Received: 18 November 2018 Revised: 25 February 2019 Accepted: 26 February 2019

DOI: 10.1111/nhs.12609

RESEARCH ARTICLE

Illness uncertainty and complementary and alternative

medicine use in patients undergoing hemodialysis
Hae Ok Jeon RN, PhD1 | Bo Hye Kim RN, PhD2 | Oksoo Kim RN, PhD2

1
Department of Nursing, Cheongju University,
Cheongju, South Korea Abstract
2
College of Nursing, Ewha Womans In this study, we identified the relationships between illness uncertainty, subjective health, and
University, Seoul, South Korea the use of complementary and alternative medicine in patients undergoing hemodialysis. In
Correspondence total, 138 participants who were diagnosed with stages 4–5 chronic kidney disease and cur-
Oksoo Kim, College of Nursing, Ewha Womans
rently receiving hemodialysis were included. A cross-sectional, correlational design was utilized.
University, 52 Ewhayeodae-gil, Seodaemun-
gu, Seoul 03760, Korea. Illness uncertainty was associated with education, monthly income, employment, and subjective
Email: ohong@ewha.ac.kr health. The use of complementary and alternative medicine was not related to illness uncer-
tainty. Among the subdomains of illness uncertainty, ambiguity and unpredictability were
related to subjective health; 24.6% of the participants were currently using complementary and
alternative medicine and 19.6% had used it in the past. Such methods were mainly used for the
effective treatment of diseases or relief of symptoms; 88.5% of those using complementary and
alternative medicine consumed vitamins, specific foods, or dietary supplements. However, the
proportion of participants who consulted with health-care providers was not high. When plan-
ning nursing interventions for patients treated with hemodialysis, assessments on illness uncer-
tainty and complementary and alternative medicine use are needed.

KEYWORDS

chronic kidney disease, complementary medicine, Korea, hemodialysis, uncertainty

1 | I N T RO D UC T I O N determine the meaning of illness-related events, which arises when

According to the 2016 Global Burden of Disease Study, there is an
estimated 2.9 billion chronic kidney disease patients worldwide (Vos
et al., 2017), and the number of resulting deaths is approximately
1.18 million as of 2016, which is a 28.8% increase in the past 10 years
(Naghavi et al., 2017). As of 2017, there are approximately 100 000
patients undergoing renal replacement therapy in Korea, with 74% of
them receiving hemodialysis, and the number of patients has been
increasing each year (end-stage renal disease (ESRD) Registry Com-
mittee, Korean Society of Nephrology, 2018). In the USA, the preva-
lence of chronic kidney disease was approximately 14.8% in 2017,
and 500 000 ESRD patients were receiving hemodialysis in 2015
(United States Renal Data System, 2018).
Patients undergoing hemodialysis might feel that their condition
is untreatable and that there will be no change, and most often experi-
ence uncertainty related to the illness, such as fear of the hemodialy-
sis treatment process and death (Sahaf, Ilali, Peyrovi, Akbari
Kamrani, & Spahbodi, 2017). Uncertainty is defined as the inability to
the individual cannot attribute definite value to objects or events, or
cannot make accurate predictions of the outcomes (Mishel, 1988).
Therefore, when patients have to undergo hemodialysis for the rest of
their lives, uncertainty should be given adequate consideration for
nursing patients. According to precedent studies, a hemodialysis
patient's confidence in the treatment and sense of control over the ill-
ness have been shown to be related to depression and health-related
quality of life (Cha & Lee, 2014), thus it is necessary to identify the
patient's level of uncertainty.
In Korea, adults, older people, and chronically ill patients often
choose complementary and alternative medicine (CAM) to maintain
their health (Kang, Kim, & Kim, 2017; Lee, Kim, Seo, Lee, & Jeong,
2014; Park et al., 2014). However, in kidney disease patients, health
management methods such as diet, nutrition, and exercise, can bring
significant change in the advancement of kidney disease; therefore, it
is necessary to utilize an approach for patients undergoing hemodialy-
sis that is different from that of other kidney disease patients
(National Kidney Foundation, 2017). For example, the National Kidney

Nurs Health Sci. 2019;1–7. wileyonlinelibrary.com/journal/nhs © 2019 John Wiley & Sons Australia, Ltd 1
2 JEON ET AL.
Foundation prohibits the use of herbal supplements by kidney disease
patients, especially patients undergoing hemodialysis, as they can con-
tain potassium or interact with prescribed medication. Therefore, it is
imperative to provide health education to ensure the proper adminis-
tration of CAM for patients.
International studies on CAM in patients treated with hemodialy-
sis were conducted in Turkey (Özdemir, Erdal, & Mehmet Haberal,
2018), India (Arjuna Rao et al., 2016), and Egypt (Osman et al., 2015),
and the CAM utilization rate was reported to be 26–49.8%. Although
there have been studies in Korea on the use of CAM in adults, older
people, and chronically ill patients (Kang et al., 2017; Lee et al., 2014;
Park et al., 2014), limited research focusing on CAM use in patients
undergoing hemodialysis has been conducted, and consequently,
there were limitations in understanding issues related to the health
management of patients undergoing hemodialysis.
An increase in illness uncertainty lowers hemodialyzed patients'
self-care (Jang, Lee, & Yang, 2015), therefore, patients' choice of
health management methods, such as CAM, might be affected by ill-
ness uncertainty. However, there is a lack of research on how uncer-
tainty is related to CAM use in patients undergoing hemodialysis.
Accordingly, this study aimed at examining the level of illness
uncertainty, subjective health, and CAM utilization in patients under-
going hemodialysis and providing baseline data for the development
of nursing.
Further, nursing interventions can lower the level of illness-
related uncertainty experienced by patients, creating a treatment
environment allowing adequate administration of CAM.
1.1 | Purpose
The purpose of this study was to identify the relationships between
illness uncertainty, subjective health, and the use of CAM in patients
undergoing hemodialysis.
The objectives of the study were as follows: to identify: (i) the
demographic and disease-related characteristics of the participants;
(ii) the differences in illness uncertainty according to the demographic
characteristics of the participants; (iii) the relationships between sub-
jective health, the use of CAM, and illness uncertainty; and (iv) to
determine the prevalence of CAM usage.
2 | METHODS
2.1 | Research design
This study used a cross-sectional and correlational design to investi-
gate the relationships between illness uncertainty, subjective health
status, and use of CAM in Korean patients undergoing hemodialysis.
2.2 | Participants
Participants who were diagnosed with stages 4–5 chronic kidney dis-
ease and currently receiving hemodialysis were included. Hospitalized
patients were excluded. G* power analysis was performed to obtain
the sample size (Faul, Erdfelder, Buchner, & Lang, 2009). In total,
128 participants were required when calculating the medium effect
size (d = .30), alpha = .05, power = .80, and number of groups = 4
based on analysis of variance (ANOVA). In total, 138 participants were
included in the study.
2.3 | Instruments
2.3.1 | Illness uncertainty
Illness uncertainty was measured using the Korean version of Mishel’s
(1988) Uncertainty in Illness Scale for Adults (MUIS-A) (Chung, Kim,
Rhee, & Do, 2005). Permission was obtained to use the MUIS-A and
the Korean version of the MUIS-A. The instrument consists of
32 items of four subdomains: ambiguity (n = 13), complexity (n = 7),
inconsistency (n = 7), and unpredictability (n = 5). The scale of the
instrument was a 5 point Likert scale ranging from “strongly disagree”
(1) to “strongly agree” (5), with possible scores ranging from 32 to
160. Higher scores indicated higher uncertainty. In this study,
Cronbach's alpha was .78.
2.3.2 | Complementary and alternative medicine usage
The National Institutes of Health (NIH) categories of CAM (NIH
National Cancer Institute, 2012) were used to identify the types of
CAM. The eight categories are as follows: alternative medical systems
(acupuncture, moxibustion), energy therapies (Qi gong, magnet ther-
apy), exercise therapies (tai chi, yoga), manipulative and body-based
methods (therapeutic massage, reflexology), mind–body interventions
(relaxation, meditation, aroma therapy), nutritional therapeutics (vita-
mins, specific foods, dietary supplement), pharmacological and bio-
logic treatments (herbs, herbal extracts), and spiritual therapies
(spiritual healing).
2.3.3 | Subjective health
Subjective health was self-assessed by participants as very poor (1),
poor (2), fair (3), good (4), or very good (5).
2.4 | Data collection
The data were collected from December 2012 to July 2013 in two
general hospitals and eight renal clinics in C province, Korea.
According to the Health Insurance Review and Assessment Service
(2013), at the time of data collection there were 644 medical institu-
tions conducting hemodialysis in Korea, 24 of which were located in C
province. Before the data collection, the researcher obtained permis-
sion from the target medical institutions. The researcher explained the
purpose of the study to the participants and asked them to fill out the
questionnaire after receiving written consent.
2.5 | Ethical considerations
This study was conducted after obtaining approval of the Institutional
Review Board of Ewha Womans University (IRB: 2012-07-06). The
participants were informed about the study's purpose and told that
they can withdraw from the study at any time. Participants’ anonymity
was assured, and written consent was obtained.
JEON ET AL. 3

2.6 | Data analysis TABLE 1 General and disease-related characteristics (n = 138)

SPSS 24.0 was used to analyze the data. Data were analyzed using Characteristics Mean ± SD or N (%)
Age (years) 57.60 ± 11.46
descriptive statistics, t-test, Pearson's correlation, and ANOVA.
Sex
Scheffe tests were used for post-hoc test.
Male 75 (54.3)
Female 63 (45.7)

3 | RESULTS Spouse
Yes 98 (71.0)
No 40 (29.0)
3.1 | Demographic and disease-related participant
Education
characteristics
≤high school 97 (70.3)
The mean age of the participants was 57.6 years; 75 (54.3%) were ≥college 41 (29.7)
male, 98 (71%) had a spouse, 97 (70.3%) had a high school or lower Monthly income (US$)
level of education, 97 (70.3%) were unemployed, 80 (58%) had a ≤2000 80 (58.0)
monthly income of <US$2000, 64 (46.4%) had a dialysis duration of 2000–3000 32 (23.2)
>5 years, and 125 (90.6%) were receiving dialysis three times per ≥3000 26 (18.8)
week. Most of the participants (94.9%) were taking medication due to Employed

chronic kidney failure, and 38 (27.5%) were on a waiting list for kidney Yes 41 (29.7)

transplantation. In the subjective health assessment, 66 (47.8%) No 97 (70.3)

responded “fair” and 38 (27.5%) “poor”; 34 (24.6%) are currently using Duration of hemodialysis (years)

CAM, and 27 (19.6%) have used it in the past (Table 1). ≤1 18 (13.0)
2–3 32 (23.2)
3–5 24 (17.4)
3.2 | Difference in the degree of illness uncertainty
≥5 64 (46.4)
according to general participant characteristics Hemodialysis frequency (times/week)
The differences in illness uncertainty according to the general and 2 13 (9.4)
disease-related characteristics of the participants are shown in 3 125 (90.6)
Table 2. The age of the participants was significantly associated with Hemodialysis medication

complexity (r = .198, P = .020) and unpredictability (r = .221, Yes 131 (94.9)

P = .009). Ambiguity was significantly higher in women than in men No 7 (5.1)

(t = −2.199, P = .030). Ambiguity of the participants without spouses Plans for kidney transplantation
Yes 38 (27.5)
was also significantly higher than that of participants with spouses
No 100 (72.5)
(t = −2.402, P = .018). Illness uncertainty (t = 2.456, P = .017), ambi-
Subjective health
guity (t = 2.604, P = .010), and inconsistency (t = 2.119, P = .036) of
Very poor 22 (15.9)
those who had a high school or lower level of education were higher
Poor 38 (27.5)
than those of who had a college or higher level of education. Illness
Fair 66 (47.8)
uncertainty (F = 4.780, P = .010) was significantly different according
Good 12 (8.7)
to monthly income. The Scheffe test showed that illness uncertainty
Experience using CAM
was significantly higher among participants whose monthly income
Current use 34 (24.6)
was <US$2000 compared to those with a monthly income of >
Past use 27 (19.6)
$US3000 (P = .020). Monthly income was also different according to
No experience 77 (55.8)
ambiguity (F = 3.382, P = .037) and inconsistency (F = 3.111,
CAM = complementary and alternative medicine; SD = standard
P = .048). Illness uncertainty (t = −3.308, P = .001) and ambiguity deviation.
(t = −2.790, P = .006) of the participants who were not employed
were significantly higher than in participants who were employed. according to subjective health. The use of CAM was not related to ill-
ness uncertainty.

3.3 | Relationships between subjective health, use of

complementary and alternative medicine, and illness
uncertainty
The relationships between subjective health, use of complementary
therapies, and the degree of illness uncertainty are shown in Table 3.
Uncertainty (F = 3.131, P = .028), ambiguity (F = 2.884, P = .038), and
unpredictability (F = 2.925, P = .036) were significantly different
3.4 | Complementary and alternative medicine usage
of participants
The most common CAM was vitamins/specific foods/dietary supple-
ments (88.5%) (Table 4); 31.2% of the users reported that they used
CAM believing that it would be effective in treating their chronic kid-
ney disease. The most common source of acquiring information was
4 JEON ET AL.

TABLE 2 Differences in uncertainty according to general and disease-related characteristics (n = 138)

Uncertainty Ambiguity Complexity Inconsistency Unpredictability

t/F/r t/F/r t/F/r t/F/r t/F/r
Variables Mean ± SD (P-value) Mean ± SD (P-value) Mean ± SD (P-value) Mean ± SD (P-value) Mean ± SD (P-value)
Age .113 −.049 .198 .043 .221
(.189) (.572) (.020)* (.615) (.009)**
Sex
Male 90.03 ± 10.31 −1.416 40.92 ± 6.98 −2.199 16.99 ± 3.58 .117 17.12 ± 3.38 −.283 15.00 ± 2.60 .477
Female 92.29 ± 8.43 (.159) 43.32 ± 5.59 (.030)* 16.92 ± 2.97 (.907) 17.27 ± 2.74 (.778) 14.78 ± 2.86 (.634)
Spouse
Yes 90.37 ± 9.59 −1.336 41.18 ± 6.40 −2.402 17.17 ± 3.37 1.210 17.04 ± 3.05 −.877 14.97 ± 2.82 .478
No 92.75 ± 9.28 (.184) 44.05 ± 6.26 (.018)* 16.43 ± 3.10 (.228) 17.55 ± 3.19 (.382) 14.7 3 ± 2.47 (.633)
Education
≤high school 92.44 ± 8.64 2.456 42.93 ± 6.03 2.604 17.22 ± 3.17 1.428 17.55 ± 3.01 2.119 14.75 ± 2.63 −.971
≥college 87.78 ± 10.78 (.017)* 39.85 ± 7.02 (.010)* 16.34 ± 3.56 (.156) 16.34 ± 3.56 (.036)* 15.24 ± 2.91 (.333)
Monthly income (US$)
≤2000 93.05 ± 8.43a 4.780a 43.21 ± 5.84 3.382 17.24 ± 2.89 2.248 17.68 ± 2.83 3.111 14.93 ± 2.60 .212
2000–3000 89.28 ± 9.09 (.010)** 40.44 ± 7.50 (.037)* 17.25 ± 4.24 (.110) 16.94 ± 3.40 (.048)* 14.66 ± 2.89 (.810)
≥3000 87.12 ± 11.74b 40.27 ± 6.40 15.73 ± 3.03 16.00 ± 3.24 15.12 ± 2.93
Employed
Yes 87.07 ± 10.47 −3.308 39.71 ± 6.77 −2.790 16.20 ± 3.01 −1.775 16.85 ± 3.07 −.826 14.32 ± 2.58 −1.645
No 92.74 ± 8.62 (.001)** 42.99 ± 6.11 (.006)** 17.28 ± 3.38 (.078) 17.33 ± 3.10 (.410) 15.14 ± 2.75 (.102)
Duration of
hemodialysis (years)
≤1 92.39 ± 8.23 43.61 ± 5.62 16.83 ± 2.28 17.56 ± 2.91 14.39 ± 1.91
1–3 90.88 ± 8.42 .440 41.91 ± 6.50 2.206 16.78 ± 3.34 .166 16.47 ± 2.61 .816 15.72 ± 2.75 2.455
3–5 89.25 ± 11.41 (.725) 39.17 ± 8.38 (.090) 17.38 ± 5.25 (.919) 17.17 ± 3.50 (.487) 15.54 ± 2.75 (.066)
≥5 91.45 ± 9.74 42.69 ± 5.64 16.92 ± 2.58 17.45 ± 3.20 14.39 ± 2.78
Plans for kidney
transplantation
Yes 90.87 ± 8.90 −.144 41.68 ± 6.96 −.369 16.87 ± 3.40 −.193 17.24 ± 3.10 .113 15.08 ± 2.49 .480
No 91.13 ± 9.80 (.886) 42.14 ± 6.31 (.713) 16.99 ± 3.28 (.848) 17.17 ± 3.10 (.910) 14.83 ± 2.81 (.632)

*P < .05, **P < .01. aScheffe test: a > b (P = .020).

SD = standard deviation.

other patients with the same disease (36.1%); 37.7% of users reported
that CAM gave them psychological stability, and 27.9% reported relief
of their symptoms. However, 18.% experienced no benefit from CAM,
and 26.2% reported that they did not know whether or not CAM was
beneficial. Among the users, 45.9% consulted with physicians and
34.4% were encouraged to use CAM by health-care providers; 67.2%
had plan to continuous use CAM.
4 | DISCUSSION
In this study, age, sex, and duration of hemodialysis were not related
to illness uncertainty; however, they were related to some of the sub-
domains of illness uncertainty. Complexity and unpredictability were
disease for a long time before starting hemodialysis. The patient might
have become accustomed to the disease before dialysis, therefore,
the duration of dialysis and illness uncertainty might not be related.
Uncertainty must be considered important regardless of disease dura-
tion (Hoth et al., 2013), and nursing assessment of illness uncertainty
is also important for patients, regardless of hemodialysis duration.
The participants without spouses had significantly higher ambigu-
ity than the participants with spouses in the study. Jang et al. (2015)
reported that patients undergoing hemodialysis with spouses had
higher levels of self-care. The role of the spouse in disease manage-
ment is important, therefore, an approach based on support from a
spouse is required to reduce the degree of uncertainty in patients
undergoing hemodialysis.

related to age, and sex was related to ambiguity. Therefore, in patients Education, monthly income, employment status, and subjective

undergoing hemodialysis, age and sex need to be considered for the
subdomain attributes of illness uncertainty. Nam and Sung (2014)
reported that uncertainty was lower for women aged >65 years with
osteoarthritis after >7 years of disease diagnosis. However, in this
study, hemodialysis duration was not related to illness uncertainty. It
is likely that patients have already suffered from chronic kidney
health were related to illness uncertainty in the study. In particular,
education level, monthly income, and subjective health status were
related to both ambiguity and complexity. This study supports the
findings of Nam and Sung (2014), which showed that education level,
monthly income, social activity, and subjective health status were
associated with uncertainty among older women with osteoarthritis.
JEON ET AL. 5

TABLE 3 Differences in uncertainty according to subjective health and experience using CAM (n = 138)

Uncertainty Ambiguity Complexity Inconsistency Unpredictability

Variables Mean ± SD F (P-value) Mean ± SD F (P-value) Mean ± SD F (P-value) Mean ± SD F (P-value) Mean ± SD F (P-value)
Subjective health
Very poor 95.19 ± 9.35 3.131 44.64 ± 5.25 2.884 16.55 ± 3.91 .544 18.05 ± 3.11 1.755 15.95 ± 2.92 2.925
Poor 92.79 ± 10.24 (.028)* 43.18 ± 6.88 (.038)* 16.79 ± 2.72 (.653) 17.74 ± 3.07 (.159) 15.07 ± 2.48 (.036)*
Fair 88.88 ± 8.65 40.86 ± 5.74 17.00 ± 3.03 16.74 ± 3.05 14.27 ± 2.47
Good 90.00 ± 9.74 39.83 ± 9.12 18.00 ± 5.06 16.33 ± 3.05 15.83 ± 3.66
CAM experience
Current use 92.44 ± 9.61 1.744 43.65 ± 7.11 2.344 16.85 ± 2.95 .915 17.18 ± 3.09 .038 14.76 ± 2.50 .664
Past use 88.11 ± 8.65 (.179) 40.07 ± 5.89 (.100) 16.26 ± 3.91 (.403) 17.33 ± 2.91 (.963) 14.44 ± 2.59 (.516)
No experience 91.48 ± 9.69 41.97 ± 6.25 17.25 ± 3.22 17.14 ± 3.19 15.17 ± 2.86

*P < .05. CAM = complementary and alternative medicine; SD = standard deviation.

Education or income can also affect health status by influencing TABLE 4 Experience of CAM (n = 61)
health-care utilization or health-care capabilities (Yoon, 2016). In this Characteristics N %
study, the level of uncertainty seemed to be higher in participants CAM type a
Acupuncture/moxibustion 11 18.0
with low education or income levels. Robinson-Cohen et al. (2014) Qi gong/magnet therapy 9 14.8
reported that low subjective health status was associated with the risk Tai chi/yoga 12 19.7
of disease progression and mortality in patients with stages 3–4 Therapeutic massage/reflexology 16 26.2
chronic kidney disease. Therefore, the assessment of the subjective Relaxation/meditation/aromatherapy 25 41.0
health status of patients should also be considered. In this study, gen- Vitamins/specific foods/dietary 54 88.5
eral or disease-related characteristics were found to be related to the supplement

subscales of illness uncertainty. In particular, ambiguity showed the Herbs/herbal extracts 14 23.0

most significant relationship with general or disease-related character- Spiritual healing 20 32.8

istics than other subscales. Hoth et al. (2013) also found that ambigu- Motivationa Treatment 19 31.2

ity was an important variable that affected depression, anxiety, and Symptom relief 14 23.0

quality of life to a greater degree than complexity. Previous studies Health promotion 17 27.9

that reviewed uncertainty studies of older adults with cancer reported Psychological stability 17 27.9

that there are many conflicting results on the relationships between Others 4 6.6
Source of Patients with the same disease 22 36.1
general characteristics, disease-related characteristics, and uncer-
informationa
Family and relatives 14 23.0
tainty, so it is unclear what factors to consider in planning interven-
Friend/neighbor/colleague 8 13.1
tions (Jabloo et al., 2017). Therefore, consideration of these
TV, newspaper 11 18.0
subdomains is also important in assessing and reducing illness
Internet/books 4 6.6
uncertainty.
Health-care providers 19 31.2
The classification for CAM might differ based on individual per-
Use effecta Symptom relief 17 27.9
ceptions (Chatterjee, 2018), therefore, participants were asked to
Psychological stability 23 37.7
choose what kind of CAM they were using based on NIH categories.
Not helpful 11 18.0
We found that 24.6% of the patients were using CAM, and 19.6% of
Do not know 16 26.2
them had used it in the past. This was similar to a previous study ,
Others 3 4.9
where 52% of patients with chronic kidney disease had experience
Consulting Physician 28 46.0
using CAM (Osman, Hassanein, Leil, & NasrAllah, 2015). In this study, experiencea
Nurse 16 26.2
most of the CAM users had used vitamins, specific foods, or dietary
Pharmacist 2 3.3
supplements, and 23% used herbs and herbal extracts. Patients
None 26 42.6
treated with hemodialysis are required to have a special dietary regi-
Consultation Encourage use 21 34.4
men and they are prohibited from using herbs, because they are likely reaction (n = 35)
Disable 14 23.0
to cause interactions with the medication they are taking or induce
Plan for continuous Yes 41 67.2
side-effects (National Kidney Foundation, 2017). Therefore, patients use CAM
No 20 32.8
need to consult with health-care providers when using dietary supple-
a
ments or herbs. However, 46.2% of the participants in this study did Multiple responses.
CAM = complementary and alternative medicine.
not consult with health-care providers about CAM use, and most of
the information about CAM use was obtained from other patients most important reason for not discussing CAM use with health-care
with chronic kidney disease. Similar results were obtained in previ- providers in previous studies of patients with hypertension and diabe-
ously published studies (Lee et al., 2014; Osman et al., 2015). The tes was that they considered CAM as separate from hospital
6 JEON ET AL.
treatment (Lee et al., 2014). Nurses need to have an open-minded
approach when discussing CAM with patients, as patients are often
cautious about disclosing CAM use because of fear that they will
receive negative feedback from health-care providers (Hall et al.,
2018). If nurses communicate effectively with patients about CAM
use, patients might not use herbal supplements, which should be
avoided for hemodialysis treatment.
Illness uncertainty and CAM use experience were not related in
this study. According to Osman et al. (2015) and Yoon’s (2016) stud-
ies, uncertainty increases when education or income levels of patients
are low, while CAM use is higher in urban areas where education and
income levels of patients are high. Further studies are needed,
because the findings on the relationship between uncertainty and
CAM use are inconsistent.
Uncertainty is closely related to quality of life, anxiety, and
depression (Jabloo et al., 2017), and it might be important to identify
the degree of illness uncertainty among patients undergoing hemodi-
alysis. The use of CAM is a major issue that might affect the patient's
disease management and mortality, so it will be necessary to identify
and educate CAM users.
4.1 | Limitations
There are several limitations in this study. First, the results cannot be
generalized, because the participants were recruited by the conve-
nience sampling method. However, the results are consistent with the
findings of other countries in relation to CAM use and disclosure. Sec-
ond, it is possible that the use of CAM was reported at lower levels
than actual levels, because the participants might not have fully dis-
closed their usage. Third, there is also the possibility of recall bias in
the participants' use of CAM.
4.2 | Conclusion
Illness uncertainty was associated with education, monthly income,
employment, and subjective health, but not with CAM use. Among
the subdomains of illness uncertainty, ambiguity and unpredictability
were related to subjective health. Almost half of the participants had
experience using CAM, and they were mainly used for the effective
treatment of diseases or relieving symptoms. Most CAM users con-
sumed vitamins, specific foods, or dietary supplements. However, the
proportion of participants who consulted with health-care providers
was not high. When planning nursing interventions for patients,
assessments of illness uncertainty and CAM use are needed. Nurses
also need to communicate with patients to encourage them to dis-
close CAM use.
AUTHOR CONTRIBUTIONS
Study design: O.K., H.O.J., and B.H.K.
Data collection: O.K. and H.O.J.
Data analysis: O.K. and H.O.J.
Manuscript writing and revisions for important intellectual content:
O.K., H.O.J., and B.H.K.
CON F L I C T S OF IN TE RE S T S
The authors have no conflicts of interest to declare.
ORCID
Hae Ok Jeon https://orcid.org/0000-0001-9933-6097
Bo Hye Kim https://orcid.org/0000-0001-5419-3467
Oksoo Kim https://orcid.org/0000-0001-9071-6093
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How to cite this article: Jeon HO, Kim BH, Kim O. Illness
uncertainty and complementary and alternative medicine use
in patients undergoing hemodialysis. Nurs Health Sci. 2019;
1–7. https://doi.org/10.1111/nhs.12609