Journal of Complementary and Integrative Medicine

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1 Journal of Complementary and Integrative Medicine Volume 4, Issue Article 11 Using the Behavioral Model for Complementary and Alternative Medicine: The CAM Healthcare Model Judith M. Fouladbakhsh Manfred Stommel Wayne State University, judif129@comcast.net Michigan State University, Manfred.Stommel@ht.msu.edu Copyright c 2007 The Berkeley Electronic Press. All rights reserved.

2 Using the Behavioral Model for Complementary and Alternative Medicine: The CAM Healthcare Model Judith M. Fouladbakhsh and Manfred Stommel Abstract Complementary and alternative medicine (CAM) therapies, products and practices are increasingly being used across the United States and worldwide by individuals who are healthy, as well as by those who are ill (Barnes, Powell-Griner, McFann & Nahin et al., 2004; Burstein, Gelber, Guadagnoli, & Weeks, 1999; Eisenberg, et al., 1998; Ernst & Cassileth, 1998; Kessler, et al., 2001; Richardson & Straus, 2002). This trend, which is anticipated to continue, reflects changing health care behavior. Individuals, who are experiencing illness, use CAM for treatment, management of illness related symptoms and to enhance quality of life. Those who are well also use CAM to promote health, and prevent disease. This increasing prevalence of CAM has created a need to identify patterns and predictors of use among the diverse populations of users. Concurrently, this trend evokes questions about the effect of CAM on the utilization of conventional health services and providers, health outcomes and quality of life. This paper presents an emerging conceptual framework, referred to as the CAM Healthcare Model. This model aims to identify factors associated with the use of CAM providers, therapies, products and practices within a health services framework, thereby providing a guide for CAM research and practice. The CAM Healthcare Model is a modification of Andersen s Behavioral Model for Health Service Use, a framework that has guided research on conventional health services for more than three decades (Andersen, 1969, 1995). The CAM Healthcare Model identifies factors influencing the use of CAM health services and resources that are provider-directed, and CAM use as a self-directed health care activity and/or practice. The authors propose that CAM use, with or without a provider, has the potential to affect utilization of conventional health services as it offers more choices to healthcare consumers. These choices ultimately affect healthcare outcomes, research, health service delivery and policy, hence the importance of this work Understanding the trends and implications of CAM use further emphasizes the need for a model to study CAM within a health service/resource context. KEYWORDS: CAM, healthcare, model, behavioral model The authors would like to acknowledge Dr. Rosalind Peters, Associate Professor, Wayne State University College of Nursing for her contributions to the development of the model.

3 Fouladbakhsh and Stommel: The CAM Healthcare Model INTRODUCTION Complementary and alternative medicine (CAM) therapies are widely used in the United States (U.S.) and worldwide by healthy individuals and those experiencing illness (Barnes, Powell-Griner, McFann & Nahin, 2004; Eisenberg, Davis, Ettner, Appel, Wilkey, et al., 1998; Ernst & Cassileth, 1998; Lewith, Broomfield & Prescott, 2002; Richardson & Straus, 2002; Wolsko, Eisenberg, Davis & Phillips, et al., 2003; World Health Organization, 2004). This usage reflects trends in health care behavior that may potentially influence the use of conventional health services (Astin, 1998; Eisenberg, et al., 1998). Persons with chronic illnesses, such as cancer, often seek CAM as a form of complementary treatment, sometimes to treat the illness directly, but often to manage symptoms such as pain and improve quality of life (Ernst & Cassileth, 1998; Vallerand, Fouladbakhsh & Templin, 2003). Trend data from population studies during the 1990s not only revealed an increase in the use of CAM therapies, but also highlighted the finding that the number of visits to CAM providers surpassed the number of visits to conventional primary care providers in the U.S. (Eisenberg, et al., 1998). Other survey data, however, has reported lower percentages of use (Druss & Rosenheck, 1999). More recently, the National Health Interview Survey (NHIS, 2002) reported that 75% of the US population had used CAM during their lifetime, and 62% reported use in the year preceding the survey (Barnes et al., 2004). Analysis examining the trend of CAM use over time supports that the prevalence of use between 1997 and 2002 has remained stable (Tindle, Davis, Phillips and Eisenberg, 2005). Inconsistencies in prevalence estimates across studies are, unfortunately, quite common and may be attributed to different operational definitions of CAM, the varying list of therapies included for study and the lack of a consistent framework for examining CAM use. Whereas some studies have examined a very extensive array of provider services, product use and self-care practices, other studies have solely focused on the use of CAM providers only. In addition, findings may vary due to different sampling procedures and research methodology such as use of face-to-face interviews versus telephone surveys, and differences in socioeconomic status of the target populations studied (Bausell, Lee & Berman, 2001; Druss & Rosenheck, 1999). Hence, existing research on CAM use suffers from conceptual and definitional inconsistencies that limit our understanding of how and why CAM is used and factors that lead to specific CAM use patterns. To address these problems and provide a guide for future research in this area, this paper presents a conceptual framework, referred to as the CAM Healthcare Model, that aims to identify factors associated with the use of CAM providers, practices and products. The CAM Healthcare Model aims to enhance Published by The Berkeley Electronic Press,

4 Journal of Complementary and Integrative Medicine, Vol. 4 [2007], Iss. 1, Art. 11 understanding of CAM health behavior, factors that predict CAM use, patterns and purposes of use, and related outcomes. This knowledge will hopefully further our understanding about CAM use, and maximize positive health outcomes as CAM users interface with the conventional healthcare sector. In addition, the model allows for the examination of the concurrent use of CAM with conventional healthcare services and may help to identify differential predictors of the use of both types of healthcare. NCCAM CATEGORIZATION DEFINITIONS AND CATEGORIZATION OF CAM The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine. A complementary therapy is defined as a selected therapeutic method, product or treatment by a practitioner used in combination with conventional mainstream medicine as a health service for patients. Alternative therapy is defined as a selected therapeutic method, product or treatment by a practitioner used in place of conventional medical therapy (NCCAM, 2004). For example, herbs used in place of pharmaceutical products would be considered alternative, whereas herbs used in combination with pharmaceutical products would be considered complementary. The NCCAM categorization of CAM distinguishes four areas and one overarching domain in an attempt to provide etiology-based CAM groupings. They include: (1) Mind-body therapies: behavioral, social, psychological and spiritual approaches to health, e.g. yoga, Tai Chi, meditation, hypnosis; (2) Biological-based therapies: natural and biologically-based products, practices and interventions, e.g. herbs, supplements, diet therapy; (3) Manipulative and body-based systems: systems based on manipulation and/or movement of the body, e.g. massage, Feldenkrais; (4) Energy therapies: systems that use subtle energy fields in and around the body to promote healing, e.g. Healing Touch, Therapeutic Touch, acupuncture, reiki; and (5) the overarching domain of Alternative medical systems: complete systems of theory and practice developed outside of a western, conventional biomedical approach to health and illness, which may include therapies from the other 4 areas, e.g., homeopathy, naturopathy, traditional Chinese medicine (Table 1). From a health services point of view, the NCCAM categorization appears less useful. To explain why people are using CAM services, it is more useful to focus on CAM characteristics that are related to ease of access, costs and the time required to engage in CAM practices. Thus, an alternative categorization is proposed. 2

5 Fouladbakhsh and Stommel: The CAM Healthcare Model Table 1: CAM Domains (NCCAM) Domain Description & Examples Mind-body therapies Alternative medical systems Biological-based therapies Manipulative and bodybased systems Energy therapies Behavioral, social, psychological and spiritual approaches to health, Example: yoga, Tai Chi, meditation, hypnosis Complete systems of theory and practice developed outside of a western, conventional biomedical approach to health and illness Example: homeopathy, naturopathy, traditional Chinese medicine Natural and biologically-based products and practices and interventions Example: herbs, supplements, diet therapy Systems that are based on manipulation and/or movement of the body Example: massage, Feldenkrais Systems that use subtle energy fields in and around the body to promote healing Example: Healing Touch, Therapeutic Touch, acupuncture, Reiki ALTERNATIVE CATEGORIZATION The alternative categorization divides CAM therapies into three broad groups based on whether a specific CAM requires the involvement of a practitioner/professional provider, is a purchasable product or primarily is a practice that can be performed independently by the CAM user (akin to self-care) These categories are not necessarily considered mutually exclusive (Figure 1) as CAM practices and products are often used and recommended by CAM providers. However, these categories do group CAM therapies based on how the potential users gain access to them. For instance, CAM services offered by Published by The Berkeley Electronic Press,

6 Journal of Complementary and Integrative Medicine, Vol. 4 [2007], Iss. 1, Art. 11 practitioners/providers, some of whom are licensed and regulated (e.g. chiropractors) resemble conventional medical care, purchasable products generally have lower barriers to use (like over-the-counter pharmaceuticals) and practices may not involve high monetary barriers but may require life-style choices or changes. The 3 categories are defined as follows. A listing of CAM therapies for the alternative categories can be found in Table 2. 1) CAM provider services (individual and group) provided by CAM practitioners, e.g. acupuncture, massage, naturopathic and chiropractic treatment 2) CAM products and resources such as herbs, supplements, essential oils, self-help manuals, books and other instructional materials 3) CAM practices (individual and communal) such as meditation, yoga practice, breath work, and use of music (Table 2). Figure 1: Dual Nature of CAM CAM Services CAM Resources CAM Practices Provider-directed Resources Self-directed Therapies & Services Products Practices 4

7 Fouladbakhsh and Stommel: The CAM Healthcare Model Table 2: Alternative Categorization of CAM Services, Products & Practices CAM Services CAM Products CAM Practices Health services Products (herbs, oils etc) Self-care activity Acupuncture Essential Oils Acupressure Chiropractic treatment Herbal products Meditation Naturopathic treatment Self-help books Nutritional variations;diets Ayurvedic treatment Educational materials: CDs, videos, audiotapes Breathing exercises Breathwork -pranayama Massage therapy Music/art materials Yoga practice; stretching Diets vegetarian, Ornish, Internet websites Music listening, playing Macrobiotic, Pritikin, Atkins Drumming, singing Energy therapy Vitamins Prayer & spiritual activities Yoga, QiGong, Tai Chi Nutritional Self-massage supplements Music therapy Teas Guided imagery Hypnosis Magazines Yoga, Qi Gong, Tai Chi Spiritual healing -use of Shamanic rituals/vision spiritual mediums, guides Food products quests Shamanic healing Spiritual artifacts Energy healing Holistic consultations Use of vitamins, herbs & Crystals supplements Cranial sacral therapy Healing equipment Progressive relaxation e.g. Full spectrum lights Aromatherapy Magnets Visualization Art Therapy Spa supplies Self-chakra balancing Guided Imagery Folk Medicine treatment Homeopathic treatment Requires CAM practitioner Often used by CAM Used independently;no to provide care/treatment practitioner; can be practitioner required used independently PROVIDER-DIRECTED CAM USE SELF-DIRECTED CAM USE Published by The Berkeley Electronic Press,

8 Journal of Complementary and Integrative Medicine, Vol. 4 [2007], Iss. 1, Art. 11 A CONCEPTUAL MODEL FOR CAM: MODIFYING THE BEHAVIORAL MODEL The proposed categorization of CAM services, products and practices can easily be integrated with the Behavioral Model of Health Service Use, which has been used extensively over the past three decades to guide research examining factors that predict utilization of, and access to, conventional health services (Aday & Andersen, 1974; Aday & Awe, 1997; Andersen, 1995; Andersen & Newman, 1973; Andersen, 1968). The application of the Behavioral Model to CAM use has been limited in the literature, although predisposing, enabling and need factors have been associated with the use of alternative and nonprescription medication for HIV disease, and pain has been found to be an important predictor of overall CAM use in this population (Smith, Boyd & Kirking, 1999; Tsao, Dobalian, Myers & Zeltzer, 2005). What is more, the Behavioral Model has primarily been applied to the CAM categories defined by NCCAM. Often lacking is a comparison of the concurrent use of conventional health care and CAM, and factors that influence these choices. Hence, we propose our alternative categorization of CAM therapies to facilitate further research with the goal of promoting consistency and comparability across studies. In the past, the Behavioral Model has largely been used to examine factors that influence use of conventional healthcare provider services. Given that CAM includes many self-directed practices that aim to improve health, it is important to extend the model so that factors related to use of the specific categories of provider services, products and practices can be examined separately. Since CAM use, with or without a provider, also has the potential to affect utilization of conventional health services, the demand for CAM will continue to influence the delivery of conventional health care services far into the future (Kessler, et al., 2001). Thus, a consistent approach to the study of CAM healthcare behavior and the concurrent use of conventional health services is highly desirable. OVERVIEW OF THE BEHAVIORAL MODEL Andersen s Behavioral Model was selected as the overarching theoretical framework for the following reasons: 1) its consistent and longstanding ability to identify factors related to use of conventional medical services, 2) its applicability to diverse populations, and 3) its ability to be modified for CAM use. The Behavioral Model focuses on the individual as the unit of analysis, with societal determinants (technology and norms) and the health services system (resources and organization) as aggregate determinants of an individual s health-careseeking behavior. According to the model, the use of health services is viewed as a function of three broad classes of determinants identified as: 1) predisposing variables - an individual s propensity to use services; 2) enabling variables - the 6

9 Fouladbakhsh and Stommel: The CAM Healthcare Model means an individual has available for the use of health services, and 3) need variables - the individual s need for care (Awe & Aday, 1997; Andersen & Newman, 1974; Andersen, 1995). The ultimate outcome of the utilization of conventional healthcare services and resources is quality of life. Predisposing variables include demographic characteristics such as gender, age, and marital status, social structure attributes identified as education, race, ethnicity, and health beliefs as indicated by individual values and attitudes about health services, good health, physician services, and health insurance. Enabling variables identified in the model are those conditions or factors that allow or impede use of health services. Included are resources specific to individuals and families that may potentially influence conventional health service use such as income, health insurance, employment, and regular source of care. Community attributes, such as physician and hospital bed ratios, and region of the country are also viewed as potential predictors of health service use. In addition, place of residence, e.g., urban or rural, influences proximity to sources of conventional health services, and may be considered as a factor affecting utilization. The theoretical construct of need variables in the Behavioral Model includes both evaluated and perceived need. Evaluated need refers to objective measurable indicators of health status, such as actual diagnostic reports, symptom severity measurement, and treatments received. Perceived need refers to the individual s perception of health status and illness state, as measured by perception of health scales scores, and other perceived health status indicators. Need for care has also been measured through: (1) presence of illness (symptoms, limitations, number of days disabled, etc.), (2) individual s responses to illness (going to a physician, clinic visits, etc.), and (3) measures taken to prevent illness and maintain health (physician exams, etc.) (Aday & Awe, 1997). Taken together, predisposing, enabling and need variables are all factors that influence the demand for services, about which information can usually be gathered through survey methods. THE CAM HEALTHCARE MODEL The CAM Healthcare Model incorporates all of the factors identified in the Behavioral Model and enhances this framework in two ways: (1) Potential individual and system level indicators have been added among the predisposing, enabling and need factors to help identify patterns and predictors of CAM use, and possibly explain the differential use of conventional and CAM services and therapies; and (2) The Behavioral Model construct of 'health service use' is expanded in the CAM model to include health practices and products, in addition to provider-directed CAM services. The model includes individual and system Published by The Berkeley Electronic Press,

10 Journal of Complementary and Integrative Medicine, Vol. 4 [2007], Iss. 1, Art. 11 level variables; predominantly system level variables and indicators are noted with asterisk* (Figure 2) As a result, it becomes easier to examine the similarities and differences in the factors that predict the use of CAM as well as conventional health care services. Since CAM therapies include provider-delivered health services, there has always been a strong likelihood that a health service utilization model would be applicable and useful as an explanatory framework. In addition, the current empirical literature on CAM use suggests that similar relationships exist between the indicators of the Behavioral Model and CAM products and practices. Furthermore, given that many CAM therapies are used to complement rather than substitute for conventional medicine, it remains important to view both CAM and conventional health service use within a unified framework. A review of the literature and extensive clinical experience in CAM led us to speculate that CAM use may be precipitated by factors that push one away from conventional medicine or pull one toward CAM. The 'push' factors include, among others, dissatisfaction with care, financial cost, lack of insurance and low income. The belief that CAM is natural, reliance on family and cultural practices, and values that emphasize responsibility for self-care, in contrast, may serve to pull an individual toward CAM. It is anticipated that this push-pull situation may be more fully identified with use of the CAM Model. Hopefully, this will provide valuable insights into both the similarities and characteristic differences in the use of either CAM or conventional health services. THE CAM HEALTHCARE MODEL CONSTRUCTS AGGREGATE LEVEL DETERMINANTS Societal determinants that contribute to CAM use include increased acceptance of CAM as 'legitimate' and 'mainstream' services and activities as well as their greater availability throughout the U.S. These developments provide evidence of changing norms, which are reflected in: (1) greater media coverage, (2) CAM availability at conventional healthcare facilities, (3) availability of CAM courses and programs in schools of medicine, nursing, pharmacy, and health sciences. Technological advances, most notably the Internet, allow for rapid access to CAM providers, products and health practice information for self-directed use. Integration of CAM into conventional healthcare delivery systems, and changing reimbursement by health insurance companies are also powerful aggregate level determinants that influence CAM utilization. 8

11 Fouladbakhsh and Stommel: The CAM Healthcare Model INDIVIDUAL LEVEL DETERMINANTS The CAM Healthcare Model (Figure 2) includes indicators that may pull a person towards CAM use, while other individual determinants may be considered push factors. Justification for addition of these indicators is discussed below for the predisposing, enabling, need for care factors (Figure 2 follows discussion of the model constructs). PREDISPOSING FACTORS Community lifestyle and cultural/ethnic practices, both of which may influence individual or family predisposition to use CAM are included in the CAM Model. Traditional medicine beliefs and ethnic practices that are passed on through generations may strongly influence likelihood of CAM use. Values and attitudes about one s responsibility for self-care, which are often learned within the family and/or community, may also pull one toward CAM. Community lifestyle may also influence one s tendency to use CAM. Although included in the CAM Model as a predisposing variable, this may also be viewed in the context of enabling one to use CAM. Community lifestyle refers to the way one lives in their immediate community of residence. If CAM approaches are simply an expected part of daily living, it predisposes one to use. For example, in certain families and/or communities it may be understood that one meditates on a regular basis, hence this CAM approach becomes the norm, and is valued within that family or community group (McEvoy, 2003; Walsh, 2003). Risk perception, both with respect to an illness and with respect to using a specific CAM as a treatment has been added to the CAM Model and is considered a factor that may predispose one to use or not use CAM and/or conventional health care services. Illness perception reflects an individual s perceived risk of illness, perceived severity of illness and perceived healthcare options, following the Health Belief Model constructs that have been extensively used to identify factors influencing health behavior. If an individual perceives high risk and severity of illness, they are generally more likely to seek healthcare services of all kinds. Whether this includes CAM therapies may well depend on beliefs about their safety, efficacy, and acceptability. Personal knowledge of CAM, and personality characteristics such as self-efficacy, risk-taking ability, perception of control and self-care ability/tendency are also possible factors likely to influence one s tendency to use CAM. Although an individual may believe in the efficacy of CAM approaches, in many sectors of society, it may still take a certain amount of courage to deviate from what is conventionally done to address given health needs; in other segments it may be downright 'fashionable' to use CAM. Published by The Berkeley Electronic Press,

12 Journal of Complementary and Integrative Medicine, Vol. 4 [2007], Iss. 1, Art. 11 Personal autonomy and the desire to remain in control over one s healthcare can be influential factors in making the decision to use CAM, given that CAM approaches offer a myriad of self-treatment possibilities for both health promotion and symptom management (Astin, 1998; Helgeson, Cohen, Schulz & Yasko, 2000; Seidl & Steward, 1998; Street & Voight, 1997). To determine the relationship of perceived control to CAM use, one could use the comprehensive and psychometrically sound Illness Perception Questionnaire-Revised (IPQ-R) (Moss-Morris, Weinman, Petrie, Cameron & Buick, 2002; Weinman, Petrie, Moss-Morris & Horne, 1996), which includes items that measure the individual s perception of control over their health condition. Yet just as powerful are some of the push factors: Evident in the literature, for example, is consumer dissatisfaction with pharmaceutical approaches for the management of pain, including lack of effectiveness and bothersome side effects (Calvin, Becker, Biering & Grobe, 1999; Lazarus & Neumann, 2001; medscape medical news, 2006; partnersagainstpain.com., 2007). Perhaps one seeks CAM because of the limits and consequences of conventional treatment. In short, the CAM Behavioral Model does not only include the usual list of psychological and cultural predisposing factors, but also highlights the push factors of disillusionment or dissatisfaction with conventional care. ENABLING FACTORS The CAM Healthcare Model retains the same enabling variables identified in the Behavioral model for conventional health service use, and adds specific potential indicators relevant to CAM use. Having a regular source of CAM healthcare is viewed as a personal resource of the individual, often serving as a source for referral and information about new CAM therapies. The community attribute of access to CAM resources has been added to the model, recognizing the potential influence on use. Availability and access refer to presence of CAM within a community, for example CAM provider services offered within conventional healthcare systems, CAM practices offered at nearby community centers, and CAM product availability in local retail stores. Access to other CAM users is also viewed as an important factor since word of mouth recommendations and referrals (referral network) may often prompt and facilitate CAM use. (Figure 2). The community where one resides may be a strong factor influencing use of CAM and can be viewed in two distinct ways: as a cultural context, it is better viewed as a predisposing variable; but when it comes to the relative richness of the CAM 'infrastructure,' i.e., the sheer availability and variety of CAM services a person has access to in a particular location or the informal referral networks, it is an 'enabling' factor. The latter also includes the availability of third-party reimbursement for select CAM provider services. It is thus not surprising that the 10

13 Fouladbakhsh and Stommel: The CAM Healthcare Model prevalence of CAM use differs substantially by geographic location in the U.S. (Cui, et al., 2004; Riley-Doucet; Fouladbakhsh & Vallerand, 2004; Vallerand & Fouladbakhsh, 2003; Zimmerman & Thompson, 2002). The enabling variables of income and insurance have strongly influenced use of conventional health services. These variables have been retained in the CAM Model, although one might question the relevance of insurance, as many CAM services or products are not reimbursable. However, there have been recent changes in the insurance coverage of some CAM therapies such as chiropractic and massage services. In addition, the lack of coverage for conventional health care services may act as a push factor and lead to the promotion of often more affordable CAM use. Thus, our model again identifies crucial links between conventional medicine and CAM use that await further empirical study. While it seems obvious that higher income is generally an enabler that would allow one to purchase more of any types of services, given one's preferences, it may also lead one to increase demand for services that are unaffordable at lower incomes. Although higher income was found to be a significant predictor of CAM by cancer patients in numerous studies (Boon, et al., 2000; Kao & Devine, 2000; Lee, et al., 2000; Fouladbakhsh, Stommel, Given & Given, 2005; Fouladbakhsh, 2006), other studies have not supported this finding (Shen, Andersen, Albert, Wenger, Glasby, et al., 2002). Thus, it remains to be seen how important this income effect is in relation to possible substitution effects between conventional health care services and CAM services, and how these effects play out among diverse populations of users. NEED FACTORS Need factors in the CAM Healthcare Model are defined under the construct of illness experience (Figure 2). Potential indicators of evaluated need that can be examined for association with CAM use include morbidity diagnosis, such as cancer and other chronic illnesses. For example, among cancer survivors, cancer site, cancer stage, symptoms and treatment can be examined as potential factors that influence CAM use (Fouladbakhsh, et al., 2005; Fouladbakhsh, 2006). Perceived need indicators include reported perception of health status as defined in the Behavioral Model. One may view perceived needs primarily as push factors that increase a person's inclination to use CAM, but that would also require the predisposing belief in the relative effectiveness of a particular CAM therapy to alleviate the health problem experienced. The need indicators used in the conventional Behavioral Model of health services use would also appear to be applicable to the examination of CAM use; they include empirical measures such as the Symptom Distress Scale (McCorkle & Young, 1978) and the Brief Pain Inventory which has been use for the measurement of pain on a global scale Published by The Berkeley Electronic Press,

14 Journal of Complementary and Integrative Medicine, Vol. 4 [2007], Iss. 1, Art. 11 (Cleeland & Ryan, 1994). In large-scale population surveys, reported symptoms can be used as the empirical indicators to measure perceived need. Specific medical record information would serve as an indicator for evaluated need, whereas reported health status such as that provided on the SF36 scale is a suggested empirical indicator to measure relationship between CAM use and perceived need (perception of health). These instruments, widely used in research studies across the world, have extensively documented reliability and validity. Empirical measures (scales) of perceived need for CAM should be developed and tested to determine the effect of this factor on use of both provider-directed and self-directed CAM. HEALTH SERVICE USE In the CAM Healthcare Model, the concept of 'health service use' is modified and expanded beyond the conventional model of provider-directed health services: It also includes self-directed CAM use, which, in turn, comprises both CAM practices as well as direct purchases of CAM products. These distinctions call one's attention to the fact that CAM approaches are often used independently, instead of under the supervision of a CAM practitioner/provider (Ersnt & Casileth, 1998; Fouladbakhsh, 2007; Thomas, Nicholl & Coleman, 2001). Still, there are parallels to conventional health care, such as the purchase of over-thecounter drugs or patient 'self-diagnoses' leading to the demand for specific services. OUTCOMES OF CARE As occurs with conventional health care services, achieving improvements in one's quality of life is also the major desired outcome of CAM healthcare therapies, and hence remains the same in the CAM Healthcare Model. Improved quality of life can be measured through the following potential empirical indicators: decreased symptom reports, increased sense of well-being, decreased functional limitations, increased satisfaction, diagnostic verification of condition improvement and increased perception of control over health. Specific Quality of Life scales can be used to measure outcome of CAM use. 12

15 Fouladbakhsh and Stommel: The CAM Healthcare Model Figure 2: The CAM Healthcare Model Predisposing Enabling Factors Factors Need for Care Factors Health Service Use Outcomes of Care Relevant Constructs & Empirical Indicators Demographics Gender Age Marital Status Social Structure Education Race/ethnicity* Cultural practices* Community lifestyle* CAM Knowledge Beliefs & Values Health & illness Healthcare treatment & satisfaction Risk Perception Illness risk, severity care options CAM risk, safety, efficacy, acceptability Personal factors Self-efficacy, risk taking, self-care ability, need for control Resources Income Employment Health insurance Provider connection Access to CAM services Conventional services CAM users Availability of CAM providers* CAM products* CAM literature & info* CAM self-help info* CAM referral network* Conventional services* Geographic location urban suburban rural country region Evaluated Need Health status Illness experience diagnosis symptoms treatment Perceived Need Perceived health status Perceived need for CAM/conventional health care CAM Use CAM providers (provider-directed) CAM products CAM practices (self-directed & provider-guided) Purpose of use Health promotion Illness treatment Symptom mgt. Manner of use Complementary: used with conventional Alternative: substitute for conventional Improved QOL symptoms limitations symptom burden well-being satisfaction perceived control Predominantly system level variables* All potential direct & indirect model relationships not shown Fouladbakhsh, JM 2006 Published by The Berkeley Electronic Press,

16 Journal of Complementary and Integrative Medicine, Vol. 4 [2007], Iss. 1, Art. 11 CONCLUSIONS In sum, the revised CAM Model: 1) uses the major constructs of the Behavioral Model as factors influencing utilization of CAM and allows for examination of concurrent use with conventional health services, 2) adds potential empirical indicators specific to CAM, and 3) modifies the Behavioral model so self-directed CAM health practice and product use is included as well as provider-directed CAM use. The CAM Healthcare Model is an attempt to identify, in a consistent manner, those factors that are related to the use of CAM provider services, products, and practices, including both mediating/intervening and moderating variables in the model, resulting in both direct as well as indirect relationships among the key variables (Figure 2). Empirical testing of the model is needed to identify the complex relationships among the model variables, which is facilitated through the availability of many standardized measures of the major concepts in the model, providing consistent empirical measures across studies on CAM utilization. The need for this is further supported by the recent National Institutes of Health mandate (2006) to identify consistent measures of health constructs, thereby promoting comparability across studies. Studies documenting predictors of CAM use are emerging in the research literature, however a unified theoretical framework predicting the use of CAM health services, products and practices is still lacking. The CAM model identifies potential indicators that may be associated with use of CAM, and aims to provide a uniform conceptualization that will promote comparison across studies of CAM use alone as well as in conjunction with the use of conventional health care services. REFERENCES Aday, L. & Andersen, R. (1974). A framework for the study of access to medical care. Health Services Research, 9, Aday, L. & Awe, W. C. (1997). Health service utilization models. In Handbook of Health Behavior Research, Vol 1., D. S. Gochman, (Ed.). New York: Plenum Press Andersen, R. M. (1968). Behavioral Models of Families Use of Health Services. Research Series No.15. Center for Administration Studies, University of Chicago. 14

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