Content uploaded by Thomas M Hooton
Author content
All content in this area was uploaded by Thomas M Hooton on Mar 29, 2015
Content may be subject to copyright.
507
Articles
Use
of
Traditional
Health
Practices
by
Southeast
Asian
Refugees
in
a
Primary
Care
Clinic
DEDRA
BUCHWALD,
MD;
SANJIV
PANWALA;
and
THOMAS
M.
HOOTON,
MD,
Seattle,
Washington
To
determine
the
prevalence
of
use
of
traditional
health
practices
among
different
ethnic
groups
of
Southeast
Asian
refugees
after
their
arrival
in
the
United
States,
we
conducted
a
convenience
sample
of
80
Cambodian,
Lao,
Mien,
and
ethnic
Chinese
patients
(20
each)
attending
the
University
of
Washington
Refugee
Clinic
for
a
new
or
follow-up
visit.
Interpreters
administered
a
questionnaire
that
dealt
with
demographics,
medical
complaints,
traditional
health
practices,
health
beliefs,
and
attitudes
toward
Western
practitioners.
In
all,
46
(58%)
patients
had
used
one
or
more
traditional
health
practices,
but
the
prevalence
varied
by
ethnic
group.
Coining
and
massage
were
used
by
all
groups
except
the
Mien,
whereas
moxibustion
and
healing
ceremonies
were
performed
almost
exclusively
by
the
M-ien.
Traditional
health
practices
were
used
for
a
variety
of
symptoms
and,
in
780k
of
reported
uses,
patients
reported
alleviation
of
symptoms.
The
use
of
traditional
health
practices
is
common
among
Southeast
Asian
refugees.
Clinicians
who
care
for
this
population
should
be
aware
of
these
practices
because
they
may
supersede
treatments
prescribed
by
physicians
or
leave
cutaneous
stigmata
that
may
be
confused
with
disease
or
physical
abuse.
Good
patient
care
may
necessitate
the
use
or
tolerance
of
both
Western
and
traditional
modalities
in
many
Southeast
Asian
refugees.
(Buchwald
D,
Panwala
S,
Hooton
TM:
Use
of
traditional
health
practices
by
Southeast
Asian
refugees
in
a
primary
care
clinic.
West
J
Med
1992
May;
156:507-511)
Over
a
million
Southeast
Asian
refugees
of
at
least
five
major
ethnic
groups
live
in
the
United
States
today,
and
over
4,000
more
arrive
each
month
from
the
war-ravaged
countries
of
Vietnam,
Cambodia,
and
Laos
(Robert
Johnson,
International
Rescue
Committee,
oral
communication,
Au-
gust
1990).
In
many
Western
countries,
these
distinct
ethnic
groups
are
often
assumed
to
represent
a
single
culture
or
population.
Members
of
these
groups
are
distinguished,
however,
by
factors
such
as
nationality,
language,
and
reli-
gion.
Values,
practices,
and
norms
in
these
cultures
also
may
differ
greatly
from
each
other
and
from
those
in
Western
society.
Knowledge
about
these
differences
is
of
particular
importance
in
medicine,
where
patients'
medical
beliefs
and
health
practices
can
result
in
inappropriate
or
inadequate
treatment.
We
surveyed
Cambodian,
Lao,
Mien,
and
ethnic
Chinese
refugees
attending
a
primary
care
clinic
to
learn
more
about
cultural
differences
in
medical
beliefs
and
health
practices.
Patients
and
Methods
Setting
The
University
of
Washington
Refugee
Clinic
is
located
at
Harborview
Medical
Center,
one
of
the
four
major
teaching
hospitals
affiliated
with
the
University
of
Washington
School
of
Medicine.
This
general
internal
medicine
clinic
was
estab-
lished
in
1982
to
meet
the
needs
of
the
rapidly
growing
Southeast
Asian
refugee
population
in
the
Seattle
area.
Ap-
proximately
4,000
clinic
visits
are
made
annually,
and
over
70%
of
the
patients
are
Cambodian.
The
staff
employs
12
medical
interpreters
who
speak
13
languages.
All
inter-
preters
finish
a
one-year
community
health
advocate
pro-
gram
designed
to
train
clinical
assistants.
Patients
A
convenience
sample
of
20
patients
in
each
of
four
ethnic
groups-Cambodian,
Lao,
Mien,
and
ethnic
Chinese
(10
from
Vietnam
and
10
from
Cambodia)-were
interviewed
by
interpreters
during
a
routine
visit.
Although
not
representa-
tive
of
the
clinic's
population
in
its
ethnic
distribution,
this
sampling
strategy
of
interviewing
unselected
patients
en-
sured
adequate
representation
of
each
ethnic
group
and
en-
hanced
our
ability
to
detect
differences
among
them.
The
Cambodian,
Vietnamese,
and
Lao
refugees
had
spent
time,
often
years,
in
camps
on
the
border
of
Thailand
waiting
for
permission
to
emigrate.
Most
refugees
from
Cambodia
and
Vietnam
are
ethnic
Khmer
or
Vietnamese;
the
minority,
ethnic
Chinese,
are
generally
better
educated
and
primarily
urban.
Both
groups,
as
well
as
the
Lao,
place
a
high
value
on
family
and
adherence
to
Buddhist
principles.
Unlike
the
lowland
Lao,
the
Mien
are
a
tribal
people
with
a
distinctly
separate
culture;
they
live
in
scattered
villages
in
the
mountainous
regions
of
Laos.
Their
religion
is
a
mixture
of
ancestor
worship,
animism,
and
Buddhism.1
The
interpreters
collected
information
on
demographics,
current
medical
complaints,
medical
beliefs,
use
of
specific
traditional
health
practices
for
current
and
past
medical
prob-
lems,
and
attitudes
toward
Western
practitioners.
This
infor-
mation
was
collected
using
a
questionnaire
that
contained
both
structured
and
open-ended
questions.
*
After
receiving
individualized
instruction
in
its
administration,
the
inter-
*Marorie
Muecke,
CRN,
PhD,
Associate
Professor,
School
of
Nursing,
University
of
Washington,
and
the
interpreters
in
Refugee
Clinic,
especially
Leng
Taing,
Sarnseng
Saechao,
Somey
Lammittre,
Serey
Mean,
and
Thomas
Heng,
helped
with
this
study.
Noel
Chrisman,
PhD,
assisted
in
preparing
the
questionnaire.
Philip
Kirby,
MD,
helped
with
photographs.
From
the
Departnent
of
Medicine,
Harborview
Medical
Center,
University
of
Washington
(Drs
Buchwald
and
Hooton)
and
the
University
of
Washington
School
of
Medicine
(Mr
Panwala),
Seattle.
Reprint
requests
to
Dedra
Buchwald,
MD,
Department
of
Medicine
(ZA-60),
Harborview
Medical
Center,
325
Ninth
Ave,
Seattle,
WA
98104.
TRADITIONAL
HEALTH
PRACTICES
IN
REFUGEES
preters
translated
and
administered
the
questionnaire.
Pa-
tients
were
asked
if
they
had
used
any
of
21
traditional
Southeast
Asian
health
practices
we
could
identify
through
a
review
of
the
literature
and
interviews
with
interpreters
and
a
medical
anthropologist.
For
each
traditional
practice
re-
ported,
we
collected
more
specific
information
on
how
it
was
performed
and
by
whom,
for
what
problem
it
was
used,
and
whether
it
helped.
The
patient's
physician
was
not
present
during
the
interview.
Written
informed
consent
was
obtained
from
all
patients.
Comparisons
between
populations
were
tested
with
the
X2
statistic.
Description
of
Selected
Traditional
Health
Practices
Coining
is
done
by
lubricating
the
skin
or
a
coin
and
then
stroking
the
skin
firmly,
usually
on
the
torso
or
extremities,
with
the
edge
of
the
coin,
resulting
in
parallel
ecchymotic
streaks
(Figure
1).
Pinching
uses
the
same
principle,
but
Figure
1.-Parallel
ecchymoses
visible
on
the
skin
are
the
result
of
coining,
in
which
the
skin
is
stroked
firmly
with
the
edge
of
a
lubricated
coin.
pressure
is
applied
by
pinching
the
skin
between
the
thumb
and
index
finger
to
the
point
of
producing
a
contusion.
Cup-
ping
is
performed
by
placing
a
small,
heated
cup
on
the
skin,
usually
on
the
forehead
or
abdomen,
and
allowing
it
to
cool.
This
results
in
negative pressure,
which
causes
a
circular
ecchymotic
area
to
appear
(Figure
2).
Moxibustion
consists
of
making
small,
circular,
superficial
buums,
usually
on
the
torso,
head,
or
neck,
by
touching
the
skin
with
burning
in-
cense
or
by
igniting
a
combustible
material
placed
on
the
skin.
Moxibustion
may
be
used
with
acupuncture,
which
involves
placing
acupuncture
needles
over
strategic
points
along
energy
"meridians"
(Figure
3).
Using
medicated
pa-
per
involves
placing
small
pieces
of
paper
on
the
skin,
often
directly
over
a
symptomatic
area;
the
pieces
of
paper
are
soaked
in
an
aromatic
oil.
Healing
ceremonies
are
done
by
a
shaman
or
traditional
healer,
who
performs
rituals
that
may
be
directed
at
illness
sources
such
as
spirits,
ancestors,
"wind,"
and
the
patient's
soul.
Results
Patient
Characteristics
Characteristics
of
the
study
patients
are
shown
in
Table
1.
The
Mien
patients
were
the
oldest,
and
the
Cambodian
group
had
the
highest
proportion
of
females.
Almost
half
the
pa-
tients
had
been
in
the
United
States
for
more
than
five
years,
whereas
20%
had
resided
here
for
less
than
a
year.
Of
those
surveyed,
24%
of
the
men
and
2%
of
the
women
were
em-
ployed
outside
the
home.
Reported,
Symptoms,
Beliefs,
and
Behaviors
Patients
reported
a
variety
of
symptoms,
health
beliefs,
and
behaviors.
The
most
common
chief
complaints
at
the
study
visit
were
joint
pain
(15%),
headache
(13%),
gastroin-
testinal
complaints
(11%),
back
pain
(10%),
and
chest
pain
(9%).
There
was
no
correlation
between
specific
symptoms
and
ethnic
background.
The
cause
of
their
illness
was
not
known
by
64%
of
the
patients.
In
all,
20%
of
Chinese,
30%
of
Lao,
40%
of
Cambodian,
and
45%
of
Mien
patients
had
previously
seen
other
physicians
outside
the
refugee
clinic
for
their
chief
complaint.
Western
medicines
not
prescribed
Figure
2.-In
cupping,
a
small
cup
is
heated
and
applied
to
the
skin,
causing
negative
pressure
as
it
cools
(left)
that
results
in
circular
ecchymoses
on
the
skin
(right).
508
TH
WETR
ORA
FMDCNE*MY19
5
Figure
3.-Acupuncture
involves
inserting
needles
into
the
skin
at
strategic
points,
called
energy
meridians,
in
this
patient
leaving
small,
pinpoint-sized
marks
on
the
skin.
by
a
clinic
physician
were
being
taken
by
10%
of
Cambodian,
15%
of Chinese,
20%
of
Lao,
and
30%
of
Mien
patients.
In
addition,
80%
of
Mien,
60%
of
Lao,
40%
of
Chinese,
and
25%
of
Cambodian
patients
stated
a
belief
that
they
would
be
cured
by
a
refugee
clinic
physician.
Use
of
Traditional
Health
Practices
Of
the
80
patients,
46
(58%)
had
used
one
or
more
tradi-
tional
health
practices
since
arriving
in
the
United
States,
but
the
prevalence
of
use
varied
greatly
among
the
ethnic
groups
(Table
2).
Women
were
more
likely
to
report
using
traditional
health
practices
than
men
overall
(69%
compared
with
39%,
P<
.01)
and
within
each
ethnic
group
(Lao
18%
versus
0%,
Cambodian
96%
versus
50%,
Chinese
64%
versus
44%,
and
Mien
91%
versus
67%).
The
use
of
these
practices
was
greater
in
patients
from
rural
areas
than
in
those
from
towns
or
cities
(81%
versus
36%,
P
<
.001).
The
prevalence
of
use
of
traditional
health
practices
was
not
associated
with
the
duration
of
residence
in
the
United
States.
Types
of
Traditional
Health
Practices
Coining
was
the
most
commonly
used
traditional
health
practice
among
the
Cambodians
(70%),
the
Chinese
(35%),
and
the
Lao
(10%);
however,
this
practice
was
not
reported
by
the
Mien
(Table
2).
Similarly,
massage
was
used
by
all
groups
except
the
Mien.
Coining
and
massage
were
the
only
practices
reported
by
the
Lao.
Cupping
was
used
commonly
by
the
Cambodians
and
the
Mien
but
not
the
other
two
groups.
Moxibustion
and
healing
ceremonies
were
used
al-
most
exclusively
by
the
Mien.
Each
of
the
commonly
used
traditional
health
practices
was
used
for
a
wide
variety
of
symptoms
(Table
3).
Practices
identified
by
our
staff
or
described
in
the
literature
but
not
reported
by
our
patients
included
the
use
of
tattoos,
holy
water,
hair
cutting,
talismans,
and
steam
inhalation.`24
Patients
reported
that
a
traditional
health
practice
defi-
nitely
alleviated
their
problem
in
62
(78%)
of
83
reported
uses.
In
only
four
reported
uses
were
practices
entirely
un-
successful
in
providing
relief,
and
in
14
they
were
helpful
only
under
certain
conditions,
such
as
if
the
problem
was
perceived
as
spiritual.
Moxibustion,
healing
ceremonies,
and
cupping
were
least
likely
to
be
reported
as
unqualified
successes;
only
5
of
11
uses
of
moxibustion,
3
of
14
uses
of
healing
ceremonies,
and
1
of
9
uses
of
cupping
were
reported
to
be
entirely
successful.
Discussion
Traditional
health
practices
are
used
commonly
by
South-
east
Asian
refugees,
including
those
who
have
resided
in
the
United
States
for
many
years.
We
documented
substantial
differences
in
the
prevalence
of
use
of
these
practices
among
ethnic
groups
and
between
sexes
within
these
groups.
The
reasons
for
these
differences
remain
unclear
but
probably
reflect
differences
in
the
sophistication
of
medical
knowl-
edge.
Populations
with
a
low
prevalence
of
use
of
traditional
health
practices
may
have
greater
exposure
to,
and
therefore
greater
acceptance
of,
Western
medical
principles.
In
the
case
of
the
Mien,
the
higher
use,
particularly
for
healing
ceremonies,
may
reflect
the
older
age
of
this
population.
There
have
been
few
studies
examining
the
use
of
tradi-
tional
health
practices
among
Southeast
Asian
refugees
in
the
United
States.
Our
results
are
consistent
with
earlier
obser-
TABLE
l.-Patient
Characteristics
by
Ethnic
Group
Ethnic
Charactenstic
Cambodian
Lao
Mien
Chinese
Total
No.
enrolled
.........................
20 20
20
20
80
Mean
age,
yr
.........................
46
45
57
47
49
Age,
9
18-39
yrs
.........................
40 45
10
30
31
40-59
yrs
.........................
50
40
40
60
48
>
60
yrs
............................
10
15
50
10
21
Female,
b
...........................
80
55
55
55
61
Residence
in
native
country,
9b
Largecity
........................
10
70
5
80
41
Town
.............................
20
10
5
15
13
Village
............................
70
20
90
5
46
Buddhist,
Ok.........................
84
85
90
88
87
Years
resided
in
US,
9b
<1
.............................
5
15
21
35 20
1-3
............................
17
20
26
15
19
>3-5
............................
28
5
11
15
14
>
5
..............................
50
60
42
35
47
Males
employed,
k
....................
25
44
11
33
24
THE
WESTERN
JOURNAL
OF
MEDICINE
o
MAY
1992
0
156
o
5
509
TRADITIONAL
HEALTH
PRACTICES
IN
REFUGEES
TABLE
2.-Patients
Using
Specific
Traditional
Health
Practices
Since
Arrival
in
the
United
States'
Ethnic
Cambodian,
Lao,
Mien,
Chinese,
Total,
Practice
n=20
n=20
n=20
n=20
n=80
Acupuncture
.........................
Coining
.............................
Cupping.............................
Hair
pulling........................
Healing
ceremonies
.................
Massage
............................
Use
of
medicated
paper
................
Moxibustion
.........................
Use
of
oils
and
balms
..................
Pinching
............................
Use
of
teas
..........................
Other..............................
Any
practice
(not
specified)
.............
--
--
1
1
2
14
2
--
7
23
4
--
5
--
9
3
--
--
1
4
14
14
5
1
--
2
8
1
1
2
1
10
--
1
1
--
--
--
2
2
1
--
2
1
4
1
--
2
--
3
1
2
3
17
2
16
11
46
'Many
patients
used
more
than
one
traditional
health
practice,
so
the
number
of
practice
uses
reported
may
exceed
the
number
of
patients
for
a
particular
ethnic
group.
vations,
which
found
that
Southeast
Asian
refugees
fre-
quently
diagnosed
and
treated
themselves
and
that
those
from
rural
areas
were
more
likely
to
continue
practices
used
in
their
native
country.5
In
one
study,
root
medicines
were
found
in
27%
of
Lao
and
7%
of
Vietnamese
households,
and
tiger
balm
was
found
in
80%
of
Lao
and
54%
of
Vietnamese
house-
holds.6
In
another
study,
49
of
50
Vietnamese
interviewed,
including
a
nursing
student
and
a
medical
assistant,
still
per-
formed
coining
four
years
after
arriving
in
the
United
States
for
a
wide
variety
of
symptoms.7
Traditional
health
practices
may
reflect
different
beliefs
about
the
causes
of
illness
that
have
evolved
in
Southeast
Asian
cultures.24
Perhaps
the
prevailing
belief
is
the
natural-
istic
theory,
in
which
diagnosis
and
treatment
involve
inte-
grating
physical
and
social
factors.
"Wind"
is
thought
to
cause
many
minor
and
major
illnesses.
Certain
foods,
such
as
beef,
may
carry
"wind"
and
so
are
avoided.
Treatment
consists
of
special
diets,
medicinal
herbs,
or
coining,
which
is
commonly
used
to
"rub
out
the
wind."
A
second
belief
is
that
certain
illnesses
are
a
punishment
resulting
from
the
influence
of
gods,
demons,
spirits,
or
malevolent
or
magical
spells.
These
illnesses
are
treated
by
healers
or
shamans,
who
negotiate
with
supernatural
forces
to
remove
or
alleviate
the
sickness.
A
metaphysical
explanation
(also
known
as
the
"hot
and
cold"
or
yin-yang
theory)
is
also
used
to
explain
illness.
In
this
case,
illness
is
caused
by
an
alteration
in
the
natural
balance
between
hot
and
cold
elements
in
the
uni-
verse.
To
restore
balance
and
harmony,
intake
of
drugs
and
foods
is
adjusted.
Coining,
pinching,
or
cupping
may
be
done
to
restore
balance
by
releasing
excessive
"air";
in
cup-
ping,
as
the
cup
cools,
it
is
believed
to
draw
the
skin
and
air
up
and
out.
Western
medicines
are
generally
considered
hot,
whereas
herbal
remedies
possess
cooling
properties.
Thus,
depending
on
the
nature
of
the
illness,
Western
medicines
may
be
avoided
or
reduced
in
dosage.
Little
is
known
about
users'
perceptions
regarding
the
mechanisms
of
action
of
traditional
health
practices.
In
our
study,
a
mechanism
of
action
was
given
in
only
26%
of
re-
ported
uses.
This
is
consistent
with
a
survey
on
coining
in
which
only
about
half
of
the
respondents
were
able
to
cite
a
mechanism,
such
as
increased
circulation
or
body
warmth,
facilitation
of
respiration,
or
a
spiritual
connection.
I
Patterns
of
use
in
our
patients
suggest
that
different
traditional
health
practices
may
serve
the
same
function
because
various
prac-
tices
were
reported
for
the
same
symptom.
In
traditional,
rural
Southeast
Asian
cultures,
herbal
rem-
edies,
dermal
techniques,
and
exorcistic
rituals
are
the
prin-
cipal
forms
of
medical
treatment.8
More
than
one
treatment
is
often
used
for
the
same
illness,
either
simultaneously
or
in
succession.
The
aid
of
a
health
practitioner
is
sought
if
home
remedies
are
not
successful,
and
Western
medicine,
if
availa-
ble,
may
be
used
only
when
all
else
has
failed.
The
same
TABLE
3.-Patients
With
Symptoms
for
Which
Selected
Traditional
Health
Practices
Were
Used
Heoling
Symptom
Coining
Cupping
Moxibustion
Mossage
Ceremonies
Body
aches
..........................
2
--
1
1
--
Dizziness
............................
4
2
-- --
--
Jointpain
...........................
1
--
3
--
--
Fever
.............................
1
1
--
--
Gastrointestinal
problems
...............
3
2
4
--
1
Headache
...........................
6
1
--
2
--
Myalgias
............................
--
--
--
2
--
Shaking
.............................
2
--
--
--
--
Other
.............................
2
2
2
2
--
Unspecified
health
problem
......
.......
3
1
--
1
13
Total
23
9
11
8
14
510
*
MAY
1992
*
156
*
5
511
pattern
of
health
care
behavior
is
practiced
in
urban
popula-
tions,
but
healers
are
used
less
often
and
Western
medicine
more
commonly.8
The
potential
benefits
of
traditional
health
practices
de-
pend
on
the
patient's
condition
and
the
type
of
practice
used.
For
example,
their
use
may
provide
the
sufferer,
who
may
feel
helpless,
with
a
sense
of
partial
control.
The
attention
given
to
patients
by
those
administering
these
practices
is
comforting
and
may
itself
be
therapeutic.
In
addition,
a
pla-
cebo
effect
may
have
a
beneficial
effect
on
minor
or
self-
limiting
disorders.
These
practices
also
may
be
harmful,
however,
because
further
feelings
of
hopelessness
may
result
if
the
treatment
fails
to
resolve
the
condition.
This
may
be
exacerbated
by
the
belief
that
the
failure
of
a
given
practice
is
the
fault
of
the
patient.
More
important,
using
traditional
health
practices
may
be
detrimental
if
patients
delay
seeking
medical
care
for
treatable
conditions
or
if
the
practices
in-
clude
harmful
ingredients.
Traditional
health
practices
may
also
involve
considerable
expense,
especially
when
a
healer
or
shaman
is
consulted.
Using
traditional
health
practices
has
resulted
in
scarring,
cosmetically
undesirable
lesions,
spurious
accusations
of
physical
abuse,
and
unnecessary
medical
evaluations.
Clini-
cians
unfamiliar
with
these
practices
may
suspect
abuse
when
a
patient,
particularly
a
woman
or
child,
presents
with
cutaneous
lesions
resulting
from
a
traditional
health
practice
(pseudobattering).9
1'
In
one
such
instance,
a
false
accusa-
tion
of
child
abuse
resulted
in
the
suicide
of
the
Vietnamese
father."1
In
our
clinic,
a
Cambodian
woman
underwent
an
extensive
evaluation
for
alopecia,
including
laboratory
tests
and
a
dermatology
consultation,
before
it
became
evident
that
her
hair
loss
was
the
result
of
pulling
hair
at
the
crown
and
top
of
the
head
to
treat
headaches.
Conclusion
Increasing
awareness
and
knowledge
of
traditional
health
practices
should
help
physicians
appreciate
a
patient's
per-
ception
of
Western
medicine.
Physicians
should
maintain
a
nonjudgmental
attitude
toward
such
practices
while
seeking
information
from
patients
about
which
traditional
health
practices
and
Western
medications
are
being
used.
Good
patient
care
may
necessitate
the
use
or
tolerance
of
both
modalities
in
many
Southeast
Asian
refugees.
REFERENCES
1,
Miles
D:
Prophylactic
medicine
and
kin
units
among
Yao
ancestor
worshippers.
Mankind
1973;
9:77-88
2.
Tung
TM:
The
Indochinese
refugees
as
patients.
J
Refugee
Resettlement
1980;
1:53-60
3.
Muecke
MA:
In
search
of
healers-Southeast
Asian
refugees
in
the
American
health
care
system,
In
Cross-cultural
medicine.
West
J
Med
1983;
139:835-840
4.
Hoang
GN,
Erickson
RV:
Culture
barriers
to
effective
medical
care
among
Indochinese
patients.
Annu
Rev
Med
1985;
36:229-239
5.
Grizzel
S,
Savale
J,
Scott
P,
et
al:
Indochinese
refugees
have
vastly
different
views
and
use
of
medical
care
system.
Mich
Med
1980;
79:624-628
6.
Fasano
MG,
Hayes
J,
Wilson
R:
Traditional
beliefs
and
use
of
health
care
services
by
Vietnamese
and
Laotian
refugees.
Tex
Med
1986;
82:33-36
7.
Yeatman
GW,
Dang
VV:
Cao
Gio
(coin
rubbing)-Vietnamese
attitudes
toward
health
care.
JAMA
1980;
244:2748-2749
8.
Aronson
L:
Traditional
Cambodian
health
beliefs
and
practices.
R
I
Med
J
1987;
70:73-78
9.
Reinhart
MA,
Ruhs
H:
Moxibustion.
Clin
Pediatr
1985;
24:58-59
10.
Golden
SM,
Duster
MC:
Hazards
of
misdiagnosis
due
to
Vietnamese
folk
medicine. Clin
Pediatr
1977;
16:949-950
11.
Nong
TA:
'Pseudo-battered
child'
syndrome
(Letter).
JAMA
1976;
236
THE
WESTERN
JOURNAL
OF
MEDICINE
e
MAY
1992
0
156
o
5
511
