and outside service organisations.

Towards a sociology of CAM and nursing

Over recent years a sporadic, but not insignificant, sociology of complementary and alternative medicine (CAM) has begun to emerge. However, to date, the systematic sociological study of the apparent affinity between CAM, nursing as a profession and its practitioners has been absent from it. In this paper we argue for the need for a rigorous sociology of nursing and CAM and set out a provisional framework through which this might be operationalized. Three broad themes, as well as cross-cutting issues, are outlined. The way in which the challenges of CAM are mediated at the level of the individual and the profession are pivotal to analysis. An understanding of this mediation is crucial both as a means of extending knowledge, and as a means of engaging with complex issues such as the role of evidence, and the equity of provision, that are likely to accompany any extension of CAM mainstreaming.

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.

Nurses' use of professional distancing in the appropriation of CAM: a text analysis

Despite the depth of interest in complementary and alternative medicines (CAM) within the nursing community, the intersection between nurses, nursing and CAM has largely avoided sociological analysis. This paper presents findings from one part of an ongoing exploratory study of how nurses present and interpret the apparent affinity of their profession with CAM. A text analysis of papers published from within the nursing community on CAM was conducted. Within the broad area of professional identity, differentiation and development, two dominant themes emerged from the analysis. Firstly, the use of professional distancing to underpin the legitimacy of the nursing/CAM axis; and second, the potential offered by the relationship for a reconstruction of lines of professional authority. As one dimension of the way in which nursing's intersection with CAM is being constructed and perpetuated, the relationship with medicine appears to be of significance and requires further attention.

Primary care as intersecting social worlds

An enhanced role for primary health care (PHC) is currently a matter of political priority in the UK. This higher profile is drawing attention to a range of unresolved challenges and issues, relating to both the structure and content of provision, which currently permeate the system. Running in parallel with this is a recognition that: to date, PHC has been under-researched; that, as a result, our understanding of it is frequently poor; and that, as a consequence, fresh perspectives are needed in order to effectively research this uncertain, evolving and increasingly important healthcare sector. In this paper we argue that social worlds theory (SWT) provides, albeit in a suitably modified form, an ideal conceptual framework for the analysis of contemporary primary care. SWT is an approach which assumes complexity and constant evolution, and its core concepts are directed towards unravelling the consequences of encounters between different interest groups--something which is of particular utility at this time given the increasing attention to user participation, and an ongoing questioning of established patterns of professional authority. It is an approach which has rarely been employed empirically, even beyond medicine. In order to illustrate the wide relevance of the approach, we discuss how it can facilitate research at all levels of PHC: i.e., in relation to aspects of medical practice (the case of medically unexplained symptoms); shifts in service organisation (changing professional roles and the introduction of policy reforms); and issues which straddle both organisation and content (the increasing use of complementary medicine in primary care). In each case the approach is able to embrace the complexity of situations characterised by the intersection of professional and lay social worlds and is able to provide the conceptual tools through which resultant processes can be tracked and investigated.

Individuals with low back pain: how do they view physical activity?

BACKGROUND

Recent guidelines for those with acute low back pain have advocated early resumption of normal activity and increased physical activity. Little is known about the relationship between low back pain and physical activity, and on the impact of that relationship on the promotion of increased levels of physical activity within a general practice population.

OBJECTIVES

We aimed to explore associations between factors that influence changes in physical activity and the way individuals perceive and behave with their low back pain, and the impact of those perceptions and behaviour on physical activity.

METHODS

Twenty-seven informants were chosen using a purposive sample from a larger group of individuals who, because of their low back trouble, had been referred by their GPs to a community-based, single-blind, randomized controlled trial (RCT) at the University of York, which is evaluating the effectiveness and cost-effectiveness of a progressive exercise programme. Fifty-four interviews were conducted with this subgroup of the RCT; four informants were interviewed once, 19 twice and four of them three times. Interviews were transcribed and analysed using manual and computer-aided approaches.

RESULTS

Physical activity was perceived as (i) activities of daily living, (ii) activities causing breathlessness that they went out of the way to do and (iii) more competitive-type activity. The avoidance of physical activity and fear of pain returning were the two main factors directly associated with informants' backs and changes in physical activity. These two factors hindered increases in physical activity, even though the majority of informants believed strongly that being physically active helped ease their low back pain.

CONCLUSIONS

When advocating that individuals with acute low back pain return to or increase physical activity, it is important that clinicians identify avoidance of physical activity and/or fear of pain at the earliest stage in order to tailor advice and reassurance appropriately. If avoidance of activity and fear of pain is identified and clinicians want to encourage patients to take up and sustain increased physical activity, they should explore issues of fear of pain, and avoidance of and confidence to do physical activities, in addition to other factors influencing physical activity.

Narrative and knowledge development in medical ethics

The role of individual life accounts has been promoted--largely through what has come to be described as narrative ethics-as important to the practice of medical ethics for a number of years. Beyond this the apparent incompatibility of personal stories with scientific procedure has limited their use. In this article I will argue that this represents a serious under-utilisation of a valuable method for researching ethical dilemmas and the settings in which these dilemmas are played out. Life stories need not simply provide a stimulus to scientific research but can in themselves yield intellectually robust evidence on the general as well as the particular. By drawing on the rigorous methods developed elsewhere, personal accounts not only allow us to "enter the world of the sick person" but allow us to do so in such a way as to contribute to empirical and theoretical knowledge.

Oscillating saw injuries during removal of plaster

The aim of this study was to assess the incidence of injuries to patients who have had a plaster cast removed by oscillating circular saw at the Alexandra Hospital, Redditch, and to recommend measures to avoid such injuries. The record of each patient who had his/her plaster removed was kept in the plaster room and later studied. Over a 12-month period (1995-96), 3875 plaster casts were removed; 28 patients (0.72%) sustained abrasions or burns over the skin. Recently there has been a sudden rise in the number of cases who sustained injury or burns by oscillating saw following plaster cast removal and a few patients have demanded compensation from the hospital. These incidences prompted the start of this study. The identified cause of injury was the removal of a plaster cast by an inexperienced, ill-trained user or blunt saw blade. Strict protocols were required and have been introduced at the Alexandra Hospital to avoid litigation.

Contingent legitimacy: U.K. alternative practitioners and inter-sectoral acceptance

Although alternative medicine has achieved an increasingly high profile in recent years, surprisingly little social research has been conducted in the area. This is noticeably the case when considering inter-sectoral contact and collaboration. This paper fills that gap by drawing on evidence from a large-scale study of non-orthodox practitioners in the U.K. By examining the lived experience of interaction the study aimed to discover the level of professional legitimacy which alternative practitioners routinely enjoy or are denied by mainstream practitioners. Results show that the last decade has been characterised by an increasing liberalisation of attitude toward inter-sectoral collaboration throughout the mainstream. However, the evidence also shows that this cannot be equated with the existence of a generalised acceptance of alternative practitioners, professional legitimacy. There is a schism within orthodoxy on this issue and that schism is occupationally based: at the extremes, consultants remain characteristically dismissive of alternative practitioners, nurses overwhelmingly enthusiastic. The nature of the non-orthodox practice being considered was of little significance. It is argued that the identification of differentiation within orthodoxy on this issue marks a significant point in developing an understanding of relations between the "sectors" and its component parts. There is a clear potential for conflicting developmental paths of action between orthodox groups, and for differing conceptions of who and what constitute a legitimate part of the medical totality. Cross-sectoral alignments, which challenge the state sanctioned dichotomy of mainstream/alternative, are viewed in quite different ways throughout orthodoxy. Knowledge of this intra-sectoral differentiation is essential to an understanding of emerging patterns of inter-sectoral relations.

Autonomy and practice: the case of complementary practitioners in the UK

OBJECTIVE

1. To identify the level of acceptance of the principle of British Medical Association (BMA) participation in the formulation of practice guidelines for complementary medicine amongst currently active non-orthodox practitioners in the UK. 2. To identify the level of support for individual BMA proposals. 3. To identify similarities and differences of attitude to the proposals between practitioners of selected non-orthodox therapies.

DESIGN

A postal survey of 1000 practitioners of complementary medicine.

SETTING

The UK between late 1993 and early 1994.

STUDY PARTICIPANTS

One thousand currently practising UK complementary therapists from 4 groups-chiropractic, "lay" homeopathy, medical herbalism and reflexology. Systematic sampling (every nth practitioner) was used to select 250 respondents from membership lists of relevant representative bodies. The reponse rate was 57%.

RESULTS

The principle of BMA participation in policy formation was accepted by the vast majority of respondents, although 87.7% stipulated that this should not constitute a major role. Each of the individual BMA proposals received majority support. Acceptance rates varied from 59.7% to 92.9%. Statistically significant differentiation between therapies was recorded on certain proposals.

DISCUSSION

The revised stance of the BMA is finding a potentially receptive audience amongst UK complementary practitioners. There is a large amount of common ground between the proposals and what is acceptable to practitioners. However, the situation is complicated by intra-sectoral differentiation. Particular therapy and issue-specific barriers exist to the universal utilization of the kind of measures proposed.