Copyright is owned by the Author of the thesis.  Permission is given for 
a copy to be downloaded by an individual for the purpose of research and 
private study only.  The thesis may not be reproduced elsewhere without 
the permission of the Author. 
 



 
 
 
 

Consumer Value and Value Co-creation  
in  

Complementary and Alternative Medicine (CAM) 
Health Services 

 
 
 
 
 

A thesis presented in partial fulfilment of the requirements 
for the degree of  

 
 
 

Doctor of Philosophy in Marketing 
 
 

at Massey University, Albany 
New Zealand. 

 
 

 
 
 

Sarah Louise Dodds 
 

2015 
  



ii 

 

  



iii 

 

Abstract 
This thesis contributes to an emergent area on consumer value co-creation in a rapidly 

growing and exciting ‘new’ service market, Complementary and Alternative Medicine 

(CAM) health services. The market for CAM health services is experiencing strong growth 

as consumers look for greater value, choice and control in managing their health. Despite 

the growth in this large health service market there is a paucity of research from a service 

marketing and consumer behaviour perspective. Yet, understanding what CAM consumers’ 

value and how they co-create value with CAM health services has important managerial 

implications. The purpose of this research is to explore what value CAM consumers’ gain 

and how they co-create value from their consumption experiences with CAM health 

services.  

The research adopts an interpretive approach employing an exploratory case study research 

strategy, using qualitative methods and an adapted version of the visual elicitation 

technique ZMET. The research process is semi-longitudinal and is conducted in three 

phases over a 12 month period. Sixteen CAM consumers with ‘lifestyle’ health complaints 

who use CAM health services participated in the study.  

The findings reveal eight consumer value components including: quality of care, treatment 

efficiency, physical environment, esteem value, social value, spiritual value, ethics and 

play. A consumer value model for CAM health services and potentially all health care 

services is proposed. Significantly this research found that CAM consumers co-create 

value on three levels according to their: approach to health care, preferred ‘consumer value 

co-creation relationship styles’ and engagement in ‘consumer value co-creation activities’. 

Consequently this thesis presents a typology of consumer value co-creation in CAM health 

services and develops a consumer value co-creation framework that can potentially be used 

for all health services. 

This research contributes to service marketing and consumer behaviour theory by 

extending the concepts of ‘consumer value’ and ‘value co-creation’ to incorporate findings 

from the CAM health service sector. The managerial implications of this research could 

help guide both CAM health care and mainstream medical practices to provide better 

health services and ultimately improved health outcomes for health care consumers. Future 

research could implement the unique three phase semi-longitudinal process and visual 

methods developed in this research, in various health care and service settings.  



iv 

 

 

  



v 

 

Acknowledgements 
Undertaking a research project of this type, although an individual pursuit, is not possible 

without the love, support, commitment, involvement, input and encouragement of many 

people. This page is dedicated to all those who have played a part in bringing this research 

to fruition. First and foremost completing this research would not have been possible 

without the unwavering love and support from my family. In particular, my husband Brian, 

who not only believed in me and my abilities, but gave me the space and freedom to pursue 

this endeavour. Special mentions need to be made to my mum, Jane Yoong, and stepfather, 

Professor Pak Yoong (my unofficial third supervisor) who provided great wisdom and 

supported me emotionally and mentally throughout the Ph.D. process; plus my loyal Dad, 

Mike McArthur, who faithfully called every week. Friends too were a huge support. I am 

so very grateful for having you all in my life. 

I am honoured to have been supervised by Dr Sandy Bulmer and Dr Andrew Murphy. 

Their guidance, encouragement, patience, humour, wisdom and commitment were pivotal 

to this Ph.D. journey. What was particularly important for me, as a mature student, was 

being treated as an equal. Not only do I now have two fine academic colleagues for the 

future but good friendships too. I would also like to acknowledge the staff, both academic 

and administrative, at the School of Communication, Journalism and Marketing at Massey 

University. Everyone was so incredibly supportive and encouraging. Specifically, I would 

like to thank Liz Eckhoff for her administrative support. Liz goes out of her way to ensure 

Ph.D. students have what they need to complete their studies effectively. A big thank you 

goes to the Head of School, Professor Shiv Ganesh, and Associate Heads of School (Dr 

Andrew Murphy and more recently Dr Sandy Bulmer) for providing contract tutoring work 

which enabled me to self-fund this research. I am also grateful for the constant 

encouragement and support by my fellow Ph.D. students at Massey University. Thanks to 

Christine who helped with the large task of transcribing some of the interviews. 

Lastly, I would like to thank each of the 16 participants who were involved in this research. 

Without your generous commitment, input and willingness to share your story about your 

CAM health service experiences this research would not be possible. I am deeply grateful 

and privileged to have had the opportunity to get to know you. This research is dedicated 

to you and may you continue to have healthy and fulfilling lives.  

  



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vii 

 

Table of Contents 
Abstract……………………………………………………………………  iii 

Acknowledgements……………………………………..…………………. v 

Chapter 1 Introduction…………………………………………………….. 1 

1.1 Overview…………………………………………………... 2 

1.2 Background………………………………………………... 2 

1.3 Overall Framework of the Research………………………. 5 

1.4 Research Objectives and Questions……………………… . 7 

1.5 Overview of the Methodology…………………………….. 7 

1.6 Importance and Contributions…………………………….. 8 

1.7 Structure of Thesis………………………………………… 9 

Chapter 2 Literature Review………………………………………………  11 

2.1 Overview of Literature Review…………………………...  11 

2.2 Introduction to Literature on CAM………………………..  11 

2.3 Why Study CAM Health Services?.....................................  12 

2.4 What Exactly is CAM?........................................................  12 

2.4.1 CAM terminology…………………………………  13 

2.5 How is CAM Defined and Classified?................................  14 

2.5.1 What CAM is not - Oppositional definition……….  14 

2.5.2 What CAM is - Positive inclusive definitions……..  14 

2.5.3 Cochrane Collaboration’s operational definition….  17 

2.5.4 Consumers’ perspective of CAM classifications….  18 

2.5.5 Classification systems chosen for this research…...  19 

2.6 Underlying Reasons for CAM Use………………………..  20 

2.6.1 Philosophical orientation…………………………..  22 

2.6.2 Disenchantment and modern health worries………  24 

2.6.3 Empowerment and self-responsibility……………..  27 

2.6.4 Holistic approach………………………………….. 29 

2.6.5 Natural underpinnings……………………………..  30 

2.6.6 Spiritual, intuition and paranormal beliefs………...  31 

2.6.7 Summary of reasons for CAM use………………...  33 

2.7 The CAM Consumer………………………………………  34 

2.8 Summary of CAM Literature……………………………...  36 

2.9 Introduction to Literature on Value……………………….  37 



viii 

 

2.10 The Concept of Value……………………………………..  37 

2.11 Axiology - Philosophical Theory of Value………………..  38 

2.12 Economic Concept of Value………………………………  40 

2.13 Concept of Value in Marketing…………………………… 43 

2.13.1 Value for the customer (VC)……………………..  47 

2.13.2 S-D Logic perspective on value………………….  48 

2.13.3 Nordic School view on value…………………….  51 

2.13.4 Consumer value………………………………….  54 

2.13.5 Typology of consumer value…………………….  56 

2.13.6 Proposed model of consumer value……………..  60 

2.13.7 Summary…………………………………………  64 

2.14 Consumer Value and Value Co-creation in Health Services 65 

2.14.1 Consumer value in health care services………….  65 

2.14.2 Value co-creation in health care………………….  72 

2.15 Summary of Literature and Exposed Gaps………………..  75 

2.16 Research Objectives and Questions……………………….  76 

Chapter 3 Methodology…………………………………………………...  77 

3.1 Introduction……………………………………………….  77 

3.2 Philosophical Paradigm…………………………………...  77 

3.2.1 Theoretical perspective of the study………………  79 

3.2.2 The qualitative research approach…………………  80 

3.2.3 Qualitative approach in consumer research……….  81 

3.2.4 Rationale for use of qualitative approach………….  81 

3.3 Case Study Research Method……………………………... 82 

3.3.1 What is case study research?....................................  82 

3.3.2 Case study research in consumer behaviour research 83 

3.3.3 Case design………………………………………..  84 

3.3.4 The unit of analysis………………………………..  84 

3.3.5 Rationale for use of case study research…………..  85 

3.4 Visual Methods……………………………………………  85 

3.4.1 Why visual methods?...............................................  86 

3.4.2 Visual methods in consumer research……………..  87 

3.4.3 Participant-produced photography………………...  88 

3.4.4 Visual techniques used in this study………………  91 

3.5 Data Collection Procedures………………………………..  93 



ix 

 

3.5.1 Selection of the cases……………………………...  93 

3.5.2 Recruitment of research participants………………  97 

3.5.3 Participant commitment…………………………...  99 

3.5.4 Three phase process interview strategy……………  99 

3.5.5 Researcher reflective writing……………………...  103 

3.6 Data Analysis Procedures…………………………………  104 

3.6.1 Thematic analysis………………………………….  105 

3.6.2 Overview of data analysis…………………………  106 

3.7 Approaches to Ensuring Quality and Rigour……………..  109 

3.7.1 Credibility…………………………………………  110 

3.7.2 Dependability……………………………………...  110 

3.8 Role of the Researcher…………………………………….  111 

3.8.1 Approaches to managing ethical issues……………  112 

3.8.2 Approaches to managing potential risk of harm…..  114 

3.9 Summary of Methodology………………………………...  114 

Chapter 4 In-case Analysis………………………………………………..  117 

4.1 Overview…………………………………………………..  117 

4.2 Case 1 - Lilian .…………………………………………..  119 

4.3 Case 2 - Jenny…………………………………………….  122 

4.4 Case 3 - Margaret…………………………………………  125 

4.5 Case 4 - Vivian……………………………………………  127 

4.6 Case 5 - Margo……………………………………………  130 

4.7 Case 6 - Olivia…………………………………………….  134 

4.8 Case 7 - Rachel……………………………………………  137 

4.9 Case 8 - Mandy…………………………………………...  139 

4.10 Case 9 - Jules……………………………………………..  141 

4.11 Case 10 - Anne……………………………………………  144 

4.12 Case 11 - Fiona…………………………………………...  146 

4.13 Case 12 - Jane…………………………………………….  149 

4.14 Case 13 - Peter……………………………………………  152 

4.15 Case 14 - Bill……………………………………………..  154 

4.16 Case 15 - David…………………………………………..  157 

4.17 Case 16 - Steven…………………………………………..  159 

4.18 Summary of In-case Analysis……………………………..  162 



x 

 

Chapter 5 Cross-Case Analysis……………………………………………  163 

5.1 Overview………………………………………………….  163 

5.2 Consumer Value Components…………………………….  163 

5.2.1 Quality of care…………………………………….  164 

5.2.2 Treatment efficiency………………………………  170 

5.2.3 Physical environment……………………………..  175 

5.2.4 Esteem value………………………………………  176 

5.2.5 Social value……………………………………….  180 

5.2.6 Spiritual value…………………………………….  182 

5.2.7 Natural…………………………………………….  186 

5.2.8 Play………………………………………………..  187 

5.3 Consumer Value Co-creation in CAM Health Care………  189 

5.3.1 Approach to health and health care……………….  190 

5.3.2 Consumer value relationship styles……………….  195 

5.3.3 Consumer value co-creation activities…………….  199 

5.4 Summary of Cross-Case Analysis………………………...  205 

Chapter 6 Discussion……………………………………………………...  207 

6.1 Overview………………………………………………….  207 

6.2 Consumer Value Co-creation Framework………………..  207 

6.3 Consumer Value Components (Horizontal dimension)…..  211 

6.3.1 Quality of care…………………………………….  211 

6.3.2 Treatment efficiency………………………………  215 

6.3.3 Physical environment (Aesthetics)………………..  218 

6.3.4 Esteem value………………………………………  219 

6.3.5 Social value………………………………………..  220 

6.3.6 Spiritual value……………………………………..  221 

6.3.7 Natural (Ethical value)…………………………….  222 

6.3.8 Play………………………………………………..  223 

6.3.9 Proposed consumer value model………………….  224 

6.3.10 Summary of research question 1…………………  226 

6.4 Consumer Value Co-creation in CAM Health Service……  227 

6.4.1 Consumer approaches to health and health care…..  228 

6.4.2 Consumer value co-creation relationship styles…...  229 

6.4.3 CAM consumer value co-creation activities………  232 

6.4.4 Typology of consumer value co-creation…………  236 



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6.4.5 Summary of research question 2………………….  239 

6.5 Methodological Considerations…………………………..  240 

6.6 Summary of Discussion…………………………………..  244 

Chapter 7 Conclusion……………………………………………………..  245 

7.1 Overview………………………………………………….  245 

7.2 Conclusions………………………………………………..  245 

7.3 Theoretical Contributions…………………………………  248 

7.4 Methodological Contributions…………………………….  253 

7.5 Managerial Implications…………………………………..  254 

7.5.1 CAM health service practice………………………  254 

7.5.2 Health care practice and policy……………………  256 

7.6 Limitations………………………………………………..  258 

7.6.1 Small sample size………………………………….  259 

7.6.2 Cultural diversity………………………………….  259 

7.6.3 Gaining access to participants……………………..  259 

7.6.4 Time commitment required of participants………..  260 

7.6.5 Researcher bias…………………………………….  260 

7.7 Future Research…………………………………………...  261 

7.8 Final Conclusions and Closing Reflections……………….  264 

References…………………………………………………………………  267 

Appendices………………………………………………………………...  295 

 

 

  

  



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List of Tables 
 
Table 1: Terms used to characterise mainstream medicine and CAM adapted from Dalen  ........... 13 

Table 2: Summary of literature review on the themes that emerged on key reasons why people use 

CAM ................................................................................................................................................ 21 

Table 3: An evolution of illustrative contributions to defining the concept of consumer value  ..... 44 

Table 4: 'Typology of Consumer Value'  ......................................................................................... 57 

Table 5: Summary of the 16 participants including the research phases involved in ...................... 97 

Table 6: Profile of the 16 participants including why they were attracted to CAM ...................... 118 

Table 7: Lilian's perceived consumer value components with illustrative quotes ......................... 120 

Table 8: Jenny's perceived consumer value components with illustrative quotes ......................... 124 

Table 9: Margaret's perceived consumer value components with illustrative quotes .................... 126 

Table 10: Vivian's perceived consumer value components with illustrative quotes ...................... 129 

Table 11: Margo's perceived consumer value components with illustrative quotes ...................... 132 

Table 12: Olivia's perceived consumer value components with illustrative quotes ....................... 135 

Table 13: Rachel's perceived consumer value components with illustrative quotes ...................... 138 

Table 14: Mandy's perceived consumer value components with illustrative quotes ..................... 140 

Table 15: Jules's perceived consumer value components with illustrative quotes ......................... 142 

Table 16: Anne's perceived consumer value components with illustrative quotes ........................ 145 

Table 17: Fiona's perceived consumer value components with illustrative quotes ........................ 148 

Table 18: Jane's perceived consumer value components with illustrative quotes .......................... 151 

Table 19: Peter's perceived consumer value components with illustrative quotes ......................... 153 

Table 20: Bill's perceived consumer value components with illustrative quotes ........................... 155 

Table 21: David's perceived consumer value components with illustrative quotes ....................... 158 

Table 22: Steven's perceived consumer value components with illustrative quotes ...................... 161 

Table 23: Quality of care component 'client centred cooperative relationship' with illustrative 

quotes ............................................................................................................................................. 165 

Table 24: Quality of care component 'empowering approach' with illustrative quotes ................. 166 

Table 25: Quality of care component 'practitioner knowledge, expertise and tools' with illustrative 

quotes ............................................................................................................................................. 167 

Table 26: Quality of care component ‘educational and co-learning' with illustrative quotes ........ 168 

Table 27: Quality of care component 'supportive, empathetic and caring manner' with illustrative 

quotes ............................................................................................................................................. 169 

Table 28: Quality of care component 'authenticity, integrity and trust' with illustrative quotes .... 170 

Table 29: Treatment efficiency component ‘treatment results and timeframes’ with illustrative 

quotes ............................................................................................................................................. 171 



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Table 30: Treatment efficiency component ‘treating the cause’ with illustrative quotes ............... 172 

Table 31: Treatment efficiency component ‘treatment ease of uses and customisation’ with 

illustrative quotes ............................................................................................................................ 173 

Table 32: Treatment efficiency component ‘access and waiting times’ with illustrative quotes ... 174 

Table 33: Treatment efficiency component ‘longer consultation and quick follow up treatments’ 

with illustrative quotes ................................................................................................................... 174 

Table 34: Treatment efficiency component ‘value for money’ with illustrative quotes................. 175 

Table 35: Physical environment consumer value components with illustrative quotes ................. 176 

Table 36: Esteem value component ‘self-responsibility’ with illustrative quotes .......................... 177 

Table 37: Esteem value component ‘sense of self and self-worth’ with illustrative quotes ........... 178 

Table 38: Esteem value component ‘self-discovery’ with illustrative quotes ................................ 179 

Table 39: Esteem value component ‘self-awareness’ with illustrative quotes ............................... 180 

Table 40: Social consumer value components with illustrative quotes .......................................... 181 

Table 41: Spiritual value component ‘considered holistically’ with illustrative quotes ................. 183 

Table 42: Spiritual value component ‘gaining meaning and purpose in life’ with illustrative quotes

 ........................................................................................................................................................ 183 

Table 43: Spiritual value component ‘connection with nature’ with illustrative quotes ................ 184 

Table 44: Spiritual value component ‘connection with energy or spiritual force’ with illustrative 

quotes .............................................................................................................................................. 185 

Table 45: Spiritual value component ‘feelings of peace and balance’ with illustrative quotes ...... 186 

Table 46: Natural consumer value components and illustrative quotes ......................................... 187 

Table 47: Play consumer value components with illustrative quotes ............................................. 188 

Table 48: Participant's approach to health and health care ............................................................. 191 

Table 49: Preferred consumer value co-creation relationship styles .............................................. 196 

Table 50: Within clinic consumer value co-creation activities with illustrative quotes ................. 199 

Table 51: Outside clinic consumer value co-creation activities and illustrative quotes ................. 202 

Table 52: CAM consumers' approach to health and CAM health care .......................................... 228 

Table 53: Summary of consumer value co-creation relationship styles ......................................... 230 

Table 54: Typology of consumer value co-creation in CAM health care ...................................... 237 

 

  



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List of Figures 
 
Figure 1: Overall Framework of the Research ................................................................................... 6 

Figure 2: The holistic health care-conventional medicine continuum model .................................. 19 

Figure 3: A value-in-use creation model  ......................................................................................... 53 

Figure 4: Research streams on perceived value  .............................................................................. 55 

Figure 5: Proposed model for the structure of consumer value  ...................................................... 60 

Figure 6: A contextualised model of the natural health value system ............................................. 70 

Figure 7: A tentative framework model for analyzing health consumption meanings  ................... 71 

Figure 8: Research process and approximate timeframes .............................................................. 101 

Figure 9: Lilian's summary collage ................................................................................................ 121 

Figure 10: Jenny’s summary collage .............................................................................................. 124 

Figure 11: Margaret's summary collage ......................................................................................... 127 

Figure 12: Vivian's summary collage ............................................................................................. 130 

Figure 13: Margo's summary collage ............................................................................................. 133 

Figure 14: Olivia's summary collage.............................................................................................. 136 

Figure 15: Rachel's summary collage ............................................................................................ 138 

Figure 16: Jules's summary collage ............................................................................................... 143 

Figure 17: Anne's summary collage ............................................................................................... 145 

Figure 18: Fiona's summary collage .............................................................................................. 149 

Figure 19: Peter's summary collage ............................................................................................... 154 

Figure 20: Bill's summary collage ................................................................................................. 156 

Figure 21: David's summary collage .............................................................................................. 159 

Figure 22: Steven's summary collage ............................................................................................. 161 

Figure 23: Consumer value co-creation framework in CAM health services ................................ 208 

Figure 24: Proposed model of consumer value in CAM health services ....................................... 225 

Figure 25: Examples of participant's images that expressed 'connection with energy, spiritual and/or 

universal force' ............................................................................................................................... 242 

Figure 26: Examples of participant's images that expressed 'inner-balance' .................................. 242 

Figure 27: Examples of participant's images that expressed 'sense of self' and 'self-discovery' .... 243 

 

 
 
 
 
 
 
 
 



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1 

 

1 Chapter 1 Introduction 

As Galen says, confidence and hope do more than physick – ‘he cures 
most in whom most are confident’…Faith in the Gods or in the Saints 
cures one, faith in little pills another, suggestion a third, faith in a plain 
common doctor a fourth…The cures in the temples of Aesculapius, the 
miracles of the Saints, the remarkable cures of those noble men, the 
Jesuit missionaries, in this country, the modern miracles at Lourdes and 
at St. Anne de Beaupre in Quebec, and the wonder-workings of our latter 
day saints are often genuine, and must be considered in discussing the 
foundations of therapeutics. We physicians use the same power every 
day. If a poor lass, paralysed apparently, helpless, bed-ridden for years, 
comes to me having worn out in mind, body and estate a devoted family, 
if she in a few weeks or less by faith in me, and faith alone, takes up her 
bed and walks, the Saints of old could not have done more (William 
Olser cited in Bliss, 1999, p. 276) 

 

This quote by William Olser in Bliss’s (1999) book William Olser: A Life in Medicine, 

highlights the importance of the practitioner in the health and wellbeing of the patient. 

William Olsen, who received his medical degree in 1872, was considered by some 

historians to be the “greatest doctor in the history of the world” and by others the “great 

American doctor”. Olsen was revered and renowned for his ‘good-nature’, ‘cheerfulness’, 

‘confidence’ and “ability to give the desire to fight to those who had lost courage and 

hope” (Bliss, 1999, p. 277). It was not just Olsen’s exceptional knowledge and air of 

authority as a doctor that influenced his patients but his warm and friendly manner coupled 

with the ability to instil ‘faith’ in his patients. Olsen understood that his role as a 

practitioner and service provider was more than just treating the symptoms but considering 

the person as a holistic (mind, body and soul) being. 

The above mirrors my own thinking, through my experience as a CAM practitioner, CAM 

consumer and patient of mainstream medicine, of the important role a practitioner plays in 

the health, wellbeing and ‘healing’ process of the person. This Ph.D. study has come to 

fruition because of my own personal conviction that the value gained and value co-created 

during the service interaction and beyond is critical to a person’s health. I believe that all 



 

 

2 

 

health care practitioners and health care providers should act as empowering co-creating 

service agents.  

This Ph.D. study not only fills an academic gap, as will be outlined in the rest of this 

chapter, but also has personal meaning and significance. When I practiced as a Naturopath 

I frequently reflected on my own practice with questions such as: What do my clients 

really need from me? What are my clients’ experiences of my practice and treatment? How 

can I help my clients achieve their health goals? Why do some clients respond well and 

others do not? As a CAM consumer, my own on-going search for health and wellbeing 

using various forms of CAM has had both success and failures. Finally, as a consumer 

researcher, I have assessed both my own behaviour as a CAM consumer and my clients’ 

behaviour, and speculated that CAM health care requires time, commitment and a strong 

belief in the value of the CAM service. In my own mind, two key questions became 

apparent and thus gave direction for this research. Firstly, what do CAM consumers’ value 

from their ‘experiences’ of CAM health services? Secondly, how do CAM consumers and 

practitioners work together successfully? And so the story begins…1 

1.1 Overview 

This chapter provides an introduction to the thesis by outlining the academic background 

which drives this study and considers why the topic is important. After which the main 

purpose of the study is highlighted, the theoretical framework relevant to the research is 

introduced, and the research objective and research questions are outlined. Subsequently an 

overview of the methodology and a summary of the contributions of this research are 

given. Lastly the structure of the thesis is presented.  

1.2 Background 

Health services are deemed a significant and worthy field to study from a marketing 

perspective with the potential to make significant contributions to the health care industry 

(Berry & Bendapudi, 2007). Furthermore, research focusing on consumers’ experiences of 

health services could provide important insights into health care practices that, if 
                                                 
1 Please note from this point forward the use of the third person ‘this researcher’ or ‘the author’ replaces the 

use of the first person. 



 

 

3 

 

implemented, could ultimately contribute to enhancing peoples’ quality of life (Sweeney, 

Danaher, & McColl-Kennedy, 2015). Notwithstanding the important managerial and 

societal implications of research on the experiences of health care services, an experiential 

approach to understanding the “service experience” of a consumer has been highlighted as 

a critical area to study in service marketing and management academia (Jaakkola, 

Helkkula, & Aarikka-Stenroos, 2015). Importantly, understanding value creation and 

enhancing the service experience has been identified as a research priority in service 

research (Ostrom, Parasuraman, Bowen, Patricio & Vos, 2015). This study examines the 

concepts of consumer value and value co-creation within a large and growing under-

researched service market, CAM health services, contributing further to our understanding 

of these two concepts within a health service context and from a consumer’s perspective2. 

Researchers show that consumer value and value co-creation in health (Gill, White, & 

Cameron, 2011; McColl-Kennedy, Vargo, Dagger, Sweeney, & van Kasteren, 2012; 

Prahalad & Ramaswamy, 2004a; Sweeney et al., 2015; Zainuddin, Previte, & Russell-

Bennett, 2013), the search for well-being (Sointu, 2006a; van Wersch, Forshaw, & 

Cartwright, 2009), and being responsible for your own health (Hughes, 2004) are the new 

frontiers of health care. The growth in CAM health services epitomizes this with 

consumers looking for greater choice and control (Bishop, Barlow, Coghlan, Lee, & 

Lewith, 2011). CAM is a large and growing market both in New Zealand and worldwide. 

The use of CAM continues to increase particularly in developed nations such as the United 

States (Barnes, Bloom, & Nahin, 2008), United Kingdom (Thomas, Nicholl, & Coleman, 

2001), Australia (Xue, Zhang, Lin, Da Costa, & Story, 2007) and New Zealand. In New 

Zealand one in five people had visited a complementary or alternative health care worker 

during a 12 month period in 2006/07 (Ministry of Health, 2008)3. Figures reveal that 

                                                 
2 Please note the cut-off date for literature was June 2015. 

3 Ministry of Health (2008) statistics do not include osteopaths and chiropractors as complementary and 

alternative health care workers whereas most overseas statistics include these as CAM therapies. In New 

Zealand these two therapies are classified under ‘other health care workers’ alongside the likes of 

physiotherapists. This would account for the seemingly low statistic in comparison to other developed 

nations like the U.S. Approximately 10% of the adult population in New Zealand have seen either a 

chiropractor or an osteopath. 



 

 

4 

 

approximately 40% of Australian adults (Xue et al., 2007), 40% of UK adults (Posadzki, 

Watson, Alotaibi, & Ernst, 2013) and 35% of U.S. adults (Clarke, Black, Stussman, 

Barnes, & Nahin, 2015) had used some form of CAM health service within a 12 month 

period. 

Consumption within this large and fast growing consumer market, developing outside the 

well-established public health care sector, raises a range of intriguing questions for service 

marketing and consumer researchers particularly with respect to the value CAM consumers 

gain from using CAM health services. Gaps in knowledge within CAM literature exist in 

the area of consumer behaviour (Vos & Brennan, 2010), particularly in terms of 

understanding and evaluating CAM consumers’ experiences. A gap in the literature is also 

apparent with regards to the perceived consumer value CAM consumers determine and co-

create from their CAM health service experiences. More research is required on ‘value’ 

from a consumer’s perspective within CAM health services (Rajamma & Pelton, 2010). 

Future research focusing on the CAM consumer is essential to understanding the CAM 

phenomenon and its place in modern health care (Adams, 2014; Vos & Brennan, 2010). 

Since Berry and Bendapudi’s (2007) call for research from a marketing perspective within 

the complex but important context of health care services, several studies have emerged. 

One such study by McColl-Kennedy et al. (2012) identifies five health care customer value 

practice styles, highlighting the significant contribution that marketing academics can 

make to the field of health care. Studying health care “through the lens of marketing” could 

provide some valuable insights for health care providers and policy makers (Spence & 

Ribeaux, 2004). The health care sector also offers an interesting and worthy context in 

which to study important existing and emerging concepts in marketing and consumer 

research, such as consumer value and value co-creation.  

There has been little research on consumer value within health care per se (Chahal & 

Kumari, 2011). Yet, “understanding the nature of customer [consumer] value in health care 

is critical given the diversity of consumer needs, an increase in the number of providers, 

and resource pressures faced by private and public providers” (Dobele & Lindgreen, 2011, 

p. 269). Most studies on value in health care have focused on the methods for practitioners 

to assess what is understood as the patient’s value (Liu, Amendah, Chang, & Pei, 2006), 

the relationship between quality, value and satisfaction (Choi, Cho, Lee, Lee, & Kim, 



 

 

5 

 

2004; Moliner, 2009), and the role of ‘health value’, defined as an “individual’s assessment 

of benefits relative to costs in engaging in preventive health care behaviour” (Jayanti & 

Burns, 1998, p. 8), and in health behaviour (Lau, Hartman, & Ware, 1986; Rajamma & 

Pelton, 2010). Research on consumer value and value co-creation in health care is 

beginning to emerge (See Gill et al., 2011; McColl-Kennedy et al., 2012; Nordgren, 2009; 

Sweeney et al., 2015; Zainuddin, Russell-Bennett, & Previte, 2011; Zainuddin et al., 2013) 

but is still in early stages. 

A review of the extant literature of CAM and CAM health services in Chapter 2 uncovers 

why CAM consumers are drawn to CAM health services. In essence CAM consumers are 

‘pulled’ towards CAM because of their underlying values, beliefs and philosophical 

orientation towards health and life. CAM offers consumers a form of health care that is 

empowering, encourages self-responsibility and has a holistic approach. Studies either 

conclude or suggest that the reason people use CAM is because of positive therapeutic 

relationships that are empowering, empathetic, client-centred, encourage self-

responsibility, participatory, holistic and supportive (Adler, Wrubel, Hughes, & Beinfield, 

2009; Bann, Sirois, & Walsh, 2010; D'Crus & Wilkinson, 2005; Gale, 2008; Long, 2009). 

However, what is not evident in the literature is once consumers start using CAM health 

services, what do they value from the experience and how do they co-create value to 

achieve greater health outcomes? 

1.3 Overall Framework of the Research 

This research uses consumer value and value co-creation theory and concepts as its 

theoretical framework. The researcher takes the perspective that value (or consumer value) 

is experiential and contextual, and ultimately determined and co-created by the ‘user’ 

during the consumption experience epitomising the value-in-use idea (Grönroos, 2008; 

Vargo & Lusch, 2006, 2008). Consumer value is “at the heart of all marketing activity and 

therefore clearly deserves the attention of every consumer researcher” (Holbrook, 1999, p. 

1). Consumer value is multi-dimensional, consisting of many interrelated components 

ranging from utilitarian value (instrumental, task-related, rational, functional, cognitive, 

and a means to an end consumption), and hedonic value (reflecting the entertainment and 

emotional worth of consuming, which is non-instrumental, experiential, and affective), to 



 

 

6 

 

aspects such as social and spiritual value, that form a holistic representation of a complex 

phenomenon (Holbrook, 1994, 1999; Sánchez-Fernández & Iniesta-Bonillo, 2007; Sheth, 

Newman, & Gross, 1991).  

Figure 1 shows the overall framework of the research including the theoretical framework, 

context and lens. Consumer value is considered foundational in marketing and consumer 

behaviour and yet little attention has been given to defining and researching it (Holbrook, 

2006a). Likewise the emerging concept of value co-creation, whereby 

consumers/customers are considered to always be co-creators of value (Vargo & Lusch, 

2008), is potentially a fundamental marketing concept that requires more empirical 

research to substantiate it, particularly from a consumers’ perspective (Gummesson, Lusch, 

and Vargo, 2010).  

Figure 1: Overall Framework of the Research 

 

 

 

 

 

 

 

 

CAM health services provide a valuable context in which to study consumer value and 

value co-creation. CAM health care by nature is considered holistic and multi-dimensional 

(Fulder, 2005). Therefore CAM health services offers a service context whereby many 

consumer value components could potentially be experienced, from utilitarian value to 

spiritual value, enabling theory building of this important yet elusive concept. CAM health 

services are also a relevant context to study value co-creation, in particular, exploring how 



 

 

7 

 

consumers co-create value. Again the nature of CAM health services which advocates self-

responsibility and being involved in the health care process provided a worthy context to 

explore the co-creation of value concept more closely. Furthermore, CAM’s popularity and 

growth alone deem it a worthy service research context in which to study consumer 

behaviour. Little is known about CAM health services from a service marketing and 

consumer perspective and is therefore an area that warrants further study using a marketing 

and consumer behaviour lens (Vos & Brennan, 2010). 

1.4 Research Objectives and Questions 

This research has two objectives. The first and primary objective of this research is to 

study and potentially build on the concepts of consumer value and value co-creation within 

a health care service context, specifically CAM health services. The second objective is to 

explore CAM consumers’ ‘lived experience’ of CAM health services in order to 

understand the CAM phenomenon. Specifically, the study aims to find out what consumer 

value components individual CAM consumers determine and co-create from their 

consumption experiences of CAM health services. 

The specific research questions for this study include: 

1. What do CAM consumers value from their CAM health service consumption 

experiences? 

2. How do CAM consumers co-create value through their consumption experiences of 

CAM health services? 

1.5 Overview of the Methodology 

The research adopts an interpretive approach and employs a semi-longitudinal exploratory 

‘multiple’ case study research strategy, using in-depth interviews and a simplified version 

of the Zaltman Elicitation Technique (ZMET). To understand the value CAM consumers 

experience and how they co-create value from their health care services it is deemed 

appropriate to use a qualitative approach that explores CAM consumers’ lived experience. 

Consumer researchers, such as Schembri and Sandberg (2002, 2011), Thompson (1996), 

Thompson, Locander and Pollio (1989, 1990), Thompson and Troester (2002), and 



 

 

8 

 

Arnould and Thompson (2005) advocate the use of the interpretive approach in consumer 

research that focuses on the lived experiences of consumers.  

The data collection section of this research involves three phases over 12 months. The first 

phase includes a face-to-face interview with each of the participants which explores the 

participants’ experiences of CAM and where emergent themes on consumer value surface. 

The second phase involves the participants collecting or taking photographs of images that 

represent their experiences of CAM. These pictures and images are then discussed in a 

second interview using five of the ZMET steps including storytelling, missed images, 

sorting task, most representative image and summary image which enabled greater depth 

than interviewing alone (Coulter & Zaltman, 1994; Zaltman & Coulter, 1995). The third 

phase involves an interview that fundamentally aims to explore the process of the 

participant’s CAM health service experience as well as gather feedback on initial analysis 

from the first two phases. 

Sixteen CAM users, 4 men and 12 women, aged between 24 and 77 years old with 

‘lifestyle’ health complaints, and are seeing a CAM practitioner on a regular basis 

participate in the study. The interviews are digitally audio recorded and transcribed. To 

ensure trustworthiness of the data all transcripts are member checked. The formal process 

of data analysis is highly iterative, following the general approach advocated by Miles and 

Huberman (1994). The transcripts are converted into table format and imported into 

Microsoft Excel. Excel is a useful tool for organising, analysing and displaying qualitative 

data (Meyer & Avery, 2009). Data analysis involves thematic analysis and a code-recode 

procedure to ensure dependability of the data.  

1.6 Importance and Contributions 

This research makes important contributions to health care practices, marketing and 

consumer theory, and qualitative methodology, in particular the use of visual techniques to 

explore consumers’ experiences of services. Health care is arguably the most personal and 

important service a consumer can buy and experience, and consumer researchers have the 

potential to make significant contributions to this critical and complex field (Berry & 

Bendapudi, 2007). A positive service experience with health care providers has the 

potential to contribute to an individual’s health outcomes, wellbeing and overall quality of 



 

 

9 

 

life (Sweeney et al., 2015). This research has the potential to contribute to both CAM and 

mainstream health care services by providing insights into what CAM consumers’ value 

from their CAM consumption experiences. This understanding could contribute to 

improved services of CAM and mainstream medical practices, enabling better 

client/patient support and potentially contributing to enhanced health outcomes.  

Theoretically, this research contributes to consumer research, services marketing and 

marketing theory by building on the concepts of consumer value and value co-creation to 

incorporate findings from the CAM health service sector. Specifically, this research 

addresses and provides an understanding of what consumers’ value and how they co-create 

value through the consumption of CAM health service experiences, advancing knowledge 

in service experience consumer value and value co-creation. Significantly, this study 

presents a modified model of consumer value4 useful for all health care services, and a new 

framework for understanding the process of consumer value co-creation that can 

potentially be applied to all service contexts.  

Methodologically, this research contributes to qualitative research literature by developing 

a research process that implements a semi-longitudinal three phase process and uses a 

visual elicitation technique. This methodology was valuable in terms of uncovering deeper 

meanings of consumer value and value co-creation enhancing our understanding of these 

concepts. Additionally, the use of visual techniques to explore consumers’ service 

experiences of health care services has not been widely used. Yet, visual methods could be 

worthwhile for gaining deeper insight into health service experiences and uncovering 

unconscious thoughts and feelings not usually found through interview and survey 

techniques. 

1.7 Structure of Thesis 

The structure of this thesis generally follows a standard monograph format starting with an 

introduction chapter, then literature, methodology, findings, discussion and conclusions. 

There are seven chapters in this thesis. Chapter 1, the introduction, has provided an 

overview of the research. Chapter 2 presents relevant literature on CAM and CAM health 

                                                 
4 The author has published a paper in the Australasian Marketing Journal on consumer value in CAM health 

care services based on the first phase of this research. See Dodds, Bulmer and Murphy (2014). 



 

 

10 

 

services and key literature on consumer value and value co-creation, and ends with the 

research questions. Due to the complexity of the CAM health service context it was 

deemed appropriate to present this before literature on value in order to provide the reader 

with an overview of the CAM health service sector and CAM terminology pertinent to this 

research. Following this the methodology is outlined in Chapter 3. Chapter 4 and Chapter 5 

include the findings. In the spirit of case study analysis Chapter 4 presents each individual 

case and highights findings from in-case analyses, and Chapter 5 presents the overall 

findings from within-case analyses. Chapter 6 discusses the findings in light of the 

literature, develops and presents new insights and highlights the study’s contributions. 

Lastly, Chapter 7 presents the overall conclusions, including managerial implications, 

limitations and future research. 

 

  



 

 

11 

 

2 Chapter 2 Literature Review 

2.1 Overview of Literature Review 

There are two main streams of literature that inform this research. The first pertains to the 

context of this study, CAM health services, and the second to value literature, specifically 

consumer value and value co-creation. It was considered important and appropriate to first 

provide an overview of the literature on CAM relevant to this thesis on consumer value 

and value co-creation in CAM health services. Understanding the context of this research 

is imperative. CAM is a complex phenomenon that is ill-defined and lacks theoretical 

grounding. CAM health care is a growing service market that warrants research from a 

services marketing and consumer behaviour perspective but firstly requires clarification. 

Secondly, literature on consumer value and value co-creation is discussed. This literature 

stream begins with an overview of the concept of value from an axiological and economic 

perspective. It then explores the literature on value in marketing, ending with a typology of 

consumer value. Thirdly, this section reviews the literature on consumer value and value 

co-creation within health care services. Lastly, gaps in the literature with respect to 

consumer value, value co-creation and CAM are exposed and the research questions posed. 

2.2 Introduction to Literature on CAM 

This section begins by looking at why CAM health services are important to study. It then 

provides an overview of CAM terminology and discusses the various definitions of CAM. 

Justification of the definition that was chosen to guide this research is given. A detailed 

overview of the extant literature on why people use CAM health services is provided. 

Lastly, literature determining who the CAM consumer is and the CAM market is 

discussed. It is important to note that this research focused on CAM health services and the 

interactions and value created between CAM providers and CAM consumers. The 



 

 

12 

 

researcher acknowledges the large CAM product and retail market; however, it was not in 

the scope of this study to address this sector of CAM.  

2.3 Why Study CAM Health Services? 

CAM is a large and fast growing consumer health care market (Adams, 2014; Barnes et al., 

2008; Xue et al., 2007). Adams (2014, p. 1) argues that research addressing “critical 

questions such as why, when, and how alternative therapies are currently consumed and 

practiced” is essential to understanding the place CAM has in “contemporary health care”. 

The majority of CAM research to date has focused on either the efficacy of treatment or 

the attitudes and integration of CAM from a mainstream medical point of view (Fries, 

2008; Lee, Khang, Lee, & Kang, 2002; Poynton, Dowell, Dew, & Egan, 2006; Sewitch, 

Cepoiu, Rigillo, & Sproule, 2008). A number of studies have attempted to understand the 

reason behind CAM use (Astin, 1998; Astin, Marie, Pelletier, Hansen, & Haskell, 1998; 

Bishop, Yardley, & Lewith, 2008; Furnham & Lovett, 2001; Lindeman, 2011; Vincent & 

Furnham, 1996), some the attitudes and beliefs of users (Furnham, 2007; Furnham & 

Lovett, 2001; Jeswani & Furnham, 2010), others the decision making processes of CAM 

consumers (Caspi, Koithan, & Criddle, 2004; Hill-Sakurai, Muller, & Thom, 2008). 

According to Vos and Brennan (2010) gaps in knowledge within CAM literature exist in 

the area of consumer behaviour (Vos & Brennan, 2010), particularly in terms of 

understanding and evaluating CAM consumers’ experiences.  

2.4 What Exactly is CAM?  

CAM ranges from established and accepted ‘complementary’ therapies such as 

chiropractors, acupuncture, osteopathy and massage therapy, to more ‘alternative’ 

therapies such as naturopathy, homeopathy, herbalism, aromatherapy, kinesiology, reiki, 

and energy healing (Robinson, Chesters, & Cooper, 2009). Each one of these CAM 

therapies has their own set of therapeutic and healing belief systems and philosophies, 

making a single definition of CAM problematic (Collyer, 2004; Kaptchuk & Eisenberg, 

2005; van Wersch et al., 2009; Willis & White, 2004). However, defining CAM is 

essential to determine if growing research in the area is to be developed (Wieland, 

Manheimer, & Berman, 2011). Various attempts to define CAM have been made, 



 

 

13 

 

including definitions describing what CAM is not (Eisenberg, Kessler, Foster, Norlock, 

Calkins, & Delbanco, 1993), positive inclusive definitions of what CAM is (Ernst, Resch, 

Mills, Hill, Mitchell, Willougby, & White, 1995), and more extensive operational 

definitions (Wieland et al., 2011). These are discussed below in more detail. Before 

discussing definitions of CAM it is important to establish the current terminology that is 

used. 

2.4.1 CAM terminology  

Complementary and alternative medicine (CAM) is the most commonly used term to 

describe therapies, medicine and systems of healing that exist largely outside of institutions 

where conventional health care is taught and provided (Dalen, 1998; Zollman & Vickers, 

1999). ‘Complementary’ refers to therapies that are used “together with conventional 

medicine”, whereas ‘alternative’ refers to therapies that are used “instead of conventional 

medicine” (Barnes et al., 2008, p. 1). Historically CAM was referred to as “alternative 

medicine” because these therapies were mostly used as an alternative to conventional 

health care (Zollman & Vickers, 1999). Latterly the use of the term ‘complementary’ was 

added when conventional and alternative medicine started being used alongside, to 

complement, each other (Zollman & Vickers, 1999). The terms used to differentiate CAM 

from mainstream medicine are listed below (Table 1). 

Table 1: Terms used to characterise mainstream medicine and CAM adapted from 

Dalen (1998, p.2179) 

Mainstream Medicine CAM 

Conventional 
Orthodox 
Regular 
Scientific 
Evidence based 
Allopathic 
Western 
Modern 
Reductionist  
Medical 

Unconventional 
Unorthodox 
Irregular 
Unscientific/pseudoscience 
Not evidence based 
Non allopathic 
Non Western/Eastern 
Traditional 
Holistic 
Natural/Alternative 

 



 

 

14 

 

2.5 How is CAM Defined and Classified? 

A common understanding of what CAM encompasses is critical if growing research in the 

area is to be compared, collaborated on and promoted (Wieland et al., 2011). Various 

scholars have attempted to define CAM with most concluding that a single definition of 

CAM is problematic because it includes a diverse range of therapeutic practices, systems 

of healing and beliefs (Collyer, 2004; Kaptchuk & Eisenberg, 2005; van Wersch et al., 

2009; Willis & White, 2004). This section will discuss the various types of definitions and 

classification systems that have been developed for CAM including an oppositional 

definition, positive inclusive definitions, an operational definition, classification models 

and consumer’s perspective of CAM classifications. The aim is to establish a suitable 

definition and classification system to guide this research. 

2.5.1 What CAM is not - Oppositional definition 

Historically CAM has been defined in terms of its oppositional relationship to mainstream 

conventional medicine (van Wersch et al., 2009), hence the widely used terms 

“unconventional, alternative or unorthodox” (Eisenberg et al., 1993). Eisenberg et al. 

(1993, p. 246) defined “unconventional therapies as medical interventions not taught 

widely at U.S. medical schools or generally available at U.S. hospitals”. Gevitz (1995) 

argued that “defining unconventional medicine by ‘what it is’ does not work” (cited in 

Kaptchuk & Eisenberg, 2005, p. 9). As Willis and White (2004, p. 52) state the term CAM 

“conceals as much as it reveals”, and is therefore defined by its “ostracism” by orthodox 

medicine. However, this view of CAM as being distinguished from mainstream medicine 

is changing. van Wersch et al. (2009) argue that the original definition of unconventional 

medicine as ‘alternative’ and incompatible with orthodox medicine has now widened due 

to the recognition that many therapies are considered ‘complementary’ to conventional 

medicine.  

2.5.2 What CAM is - Positive inclusive definitions 

Inclusive, positive approaches that describe what CAM is are considered more constructive 

than a definition that describes what it is not (Ernst et al., 1995). Definitions, in this 

‘positive inclusive’ format, have been created by scholars, organisations and Governments 



 

 

15 

 

in an attempt to describe what CAM entails and involves. Here are some examples of these 

types of definitions. 

 Ernst et al. (1995) put forward the following definition: 

Complementary medicine is diagnosis, treatment and/or prevention 
which complements mainstream medicine by contributing to a common 
whole, by satisfying a demand not met by orthodoxy or by diversifying 
the conceptual frameworks of medicine (p. 506).  

 

The World Health Organisation also offers an inclusive approach and defines CAM as: 

The sum total of knowledge, skills and practices based on the theories, 
beliefs and experiences indigenous to different cultures that are used to 
maintain health, as well as to prevent, diagnose, improve or treat physical 
and mental illnesses (Themedica, 2009, p. 1). 

 

Many Governments have attempted to define CAM. In New Zealand, for example, the 

Ministry of Health (2008, p. 299) defines CAM as: 

a term used to describe a broad range of healing techniques that 
encompass all health systems, practices and their accompanying theories 
and beliefs, other than those in the mainstream health system of New 
Zealand. Complementary and alternative health care services generally 
take a holistic approach to health care, including the interactions between 
physical, spiritual, social and psychological aspects.  

 

The Cochrane Collaboration has perhaps provided the most widely used and 

comprehensive definition of CAM: 

Complementary and alternative medicine (CAM) is a broad domain of 
healing resources that encompasses all health systems, modalities 
[therapeutic approach], and practices and their accompanying theories 
and beliefs, other than those intrinsic to the politically dominant health 
system of a particular society or culture in a given historical period. 
CAM includes all such practices and ideas self-defined by their users as 
preventing or treating illness or promoting health and well-being. 
Boundaries within CAM and between the CAM domain and that of the 
dominant system are not always sharp or fixed (Zollman & Vickers, 
1999, p. 319). 



 

 

16 

 

 

The Cochrane Collaboration, established in 1993, is an independent international network 

that produces and disseminates up-to-date research and information on all areas of health 

care (Fitzgerald & Howcroft, 1998). The Cochrane Collaboration has an extensive 

database of systematic reviews of various health care topics and its core work is done by 

“collaborative review groups whose function is to prepare and maintain systematic reviews 

on related topics” (Bero & Drummond, 1995, p. 1936). “To meet increasing demand for 

evidence-based complementary medicine (CM), a CM field, funded by the National 

Institutes of Health Office of Alternative Medicine, was established within the Cochrane 

Collaboration in 1996” (Ezzo, Berman, Vickers, & Linde, 1998, p. 1628). 

Recently the Cochrane Collaboration has argued that an operational definition as opposed 

to a theoretical definition of CAM is required for on-going research (Wieland et al., 2011). 

Wieland et al. (2011) argue that a theoretical definition characterises the fundamental 

nature of a construct whereas an operational definition tests whether a specific instance is 

or is not a member of the construct through a series of criteria or tests. This has become 

important as acceptance for CAM among mainstream medicine practitioners is increasing 

and the need for an operational definition of CAM to facilitate and harmonise research is 

required (Wieland et al., 2011). However, even operational definitions are not consistent, 

especially among Western Governments. In New Zealand, for example, the type of CAM 

therapies the Ministry of Health (2008) include in their definition are: massage therapy, 

homoeopathy, naturopathy, acupuncture, traditional Chinese medicine, herbalism, aroma 

therapy, spiritual healing, Maori traditional ‘Rongoa’ healing, Pacific traditional healing, 

and other. Interestingly, chiropractors, and osteopaths are classified under ‘other health 

care workers who also work in the primary health sector’. This is not consistent with 

definitions of complementary and alternative medicine in the United States and United 

Kingdom which generally classifies chiropractors and osteopaths under CAM (Miller & 

Washington, 2011; Vos & Brennan, 2010; Wieland et al., 2011). This difference highlights 

the need for ‘one’ recognised operational definition and classification system. 



 

 

17 

 

2.5.3 Cochrane Collaboration’s operational definition 

The Cochrane Collaboration’s complete operational definition, published and updated 

online (Wieland et al., 2011) is essentially an alphabetical list of what the Cochrane 

Complementary Medicine Field classifies as complementary or alternative medicine 

(includes therapies, herbs and nutritional supplements). An alphabetical list of CAM 

therapies, included in the definition, can be found in Appendix A.  

After an extensive review of the literature Wieland et al. (2011) declared that a group 

classification system would be superior to an alphabetical system. Hence, Wieland et al. 

(2011) developed a structure based on the US National Institute of Health’s Centre for 

Complementary and Alternative Medicine (NCCAM) categories. The NCCAM categories 

include: 

 Mind-Body Medicine, which uses a variety of techniques to enhance the mind’s 

capacity to affect bodily function and symptoms. 

 Natural Product Based Therapies, which use substances found in nature to promote 

health. 

 Manipulative and Body-Based Practices, which are based on manipulation and/or 

movement of parts of the body 

 Energy Medicine, which involves the use of energy fields, either the 

unconventional use of electromagnetic fields, or the manipulation of energy fields 

that purportedly surround and penetrate the human body. 

 Whole Medical Systems, which are complete systems of theory and practice 

outside the conventional allopathic model. 

(Wieland et al., 2011, p. 9) 

The latest Cochrane Collaboration CAM classifications includes (Wieland et al., 2011): 

 Mind-Body Interventions 

 Natural Products Based on Therapies 

 Manipulative and Body-Based Methods 

 Energy Therapies 



 

 

18 

 

 Alternative Medical Systems – includes complete systems such as homeopathy and 

naturopathy 

Appendix B contains the fully expanded Cochrane CAM field topic list, which displays the 

topics and subtopics, plus in brackets the number of research papers that have been 

reviewed by the Cochrane Collaboration associated with each topic. 

2.5.4 Consumers’ perspective of CAM classifications 

Little consideration has been given to what and how the CAM consumer classifies CAM 

services. The above CAM categories and definitions are all based on what medical experts, 

both mainstream and CAM, believe constitutes alternative and complementary. If we are to 

understand the value consumers get from consuming CAM health services and how they 

co-create value, the CAM user’s perspective is an important consideration. One such study 

has attempted to categorise CAM based on CAM users’ perspectives. Robinson et al. 

(2009) explored whether CAM users view CAM as a unified concept or categorise the 

different CAM health services. Robinson et al. (2009) found that CAM users did not view 

CAM as a unified concept, supporting the view that CAM is diverse and difficult to define. 

In fact, the CAM users they researched chose a CAM health service for themselves 

according to their beliefs, concerns and characteristics. Based on the users’ perspective 

Robinson et al. (2009, p. 156) divided CAM health services into four categories: 

 Natural remedy: includes naturopathy, homeopathy, Chinese medicine, and 

herbalists 

 Wellness: includes aromatherapy, kinesiology, spiritual healing, shiatsu, reiki, 

reflexology, yoga, and meditation 

 Accepted: includes acupuncture, osteopathy, tai chi, and hypnotherapy 

 Established: includes chiropractic, massage therapy, prayer, magnet therapy, and 

Bowen therapy 

These lie along a continuum from natural remedy modalities (therapeutic approaches) and 

holistic health care beliefs at one end to established modalities and a belief in conventional 

medicine at the other (Figure 2). 



 

 

19 

 

Figure 2: The holistic health care-conventional medicine continuum model (Robinson 

et al., 2009, p. 159) 

 

 

Robinson et al. (2009) argue that this “Holistic Health Care – Conventional medicine” 

continuum model “enables conventional medicine and scholars of CAM to understand the 

diversity within CAM use” (p. 161). Importantly, the model goes beyond classifying CAM 

services it also provides an insight into the attitudes, beliefs, and demographics of CAM 

consumers and the CAM health services they chose based on these characteristics. 

Interestingly, CAM health services such as naturopathy, homeopathy, Chinese medicine 

and herbalists are more likely to be used by CAM consumers who have ‘higher’ beliefs in 

natural remedies, holistic health, spirituality and environmentalism, and have a positive 

attitude towards CAM. On the other hand CAM consumers using ‘established’ CAM 

health services such as chiropractors and massage therapy, have lower beliefs around 

holistic health, natural remedies and spirituality. According to Robinson et al. (2009) CAM 

consumers of these ‘established’ CAM services tend towards a more conventional 

approach to medicine. 

2.5.5 Classification systems chosen for this research 

Although an oppositional definition is supported by some (for example, Eisenberg, 1993), 

many believe a positive inclusive definition of ‘what it is’ is actually more helpful (Ernst, 

1995). The Cochrane Collaboration’s operational definition and classification system has 

gone some way to providing a comprehensive field list that enables researchers of CAM to 

categorise what CAM includes, and create synergy around future research. This researcher 



 

 

20 

 

believes an inclusive approach and a comprehensive classification system to define CAM 

is important for future research on CAM health services. Therefore this research uses the 

Cochrane Collaboration’s classification system for selecting participants for the study, to 

ensure the results could be compared with international research on CAM, and to give the 

research credibility. Robinson et al’s. (2009) holistic health care-conventional medicine 

continuum model is also used to help guide the selection of participants to ensure ‘popular’ 

CAM health services consumers use are targeted. Although the model is limited to 

‘popular’ CAM services it provides an excellent framework in which to understand CAM 

users. Like scholars before them, in particular Astin (1998), Robinson et al’s. (2009) 

research shows that CAM services are diverse and are used by people on the basis of their 

beliefs, characteristics, and health concerns. Understanding why people use CAM health 

services is critical to understanding what value is gained, and how value is co-created from 

CAM consumption. It is therefore instructive to now explore the reasons for CAM use. 

2.6 Underlying Reasons for CAM Use 

The growth and popularity of CAM is an interesting phenomenon considering the 

controversy over the scientific validity and efficacy of the treatments themselves, and 

sceptical attitudes towards CAM by mainstream medical practitioners (Berman & Straus, 

2004; Hughes, 2008; Thompson & Troester, 2002). Although there are a number of studies 

on why people use CAM (see Astin, 1998; Astin et al., 1998; Bishop et al., 2008; Furnham 

& Lovett, 2001; Lindeman, 2011; Vincent & Furnham, 1996) the underlying reasons are 

still poorly understood (Lindeman, 2011). Lyons and Chamberlain (2006) argue that the 

question of who benefits from CAM use and how CAM use relates to a CAM consumer’s 

understandings of health and illness is also under researched. To address these questions 

regarding the underlying reasons why people use CAM and who benefits from CAM use, 

an extensive review of the extant literature was carried out by the researcher of this study. 

A review of the literature revealed six key underlying reasons for CAM use and include: 1) 

Philosophical orientation and postmodern values; 2) Disenchantment with orthodox 

medicine and modern health worries (MHW); 3) Empowerment and self-responsibility; 4) 

Holistic approach; 5) Natural underpinnings; 6) Spiritual, intuitive and paranormal beliefs. 

A summary of each theme is outlined in Table 2 along with a chronological list of  



 

 

21 

 

Table 2: Summary of literature review on the themes that emerged on key reasons 

why people use CAM 

 

Main Reason Summary  Literature in chronological order 

Philosophical 
Orientation & 
Postmodern 
values 

People’s attitudes, values and 
beliefs towards health, health care 
and life. Postmodern health values 
include: a preference for ‘natural’ 
products, belief in holism, self-
responsibility and empowerment. 

Goldstein et al. (1988) 
Coward (1989) 
Furnham & Kirkcaldy (1996) 
Kelner & Wellman (1997a) 
Ray (1997) 
Astin et al. (1998) 
Kaptchuk & Eisenberg (1998) 
Siahpush (1998, 1999a) 
 

Ray & Anderson (2000) 
Furnham & Lovett (2001) 
Andrews (2002) 
O’Callaghan & Jordan 
(2003) 
Nichter & Thompson 
(2006) 
Bishop et al. (2007) 
Furnham (2007) 
 

Disenchantment 
with orthodox 
medicine and 
modern health 
worries (MHW) 

Disenchantment with orthodox 
medicine’s philosophy of healing 
and therapeutic relationships. 
Modern health worries (MHW) 
involves people’s concerns that 
their health is impacted by aspects 
of the modern world, e.g. 
technology, environmental 
pollution, pesticides, GMO foods. 

Furnham & Smith (1988) 
Vincent & Furnham (1996) 
Astin et al. (1998) 
Siahpush (1999) 
Barrett el al. (2000) 
Kelner & Wellman (2001) 
Sharma (2001) 
 

Andrews (2002) 
Petrie & Wessley (2002) 
Bishop et al. (2007) 
Furnham (2007) 

Empowerment 
& self-
responsibility 

CAM is ‘empowering’, where 
people are encouraged to take 
responsibility for their own health 
and gain a sense of control over 
their health. Active versus passive 
approach to health 

Barrett et al. (2000) 
Andrews (2002) 
Hughes (2004) 
Hutch (2006) 
Sointu (2006) 
Gale (2008) 
Bann et al. (2010) 

 

Holistic 
Approach 

Treats the whole person in terms 
of emotional, physical, 
psychological, spiritual and social 
factors 

Vincent & Furnham (1996) 
Kaptchuk & Eisenberg (1998) 
Barrett et al. (2000) 
Andrews (2002) 
Hill (2003) 
Coulter (2004) 

Ernst et al. (2005) 
Fulder (2005) 
Bishop et al. (2008) 
van Wersh et al. (2009) 

Natural 
Underpinnings 

Basis is from nature and uses 
natural remedies. Philosophical 
orientation that believes the body 
has the natural ability to heal 
itself. 

Coward (1989) 
Kaptchuk & Eisenberg (1998) 
Siahpush (1999) 
Coulter (2004) 
Nichter & Thompson (2006) 
Hill-Sakurai et al. (2008) 

 

 
Spiritual, 
Intuitive & 
Paranormal 
Beliefs 

 
Sense of connection with oneself, 
the universe and the divine.  

Goldstein et al. (1988) 
Vincent & Furnham (1996) 
Astin (1998) 
Kaptchuk & Eisenberg (1998) 
Andrews (2002) 
Hill (2003) 

Capsi et al. (2004) 
Petry & Finkel (2004) 
Hutch (2006) 
Bishop et al. (2007) 
Jeswani & Furnham 
(2010) 
Lindeman (2011) 



 

 

22 

 

literature that contributes to each category. Although six different themes surfaced in the 

review of the literature it was a person’s ‘philosophical orientation’ that appeared to be the 

dominant dimension that influenced CAM use. Postmodern values have also greatly 

contributed to CAM’s increasing popularity. Philosophical orientation and postmodern 

health values appeared to run through all the other five reasons. However, each reason 

warrants exploration in its own right therefore a discussion of each theme follows, 

highlighting the underlying reasons for CAM use. 

2.6.1 Philosophical orientation & postmodern health values 

A person’s philosophical orientation and values towards health (postmodern health values) 

are considered the main underlying reasons why people use CAM. A discussion of these 

two aspects follows and concludes that underlying attitudes, beliefs and values towards 

health and healing are the best predictors of CAM use.  

Philosophical orientation refers to a person’s beliefs, attitudes and values towards health, 

health care and life (Astin, 1998). Astin (1998) concluded from his U.S nationwide study 

that a key reason for CAM use is because it is consistent with a person’s philosophical 

orientation. The majority of CAM users in the U.S choose alternative medicine because it 

is “more congruent with their own values, beliefs, and philosophical orientations towards 

health and life” (Astin, 1998, p. 1548). Having a holistic philosophy of health (belief in the 

view that body, mind, and spirit are related) was predictive of alternative health care use. 

Even prior to Astin’s (1998) study a number of scholars had argued that people who use 

alternative health care services do so because they subscribe to a distinctive set of beliefs 

about health, illness and healing, that is often referred to as an alternative treatment 

ideology (see Coward, 1989; Furnham & Kirkcaldy, 1996; Goldstein, Sutherland, Jaffe, & 

Wilson, 1988; Kaptchuk & Eisenberg, 1998; Kelner & Wellman, 1997a, 1997b). Kelner 

and Wellman’s (1997b) study found that some CAM users subscribed to ‘an alternative 

ideology’ while others chose CAM for more pragmatic reasons such as ‘disenchantment 

with orthodox medicine’. More recent literature concurs with the ‘philosophical, ideology 

and beliefs’ argument (Bishop, Yardley, & Lewith, 2007; Furnham & Lovett, 2001; 

Lindeman, 2011; Nichter & Thompson, 2006). Furnham and Lovett’s (2001) study on 

predicting the use of CAM found that attitudes, beliefs, subjective norms (social 



 

 

23 

 

approval/disapproval), perceived control and past behaviour were good predictors of 

intentions to use CAM. These intentions were significant predictors of actual use.  

Studies have suggested that people are “pulled towards” CAM because of an underlying 

philosophy and “a new set of health beliefs and values in society, entitled the post-modern 

philosophy” (O’Callaghan, 2003, p. 28). Postmodern values refers to the shift in values 

that have signified a transition from the late modern era to postmodernism (O’Callaghan, 

2003). A number of postmodern health values have been identified and include: rejection 

of authority, an increase in consumerism, importance of individual responsibility for 

health, emphasis on nature and natural remedies, anti-science sentiments and a holistic 

view of health (Siahpush, 1999a). Several studies have found that subscribing to 

postmodern values of health were significant predictors of attitudes towards and use of 

CAM (O’Callaghan & Jordan, 2003; Siahpush, 1998, 1999a). O’Callaghan and Jordan 

(2003) concluded that an emergence of postmodern values of health can partly explain the 

increased popularity of CAM. Interestingly, Siahpush (1999b) found that CAM users do 

not reject mainstream medicine and science outright. Many believed there were 

circumstances when medical science and technology was useful. 

These findings suggest that CAM use may reflect a cultural paradigm shift towards health 

care from an emphasis on curing sickness to creating wellness (Prahalad & Ramaswamy, 

2004). In fact Astin et al. (1998) found belonging to the value group ‘cultural creatives’ 

was a significant predictor of consumer use of CAM as was having higher education. 

‘Cultural Creatives’ described by Ray (1997) and Ray and Anderson (2000) are a group of 

Americans who have a distinct set of values that are argued to be emerging beyond 

modernism to become what is called ‘Trans-Modern’. Based on 12 years of survey 

research, 100 focus groups and dozens of interviews, Ray and Anderson’s (2000) study 

presents a complex portrait of this emerging group. The core values this group hold 

include: concern for environment and social issues; feminism; love of foreigners and the 

exotic; altruism and interest in self-actualisation, personal growth and spirituality; belief in 

authenticity, holism and everything natural, believing that body, mind, and spirit is unified. 

Cultural Creatives who make up approximately 26% of the U.S population are considered 

the core market for psychotherapy, alternative health care, and natural foods (Ray, 1997; 

Ray & Anderson, 2000).  



 

 

24 

 

In New Zealand this group could be compared to what Lawson, Todd and Evans (2006) 

term ‘Educated Liberals’ who make up 9.4% of the New Zealand population. ‘Educated 

Liberals’ are progressive and egalitarian who value equality, social justice and the 

environment along with “creativity, love and inner harmony” (p. 11). Food choices for this 

group tend to be healthy and natural with a preference for fresh produce and organic foods. 

Seventy percent of the Educated Liberals are female between the ages of 35-60 years, 

highly educated with high household incomes. Interestingly, there has been little growth in 

this group in New Zealand 2000 (Lawson et al., 2006). Lawson et al. (2006) have observed 

an overall trend of conservatism and a shift to traditional values, which is opposite to what 

Ray and Anderson (2000) proclaim is happening in the U.S. Kelner and Wellman (1997b) 

argue that there is an increasing number of what they term ‘smart consumers’ who are 

seeking better health and making informed choices about health care. This ‘smart 

consumerism’ is thought to reflect the growing interest in CAM and a wider consumer 

interest in health and body matters in Western society. 

2.6.2 Disenchantment and modern health worries 

Despite a growing body of literature that suggests CAM consumers are ‘pulled’ to CAM 

because of CAM’s health and healing philosophies, there is still debate among scholars 

about whether some CAM consumers are ‘pushed’ away from mainstream medicine 

towards CAM health care due to disenchantment and bad experiences. This section 

discusses the literature that supports the notion that some CAM consumers have become 

disenchanted with mainstream medicine and associated aspects, such as the pharmaceutical 

industry. It also discusses the concept of modern health worries (MHW) which has also 

had an impact on consumers’ choices of health care. The section concludes that there is 

evidence to suggest that consumers are both ‘pushed’ and ‘pulled’ towards CAM. 

Disenchantment and bad experiences of mainstream medicine and medical practitioners is 

considered one reason why people choose alternative medicine (Furnham & Smith, 1988). 

According to Astin et al. (1998, p. 2303) “the most frequently cited reason for consumer 

use of CAM is dissatisfaction with the ability of conventional medicine to adequately treat 

chronic illnesses”. Sharma (2001) argues that dissatisfaction with orthodox medicine is not 

about medicine’s failure to ‘cure’ a disease or even the medical practitioners’ competence 



 

 

25 

 

but more about the process of healing that today’s health consumers are seeking. Bishop et 

al. (2007) found those with favourable attitudes and strong beliefs about CAM and holistic 

approaches to health tended to be the most dissatisfied with conventional medicine. 

Sharma (2001, p. 103-104) provides five key reasons why CAM consumers have become 

dissatisfied with conventional medicine: 

1. The claim that conventional medicine fails to get at the ‘root cause’ of 

chronic illness or fails to take a preventative approach, and can therefore 

only treat the symptoms. 

2. The fear of drugs which might become habit forming, or the dislike of side 

effects of particular drugs. 

3. Fear or dislike of forms of treatment which are seen too radical or invasive. 

4. Perceived inability of conventional medicine to cope with the social and 

experiential aspects of illness. 

5. Dissatisfaction with the kind of relationship between doctor and patient 

which interviewees feel that conventional medicine requires and 

presupposes 

Scepticism and disenchantment towards modern medicine and an increase in CAM use has 

been associated with high levels of what is termed ‘modern health worries’ (Furnham, 

2007). The term ‘modern health worries’ (MHW), coined by Petrie and Wessely (2002), 

relates to concerns that personal health is impacted by aspects of the modern world. Such 

aspects include supposedly toxic interventions (for example, pharmaceutical drugs, 

vaccines, amalgam fillings, fluoridation of water), environmental pollution, technology 

(particularly mobile phone use), tainted food (pesticides, genetically modified food) and 

radiation. Petrie and Wessely (2002) argue that people’s suspicion of modernity has 

created a distrust of ‘experts’ and “fostered a migration to complementary medicine” (p. 

690).  

Some studies have found the ‘push’ factor to be more dominant than the ‘pull’, in that, 

people turn to CAM because they are dissatisfied with “various aspects of conventional 

medicine practice” such as short length of visits, poor interpersonal attitudes and low 

availability (Shmueli & Shuval, 2006). The poor therapeutic relationship between patient 



 

 

26 

 

and practitioner is often cited as a reason for the disenchantment towards mainstream 

medicine among CAM users (Andrews, 2002; Kelner & Wellman, 2001). CAM consumers 

tend to be more critical of mainstream medicine (van Wersch et al., 2009) with complaints 

of disempowerment, paternalistic manners, standardisation of treatment and insufficient 

consultation time (Barrett et al., 2000; Kelner & Wellman, 2001). Furnham and Smith 

(1988), for example, found that patients who seek CAM are less likely to feel satisfied 

from a short ‘GP consultation’ and prefer the longer sessions that CAM practitioners 

provide. Siahpush (1999b) discovered that it was dissatisfaction with the medical 

encounter rather than the practitioner’s ability that led to a favourable attitude towards 

CAM. Some people favour CAM because they think medical practitioners do not listen, 

allow enough time, give respect, and enable participation in the healing process.  

However, as previously discussed in 2.6.1 other studies have found that CAM users are 

predominantly ‘pulled’ towards CAM due to their belief and underlying philosophy as 

opposed to ‘pushed’ away from conventional medicine (Furnham & Forey, 1994; Furnham 

& Kirkcaldy, 1996; Lovgren, Wilde-Larsson, Hok, Levealahti, & Tishelman, 2011). Astin 

(1998) found in his U.S national study of CAM users that dissatisfaction with orthodox 

medicine was not necessarily a good predictor of CAM use but that ‘philosophical 

orientation’ was a better predictor. Siahpush (1998) concluded the same in his Australian 

study, stating that ‘postmodern values’ were a better indicator of CAM use than 

dissatisfaction with orthodox medicine. Furnham and Kirkcaldy (1996) had also observed 

this phenomenon in their German study. They found that: 

Clients who select complementary forms of treatment may do so less 
from disenchantment with, and bad experiences of, orthodox medical 
techniques rather than from a deep-seated belief in the effectiveness of 
complementary medicine (Furnham and Kirkcaldy, 1996, p. 49) 

It is argued that any disenchantment with orthodox medicine is primarily due to people’s 

philosophical orientation towards health and beliefs about CAM and modern medicine as 

opposed to poor health care and bad experiences. Therefore CAM consumers are both 

‘pushed’ and ‘pulled’, often simultaneously. Bishop et al. (2007) found people who use 

CAM “value non-toxic, holistic approaches to health and hold ‘postmodern belief systems’ 

while viewing themselves as unconventional and spiritual” (p. 862). Vincent and Furnham 



 

 

27 

 

(1996) found that CAM consumers do not appear to be ‘in flight of science’ or to have 

‘unusual’ views, but have a belief in the efficacy of CAM treatments and value the 

“willingness of their practitioner to discuss emotional factors, the explanations given for 

their illnesses [and] the chance to play an active part in their treatments” (p.47). Kelner 

(2005) argues that the CAM therapeutic relationship is primarily based on ‘partnership in 

healing’, whereas orthodox relationships are mostly based on ‘trust in expertise’. Barrett et 

al. (2000) believes that CAM practitioners facilitate rather than direct the healing process 

and rely on self-empowerment and personal responsibility for health. Modern health care 

consumers have greater choice and are becoming actively involved in the management of 

their health care. Therefore many are choosing private health care services such as CAM 

because not only does it resonate with their underlying philosophies, beliefs and values on 

health and healing (pulled), it also provides an empowering alternative to mainstream 

medical care (pushed).  

2.6.3 Empowerment and self-responsibility 

Empowerment and self-responsibility are themes that emerged in the literature as key 

determinants of CAM use. These two terms are described and the literature pertaining to 

these concepts in CAM is discussed. 

The attraction of CAM has been attributed to its empowering nature, where people are 

encouraged to take responsibility for their own health and gain a sense of control 

(Andrews, 2002; Bann et al., 2010; Barrett et al., 2000; Barrett et al., 2003; Sointu, 2006). 

CAM consumers are seeking more equitable practitioner-patient relationships and hence 

patient empowerment is often cited as a reason why great numbers of people are turning to 

CAM (Gale, 2008). “In the context of CAM treatment, empowerment reflects a type of 

support that enables and motivates people to take the necessary steps to manage and 

improve their health in a self-directed manner. Empowerment has been described as being 

characterised by responsibility and readiness for change” (Bann et al., 2010, p. 746). 

Personal empowerment is considered important for health and CAM practitioners tend to 

focus on personal empowerment more than their conventional counterparts (Barrett et al., 

2000). Barrett et al. (2003) points to increasing evidence of people desiring to be in control 

of their health. This desire for self-responsibility reflects changing societal values. CAM 



 

 

28 

 

provides an ideal environment to promote empowerment and self-responsibility due to the 

‘patient-centred’ nature of the CAM therapeutic relationship (Gale, 2008).  

Sointu (2006, p. 507) argues that CAM health practices “facilitate the recognition of 

personal, often emotional concerns” that foster a sense of self-worth and empowerment. 

Sointu (2006) also believes CAM consumers are looking for a sense of wellbeing as 

opposed to just health. This need for wellbeing expresses a demand to be “recognised as an 

active, empowered and knowledgeable agent” (Sointu, 2006a, p. 346). Wellbeing 

“signif[ies] a sense of rediscovered belonging, and even a sense of rediscovered identity as 

a full person” (Sointu, 2006, p. 506). Wellbeing in this sense is connected to the idea of the 

self-responsible, empowered ‘contemporary self’ as Sointu, 2006a, p. 337-338) identifies: 

Being a ‘choosing, deciding, shaping human being who aspires to be the 
author of his or her own life, the creator of individual identity’ (Beck 
2000: 165) is important in contemporary Western societies where 
‘[e]xploring and engaging with the inner-self has become an important 
constituent of contemporary identity’ (Furedi 2004: 17).  

Bann et al. (2010) found evidence that aspects of the CAM therapeutic relationship were 

associated with empowerment, and this was responsible for shaping the healing experience 

as well as being linked to beneficial health outcomes. An empowering therapeutic 

relationship between the CAM practitioner and client is recognised as being a key factor in 

positive treatment outcomes (Bann et al., 2010).  

The flip side of CAM’s ideology around ‘empowerment’ and ‘self-responsibility’ has been 

the accusation that CAM practitioners are absolving patient care (Miskelly, 2006). CAM 

has also been criticised as being consumerist, implying good health can be purchased 

(Miskelly, 2006; Gale, 2008). The idea of paying for health care is associated with 

‘individualistic’ and ‘neo-liberal’ ideologies that advocate accepting responsibility for 

health. Accordingly with this responsibility comes self-blame when health goals are not 

achieved (Miskelly, 2006) and raises questions about the impacts of ‘patient burden’ 

(Alder, Wrubel, Hughes, & Beinfield, 2009) and who is responsible for a person’s health 

(Miskelly, 2006).  

There is evidence that the growing interest and use of CAM reflects a larger societal and 

cultural paradigm shift towards a more holistic, spiritual and empowered way of being 



 

 

29 

 

(Astin, 1998; Barrett et al., 2003; Ray, 1997). This has also been recognised in marketing 

literature where discussion of a new consumer has emerged, one that is well-informed and 

highly empowered (Baker, 2003; Kotler, Kartajaya, & Setiawan, 2010). An overview of 

the ‘new consumer’ is discussed later in section 2.7. 

2.6.4 Holistic approach 

CAM is considered more holistic than mainstream medicine (Fulder, 2005) which is 

considered relatively more reductionist (Coulter, 2004). Individuals who seek CAM 

practitioners generally do so knowing they will be regarded holistically in both diagnosis 

and treatment (Fulder, 2005). The reason many people use CAM is the emphasis on 

treating the whole person, in that all aspects of the person are taken into account (Vincent 

and Furnham, 1996). In this context a holistic approach or ‘holism’ is referred to as 

“treating the whole person in terms of emotional, physical, psychological, spiritual and 

social factors” (Barrett et al., 2000). Coulter (2004, p. 113) argues that:  

Holism postulates that health is related to the balanced integration of the 
individual in all aspects and levels of being: body, mind, and spirit, 
including interpersonal relationships and our relationships to the whole of 
nature and our physical environment. Holism therefore is contradictory to 
the notion of reductionism since it holds that the whole is different from, 
and greater than, the sum of the parts.  

Despite the apparent allure of holism, Miskelly (2006) believes that CAM largely ignores 

societal and individual circumstances, for example, ethnicity, social class, gender, 

economic circumstances, and educational background. Baer (2003) too argues that because 

CAM is only interested in the individual and ignores society and its institutions it lacks 

‘holism’, an aspect it is often praised for. Miskelly (2006) argues that CAM has adopted 

such a strong neo-liberal and individualist discourse that advocates individual 

responsibility which often results in people ‘therapy-hopping’. Paradoxically as a 

consequence a long-term therapeutic relationship based on principles of holism may be 

prevented. Conventional medicine on the other hand is more collectivist and is therefore 

more holistic from a societal public health viewpoint. Nevertheless CAM continues to 

attract people because of its holistic and personalised approach that empowers people to 

take control of their own health (Andrews, 2002). As discussed previously this is mostly 

because CAM is consistent with individual personal values and their philosophical 



 

 

30 

 

orientation (Astin, 1998; Barrett et al., 2003; Bishop et al., 2007; Kaptchuk & Eisenberg, 

1998). 

2.6.5 Natural underpinnings 

Natural underpinnings is the foundation of many CAM therapies which advocates natural 

forms of healing, treatment and medicines that work in harmony with the body (van Wersh 

et al., 2009). Consumers who use CAM are attracted by this natural aspect, hence this 

theme consistently arose in the literature (Coulter, 2004; Hill-Sakurai et al., 2008; 

Kaptchuk & Eisenberg, 1998; Nichter & Thompson, 2006). Once again the reason for 

using CAM can be related to the power of its underlying shared beliefs and cultural 

assumptions that most CAM therapies are considered natural and/or has its fundamental 

premise in nature (Kaptchuck & Eisenberg, 1998). Coulter (2004, p 113) in his study of 

CAM users found that 

most of the CAM groups express a preference for natural remedies. This 
is bound up with a set of philosophical principles which may be 
expressed as: the body is built on nature’s order; it has natural ability to 
heal itself; that this is therefore reinforced by the use of natural remedies; 
that it should not be tampered with unnecessarily through the use of 
drugs or surgery; and that we should look to nature for the cure.  

Other studies support this notion of CAM being natural and supporting the body to heal 

itself (Hill-Sakurai et al., 2008; Nichter & Thompson, 2006). Hill-Sakurai et al. (2008) in 

their study of menopausal women discovered that “most women who used CAM valued 

that it was natural” (p. 621). ‘Natural’ from their perspective sometimes meant gentler or 

safer than orthodox medication. However, many also described natural in relation to 

obtaining balance in the body and the body’s ability to heal itself. Nichter & Thompson’s 

(2006) ethnographic study of supplement use found that some CAM users “expressed overt 

ideological reasons” for using CAM supplements such as being “natural”. These 

consumers preferred “natural” medicines for their bodies instead of what they perceive as 

more “toxic” pharmaceuticals. CAM consumers also reported to be making choices that 

have positive impacts on others such as using herbal remedies believing they are better for 

the environment (Nichter & Thompson, 2006). Kaptchuk and Eisenberg (1998) argue that 

a consumer’s use of ‘natural’ treatments or adhering to ‘natures’ healing philosophy is an 

opportunity to save both the self and the world. In the postmodern world ‘nature and 



 

 

31 

 

natural remedies’ are highly regarded (Siahpush, 1999a) and viewed as gentle, caring, 

kind, benevolent and safe (Coward, 1989). In contrast, conventional medicine’s use of 

science and technology is increasingly considered harmful and invasive by CAM 

consumers (Siahpush, 1999a).  

2.6.6 Spiritual, intuition and paranormal beliefs 

Lastly, having spiritual, intuitive and paranormal beliefs are themes that arose in recent 

literature about why people use CAM. Scholars have recognised that the CAM 

phenomenon is mostly about people’s beliefs and values, therefore research has been 

directed towards uncovering exactly what these beliefs are. This section will discuss each 

of these three beliefs (spirituality, intuition and paranormal) and its relationship to CAM 

use. 

‘Unconventional’ spiritual beliefs, rather than formal religious beliefs, have been 

associated with CAM use (Bishop et al., 2007). Studies have shown that many CAM 

practitioners see spirituality as an essential component to health and healing (Goldstein et 

al., 1988; Hill, 2003). These CAM practitioners understand the importance of spiritual 

experiences and spiritual beliefs in health, illness and healing (Goldstein et al., 1988). For 

them CAM enables people to connect with a ‘power’ and/or life-supporting cosmic forces, 

referred to as vital energy or ‘vitalism’ (Kaptchuk & Eisenberg, 1998).  

This vital energy takes myriad forms: homeopathy speaks of a “spiritual 
vital essence”, chiropractic refers to the “innate”, and acupuncture is said 
to involve the flow of “qi”. Ayurvedic medicine is based on the power 
called “prana”, and new age healing practices work with “psychic” or 
“astral” energies (Kaptchuk & Eisenberg, 1998, p.1062). 

Not only do some CAM consumers experience this ‘vital energy’, their search for health 

can take on “sacred proportions” enabling a person “to discern ultimate meaning and make 

profound connections with the universe” (Kaptchuk & Eisenberg, 1998, p. 1063). 

Consumers of CAM are generally thought to be ‘pulled’ by the spiritual dimension of 

CAM that is not seen in orthodox medicine (Vincent & Furnham, 1996). Petry and Finkel 

(2004) found a direct relationship with spirituality and CAM by using an easily 

administered measure - Spiritual Involvement and Beliefs Scale (SIBS) that was developed 

for use in a general medical practice by Hatch, Burg, Naberhaus, & Hellmich (1998). The 



 

 

32 

 

scale measures two factors of spirituality; core spirituality (connection, meaning, faith, 

involvement and experience) and spiritual perspective. Petry and Finkel (2004) found that 

“persons choosing CAM practitioners for their health care possess a measurably higher 

level of spiritual involvement” (p. 943).  

Despite using the SIBS measurement tool in their study to assess the relationship between 

CAM use and spiritual beliefs, Petry and Finkel (2004) argue that it is difficult to measure 

‘spirituality’ because “the very definition of the construct that we measured is an elusive 

one” (p. 942). Part of the difficulty of researching spirituality is its “lack of grounding in 

theoretical and empirical literature” (Giacalone & Jurkiewicz, 2003, p. 17), and its elusive 

meaning (Petry & Finkel, 2004). Definitions of spirituality vary from ‘meaning and 

purpose in life’ (Eisler & Montuori, 2003; Post, Puchalski, & Larson, 2000), belief in a 

higher power (Petry & Finkel, 2004), a sense of connection with oneself, other people, 

nature, a higher power or spiritual force (Dossey, 2003; Hungelmann, Kenkel-Rossi, 

Klaasen, & Stollenwerk, 1996) to emotional transcendence where feelings of peace, inner 

harmony, joy, and ecstasy are experienced (Skousgaard, 2006). 

Intuitive reasoning, a process that is unconscious, non-verbal, pragmatic, holistic, and 

relies on personal experiences, was found to be an underlying reason why so many people 

believe in CAM (Lindeman, 2011). A number of studies have found a link between a 

person’s intuition and CAM use (Caspi et al., 2004; Hill-Sakurai et al., 2008; Jeswani & 

Furnham, 2010; Lindeman, 2011). The decision to use a CAM therapy because it “felt 

right” is often touted by users, especially those that only adhere to CAM (Capsi et al., 

2004; Hill-Sakurai et al., 2008). Capsi et al. (2004) found that CAM users based their 

treatment decisions on “spiritual signs” or an “intuitive feeling” signalling that it was 

“right for them”. They argue that the “locus of control to a powerful other (God/spirit)” 

was particularly evident for consumers who only use alternative forms of medicine. 

However, Hill-Sakurai et al. (2008) associate user’s intuition more with “listening to one’s 

own body” (p. 621).  

Recent studies have shown that paranormal beliefs correlate with users’ belief in CAM 

(Jeswani & Furnham, 2010; Lindeman, 2011). Those with higher paranormal belief scores 

were more likely to believe in CAM, in particular the efficacy of CAM. People who 



 

 

33 

 

subscribe to supernatural thinking tended to be attracted to CAM therapies whose 

frameworks are grounded in the ‘supernatural’, such therapies include Acupuncture, which 

is based on the idea of chi or vital energy and Reiki, a form of energy healing (Jeswani & 

Furnham, 2010). Lindeman (2011) also found paranormal beliefs to be related to belief in 

CAM and argues that belief in CAM,