The Use of Qigong and Tai Chi as Complementary and Alternative Medicine (CAM) Among Chronically Ill Patients in Hong Kong

Practicing qigong and tai chi in public parks is a common activity in mornings of Hong Kong. Many people have the impression that qigong and tai chi practice is mainly an exercise for the elderly. However, many young people are also practicing qigong and tai chi in Hong Kong. There were more than 300,000 people participating in the morning tai chi classes in 2001 (Hong Kong Tai Chi Association 2001: 194), and the number keeps increasing. As some followers practice qigong in other classes, presumably there should be more than 300,000 qigong and tai chi followers in Hong Kong.


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Cultural perceptions of medical systems influence how people perceive the strengths and weaknesses of different medical systems, which influence them in choosing a suitable therapy.
Beliefs and expectations also motivate people to practice qigong. The health benefits that they either expect or have already experienced serve as a motivation.
Although biomedicine is the mainstream medical system in Hong Kong, there are quite a number of followers practicing qigong for health purposes. Their experiences in seeking biomedical remedies also explain their motivations to practice qigong.

Research methods and participants
A qualitative approach by using an anthropological study approach was adopted to investigate the in-depth experiences and perceptions of the sampled qigong and tai chi followers in Hong Kong. Participant-observation and semi-structured in-depth interviews were conducted in the data collection procedure.
Participant-observation involves "getting close to people and making them feel comfortable with your presence so that you can observe and record information about their lives" (Bernard, 2002: 322). Participant-observation was conducted in three morning tai chi classes which were organized by the Leisure and Cultural Services Department of the Hong Kong government. Each class consisted of 40 followers. The majority of the followers were females, with only 12 male followers among these three classes. Most of the followers in these classes were in the mid-aged from 40s to 50s. Only a few were in their 20s and 60s to 70s. All the followers in these three classes were suffering from chronic conditions and requiring regular follow-ups in biomedical settings. The common chronic conditions that the followers were suffering included cancers in the recovering stage, hypertension, diabetes mellitus, heart diseases, and bone and joint problems.
Semi-structured interviews were conducted with 30 participants who were sampled in these 3 classes by purposive sampling. The interviews were conducted with an interview question guide which covered the main areas of concern. Participant information sheets were distributed to the participants prior to the interviews so to ensure their clear understanding of the research. Twenty participants who had learnt qigong and tai chi for more than five years and another 10 participants who had just started the learning were purposively sampled. To examine the motivations of the practice in relation to their health conditions, the participants with chronic conditions and were receiving biomedical follow-ups were purposively sampled.

Perceived role of biomedicine and TCM in health maintenance and disease treatment
Biomedicine and TCM are the two largest medical systems in Hong Kong. Perceptions and understandings of these two approaches by the participants enable the understanding of the perceived strengths and weaknesses of these medical systems, and so the underlying motivations for practicing qigong. For the remedy to appear effective, it is often important that the remedy ideas are compatible with the cultural ideas of patients.
Health maintenance has never been in the concept of biomedicine to the participants. The followings were the most common impressions of the participants on biomedicine: www.intechopen.com I have never heard western medicine [biomedicine] has such concept. Perhaps taking vitamins is an approach. However, I would not think it is a good approach to maintain health. To me, vitamins are drugs, and I think taking drugs definitely would not have any positive effect on health. Besides vitamins, I cannot think of any other approaches that can maintain health from the viewpoint of western medicine. [P3] I think [biomedical] doctors would only ask you to do more exercise and have a balanced diet to maintain your health. However, I think the advice is so vague that it seems they have recommended nothing at all for people to keep up their health. What western medicine recommends is only a common sense that even a primary school kid can tell you the same thing. [P14] Although more participants perceived that TCM could help to maintain health, many of them believed that its concept of health maintenance is not strong. Participants perceived biomedicine and TCM as forms of therapy, to which they would only turn to when they suffered from health problems. Although many participants believed that TCM has the concept of health maintenance, they would only consult TCM practitioners when they encountered health problems. This comment represents the most typical viewpoint among the participants: I would just only see [TCM]

Perceived role of qigong in health maintenance and disease treatment
In contrast to their views of biomedicine and TCM, the participants perceived qigong as having more role in maintaining health. They perceived qigong as a form of exercise, and exercise is one of the approaches to maintaining health. However, the form of exercise represented by qigong and the form of exercise that the biomedical doctors mention are, to them, two different things. As this female informant stated: Tai chi is different from other exercises like running. Western [biomedical] doctors often recommend people to do running or swimming; but these exercises are "hard exercises"; they train your muscles only. Tai chi is different. Though it is also an exercise, it is an exercise that can strengthen you internally; you can feel the "hot qi" flowing from inside to outside. This "hot qi" is very good for you; your health becomes better because of this "hot qi". Having those "hard" exercises cannot produce "hot qi". You feel hot only, but not due to the "hot qi". The exercises with no "hot qi" are not as good as qigong. [P22] On the other hand, most participants would not perceive qigong as a form of standalone therapy that can treat diseases. They would not think one can rely solely on the practice of qigong for recovery. Rather, they believed they still had to consult doctors, no matter biomedicine or TCM. Qigong could only serve as a form of complementary remedy for them after prior diagnosis and treatment by biomedicine or TCM: However, a minority of participants believed one can use qigong only as a therapy for emotional problems, stress, depression, and psychiatric and psychological illnesses, since they perceived biomedicine and TCM were unable to deal with these problems: Qigong can be used as a major therapy for some diseases, though not all. If you often feel stressed, nervous, or have psychiatric diseases, I think it is enough for you to practice qigong only, since qigong can help you to relax. For these mind problems, qigong is the best and you can practice it alone. Western doctors can only give you some tranquilizers or other drugs, but it is difficult for you to have a full recovery, and I have never heard Chinese medicine can treat these problems, so I think qigong alone is enough already. [P2] 6. Degree of participation of patients

Biomedicine
The perceived degree of patient participation in biomedicine and TCM as active or passive also provides another aspect to understand the motivations to practice qigong as related to the perceptions of patients' role in treatment.
The majority of participants perceived their role in biomedical remedies as passive. "Active" in the therapeutic process, to the participants, means they have the opportunity to ask questions; whereas a "passive" role means that they rarely have the opportunity to ask questions and have little room for making decisions.
Participants always felt difficulty in raising questions in the biomedical encounter due to the short consultation time. However, short consultation time was not the only reason for their inability to ask questions in many cases. Limited knowledge of biomedicine also led to their sense of helplessness, since they did not know how and what to ask. Even if they asked their doctors about their health problems, they would not necessarily get the feedbacks as doctors held absolute control and power to determine what and how they would tell the participants: The biomedical encounter is a setting with clear power relations. Professional knowledge of medicine and treatment is under the absolute control of doctors. The experience for those participants with higher education level was better in communicating with doctors than those with lower education level, since a higher education level often enabled them to ask questions. However, their feelings about the responses of biomedical doctors were similar: In western medicine [biomedicine], it is impossible for a patient to be active. It is the [biomedical] doctors to take the leading role in the therapeutic process. It is the doctors who give the prescription and help you, though you still need to put the drugs into your mouth by yourself. Sometimes I tried to be more active by asking doctors some questions relating to my diseases, and sometimes I asked the doctors whether there were any other possibilities with my case. However, the doctors would start becoming unhappy and keep silent. Even worse, they would just reply me with one sentence -"if I said yes, then it would be yes". Perhaps they thought that even if they explained to me, I would not understand; or they were unhappy about that I was challenging them. [P9] Some participants also noted that the "order" of biomedical doctors could make them feel they were expected and required to be obedient during the therapeutic procedure. Such feeling was particularly strong when they were under physical and clinical examination: The instructions from [biomedical]  The participants' experiences in biomedical encounters illustrated the hierarchical doctorpatient relationship. This relationship could lead to a sense of helplessness on the participants. The pretence that they were being given a choice of remedies also led to a sense of helplessness among the participants in the context of biomedical treatment:

My doctor had suggested several therapeutic options as well as their advantages and disadvantages to me. Then he asked me to choose which remedy I would pick. However, I really think that I do not have much room to choose. During the discussion, the doctor would reveal his preference and indicate which one is the best option. Will you dare to choose another option? [P19]
The one-way communication from doctors to patients was a major factor contributing to the passive feeling of the participants in the rem e d y p r o c e s s . T h i s , i n t u r n , s e r v e d a s a motivating force for them to seek other forms of remedy which enabled them to take a more active control on their own health.

TCM
Participants perceived their role in TCM as more active than biomedicine, though it was still passive to them. Being able to ask more questions enabled them to experience a more active role in the therapy, as both the patients and TCM practitioners shared a common cultural knowledge in TCM. Longer consultation time and their deeper knowledge of TCM contributed to such sense: Although participants perceived themselves as more active during the therapeutic process in TCM than biomedicine's, still they perceived their role as not active enough. As a result, they are motivated to search for other alternatives, such as qigong, which served as a solution for them.

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The Use of Qigong and Tai Chi as Complementary and Alternative Medicine (CAM) Among Chronically Ill Patients in Hong Kong 181

Qigong
The practice of qigong enhances and empowers participants with an active role in their health. Compared with biomedicine and TCM, most participants believed that the participation role is most active in the practice of qigong: "There is a potential for people to resist the passive patient role" (Lupton, 2000: 115). The search of "feel like they can do something for their health" reveals their unconscious desire to regain an active role in their health, and they were able to regain an active control on their health through the practice of qigong.
Alternative therapies ascribe the causes of ill health to more than just the purely biological, and encourage individuals to take responsibility for their own health by rejecting the disempowered role of the submissive patient. The emphasis is upon the perception of health as a value in itself, and upon the individual actively participating in the ongoing maintenance of good health… Unlike biomedical medicine, alternative therapies can provide satisfactory explanations for the questions 'Why me?' and 'Why now?'… (Lupton, 2000: 125 -126).

Motivations of the qigong practice
Both biomedicine and TCM were inadequate to fulfil participants' cultural perceptions and needs of health and diseases. As they perceived biomedicine and TCM as a form of therapy, they turned to qigong for health maintenance and body strengthening after the therapeutic process. To the participants, only qigong could provide them with such a concept. The passive role of patients in biomedicine and TCM, in addition, explains why the participants were driven to practice qigong as an alternative for remedies and health maintenance. As the followings demonstrate, the practice of qigong is often due to a hybridization of concerns, including health, social and emotional concerns.
The concept of remedy, if it is to appear effective, needs to be compatible with the cultural ideology and needs of patients. As biomedicine and TCM are inadequate to provide satisfactory explanations and fulfil the needs in treatment, the participants were attracted to www.intechopen.com the practice of qigong, which is more compatible with their cultural understandings on health and illnesses.

Health motivations of qigong practice
Health concerns and illness experiences were the chief motivations in the practice of qigong among the participants. The particularly high sense of health consciousness was apparent among the participants, who were mostly middle-aged persons and having been suffering from chronic diseases.

Concept of "legitimacy" of health maintenance
Definition of "legitimacy" among the participants on perceiving a suitable health maintenance method was greatly influenced by their cultural perceptions. Health maintenance shopping is common among the participants. Although they also tried exercising, still they perceived qigong as the most "legitimate" form of health maintenance approach: Before I came here to learn tai chi, I had tried having many kinds of exercises. I had tried jogging and dancing in the past. However, I really think that if you want to maintain your health, you should find a more "legitimate" practice. Simply moving your hands and legs is definitely not enough. I think tai chi is more "legitimate" because you have to follow the procedures in the practice. [P6] The concept of "legitimacy" was often closely tied to the concept of "healing" and "tradition":

Deteriorating of health status
The participants were mainly aged 30s to 50s, and one of the major motivations was their deteriorating health status associated with their age. All the participants reaching such middle age indicated that they have experienced some extent of deteriorating health status. They caught diseases much easier than when they were young, though these diseases were not necessarily serious and life threatening: The suffering of menopause was a significant reason that motivated middle-aged women to practice qigong. The classes had a gender imbalance with a high proportion of female followers. The participants suffered from different degrees of discomfort associated with menopause, and the prevention of such discomforts was a key concern for these middleaged female followers. Quite a number of middle-aged female followers were attracted to practice qigong because of the frequent reports about its efficacy in preventing osteoporosis: My doctor said he could prescribe some hormones for me to alleviate my discomforts. However, I am reluctant to take these drugs, because it is said that taking such medicine for a long time can increase the probability of getting cancers. Also, medicine is medicine, and it is unnatural, so it can have a lot of side effects. The newspaper reports said tai chi can help to prevent osteoporosis, and said tai chi is good to bones and health for old people, so I come to try. [P25]

Suffering from diseases
Disease suffering was a major motivation for the participants. Two main categories of diseases were identified from the participants: 1) the life threatening diseases such as cancers, and 2) chronic illnesses. Although all participants had already completed the major therapeutic procedure, many of them felt uncertainty, which was a strong motivation for them to practice qigong: Although I have finished the surgery and chemotherapy in the hospital, I still need to go to the hospital regularly for check-ups. Superficially, it seems that I have recovered, and the regular checkup is just for safety concern. But I understand that there is still a possibility for the cancer to relapse. It may not be in the same place [ Some participants were second-time learners of qigong. They had the experience of practicing qigong many years ago but stopped practicing after some time. The suffering of diseases motivated them to re-engage in the practice: Some participants were "forced" to practice qigong because of their diseases. Although they thought qigong is boring, still they practiced it because they believed qigong could help with their diseases:

Honestly speaking, I really have no interest in learning tai chi. It is very boring. If I were not sick, I would not have come to learn tai chi. [P11]
Some young participants were reluctant to practice qigong because they believed such practice was not appropriate for their generation. However, they were "forced" to practice qigong because of their health problem:

If I were healthy, of course I would not have come here to learn tai chi. You know, tai chi is an activity for the elderly. I am still young, so I should choose other kinds of sports instead of tai chi. I had been struggling for a long time whether I should come, because I am afraid that my friends would tease me. However, I have no choice. My bones have problems; if I play sports, I would further injure myself. As I heard that tai chi can help with the bones, so I come and try. [P8]
Suffering from chronic diseases was another common motivation, since biomedicine and TCM failed to ensure total recovery for them:

Seeking a faster recovery
Qigong was expected to provide faster recovery to many participants. They believed the recovery process would be shortened if they practiced qigong in addition to the biomedical treatment.
"Recovery" was a subjective perception to participants, as they often had their own definition of "recovery". This subjective perception motivated them to practice qigong for attaining full recovery:

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The subjective understanding of "recovery" was thus different from the clinical definition. This revealed the conflicting explanatory models between biomedical doctors and patients. The conflict in the explanatory models, I argue, is due to the different concerns on "disease" and "illness". Unlike biomedical doctors who concerned about "disease", participants concerned about their "illness" experience. Indeed, past literature shows that the distinction between "disease" and "illness" is often vague for chronically ill patients: In chronic disorders…it may be difficult to distinguish the disease from the illness. In such disorders, illness may exist when the disease is in remission, and recurrence of the disease itself may be due to the illness… illness can occur in the absence of disease, for example, in…chronic "functional" complaints… In that sense, illness is a reaction to an imagined, perceived, or even desired disease… (Kleinman, 1980: 74).
Patients recovering from cancers often require long-term care and regular medical checkups. Such experiences made these recovering participants felt that they were still "sick", because they were under the influence of their illness experience.
The idea of the "five-year recovery period" as mentioned by biomedical doctors also motivated participants to keep on practicing qigong:

Alleviating chronic pain
Alleviation of chronic and long-term pain was another motivating factor for their qigong practice. This motivation was particularly apparent among those participants who were suffering from rheumatic and bone pain. Although biomedicine could relieve their pain quickly, the efficacy was short unless they took painkillers on a long-term basis. As they had a negative impression on biomedical drugs, they searched for a more natural approach to alleviate their pain. This led them to qigong practice: The desire for long-term alleviation of chronic pain was often spurred by their desire to avoid physiotherapy. Some participants perceived physiotherapy as a painful experience, both physically and emotionally. Qigong could thus serve as an escape for them: physiotherapy. It is really very painful for me. I needed to go into the hospital for treatment every few months. It is really an endless therapy and a nightmare for me. The most discouraging thing is my situation did not get any better. I just felt like I was wasting time on doing useless and painful things. I therefore learned tai chi. I do not feel pain anymore since I started practicing it. Therefore, I will keep on practicing it with the hope that I will not need western medical treatment again. [P13] The concept of "Chinese" physiotherapy was mentioned by the participants. They perceived tai chi as a Chinese form of physiotherapy. However, unlike biomedical physiotherapy, this "Chinese physiotherapy" was much better in the perception of the participants:

Restoring of health after surgical treatment
The desire to restore health after surgery was another most common motivation for those participants who received surgical treatment. Surgery was perceived as harmful to their body and could lead to "depletion" as a result. As "depletion" is a Chinese concept, they believed only a "Chinese" approach could help. Qigong was the first approach that they could think of.
I learn tai chi because I had a major surgery ten years ago. After the surgery, I felt "depleted". I often felt dizzy and tired, and my friends told me that I looked really pale. My relatives had prepared some Chinese medicine tonics for me after the surgery. I felt a little bit better, but I still felt it was not enough -I still could not return to the health status I had before surgery. Some of my friends who had surgery before also practiced tai chi at that time and they told me that it could help. Hence, I went to learn tai chi. [P3]

Experiencing the side effects of biomedical treatment
The side effects induced by biomedical treatment were a common motivation. In many cases, they experienced side effects of long-term medication due to their chronic disease suffering. They believed practicing qigong was the first step to rebuild their health.
The idea of side effects was also a subjective feeling of the participants. In some cases, they did not really experience any side effects, but they perceived they did because the popular belief on biomedicine led them to link biomedical drugs with the side effects together:

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In other cases, the "side effects" that the participants experienced were the symptoms of their diseases. However, they perceived the uncomfortable feelings as due to the biomedical drugs. The attempt to alleviate the "side effects" of the biomedical drugs could motivate them to practice qigong:

Positive belief on health of qigong
Strong belief in qigong on health was a remarkable motivator for the qigong practice. Participants believed that qigong could serve as a long-term health maintenance approach, provided that they have the patience to practice it continuously. They believed that even if qigong did not bring health benefits, it would not have harmful effects on them either.
Their belief in the positive effects of qigong on their health was often due to their experiences of improved health, which gave them confidence in continuing with the practice. Even those participants who had not experienced obvious health improvement still believed in its efficacy provided they would continue with the practice. They would blame themselves for being lazy and unserious in their practice if they failed to experience these benefits: The strong belief in the efficacy of qigong did not diminish even when the participants experienced adverse effects from it. Even though they felt worse with their ailment after practice, they believed it as the healing process of qigong:

Social and emotional motivations of qigong practice
Besides their health concerns and their hope for treatment and recovery, the social support, bonding, and network that had been built up during the practice was also a significant motivation for their continuing practice.

Emotional attachment with qigong masters and fellow followers
The close relationship between qigong masters and fellow followers was particularly apparent in the morning tai chi class. Owing to their continuing practice, their relationship has become closer and closer. Such emotional attachment encouraged them to continue with the practice. Besides relationship in class, such close bonding could be recognized from the www.intechopen.com activities and gatherings other than lectures. It was a common practice for them to go to Chinese restaurants to have breakfast together after class. At the end of each course and during some important Chinese festivals, the followers would invite the master for a "thank master feast". Such emotional attachment among fellow followers and with the master was an important consideration for them in the practice: We have practiced together for several years. Our relationship is not just only a master-follower relationship, but we have become very good friends as well. The family atmosphere was significant in motivating the followers to continue with the practice. The master was viewed as a core of spirit for the followers, whereas the senior followers in the class often served as the "elders" in a family, supervising the practice of other followers. In the first lecture of the course, the master announced: All the followers here should be treated as family members with one another. As you participate in this class, you are just like a member in our family. Therefore, we should take care of one another, and be devoted to the practice.

Social networking
As most participants have followed the master for a long time in the morning class, learning new things was not their aim. Although some of them practiced in the hope to sharpen their skills, the morning class was also a kind of social gathering for the followers and master in reality.
The participants also sought for a social relationship and a wider social network, which was a motivation for the continuous practice. The search for a social support was apparent as most participants were housewives or having been retired, they would perceive the class practice as a form of social resource for support.
I feel happy to come to practice tai chi here every morning, because I feel like I am back to the family. We will greet and chat each other, and will have gatherings other than lectures.

Conclusions
As discussed in this chapter, there are many motivations for the participants' practice of qigong. In many cases, these motivations were intertwining together to motivate the practice. These motivations related to their experiences in seeking medical treatment, their illness experiences, their search for a social support network as well as an emotional attachment with fellow followers and masters. Besides, their perceptions on biomedicine and TCM in the role of health maintenance and disease treatment, in addition to their search for a more active control in their health also accounted for their practice.