Introduction

The process of insertion of traditional, complementary and integrative medicines (TCIM) in national health systems is a point of discussion worldwide, considering the strategies recommended by the World Health Organization ([WHO] 2014-2023) as an alternative to valuing a comprehensive approach to health care in a safe, respectful, accessible and effective manner ¹.

Despite the understanding of the benefits of TCIM as a therapeutic resource in integrative care models to promote health in chronic situation prevention, prevention, management, and control of chronic situations, in addition to practices that favor quality of life, implementation and public financing of these practices are not consensual in different countries ^2-6.

Scholars on the subject point out that, despite the undeniable political-institutional and social advancement of TCIM in the Americas in recent decades, there are still challenges in overcoming the rationality that, since modernity, has been leading medical care practice based on the “science of pathologies” instead of comprehensive care of human beings ^7-11.

Scholars of the historical process of rationalization of medical systems argue that the vitalistic holistic health model, present in ancient Eastern and Western societies’ cultural traditions, aims at the state of a dynamic balance of living beings in the whole-part relationship of the universe. This comprehensive perspective for interpreting health and illness has been replaced since pre-modern Western society to the extent that the development of specialized knowledge and the creation of disciplines in the fields of medicine, botany and pharmacy led to the epistemological disqualification of traditional ways of knowledge practiced, organized, preserved and reproduced through empirical observation in different cultures. Instead, the biomedical model with structured knowledge focused on curing the disease determined the hegemonic paradigm for health care ⁷.

In this regard, the variety of therapeutic systems and resources that make up TCIM includes practices from different cosmologies that, on the one hand, break with the colonial character of biomedicine, valuing, in its specificities, the inclusion of different knowledge and care practices in sociocultural contexts, but, on the other hand, favors the construction of bonds of socio-affective-cultural belonging that these practices allow ^12,13.

Such challenges are more evident in the field of highly complex care, as in the case of oncology. Discussions about using TCIM in oncology care were strengthened with the creation of the Society of Integrative Oncology (SIO), a non-profit multidisciplinary organization founded in 2003 to promote research and practice of integrative approaches to cancer prevention, treatment and palliative care through the proposition of clinical protocols ^14,15. Over the past 20 years, efforts have been made by experts who are members of the SIO, including countries in North America, Europe and Asia, both for a more comprehensive understanding of this emerging field of activity and for the search for evidence for systematization of practices and professional training ^16,17.

From this perspective, the consensus definition presented by the SIO is that integrative oncology is “a patient-centered, evidence-informed field of cancer care that utilizes mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatments” ^{16: 702}. Therefore, it aims to enable people to become active participants in the care process to improve health and quality of life and prevent cancer, in addition to optimizing clinical results throughout treatment, improving health conditions in survival and/or reducing symptom burden associated with cancer or treatments ^16,17.

Research and discussions by experts on the subject conducted to date represent a major advance towards TCIM insertion in the field of oncology care. International recommendations regarding clinical practices and educational skills for the multidisciplinary team were proposed to benefit people with cancer, health professionals, managers and public policymakers. However, such evidence emerges from countries in North America, Europe and Asia, which leads us to reflect on the warning that the process of implementing TCIM in health care requires analysis of socio- environmental contexts and sociocultural and political implications in which these practices are inserted, playing their role in restoring people’s and communities’ life and health ^7,17. In view of this, the question arises as to TCIM implementation status in oncological care in countries on other continents.

A recent study on TCIM mapping in the Americas and the Caribbean region highlights that such practices have been used in different contexts in America, but little is known about these interventions and how implementation policies have been developed, especially in South America. This region includes 13 countries that concentrate the highest percentage of the continent’s urban population, marked by multiculturalism and diversity in health management systems. Regarding TCIM regulation, South American countries have the greatest diversity of types of specific regulations ².

Therefore, the intention is to contribute to the discussion about TCIM insertion in oncology care in Latin America based on health care management. This study aims to analyze the health care management dimensions included in scientific production in integrative oncology in Latin America.

Materials and Method

This is an integrative literature review conducted based on the following steps: review theme/question definition; establishment of search and selection criteria for primary studies; extraction of data from selected studies; critical data assessment; synthesis of knowledge and dissemination of results ^18-20.

Search and selection of primary studies were carried out from July to September 2022, based on the guiding research question: How have health care management dimensions been addressed in Latin American scientific production with a focus on integrative oncology? This question was elaborated based on the PICo strategy (acronym for “participants,” “interest,” and “context”) according to The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews recommendations ²¹.

LILACS, Mosaico and IBECS via Virtual Health Library (VHL), MEDLINE via PubMed and Embase, using Health Sciences Descriptors (DeCS), Medical Subject Headings (MESH) and keywords that expressed the theme were consulted, combined with the Boolean operators OR and AND through the association of a set of free terms related to the descriptors “Integrative Oncology” and “Complementary Therapies,” “Health Care and Care Management,” and, finally, “Countries That Make Up Latin America.”

Considering their extension, possibility of permanent consultation and reproduction, such complete strategies were deposited in the SearchRxiv^® repository.¹

Original articles available in full in databases, published in Portuguese, Spanish or English, from 2017 to September 2022, were included. The initial time frame adopted is related to the year in which the WHO included the term “integrative” in the name of TCIM, based on the formation of the TCIM Americas Network as well as the construction of the VHL TCIM, in line with the strategic objectives for the expansion of the 2014-2023 model proposed by the WHO ².

To organize the articles, the Endnote^® reference manager was used ^22,23. Articles selected in pre-analysis were organized according to title, year of publication, country in which the study was performed, design and type of TCIM researched, participants, and health care management dimensions.

Selected articles after in-depth reading were analyzed regarding the six health care management dimensions, which were initially explored in isolation, based on the researchers’ objective intention in delimiting the object of study ²⁴. Subsequently, the presence of other interdependent dimensions was identified in the discussion of the results of studies that made up the sample for the review.

The “individual” dimension comprises individuals who are part of the care process, and the main elements are autonomy, self-care and choice; the “family” dimension includes family members, friends, neighbors and others who help support individuals in their daily lives; the “professional” dimension focuses on technical and ethical aspects related to professionals in user care; the “organizational” dimension highlights elements related to teamwork coordination and technical division; the “systemic” dimension deals with formal, regular and regulated connections between health services, composing networks or lines of care; and the “societal” dimension addresses social policies and their relationship with health, focusing on the State’s and civil society’s role ²⁴.

Considering the integrative review method, based on published data without the involvement of participating subjects, there was no need for submission to a Research Ethics Committee.

Ethical and legal aspects related to authorship were guaranteed.

Results

The process of selecting studies, based on identification, screening, eligibility, and inclusion, resulted in 204 articles. After applying the filters, 91 studies remained and had their titles and abstracts read. Of these, 3 duplicates were excluded and, after read in full, 8 articles were chosen to compose the final sample for the review ^25-32, as shown in Figure 1.

Source: adapted from The PRISMA 2020 Statement ²¹

Figure 1 Flowchart of Search Stage Synthesis and Selection of Integrative Review Primary Studies. Rio de Janeiro, RJ, Brazil, 2023 

The critical assessment resulted from the analysis of selected articles, as presented in Table 1. Data production from studies analyzed took place in Brazil (n = 4), Chile, Colombia, Peru and Uruguay (n = 1, respectively). Of these, 62 % were published between 2018 and 2019.

Regarding design, studies had a comprehensive approach (n = 2), epidemiological for mapping and situational diagnosis (n = 2), clinical and assessment (n = 4). TCIM practices analyzed were herbal medicine (n = 5), acupuncture (n = 4), homeopathy, meditation, reiki, yoga, and chiropractic (n = 1, respectively). Actions related to food/ nutrition and prayer also stood out.

In the sample analyzed, there was a predominance of focus on the “individual” health care management dimension when including adults (n = 6) and children (n = 1) with cancer as participants. Interdependence between dimensions emerged in the analysis of results with emphasis on the “professional” dimension, in addition to the “family,” “societal,” and “organizational” dimensions.

Discussion

Health care management is explained in the strategies recommended by the WHO (2014-2023) to insert TCIM into health systems in the global context based on its strategic objectives of developing a knowledge base for management through national policies; strengthening TCIM safety, quality and effectiveness through regulations; and promoting universal health coverage through service integration and self-management promotion in health systems. Such strategies created the TCIM Americas Network in 2017 ⁶, which may have influenced the predominance of studies in the study sample in 2018 and 2019.

Latin America is a region with great cultural and social diversity, in addition to diverse climatic and geomorphological aspects and rich biodiversity. There are 431,425,737 inhabitants living in Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, French Guiana, Paraguay, Peru, Suriname, Uruguay, and Venezuela. Studies performed in Brazil were analyzed with greater predominance, in addition to Chile, Colombia and Peru, which may reflect the existence of regulation for TCIM in these countries, whether within the scope of traditional medicines or in integrative and complementary medicine ².

Otherwise, according to the Mapping of Traditional, Complementary and Integrative Medicines Report in the Americas and the Caribbean, carried out in 2022 ², the aforementioned countries have a record of integration of TCIM into the health system, provision in Primary Care, training programs, in addition to research financing initiatives, strategies that can favor the search for knowledge production.

From this perspective, the importance of producing knowledge to strengthen TCIM dissemination in health systems in line with WHO strategic objectives stands out. The design of studies analyzed included both studies with an epidemiological approach and comprehensive understanding of the reality experienced in TCIM use as well as clinical studies that contribute to effectiveness assessment. Therefore, the researchers’ objective intention focused, predominantly, on people with cancer as study participants, contributing to the individual health care management dimension.

Health care management is defined as “the provision or availability of health technologies, according to each person’s unique needs, at different moments of their life, aiming for their well-being, safety and autonomy to continue with a productive and happy life” ^{24: 589}.

Consequently, the “individual” dimension with a focus on the person who requires care occupies the centrality of the management process. Indicators such as self-care and autonomy stand out, in the sense of recognizing each individual’s power to, based on their choices, “produce a unique way of living, making life a work of art” ^24:589, which is in line with TCIM principles ^1,24.

Analyzed studies focused on adults with cancer, mainly in the treatment process, which indicates the potential for using TCIM as a complement to specialized care. Studied practices with greater focus were herbal medicine and acupuncture, in addition to homeopathy, meditation, reiki, yoga and chiropractic. Actions related to food/nutrition were also highlighted in almost all studies. This result reflects a trend observed in the literature of the growth of studies on the aforementioned therapies ^33-38.

It is worth highlighting that TCIM proposals point to the articulation of practices with care strategies based on the concept of person-centered comprehensive health with the integration of daily actions to promote health and well-being related to three main lines: nutrition and healthy eating; physical activity; and balance in emotional and mental state ².

All studies indicated positive results with TCIM use. It was possible to recover autonomy by encouraging self-management to deal with the effects of treatment ^25,27,28,31, favoring processes of self-knowledge and improving health conditions ^26,39. Furthermore, this entire process allows users to safely decide on the choice of their lifestyle ^26,29.

Practices identified in Latin American studies are also researched in other countries in the Americas. Study indicates an increase in TCIM supply in cancer centers in the United States whose most offered therapies are acupuncture, massage, meditation, yoga, nutrition/ dietary supplementation, and herbal medicine ⁴⁰.

It is worth noting that practices related to traditional medicine were not the subject of investigation in the studies analyzed, suggesting the possible invisibility of popular knowledge use in research in the field of Latin American integrative oncology ³⁰.

As part of the discussion of the results of the sample of studies analyzed, interdependence with other health care management dimensions was noted, especially the “professional” dimension. This is understood as that which occurs in the meeting between professionals and users, and nucleates micropolitics in health, i.e., the set of relationships that configure care production ²⁴.

The “professional” dimension emerged in the highlights regarding the need for professional training to assess therapeutic efficacy and safety in herbal medicine and other practice use ^27,29; guide people with cancer about the most appropriate TCIM for their needs and in interaction with treatments ²⁸; and inform about changes in eating habits during cancer treatment ²⁶.

An extremely relevant aspect that emerged regarding the “professional” dimension was presented as a result of the only study that focused on that dimension. Study participants highlighted that professionals’ knowledge about NCI TCIM must begin with personal use so that they can have a positive attitude and feel motivated to enter clinical practice ³⁰, which confirms the importance of articulating the “individual” and “professional” dimensions to understand micropolitics in health care production. From this perspective, it is essential to recognize that there are several connections between health care management dimensions, composing a network of interconnected points arising from interactions between users, family members, workers and managers in daily clinical and management practice ²⁴.

The “family” dimension, made up of family members, friends and the support network for people with cancer, was addressed in the discussion of one of the studies, which highlighted the importance of family learning about TCIM, in addition to supporting the process of changing habits ²⁶. This result confirms the need to include family members/caregivers in care planning to insert TCIM effectively and safely. A recent study to investigate how Taiwanese families of people with cancer react regarding complementary and alternative medicine use highlighted cases in which family members/caregivers do not share the same view of people with cancer regarding TCIM, making communication not effective ⁴¹.

In this context, aspects related to the societal health care management dimension are considered. Support groups, social networks and television media were mentioned in one of the studies analyzed as elements that contribute to information about TCIM for people with cancer ²⁶.

Regarding support groups, the growth in the organization of this care technology has been analyzed both in health institutions and within civil society. Such groups bring together people with cancer who experience common problems and develop actions to help find ways to solve the problems they experience through voluntary work ^42-44. In many situations, the sources of information to support activities promoted are social networks and television media ^45,46.

A study that assessed complementary and alternative medicine methods for cancer treatment published on 85 websites in nine Spanish-speaking countries in South America identified 158 different alternative procedures offered with promises of cure or as an essential part of therapy. One of the methods highlighted was homeopathy, mentioned on 12 out of 85 web pages. Then, there was the dissemination of Aloe Vera products, the consumption of soursop, the practice of yoga and meditation, acupuncture and Bach flower remedies. Among the South American methods are the Aloe mixture called “Frei Romano,” Uncaria (popularly known as “cat’s claw”), soursop (Annona muricata), “Hansi method” and lapacho tree components stood out. Furthermore, a study points to Facebook as the fifth most used resource as a source of searches by patients (after websites). Despite the breadth of information available, it is clear that existing platforms still do not meet all patients’ needs. Therefore, there is an urgent need to produce quality websites ^47,48.

Therefore, the implications of this problem are in line with the discussion within the scope of the systemic health care management dimension to the extent that professionals and managers who integrate networks and lines of care regulated in health services need to create monitoring strategies related to the different ways in which TCIM are being offered to people with cancer ⁴⁸. Furthermore, discussions about including content in the curricula of training courses for health professionals and professional training are broadened, as highlighted in analyzed studies ²⁵.

The “organizational” dimension was highlighted in the four articles developed in Brazil ^27,29,31,32, with an emphasis on integrative and complementary practices as important therapeutic tools, however requiring changes in care and management process organization. This result may indicate that, although there is evidence of recognition of TCIM effectiveness in the field of oncology by professionals and people with cancer, it is possible to infer the lack of investment by health institutions and the State in Latin American countries concerning integrative oncology. As highlighted in analyzed studies, greater investment is needed both in strengthening practice insertion and evidence production to support clinical practice ^28,30,49.

Conclusions

The sample of studies analyzed revealed that the “individual” health care management dimension was the main emphasis of the research, which indicates an interest in the greater understanding of TCIM used by people with cancer in Latin American countries, especially herbal medicine.

The “family” and “societal” dimensions emerge in interdependence with the individual dimension when highlighting the participation of family, friends and civil society support groups in supporting and guiding people with cancer regarding TCIM use.

Based on the findings, it is possible to draw an overview of scientific production on integrative oncology use in Latin America. From the few countries in which the studies were developed, discussions emerge both about the need to train health professionals about TCIM and to inform the population about its informed and safe use. Furthermore, studies highlight the importance of investment to implement these practices in health services in different countries in the region.

Such results are in line with international discussions that aim to enhance evidence to support health care management strategies to implement TCIM according to the peculiarities of the different Latin American health systems. This involves thinking about macro and micropolitical aspects based on dialogue with different social actors, in the field of health and society for regulation, availability and access, curricularization for interdisciplinary professional training, in addition to strategies for monitoring and assessing effective and safe practices ¹.

To contribute with evidence to strengthen integrative oncology insertion in national health systems in Latin America, under the WHO recommendations (2014-2023), it is suggested that future research with different theoretical-methodological strategies regarding the knowledge and practices of people with cancer and health professionals regarding TCIM; successful strategies for implementing integrative oncology in the oncology care network; and challenges for organization of services and professional training for work in integrative oncology, including strategies for integrating the care network with support groups implemented by civil society.

Study Limitations

We chose to perform searches in health databases without crossing them with a specific TCIM database, so the review may not have included all articles on the theme. Otherwise, the time frame adopted can be expanded considering the temporality of the creation of regulations for TCIM in some countries that did not present studies in the sample analyzed. This could favor a more comprehensive analysis of possible aspects related to multiculturalism in TCIM use in oncology care in Latin America.