Can, G., Erol, O., Aydiner, A., & Topuz, E. (2011). Non-pharmacological interventions used by cancer patients during chemotherapy in Turkey. European Journal of Oncology Nursing, 15, 178-184. 

To determine the kind of nonpharmacological interventions used by Turkish patients with cancer for symptom management during chemotherapy, whether a relationship exists between symptom experience and nonpharmacological intervention use, and what personal and illness-related variables predict the symptom experience and nonpharmacological interventions use in this population

Patients completed the following. If patients were unable to complete the tools themselves, a friend or relative verbally asked the patient the questions.

• Patient Characteristics Form
• Eastern Cooperative Oncology Group (ECOG) Performance Status scale
• Nightingale Symptom Assessment Scale (N-SAS)
• Use and perceived effectiveness of nonpharmacological interventions used during chemotherapy using dichotomous responses (0 = not effective, 1 = yes, effective)

• The study reported on 202 pages with a mean age of 48.82 years (SD = 1.44 years).
• The sample was 41.6% male and 58.4% female.
• Cancer diagnoses were breast (27.2%), colorectal (16.8%), gynecologic (14.4%), lung (13.4%), lymphoma (7.4%), urologic (6.4%), gastric (5.4%), bone (4.5%), head and neck (2.5%), skin and sarcomas (2.0%).
• Other key sample characteristics include that 66.8% of patients had primary disease and 33.2% had metastatic disease; 58.4% had ECOG performance status of 0 (fully active), 29.7% had ECOG performance status of 1, and 11.9 % had ECOG performance state of 2.

The study was conducted at a single site, outpatient setting at the Istanbul University Institute of Oncology in Turkey.

Patients were undergoing the active phase of treatment care.

This was a descriptive study.

• The Patient Characteristics Form had 17 items that addressed demographic, disease, and treatment characteristics at the time of initial diagnosis. 
• The Eastern Cooperative Oncology Group (ECOG) Performance Status assesses performance status of patients with cancer using six possible number responses.
• The Nightingale Symptom Assessment Scale (N-SAS) is a Likert -type, quality-of-life scale that includes 38 items addressing symptom experience of patients with cancer during chemotherapy. Three subscales (psychological well-being, social well-being, and physical well-being) are used. The original study using this author-developed scale reported that the subscales have high internal reliability and Cronbach’s alpha values between 0.81 and 0.87 and 0.93 for the overall tool. This study reported Cronbach’s alpha reliability for the subscales as follows.
  • Psychological, 0.88
  • Social, 0.80
  • Physical, 0.85
• Effective nonpharmacological interventions were identified from the literature and grouped into three subgroups based on the scale’s subgroups of psychological, social, and physical.

• Physical symptom distress was higher than psychological and social symptom distress.  The most frequent symptoms reported were fatigue (85.1%), nausea (70.8%), alopecia (68.3%), dry mouth (64.4%), and impaired sleep habits (62.9%).  Nonpharmacological interventions used to relieve physical distress included resting (38.2%) and sleeping (12.9%) for fatigue; drinking liquids (9%) and oral care (15.9%) for dry mouth; and exercise (8%) and massage (5.5%) for other physical symptoms. Most subjects (72.5%) preferred pharmacological interventions for physical symptoms.
• Psychological symptom distress was most frequently addressed by support (7.5%), resting (6.5%), and exercise (1.5%). Only 3% of patients preferred pharmacological interventions for psychological symptoms. Social interventions included pomades for skin and nail changes (19.4%) and berets, scarves and wigs for alopecia (6.5%).  An increase in symptoms “enhanced” the use of the physical and all nonpharmacological interventions in general.  The well-being of women and younger patients and patients who had metastatic disease, surgery, and high ECOG performance scores were low for all subgroups and overall (p < 0.05).
• Social well-being was lower in patients with breast cancer, patients who received taxane-based therapy, and those who were housewives. Social interventions were more frequently used by university graduates (p = 0.024). Psychological interventions were more often used by students compared to housewives, retired, self-employed people, and working people (p = 0.028). Patients below the age of 50 preferred to use psychological interventions using logistic regression (overall response [OR] = 3.06 [95% confidence interval (CI) = 1.17–7.96]).

Most patients with cancer in Turkey preferred pharmacologic interventions for symptom management.  Exercise, as a recognized evidence-based intervention, was only reported to be used by a few patients. The authors recommended that oncology nurses teach patients more about the side effects of chemotherapy and associated nonpharmacological interventions. Although other studies have produced such evidence-based recommendations, they were not developed from this study of self-reported symptoms and interventions of Turkish people receiving chemotherapy. The authors did not report if or how teaching occurred from the perspective of the nurse or the patient or family.

• No appropriate control group was included.
• Only patient survey data was used.
• Data was exclusively from a Turkish patient population at one point in time (which differed among patients) and with various diagnoses and treatments . 
• No discussion was included comparing these results to results from similar symptom and intervention surveys in other countries and cultures.

An individualized assessment of each patient's knowledge and preferences is important to all cultures and practices.