USE OF ALTERNATIVE THERAPY AMONG PEDIATRIC ONCOLOGY ...

Pediatric Hematology and Oncology, 17:55± 65, 2000 Copyright ° C 2000 Taylor & Francis 0888-0018/00 $12.00 + .00

USE OF ALTERNATIVE THERAPY AMONG PEDIATRIC ONCOLOGY PATIENTS IN TAIWAN Chao-Hsing Yeh, RN, PhD h Graduate Institute of Nursing Science, Chang Gung University, Taiwan, Republic of China Jia-Ling Tsai, RN, MSN Republic of China

School of Nursing, Chang Gung University, Taiwan, h

Wenjun Li h Massachusetts Eye and Ear In® rmatory, Harvard Medical School, Cambridge, Massachusetts, USA Hui-Me Chen, RN, MSN Republic of China h

National Taipei College of Nursing, Taiwan,

Shu-Chu Lee, RN, and Chiou-Fen Lin, RN Taiwan, Republic of China h

Chang Gung Children’s Hospital,

Chao-Ping Yang, MD h Chang Gung Children’s Hospital and Chang Gung University, College of Medicine, Taiwan, Republic of China Both alternative medicine and western medicine have been commonly used to treat pediatric cancer patients in Taiwan. Each has its own intrinsic strengths and weaknesses and they can be complementary. Little is known about medical help-seeking behaviors of parents of pediatric cancer patients, especially those related to alternative therapies. This study investigated the extent and parental expectations on use of alternative therapies. All primary caregivers of 63 eligible patients were interviewed. Use of alternative therapies, regardless of education level or social status of their families, is prevalent (n = 46, 73%) in Taiwan. Commonly used alternative therapies included, in order of popularity, formulated functional food (n = 22, 48%), temple worship/shamanism (n = 19, 40%), traditional Chinese medicine (n = 9, 20%), secret recipes/herbs (n = 13, 28%), and diet supplements (n = 9, 19%). Such practices generally occur without medical guidance from oncologists, largely because of poor interactions between parents and oncologists. Future efforts should be made to encourage both parents and oncologists to discuss this issue. Nurses may serve as mediators by developing mutual trust and a sharing relationship between these groups. h

Keywords. alternative therapy, medical help-seeking behavior, oncology, pediatric patient

The parents of pediatric cancer patients (hereafter, the parents) often have to make decisions on medical treatments for their children. The long duration, painfulness, and uncertainty of existing standard treatments [1] Received 19 November 1998; accepted 20 January 1999. This research was supported by a grant to Dr. Yeh from Chang Gung University, Taiwan, Republic of China (CMRP765). Address correspondence to Chao-Hsing Yeh, RN, PhD, Chang Gung University, Graduate Institute of Nursing Science, 259 Wen-Hwa 1 Road, Kwei-San, Tao-Yuen, Taiwan, ROC. E-mail: [email protected]

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usually bring excessive stresses to parents, which may lead them to consider less painful alternative therapies [2± 5]. Several kinds of alternative therapies have been commonly used in TaiwanÐ popular, folk, Western, or traditional Chinese medicine [6]. They are often used, simultaneously or consecutively, as a supplementary therapy to standard treatments [6, 7]. However, little is known about the use of these therapies and particularly the related parental medical assistance-seeking behavior. In general, Western medicine is believed to be capable of curing a disease in its acute phase while alternative therapies can not only cure disease but also rehabilitate and prevent a disease by improving patients’ immune function. Parents usually demand more effective but less painful therapies for their children. The doubts about the effectiveness or misunderstanding of a treatment or prognosis might lead parents to decide to withdrawal from it or switch to alternatives [8]. Although parents have the responsibility to make medical decisions for their children [8], it is the responsibility of health professionals to provide adequate information and educated advice regarding the disease and the proposed treatment. Lack of understanding of parents’ medical help-seeking behavior during decision-making and lack of communication skills often prevent medical practitioners from providing informative counseling to the parents. Without such counseling, however, no parent could possibly be psychologically and emotionally prepared for the completion of a long-lasting and painful medical treatment. To elucidate parents’ medical help-seeking behavior and to provide a theoretical and empirical background for nursing counseling, we conducted a series of interviews with parents regarding the use of alternative therapies. We analyzed the process of decision-making and factors relevant to parents’ help-seeking behavior. For the purpose of this study, the de® nition of alternative therapy was adapted from the classi® cation of Murray and Rubel [9]. The study aimed to reveal the extent and parental expectation on alternative therapies, and the interactions between parents and medical professionals regarding these therapies. METHOD Sample Subjects were recruited from oncology patients treated in pediatric oncology wards and the clinic at Chang Gung Children’s Hospital at Lin Ko, Taiwan. Eligible patients were those 18 years old or younger and diagnosed at least 2 months before ® rst interview. There were 63 eligible patients in total, and all their primary caregivers were interviewed (response rate = 100%). Of these patients, 46 (73%) had used or were using at least one kind of alternative therapy.

Alternative Therapy in Pediatric Patients in Taiwan

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Data Collection A semistructured, individual, in-depth interview guide was constructed based on the researchers’ previous experiences and recent literature. The interview guide was piloted for three parents to determine the adequacy of the construct. The ® nalized interview guide included, but was not limited to, the following questions: (1) Who was the decision maker for using alternative therapy? (2) Why was it decided to use it? (3) What did the parents expect from it? (4) What were the actual outcomes after using it? And (5) Did the parents ever discuss the use of alternative therapy with the child’s primary oncologists? In addition to interviews, data were also collected using onsite observation and 4 focus group discussions (2 to 5 participants in each group) during the hospitalization of the patients, and reviews of medical charts and researchers’ re¯ exive journals. All participants under observation were informed when observation and data collection were in progress. Procedure The approval for studying human subjects was obtained from Chang Gung Children’s Hospital prior to the study. Its established procedures for protecting anonymity and con® dentiality were strictly followed. A semistructured interview was conducted with the parents in May, June, and July 1998. The subjects were sequentially scheduled by individual or group and interviewed face to face in hospital wards or clinics by one of the three trained interviewers (Chao-Hsing Yeh, Chiou-Fuen Li, and Wei-Mei Chen). The interviews were begun with general topics such as situation of the children, their concerns about disease, and personal interests, and then moved to more speci® c topics following the interview guide. At the end of each interview, the parents were encouraged to ask questions. The interviewers clari® ed questions raised by the parents and provided necessary advice. In addition, medical information and demographic data about the parents and patients were also collected, i.e., diagnosis, type of treatment, age at diagnosis, gender, primary caregiver, occupation of parents, and religious belief of the family. Data Analysis Data analysis was guided by the techniques suggested by Miles and Huberman [10]. We used a content analytic summary table based on research questions to reveal similarities and differences in ® ndings between the interviews. Criteria outlined by Lincoln and Guba [11] and Sandelowski [12] were followed to ensure trustworthiness of the data. For each interview, the data coders (Chao-Hsing Yeh and Jia-Ling Tsai) coded the raw data independently after the data were transcribed to ensure interrater reliability. The

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initial interrater agreement reached 89%. The coding from 2 coders was compared and discussed until agreements were reached, and then the data were combined for each subject. To ensure truth value, the authors used methods of prolonged engagement (until data analysis reached saturation from the authors). To ensure consistency of interviewing techniques and skills, three interviewers were trained and practiced until their interview skills were consistent and appropriate. The semistructured interview guide was used for all interviews. A transcript of the interview was given to the subjects to check before the analysis was completed. After all interviews were completed, the data were summarized and classi® ed into categories as presented in this report. RESULTS Characteristics of Patients and Parents Of the 63 patients, 25 were female and 38 were male, and their average ages were 6.1 (SD = 5.6) and 7.65 (SD = 4.91), respectively. Their oncology diagnosis included leukemia (n = 38, 60%) lymphoma (n = 7, 11%), and solid tumor (n = 18, 29%). The primary caregivers of patients consisted of 57 mothers and 6 grandparents. The average age of mothers of the patients (n = 63) was 34.6 (SD = 6.3, range 24 to 54 years) and their average education was 10.4 years (SD = 3.4, range 6 to 12 years); the average age of fathers was (n = 63) 36.9 (SD = 5.7, range 27 to 70 years) and their average education was 11.2 years (SD = 3.5, range 6 to 16 years). Prevalence of Alternative Therapy Use Among the 63 patients, 46 (73%) used at least one alternative therapy, 17 (27%) used two, and 6 (9.5%) used three or more during the course of illness. The most commonly used alternative therapies included, in order of popularity, functional food (n = 22, 48%), temple worship/shamanism counseling (n = 19, 41%), folk medicine/herbs (n = 13, 28%), and traditional Chinese medicine (n = 9, 20%) (Table 1). Decision Makers of Alternative Therapy Use Decisions on use of alternative therapies were made either by parents (n = 41) or by grandparents (or other family members) (n = 5). Some grandparents and close friends also suggested a variety of treatments that the parents pretended to accept but did not actually use (n = 8). The difference in education levels of users and nonusers of alternative therapies was evident (v 2 = 17.2, df = 2, p < .005). Fifty-six percent (n = 26)


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TABLE 1 Alternative Therapies Used by Pediatric Oncology Patients Categories

n

Percentagea

Functional food Folk medicine Secret recipes/herbs Qi-gong Nutritional supplements Vegetable juices Megavitamins Folk healing (religious/spiritual) Divination/change name/temple worship/ shamanism Vegetarian Traditional chinese medicine

22

48%

13 1

28% 2%

4 5

9% 11%

19

41%

2 9

4% 20%

a The percentages do not add up to 100% because some children used more than one therapy.

of the mothers with high school level education made decisions to use alternative therapies while less than 23% (n = 11) of the mothers with only primary school level of education did. There was no signi® cant difference in age and education of fathers between users and nonusers. Similarly, there were no differences in age and gender ratio between user and nonuser patients. Primary caregivers were generally mothers (n = 57, 89.5%). Except for two single mothers, all parents were married and lived together. Religious beliefs of parents included Taoism (n = 21), Buddhism (n = 30), Catholicism (n = 2), and others (n = 10). Family incomes were primarily from fathers (n = 47), both parents (n = 10), mothers (n = 2), or other family members (n = 4). In general, except for partial payments by patients’ families, medical expenditure of cancer treatment was mostly covered by the national health-care insurance of Taiwan. The uncovered medical expenditures of established standard treatments were almost fully reimbursed by Chinese Cancer Foundation, while none of the alternative therapies were covered. Functional Food Parents of functional food users (n = 22, 48%) believed that functional foods (particularly ginseng and ganoderma lucidum) were effective in improving physiological functions and thus preventing and relieving illness. Functional foods were commonly used as a supplement to Western treatment to limit side effects and increase immune function. Most functional foods in retail were manufactured by modern technology and packed either in liquid or powder. They were advertised as natural remedies that provide rich nutrition and are effective in improving prognosis. Thus, parents may have perceived the safety of such remedies without questioning their potential toxicity. Functional foods were generally expensive and regular use of

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them often brought additional ® nancial burdens to patients’ families. Family members often disagreed with each other over doubts about the effectiveness or different attitudes toward the use of them. Medical practitioners generally doubted the effectiveness of functional foods and thus did not suggest parents use them. Spiritual Beliefs Spiritual beliefs played an important role in shaping parents’ medical help-seeking behavior. While the parents considered Western cancer treatments as proper and essential of curing cancer, they might interpret the illness as their own or child’s past sin from Buddhist karma. To rectify past sin, most of the parents (n = 35) made offerings at Buddhist temples or requested Taoist priests or shamans to perform rites for their children. Besides praying, other religious help-seeking behavior was observed as well, such as shamanic counseling (n = 19, 41%), divination of child’s fate (n = 18, 39%), and reading of ªBa-Ziº to change the child’s name (n = 10, 22%). For instance, after shamans received health-related questions from clients, they wrote on a piece of paper (Fu) while performing certain ritual (i.e., spiritual writing). The paper (Fu) carrying ªspiritº could then be either worn with a necklace or burnt into ashes and drunk with water by the sick child. Wearing Fu was commonly accepted by parents and family of patients. Most parents reported improvement of their children, i.e., their children were more responsive to the treatment and felt energized. Drinking ash water, mostly requested by the elders, was considered unhygienic. However, it might be perceived as negligence of caring if the parents refused to let their child drink ash water. Although some parents (n = 17, among whom ever searched more advanced religious-related behavior) reported that religious help-seeking activities had no effect on their child’s disease, nearly all of them thought the activities had psychosocial bene® ts on their children, e.g., patients were more motivated to ® ght the disease and experienced helpful psychological relief from religious ªhope.º Folk Medicine/Herbs Folk medicine was a popular practice, which involved using herbs without a prescription from a trained medical practitioner. In general, parents believed that western medicine was good for curing a disease at its acute phase, while herbs can regulate and promote immune function of a patient’s ªinternal body.º Such remedies often spread quickly by word of mouth. For example, one parent stated that ªXX’s mother gave me this remedy. Her son looks healthy after having taken such remedies.º Improper use of such remedies might result in severe consequences to patients. Thirteen patients (28%) used folk medicine. Two of them dropped


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out of the standard cancer treatment to take folk medicine remedies; later, they relapsed and were rehospitalized. In addition, such help-seeking behaviors were exhibited mostly in the elders, close relatives, or friends who were overly enthusiastic. They often brought extra psychological burdens to parents. The education level of parents who decided to use folk medicine was mostly at the high school level (n = 40, 87%). Prescribed Traditional Chinese Medicine Nine parents (19%) sought medical care for their children from both Western medicine and prescribed traditional Chinese medicine (hereafter, TCM). These parents believed that TCM has certain advantages over Western medicine, since it has a long history of several thousand years, and that TCM and Western medicine could be complementary. Many TCM doctors may request patients withdraw from treatments of Western medicine before they start a TCM therapy. Since no convincing scienti® c evidence is available regarding the effectiveness of TCM and there exists no referral system, parents usually faced controversies on choices of the ªbestº treatments for their children. Such controversies may delay treatments. Most parents chose both TCM and standard Western treatments either simultaneously or consequently without consulting their oncologists. In addition, parents might perceive that TCM doctors wanted to sell them more medications at a higher price. To reduce the cost of medication, they went to a free-standing (retail) herbal pharmacy to re® ll medication after the ® rst visit to their TCM doctors. The administration of Chinese medicine was judged by parents according to child’s physical responses or their previous experiences without consulting certi® ed medical practitioners. Such self-mediation behavior, consequently, caused overmedication (i.e., relapse) when used in addition to western standard treatments for the patients (n = 13, 28%). Other Therapies Besides common protein and nutritional supplements, a few patients used vegetable juices (n = 4, 9%), megavitamins (n = 5, 11%), and Qi Gong therapies (n = 1). Two patients went on vegetarian diets (n = 2) according to parental religious belief. Metabolic therapy that needed organic farm products (without any exposure to chemical toxins) was also mentioned by many parents (n = 28, 61%), but no patient tried such therapy because of unavailability. Interactions Between Parents and Oncologists Only ten parents (23%) ever discussed the use of alternative therapy with their oncologists. Their children usually used nutritional supplements

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following the advice of their oncologists. One parent discussed use of herbs with her oncologist and gave up her effort after having perceived negative attitudes of the doctor. Expectations From Use of Alternative Therapies Parents’ expectations from the use of alternative therapies ranged from reducing pain, shortening the therapeutic cycle, limiting side effects, increasing the child’s internal strength, improving the child’s ability to cope with unpleasant medical events, and curing the disease. Some parents believed that alternative therapies have body-building effects even though they may fail to cure cancers. Eleven parents (24%) reported that alternative therapies were indeed effective in pain relief, enhancement of immune function, and maintaining patients’ hope. By contrast, 12 parents (26%) reported ineffectiveness of alternative therapies; and 2 parents noticed severe side effects from using herbal medicine. DISCUSSION Although the majority of parents (74%) reported that their children used alternative therapies, some parents, particularly those who answered ªno,º might be reluctant to reveal their status of use to interviewers for various reasons. Therefore, prevalence of use of alternative therapy in this patient population might have been underreported. Poor interactions between parents and medical practitioners are common in Taiwan. Less than one fourth of the parents in our study ever discussed use of alternative medicine with their oncologists. They perceived that such discussion might imply distrust or dissatisfaction with standard treatments [8]. They also perceived negative attitudes of oncologists toward alternative therapies and thus any discussion of this issue might jeopardize their relation with their oncologists [13]. For many of our pediatric cancer patients and their parents, standard Western treatments might not have given them satisfactory relief. Use of alternative therapies became prevalent when the parents perceived distress from standard treatments. Thus, alternative therapies were generally used to supplement but not replace standard treatments. In general, use of alternative therapy could be categorized as invasive therapies (functional food, folk medicine, herbs, and traditional Chinese medicine) and noninvasive therapies (psychological and attitudinal approaches, such as divination, temple worship, and diet supplement). Folk medicine, herbs, functional food, and traditional Chinese medicine have played an important role in the management of pediatric oncology among Taiwanese parents, especially as an adjuvant to other modalities and


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in supportive care [6, 14]. However, many important questions remain to be answered. First, the distinction of the three medicines and functional food stated above is vague [15]. In general, folk medicine is herbal medicine prescribed by practitioners or experienced others without formal medical education. Herbal medicine is a ªsecrete recipeº prescription, which may be from experienced others, shaman writing, or unlicensed herb practitioners. Such folk or herbal medicine is administered by parents without systematic assessment from health-care providers and, thus, often causes adverse effects. Functional foods have wide range of application in various therapies, but their mechanisms and active components of functional foods remain unclear [16]. Most formulated functional foods and Chinese herbs have many unknown components and have never been scienti® cally tested for safety and ef® cacy [6, 17]. For example, ginseng and ganoderma lucidum have been widely used as a remedy for promoting longevity, curing tumor, and maintaining the vitality of human beings [18± 20]. Individuals may consider ganoderma lucidum and ginseng as functional food and self-administer them without consulting trained practitioners. Vanherweghem [21] has identi® ed three threats of herbal poisoning: the unknown toxicity of an identi® ed plant, misidenti® cation of plant species, and powdered plant extracts that are intentionally altered with other drugs for the immediate effect. There are still no standard criteria for examining the effectiveness of herbs, so it is necessary to establish the same quality control as for common drugs prior to their release on the market to avoid the possible toxicity of certain herbal remedies [22]. On the other hand, the treatment strategy of TCM is aimed at how to solidify the basis and nourish the origin [23]. The mechanism of Chinese medicine to inhibit the growth of cancer cell has not been proved by systematic scienti® c evidence. Taiwanese people believed that Chinese medicine and Western medicine have their strengths and weaknesses. They usually seek health care from both systems [24]. The lack of a referral system blocked communications between Chinese and Western medicine practitioners [25]. Facilitating such communications is thus necessary even if joint efforts from both sides are unlikely in the near future. It is essential that physicians of both Chinese medicine and Western medicine have basic knowledge about the strengths and weaknesses of both [25, 26]. Religious faith in Taiwan is polytheism, which implies that individuals may have diversi® ed religious beliefs. Many astrologic theories have been developed based on people’s perception of the world as well as their religious perspectives (e.g., Taoism, Confucianism, and Buddhism) over the long course of Chinese history, and continue to in¯ uence the daily life of the Chinese people. Some of the parents in our study performed ritual and prayed to rectify past sin or searched for alternative therapies in addition to standard cancer treatments. Such behaviors were similar to those reported as problemfocused coping by Folkman and Lazarus [27]. Meanwhile, parents realized

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that such behaviors were limited to satisfying their psychosocial expectation for curing the illness, but not actually curing. Mostly, parents reported physical improvement of their child’s situation during that time, which is again comparable to emotion-focused coping [27]. Pain relief, emotional care, and wellness care were the top reasons for parents to seek alternative therapy for their children. Other aspects of such therapies include improved physiological and improved psychosocial adaptation, close and warm patient± practitioner relationship [28], and attention to the wholeÐ physical, mental, emotional, spiritual, and social bodies. This implies that these parents did not really intend to use alternative therapies, but rather sought ªholistic care,º i.e., a close and horizontal or peer relationship with their patients, listening carefully and offering suggestions, and education about actions patients can take on their own to prevent reoccurrence of symptoms, enhance health, or, indeed, redirect their lives to other meanings. CONCLUSION Use of alternative therapies is prevalent in Taiwan, though oncologists were reluctant to discuss them with parents. Patients, regardless of education level or social status of their families, have been using a variety of alternative therapies. Such practices were generally undertaken with lack of medical guidance from oncologists. Efforts should be made to encourage both parents and oncologists to discuss this issue. Nurses can serve as mediators between them by developing a mutual-trust and sharing relationship. In addition, facilitation of communications between TCM and Western medicine practitioners is urgently needed. REFERENCES 1. Kersey JH. Fifty years of studies of the biology and therapy of childhood leukemia. J Am Soc Hematol. 1997;90:4243± 4251. 2. Cassileth BR. The social implications of questionable cancer. Cancer. 1989;63:1247± 1250. 3. Ernst E, Cassileh BR. The prevalence of complementary/alternative medicine in cancer. Am Cancer Soc. 1998;83:777± 782. 4. Grootenhuis MA, List BJ, de Graaf-Nijkerk JH, Van der wel M. Use of alternative treatment in pediatri oncology. Cancer Nursing. 1998;21:282± 288. 5. Yeh CH, Tsai JL, Lin CF. Psychosocial process of parents with acute lymphoblastic leukemia child who decide to continue chemotherapy protocol after dropped out. Chang Gung Nursing. 1998;9:51± 58. (In Chinese) 6. Wen JK. Folk beliefs, illness behavior and mental health in Taiwan. Chang Gung Med J. 1998;21:1± 12. 7. Kleinman A. Patients and Healers in the Context of Culture. Berkeley: University of California Press; 1980. 8. Yeh CH, Lin CF, Tsai JL, Lai YM, Ku JC. Determinants of parental decision on drop out from cancer treatment for childhood cancer. J Adv Nursing. 1999;30:193± 199. 9. Murray RH, Rubel AJ. Sounding board physicians and healers-unwitting partners in health care. N Engl J Med. 1992;326:61± 64. 10. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. Thousand Oaks, CA: Sage; 1994.


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11. Lincoln Y, Guba E. Naturalistic Inquiry. Newbury Park, CA: Sage; 1985. 12. Sandelowski M. The problem of rigor in qualitative research. Adv Nursing Sci. 1986;8:27± 37. 13. Sawyer MG, Gannoni AF, Toogood IR, Antoniou G, Rice M. The use of alternative therapies by children with cancer. Med J Australia. 1994;160:320± 322. 14. Hsin LS, Chiu TY, Hu WY, Cheng SY, Chen CY. The behavior of alternative therapies among terminal cancer patients. Chinese J Family Med. 1996;6:127± 137. 15. Chow KC, Chen K Y. The viewpoints of modern medicine and Chinese medicine tow and diagnosis and treatment of cancers. Ther Radiol Oncol. 1994;3:269± 279. 16. Weng W, Chen J. The eastern perspective on functional foods based on traditional Chinese medicine. Nutr Rev. 1996;54:s11± s16. 17. Skolnick AA. China is eager to export its traditional medicine, but some Chinese scientists urge more skepticism. JAMA. 1996;276:1707± 1709. 18. Lieu CW, Lee SS, Wang SY. The effect of ganoderma lucidum on induction of differentiation in leukemia U937 cells. Anticancer Res. 1992;12:1211± 1216. 19. Chen WC, Hau DM, Wang CC, Lin IH, Lee SS. Effects of Ganoderma Lucidum and Krestin on subset T-cell in spleen of c -irradiated mice. Am J Chinese Med. 1995;3:289± 298. 20. Wang SY, Hsu ML, Hsu HC, et al. The anti-tumor effect of Ganoderma Lucidum is mediated by cytokines released from activated macrophages and T lymphocytes. Int J Cancer. 1997;70:699± 705. 21. Vanherweghem JL. Misuse of herbal remedies: the case of an outbreak of terminal renal failure in Belgium (Chinese herbs nephropathy). J Altern Complement Med. 1998;4:9± 13. 22. Huxtable RJ. The myth of bene® cent nature: the risks of herbal preparation. Ann Intern Med. 1992;117: 165± 166. 23. Lin TY, Tseng WS, Yeh EK. Chinese Societies and Mental Health. New York: Oxford University Press; 1995. 24. Lin YY. On the choice for Chinese medicine or Western medicine. Chinese J Family Med. 1992;2:1. 25. Chi C, Lee JL, Lai JS, Chen CY, Chang SK, Chen SC. The practice of chinese medicine in Taiwan. Soc Sci Med. 1996;3:1329± 1348. 26. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbaco TL. Special article: unconventional medicine in the United States. N Engl J Med. 1993;328:246± 252. 27. Folkman S, Lazarus RS. The relationship between coping and emotion: implications for theory and research. Soc Sci Med. 1988;26:309± 317. 28. Cassidy CM. Chinese medicine users in the United States, part II: preferred aspects of care. J Altern Complement Med. 1998;4:189± 202.