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ALTERNATIVETHERAPIESsepoct2011VOL.17NO.535physical.34ManystudiesinvestigatingCAMusehaveuncoveredthatuseishigheramongmoreafAuentpopulationsspecicallywithhigherincomes.7WedenenancialaccesstoCAMservicesastheabilitytopayfortheCAMservicesorhaveaccessthroughahealthinsuranceplan.TheoriginalversionoftheAndersenSociobehavioralModelconsidersnancialaccessasanenablingfactor.30TheabilitytoeitherpaydirectlyforaCAMserviceout-of-pocketorindirectlythroughahealthinsurancepremiumwilldictateanindividualx19suseofCAM.AconsiderableportionofexpendituresonCAMcontinuetobefromout-of-pocketpay-ments35despiteatrendofincreasedcoveragebygovernmentandprivateinsurers.36ThestateofWashingtonservesasaninterestingexamplein1996privateinsurerscoveredCAMpractitionerx13basedservicesandconsequentlyasubstantialportionofhealthinsurancebeneciarieshaveusedtheservicein2002of600000enrollees13.7hadmadeaclaimforaCAMservice.37TheincreaseinaccesstoCAMserviceshasencouragedutilizationbyreducingthenancialbarrier.AmongtheuninsureditispossiblethatahigherbarrierofnancialaccesstotraditionalmedicalcaremayleadanindividualtoseekalessexpensiveCAMservice.GeographicaccessishavingCAMservicesavailableinagivenarea.ForinstancethenumberofchiropractorspercountydiffersdramaticallythroughouttheUnitedStates.38UndoubtedlytherewillbeareaswherethereislimitedaccesstoCAMservicesbecauseservicesarenotavailableinagivenarea.ConverselyaccessorlackofaccesstomedicalphysiciansmayinAuenceCAMuse.3940AccesstoCAMservicesmayalsobeaffectedbypersonalsocioculturaltemporalandphysicalfactorsaswell.Socioculturalfactorsincludepotentialbarriersincommunica-tionorritualsacrossgroups.Temporalandphysicalfactorsrelatetoapatientx19sabilitytoseeaCAMpractitionerforinstanceanappointmenttimeconducivetoonex19sworkscheduleandphysicallyhaveaccesstoapractitionerx19sofce.Differentiationx0ofx0Complementaryx0andx0Alternativex0Medicinex0ServicesTheNationalInstituteofHealthx19sNationalCenterforComplementaryandAlternativeMedicineNCCAMclassiesCAMpracticesintovedomains1wholemedicalsystems2mind-bodymedicine3biologically-basedsystems4manipu-lativeandbody-basedpracticesand5energymedicine.41ThevedomainsasdescribedbyNCCAMdifferentiateCAMservicesbymechanismofactionwhichisapplicablefordirectingstudyhowevertheNCCAMsystemmaynotbefeasibleparametersforstudyingCAMutilization.WeseparateCAMpracticesintotwocategorieseitherprac-titioner-basedproductsorservicesegchiropracticacupunc-turemassagetherapyosteopathyReikipractitionersandself-practiceCAMtherapies.Self-practicetherapiesincludeprod-uctssuchasnaturalsupplementsmegavitaminsherbalsandmineralsaswellasself-practiceCAMactivitiessuchasyogameditationanddeepbreathing.OurdecisiontoseparateCAMpracticesinthisfashionisbasedontheprocessofselectingaCAMtherapy.Inotherwordsapatientx19sdecisiontoeitherself-treatwithaCAMproductortherapyisverydifferentthanadeci-siontoconsultaCAMpractitioner.PreviousauthorshavesuggestedthecreationthreecategoriesofCAM1CAMprovid-ers2CAMproductsand3self-practices.21AlthoughitcouldbearguedthataCAMproductisdissimilartoself-practicethera-pysuchasyogaourrationaleincombiningtheseintoonecate-gorystemsfromcontroltoself-treatusingthemodality.Thedifferenceineitherself-treatmentorconsultingaCAMpractitio-nermaybebasedinpartonperceptionofcontrol.Thex1clocusofcontrolx1dconceptisapsychologicaltheorythatdifferentiatesindividualswhoperceivehavinggreatercontrolovertheiractionsandfatehighinternallocusofcontrolvsthoseindividualswhoperceivelowerpersonalcontrolhighexternallocusofcontrol.42Thirteendifferentcross-sectionalstudieshaveexaminedCAMvsnon-CAMusersx19locusofcontrolmetricswithlittleconsistencyofndings.8Inthesestudiesde-nitionsofCAMvariedandperhapsaninterestingstudywouldbetocompareusersofdifferentservicetypeswithintheCAMrealm.WeillustratethegradientbetweenourtwocategoriesofCAMtherapybasedonperceivedcontrolinourmodelwetheo-rizethatCAMuserswithahighinternallocusofcontrolaremorelikelytoutilizeCAMproductsorself-practicetherapiesasopposedtopractitioner-basedCAMservices.WedescribethetwocategoriesofCAMaspotentiallyimpact-ingeachotherx19suse.ForexampleaCAMpractitionermayrecom-mendeitheraCAMproductorself-therapyintervention.Thex0Endpointsx0ofx0Complementaryx0andx0Alternativex0Medicinex0UseThetwoultimateendpointsofCAMuseareeitherthecon-clusionoftreatmentorthecontinuationoftreatment.Thecon-ceptofcontinuoustreatmentisinpartauniqueaspectofCAMservices.ContinuoustreatmentmayoccurinthecaseofCAMuseasapreventivemodalityorasongoingsymptomreliefforachroniccondition.Thedivergencebetweenthetwoultimateendpointsofcareisdictatedbytheindividualx19spersonalcharacteristicsandhealthstatusaswellastheoutcomesoftheCAMexperiencetheper-ceivedeffectivenessofaddressingtheirpersonalgoalstheassoci-atedcostsandsatisfactionwithCAM.IncaseswheretreatmentisconcludedforaspecictreatmentepisodetheexperiencewithCAMwilltheninturninAuencefutureuseofCAMservices.FUTUREx0USESx0OFx0THEx0CONCEPTUALx0MODELOurproposedconceptualmodelmayserveasareferenceforfutureCAMeducationaswellashelpdirectfutureresearchinquiry.Theparadigmsusedtodescribemedicalserviceutiliza-tioninpublichealthtextsandthehealthsociologyliteraturearenotnecessarilyapplicabletoCAMuse.TheproposedconceptualCAMutilizationmodelisaimedatdescribingtheuniquewaysinwhichindividualscometouseCAMtheinteractionofdifferentCAMpracticesandtheultimateendpoints.AlthoughthemodelissubjecttofuturechangesitprovidesaninitialframeworktoconceptualizeCAMutilizationandpotentiallyformmorequan-titativemodels.AProposedCAMConceptualModel