The impact of consumer value on long-term relationships within the field of Complementary and Alternative Medicine : the moderating role of consumer user group

University of Amsterdam

Faculty of Economics and Business

The impact of consumer value on long-term

relationships within the field of Complementary and

Alternative Medicine: the moderating role of

consumer user group

Master Thesis

Author: Eleni Foulidou (10826769)

University of Amsterdam

Faculty of Economics and Business

Under the Supervision of: Dr. Sonja Wendel

Statement of originality

Statement of originality

This document is written by Student Eleni Foulidou, who declares to take full responsibility

for the contents of this document. I declare that the text and the work presented in this document

is original and that no sources other than those mentioned in the text and its references have

been used in creating it. The Faculty of Economics and Business is responsible solely for the

Contents

Contents

Abstract……….….1

Introduction………....……1

Research question………..………...6

Theoretical and managerial contributions………...6

Limitations of the study………7

Structure of the study………...……7

Theoretical Framework………….….………....8

Loyalty towards CAM ………...………...….8

Consumer value………...10

Consumer value components ...13

Quality of care………...13

Treatment efficiency………...14

Physical environment (aesthetics)…… ………..……….15

Social (esteem) value………...16

Altruistic value……….…17

a. Spiritual value...………..……..……18

b. Ethics (natural aspect of treatment)..………....19

Play (leisure activities, relaxation) ...20

CAM user groups……….….21

Research Method………...………...24

The sample……….………..…….25

Translation-back translation procedure………...27

Pilot testing...……….…...27

Sample demographics………..……….28

Measurement of variables………...………...………...29

Consumer value………....29

Consumer value components’ measurements…..………..…..30

Quality of care……….……….…31

Treatment efficiency….……….………..31

Social value……….………32

Play.……….………..……….32

Physical environment (aesthetics).…….…..………..32

Altruistic value……..………..33

Loyalty……….…33

Contents

Results………..35

Outliers….….……….35

Missing values….………..…36

Factor analysis…….………....………..36

Reliabilities and normality tests…...………...………39

Value components’ rating differences between seekers and believers…....……….40

Hierarchical multiple regression analysis…………...…….……….41

Assumptions……….….………41

Hierarchical multiple regression results………....42

General discussion………...44

Theoretical implications………...47

Managerial implications………..48

Limitations of the study and suggestions for future research………...……...49

Conclusion………51

References………52

Appendices………...59

Appendix 1: List of Complementary and Alternative Medicine types that were included in the research……...……...……….59

Appendix 2: English and Dutch versions of the questionnaire………..…….61

Appendix 3: Factor analysis full output.…..……...………71

Appendix 4: Skewness and kurtosis of the 36 items...…...……...………74

Appendix 5: Hierarchical multiple regression outputs……..………..75

Multiple regression without the inclusion of the control variables………...75

Multiple regression with the inclusion of the control variables……….………...78

List of tables and figures Tables Table 1: Holbrook’s typology of consumer value………...11

Table 2: Consumer value dimensions and scale items..………...34

Table 3: Primary factor loadings and communalities based on a principal component analysis with oblimin rotation………..………37

Table 4: Means, standard deviations, correlations and reliabilities………40

Table 5: Hierarchical multiple regression model for loyalty towards CAM...….……..44

Figures Figure 1: Sanchez-Fernandez et al (2008) reformed typology of consumer value……..12

Figure 2: Cognitive and affective components of spirituality……….…...18

Introduction|1

Introduction

Complementary and alternative medicine (CAM) has been experiencing an astonishing growth

in the last decades (Eisenberg et al, 1993; 1997; Fisher and Ward, 1997). In the United States

unconventional medicine use increased from 33, 8% in 1990 to 42, 1% in 1997, and total visits

to CAM practitioners exceeded those of conventional medical doctors in both years (Eisenberg

et al, 1993; 1997). This acceleration is primarily caused by an increase in the number of users,

rather than in the number of total visits per person (Eisenberg et al, 1993; 1997). In Europe,

surveys exhibit that consumers hold positive attitudes toward CAM therapies and are willing

not only to try CAM, but also to pay an extra amount of money for a CAM therapy (Fisher and

Ward, 1994). In the Netherlands alone, CAM has seen a rise from 9, 1% in 1985 to 15,7% in

Abstract

Consumer value has been identified by academicians as a crucial element in understanding

consumer behavior. Although very much researched in the service industries, value has not been

adequately tested within the field of Complementary and Alternative Medicine (CAM), which

has gained extreme popularity in western societies over the past two decades. This research is

the first attempt to quantitatively investigate relevant value constructs within the CAM field and research their impact on consumers’ loyalty towards the CAM domain; a subject that also has

not received enough attention in the literature. Moreover, no research up to date has taken into

account the two different CAM user groups that have been identified in previous studies, nor has

identified potential rating differences in value components between the two groups. This study

seeks to fill the gap. The findings indicate that quality of care and altruistic value are significant

predictors of loyalty, whereas no moderating role of user group was identified. However, user

group was found to be a significant predictor of loyalty, with users with a health issue exhibiting

higher levels of loyalty towards CAM, compared to users for well-being reasons. The theoretical

Introduction|2 1990 with 60% of the Dutch population declaring that they would try CAM therapies despite

the fact that they would have to pay for it out-of-pocket or adapt their health insurance to

include CAM practitioners (Fisher and Ward, 1994). The World Health Organization indicates that 70% of the world’s population relies on non-allopathic medicine and while individuals in

the developing world have been using alternative therapies from ancient time up until today,

its exponential adoption from customers in the Western world is a relatively new phenomenon

that is believed to have its foundations in the postmodern consumer culture (Thomson and

Troester, 2002).

In order to understand CAM, the first step is to define what CAM consists of. The National

Center of Complementary and Alternative medicine of the U.S Department of Health and

Human Services (NCCIH), defines CAM as the cluster of health care approaches with a history

of use or origins outside of mainstream medicine (Complementary, Alternative or Integrative

Health: What's in a name?, 2014). Nevertheless, available definitions of CAM are rather vague

and could be interpreted differently by different people (Fisher and Ward, 1994; Coulter and

Willis, 2004). In general, complementary medicine consists of non-mainstream approaches that

are used along with Conventional Medicine (CMT), whereas alternative medicine includes the

non-mainstream approaches that are used by individuals in place of CMT. The most popular

forms of complementary and alternative medicine are acupuncture, homeopathy, manipulation

and herbal medicine (Fisher and Ward, 1994), but CAM types extent as far as yoga, diet

supplements and prayer (Eisenberg, 1993).

This definition problem, has directed health organizations and academia into designing

classification systems, in an effort to categorize and understand the great number of different

CAM medicine and therapies. Driven by the incoherent and confused nature of the previous

CAM categorizations, Tataryn (2002), presents one of the most comprehensive classifications

Introduction|3 paradigms that are linked with a hierarchical relationship, and derive from the assumptions

regarding health and illness. The first paradigm is the body paradigm, which assumes that

biomedical factors are responsible for health or illness. The mind-body paradigm extents the

previous paradigm by acknowledging the importance of psychological factors, such as stress,

in the maintenance of health. The third paradigm is the body-energy paradigm, which states

that illness is a result of imbalance of our inner energy. Finally, the body-spirit paradigm,

demonstrates that there are one or more higher, non-material and transcendent forces that

influence health or disease. The author concludes that, according to the approach that a CAM

therapy adopts to treat illness, it can be categorized into one of the four paradigms.

The undeniable growth of CAM in the Western World, has raised a serious debate among health

care providers and academia, with many people condemning CAM, primarily because of the

scarcity of evidence of its effectiveness, and expressing concerns of its safety to public health

(Adams, 2014). However, this controversy of opinions is what makes CAM an interesting and

urgent topic that calls for more in depth research in order to grasp the reasons behind its

immergence and continuous adoption by consumers. CAM is a fast-growing industry, with

Americans spending a total of 33, 9 billion dollars on CAM in 2007 (Americans spent $33.9

billion out-of-pocket on complementary and alternative medicine, 2009), and Europe

presenting a similar growth in CAM expenditures (Fisher and Ward, 1994; Thomas et al, 2001).

Under these considerations, Berry and Bendapudi (2007) state that observing health care

services in general, and consequently CAM practices, from a marketing perspective, will have

an enormous contribution to both academia and the health sector.

Nevertheless, the question of why people decide to turn to CAM is an issue that has been

addressed by many authors (Chao et al, 2006; Roessler et al, 2007; Sirois, 2008), yet with no

conclusive answer up to date. Motivations for using CAM have been classified into two

Introduction|4 effects or inefficiency of treatments, and the positive aspects of CAM (pull factors), such as

the holistic approach of CAM and the desire to take an active role in one’s health. Research

indicates that there is a swift in consumers’ motivations in engaging with CAM from both push

and pull factors to mostly pull factors (Furnham and Forey, 1994; Sirois, 2008).

Furthermore, it has been illustrated that age, gender, geographic location and race are

determinants of the likelihood of visiting a CAM practitioner (Bausell et al, 2001), with

middle-aged white women, of higher education and income reporting greater CAM use

(Eisenberg, 1993). Other studies, have found that CAM use is significantly moderated by age,

with older people more prone to CAM use, but no association with race/ethnicity is present

(Grzywacz et al, 2007). However, a study by Furnham and Forey (1994), found no

demographic differences between conventional medicine and CAM users, indicating that

perhaps demographic variables are not suitable for answering questions about CAM use.

Financial considerations have also been examined, with data revealing that due to the

increasing cost of conventional medical care, affordability of CAM usage among low income

individuals could be a motivation for CAM use (Chao et al, 2006), whilst practitioners

recognize that the high financial burden for some CAM therapies could act as a deterrent factor

for engaging and mostly for maintaining CAM usage (Bishop et al, 2010), especially since a

substantial number of CAM therapies is partly covered by health insurance packages, if not at

all (Eisenberg et al, 1993; 1997; Fisher and Ward, 1994; Pagan and Pauly, 2005).

These inconclusive results from the above studies have given birth to a body of literature that

argues that, in order to grasp the motivations behind CAM usage patterns, CAM users should

be seen as consisting of distinct and heterogeneous groups of individuals, rather than being

treated as one, homogenous group. (Sirois and Gick, 2002; Smuel and Shuval, 2006). Recent

Introduction|5 divergent groups of individuals: those who turn to CAM in order to cope with disease or chronic

pain and those in search of general well-being (Schuster et al, 2004; Spence and Ribeaux, 2004;

Sointu, 2006).

However, the categorization of CAM users into two different groups only, is not sufficient to

determine the antecedents of CAM usage among individuals. For that reason, scholars drew

their attention in the value consumers derive from their CAM experiences. Consumer value is

considered the most important source of competitive advantage and it is commonly agreed that

it is critical in attracting and retaining costumers (Sanchez-Fernandez and Iniesta-Bonillo,

2006). By adopting this new approach, scholars hope to gain deeper knowledge of the CAM

domain, including not only consumer value, but also the motivations for engaging in CAM

activities as well as the decision drivers for maintaining CAM use (Dodds et al, 2014).

In an effort to apprehend CAM use, Dodds et al (2014), adopt Holbrook’s reformed typology

of value (Sanchez-Fernandez et al, 2008), and conduct the first qualitative study that deals with

consumer value within the CAM domain. Their research on what consumers value about their

health experiences within the CAM context reveals seven consumer value components: 1)

quality of treatment, 2) treatment efficiency, 3) physical environment (aesthetics), 4) social

(esteem) value, 5) spiritual value, 6) natural (ethics) and 7) play (relaxation and leisure

activities). They argue that quality of care and treatment are valued the most with physical

environment playing a minor role. Furthermore, they note that through evaluating the first two

components, consumers start to value all the remaining components of their proposed consumer

value model within CAM health care. The authors conclude, though, that further quantitative

Introduction|6

Research question

The aim of this research is to address the above mentioned literature gap by identifying and

quantitatively testing how the value dimensions, proposed by Dodds et al (2014) influence consumers’ decision to engage in long-term CAM use or, in other words, the impact of

consumer value on loyalty towards the CAM domain. The objectives of this study are: 1) to

identify potential rating differences among the value components derived from CAM

experiences between those who turn to CAM due to health issues and those who seek general

well-being, 2) to determine the extent to which these value components influence consumers’

decision to form long-term relationships with CAM and 3) to examine whether the user group

that consumers belong to moderates the relationship between these value components and

long-term relationships with CAM.

Theoretical and managerial contributions

From a theoretical perspective, this study is the first empirical test of the validity and generality

of the only present consumer value model of CAM in the existing literature. Furthermore, it is

the first attempt to research the impact of the components on the formation of long-term

relationships with CAM in general, by taking also into consideration users that consume CAM

for well-being reasons, a variable that was not included in the exploratory study conducted by

Dodds et al (2014). Although, users’ motives for maintenance have been partly researched in

previous studies, the focus has been on people with specific or often severe medical conditions

(Adler and Fosket, 1999; Pan et al., 2000; Henderson and Donatelle, 2004; Molasiottis et al.,

2005; Yates et al., 2005). Therefore, this study will contribute to the growing body of literature

that aims to navigate into CAM consumers’ beliefs, behaviors and motivations for engaging in

CAM use, as well as into the value they derive from CAM practices and its impact on the

Introduction|7 context has a double contribution: a better understanding of CAM users and their motives and

a better insight on loyalty for service industries, where, as Caruana (2002) states, loyalty

remains an underexplored topic and studies that research the link between value and loyalty

are scarce (Gallarza et al, 2011).

Moreover, the findings will add knowledge to health care managers and CAM providers, since

potential differences in value between the two CAM user groups, may imply that divergent

ways for approaching each group may be needed. In addition, by recognizing what aspects may influence consumers’ decision to keep up with CAM use, practitioners will be able to enhance

overall perceived value and increase the outcomes of these practices for their consumers.

Limitations of the study

This research, however, is not without limitations. First of all, the proposed model by Dodds

et al. (2014) and its components are adopted. Thus, there is a possibility for other aspects of

consumer value, that could be of equal importance to consumers, to be overlooked, such as for

instance divergent service quality dimensions (Zeithaml, 1988; Zeithaml et al, 1996).

Additionally, the focus is on CAM therapies that are provided by a CAM practitioner, so as to

assess the impact of quality of care, treatment efficiency and physical environment to the

decision of maintaining CAM use. Consequently, it excludes any CAM therapy that is

self-selected, such as home remedies or dietary supplements, and not provided or monitored by a

practitioner. Finally, the study seeks to test the effect of consumers’ evaluations on loyalty,

without taking into account other aspects that may impact or mediate the relationship, such as

satisfaction. (Gallarza et al, 2011)

Structure of the study

The remainder of this research is organized as follows: chapter 2 presents the theoretical

Theoretical Framework|8 and the procedure that was followed during the data collection. Chapter 4 presents the data

analysis and chapter 5 discusses the meaning of these results, the theoretical and managerial

implications of the findings and the limitations of the study. Finally, chapter 6 provides the

conclusion.

A detailed explanation of the theoretical framework that is needed to address the above

introduced research question, is catered in the following chapter.

Theoretical Framework

A study by Bishop et al (2010) indicates that consumers evaluate their CAM experiences along

four dimensions: interpersonal, physical, affective and cognitive. The authors conclude that

consumers assess their experiences in relation to their needs and expectations. The line of

thinking behind these evaluations is that if customers of a CAM provider assess positively not

only the physical outcome of the treatment, but also the interaction with the provider as well

as the positive affective effect the treatment has on their overall well-being, there is a much

greater possibility to continue CAM use (Bishop et al, 2010).

However, this does not mean that individuals will continue the use of the exact same treatment,

nor their relationship with the same provider. In a longitudinal study of a US national

representative sample, Kessler et al (2001) find that almost 50% of the participants continue to

use CAM therapies for many years after their initial encounter with CAM. This indicates that

a positive assessment of a CAM therapy could act as motivation to continue the use of that

same therapy, as well as the trial of other CAM therapies. In other words, if a treatment

experience is deemed successful by a consumer, a swift in attitudes and behaviors can occur

Theoretical Framework|9 Long-term use of CAM can and will, therefore, be defined as loyalty towards the CAM domain

as a whole. Loyalty has been illustrated to derive from consumers’ repeated satisfaction with a

product or service (Oliver, 1999). Furthermore, numerous studies link affect, which is the essence of consumers’ satisfaction with patronage behavior (Bitner, 1992; Kim et al, 2007).

Thus, if a consumer feels satisfied with a particular CAM experience, it is expected that there

is a possibility to continue the use of that CAM therapy.

Nonetheless, consumer value has emerged as a key concept in understanding consumer

behavior (Zeithaml, 1988) and the role of satisfaction in loyalty creation (Varki & Colgate

2001; Wang et al. 2004). Yang and Peterson (2004) find in their research that consumer value

is a major antecedent of both satisfaction and loyalty. The authors state that superior consumer

perceived value, derived from exceptional services or products, is the most effective way to

create loyal customers. Loyalty can be either attitudinal or behavioral (Dick and Basu, 1994;

Oliver 1999; Yang and Peterson, 2004). On the one hand, attitudinal loyalty translates into the

desire of the consumer to maintain the use of the particular service, while, on the other hand,

behavioral loyalty is manifested by repeat purchases of the service (Dick and Basu, 1994; Yang

and Peterson, 2004).

Therefore, it is claimed that, by either affecting attitude or actual behavior, superior perceived

value has the ability to influence CAM users’ decision to keep up with CAM. However, as it

was stated above, many CAM users exhibit loyalty not to a provider but to the CAM domain

as a whole. In a different context, Jayawardhena (2010) illustrates that there is a strong

relationship between commitment towards an individual service provider and the service

organization as a whole. Thus, in the same notion, it is argued that consumers’ positive

evaluations of a CAM provider and a CAM therapy have the capacity to influence CAM users’

decisions to maintain CAM use in general. Hence, consumer value can lead to the formation

Theoretical Framework|10

Consumer Value

Academics have been concerned with the social processes by which individuals and different

usage groups understand and consequently experience health, arguing that individuals

experience health in five distinct dimensions: physically, psychologically, functionally,

socially and spiritually (Schuster et al, 2004). For these reasons, motivations and derived value

from CAM usage are different for each unique individual. Although it is generally accepted

that sick people use CAM therapies for pain relief, a study by McColl-Kennedy et al (2012),

indicates that CAM usage among cancer patients, and perhaps in other disease contexts as well,

could be considered a value co-creation activity, mostly for team management and pragmatic

adapting value co-creation practice styles of cancer patients. As far as “true CAM believers”

are concerned, another study by Thomson and Troester (2002), illustrates that natural health

values derive from the concepts of countermonternism, postmodern integrativeness, systemic

risk awareness and postmodern reflexive relativism, with the rise of CAM explained by

consumers with personal values such as harmonious balance, making connections, mindfulness

and flexibility.

In a series of papers, Sanchez-Fernandez and Iniesta-Bonillo, (2006; 2007), review the existing

literature on consumer value and note that two general approaches are present: the

unidimensional and the multidimensional. The unidimensional approach represents the earlier

body of research and views value as purely utilitarian and cognitive, suggesting that the value

consumers derive from their consumption experiences is based on a cognitive evaluation of

benefits and costs. The multidimensional approach, on the other hand, is more recent and

embodies several models of consumer value, with a more complex nature than the earlier

approaches of the concept. In addition, the multidimensional approach recognizes that value is

a concept that consists of several components and that both affect and cognition play an important role in consumers’ evaluations of their consumption experiences

(Sanchez-Theoretical Framework|11 Fernandez and Iniesta-Bonillo, 2007). After assessing the relevant literature, the authors

support the multidimensional typology of consumer value proposed by Holbrook (1999), as

the most comprehensive model of consumer value in existence. Sanchez-Fernandez and

Iniesta-Bonillo (2007) conclude that Holbrook’s typology is the most extensive approach to

value, since its interactive, comparative, personal, situational and preferential nature captures

all the economic, social, hedonic and altruistic components of consumer value.

As it can be seen in table 1, Holbrook’s typology of consumer value consists of eight value

components that are categorized as active or reactive, extrinsic or intrinsic and self-oriented or

other-oriented (Holbrook, 1999). These are: efficiency, excellence, status, esteem, play,

aesthetics, ethics and spirituality. Sanchez-Fernandez et al (2008) reform this typology for the

purpose of assessing consumer value in services, where they state that little attention has been

given in the existing literature so far. Their proposed model, which is shown in figure 1,

consists of six components, instead of Holbrook’s original eight components. Excellence is

named quality, status and esteem are positioned as social value, while ethics and spirituality

are situated as altruistic value. Based on the work of Sanchez-Fernandez and Iniesta-Bonillo

(2006; 2007) and Sanchez-Fernandez et al (2008), Dodds et al (2014) adopt this reformed

typology of consumer value in services and conduct the first interpretive, qualitative research

of consumer value within CAM.

Table 1: Holbrook’s typology of consumer value

Extrinsic Intrinsic

Self-oriented Active Efficiency (output/input, convenience) Play (fun)

Reactive Excellence (quality) Aesthetics (beauty)

Other-oriented Active Status (success, impression, management) Ethics (virtue, justice, morality)

Reactive Esteem (reputation, materialism, possessions)

Spirituality (faith, ecstasy, rapture, sacredness, magic) Source: Holbrook (1999)

Theoretical Framework|12 In order to gain further knowledge into CAM use, this research adopts the study of Dodds et

al. (2014), since it represents one of the most recent views of CAM value, from a consumers’

perspective. Dodd’s et al (2014) findings, indicate that CAM users evaluate their CAM

experiences around seven value dimensions: quality of care, treatment efficiency, physical

environment (aesthetics), social value (esteem), spiritual value, ethics (natural aspect of

therapy) and play (leisure activities, relaxation). The social value component of consumer

value is a grouping of the esteem and status categories of Holbrook’s typology (1999) as

proposed by Sanchez-Fernandez et al (2008), whereas spirituality and ethics were kept as two

separate components, since their research indicated that both of them are deemed important by

consumers and that their grouping into one category will underestimate their impact on the

value construct. Nevertheless, their research is a qualitative study that is conducted with 12

in-depth interviews with CAM female users, therefore its quantitative test is essential (Dodds

et al, 2014).

An extensive analysis of the seven value components within CAM is presented below.

Figure 1: Sanchez- Fernandez’s et al (2008) reformed typology of consumer value

Source: Sanchez-Fernandez et al (2008) Consumer value Quality Efficiency Aesthetics play Altruistic value (spirituality and ethics) Social value (esteem and status)

Theoretical Framework|13

Consumer Value components

 Quality of care

Definitions of quality are rather vague and generic (Campbell et al, 2000). Quality of care can

be defined as excellence or as the sum of expectations from a patient’s perspective and the

degree to which these expectations are met (Steffen, 1988; Ellis & Whittingham, 1993).

Campbell et al (2000), note that patients’ view of quality emphasizes in their personal needs

and includes notions such as humanness, kindness, communication and access.

Academia’s interest in quality of care, however, is a relatively new phenomenon that dates

back to the 1980s. Until then, quality of care was seen as some kind of a mystery (Donabedian,

1988). The first step in comprehending quality of care was conducted by Donabedian (1988),

who stated that quality of care is a laddering construct that consists of four components. The

first component is the performance of the physician or practitioner, which is divided into two

sub-components: technical and interpersonal performance. Technical performance refers to the provider’s knowledge, judgements and skills, whereas interpersonal performance involves the

communication between the practitioner and the patient and includes notions such as empathy,

honesty, privacy, tack and confidentiality (Donabedian, 1988). The second component is the

amenities of care, which is followed by the contributions to the treatment not only from the

provider but also from the patient and his family. Finally, the last component of quality of care

is the care received by the community as a whole, which involves the social distribution of

levels of quality in a given community, and depends on the access to and quality of health care

for the different social groups within it (Donabedian, 1988). According to the author, health

care and, consequently, quality of care consists of the structure (attributes of material resources,

human resources and organizational structure), the process (technical and interpersonal

Theoretical Framework|14 Within the CAM context, quality of care can be determined by the client-practitioner relationship, the clients’ involvement in treatment decisions, the educational and co-learning

nature of the therapy, the holistic approach to health, the knowledge and expertise of the practitioner, the practitioner’s authenticity and integrity and the mutual respect between

practitioner and client (Dodds et al, 2014).

For the purpose of this study quality of care is defined as the sum of patients’ expectations of

technical and interpersonal performance that are met by a practitioner. This definition is chosen

after careful consideration of the divergent views of quality of care that are present in the

literature and of the different attributes that are highlighted by CAM users as signs of quality.

According to Zeithaml et al (1996), the quality of a service, if perceived favorably by

consumers, can facilitate favorable behavioral intentions and lead to long-term relationships

with the service provider. By the same token, quality of care can be a major factor in the

assessment of a treatment and, if expectations are met, it has the ability to facilitate loyalty

towards CAM.

Hypothesis 1: Quality of CAM care has a positive effect on CAM loyalty.

 Treatment efficiency

In general, a result is deemed efficient if it is produced with the minimum amount of time,

effort, skill and money (Zeithaml, 1988; Holbrook, 1999). Accordingly, treatment efficiency

is defined as a three component construct that consists of the results gained from the treatment

in terms of the money spent, the convenience of the treatment in terms of time involved and

the effort the patient has to put in order to get it (Sanchez-Fernandez et al, 2008). In mainstream

health care this can be translated into speedy admissions, short waiting times, ease of access to

treatment and efficient dealing with health problems. For CAM therapies the efficiency of a

treatment is evaluated by consumers along five dimensions: treatment results and timeframes,

Theoretical Framework|15 times, longer consultation time and quick treatment time, and value for money (Dodds et al,

2014). It can be argued that treatment results and timeframes are perhaps the most important

component of efficiency that facilitates CAM maintenance, since qualitative studies show that

if a treatment delivers what it promises in the timeframe given, it is considered highly efficient

by consumers and can influence their intention to maintain the particular therapy or CAM use

in general (Bishop et al, 2010).

Nonetheless, if a CAM therapy produces the desired result with the minimum effort, time and

money input by the user, its efficiency is favorably evaluated. Consequently, since favorable

evaluations have the ability to lead to desired behaviors (Zeithaml et al, 1996), positive

assessments of treatment efficiency can facilitate CAM loyalty.

Hypothesis 2: Treatment efficiency has a positive effect on CAM loyalty.

 Physical environment (aesthetics)

Environmental psychology notes that, a relationship between the physical environment and the

human behavior is evident in several settings (Mehrabian and Russell, 1974). Aesthetics are an

important aspect for providers of both tangible and intangible goods, and it is argued that the

physical environment of a purchase context can impact consumers’ evaluation of quality

(Hightower et al, 2002), enhance their satisfaction levels and lead to positive word of mouth

(Bitner, 1992). Moreover, research has shown that the physical environment can influence consumers’ affective responses towards hedonic consumption goods and services (Wakefield

and Blodgett, 1999). Especially for service providers, aesthetics is extremely important due to

the intangibility of the offering, as it provides consumers with a quality evaluation cue prior to

consumption (Bitner, 1992).

In the health context, the role of physical environment is important in the assessment of a health

Theoretical Framework|16 Dodds et al, 2014). Dodds et al (2014) observe that for CAM users, the role of the physical

environment is less important that quality of care and treatment efficiency, but still essential

for the evaluation of play, social value, spiritual value and ethics. Up-to date equipment, neat,

visually appealing and consumer friendly physical facilities can impact a CAM user’s

evaluation of a CAM provider, especially in their first interaction. Thus, the layout and decoration of a CAM provider’s facility, if perceived favorably and seen as suitable for a

medical provider, can influence CAM loyalty. Conversely, the result of a non-appealing

environment can have a negative effect on the continuation of the relationship between the user

and this particular provider. Furthermore, a non-appealing physical environment, specifically

for new CAM users, can possibly lead to aversion to CAM therapies if perceived as

unprofessional and non-legitimate.

Hypothesis 3: Physical environment (aesthetics) has a positive effect on CAM loyalty.

 Social (esteem) value

Social value within consumption experiences, is defined as the ability of a product or service

to enhance the social self-concept (Sweeny and Soutar, 2001). It is composed of the status and esteem components of Holbrook’s (1999) typology of consumer value, which refer to the

manipulation of one’s consumption in order to be perceived favorably by others and to the appreciation of the prestige that is associated with one’s possession, respectively (Sanchez-

Fernandez and Iniesta-Bonillo, 2007).

Within the CAM context, social value revolves around a person’s physical and mental

well-being and self-esteem evaluations (Dodds et al, 2014). CAM users report that the healing

produced by CAM, transcends physiological health and leads to feelings of fulfillment,

harmony and acceptance (Sointu, 2006). Furthermore, they state that CAM encourages an

Theoretical Framework|17 a knowledgeable and empowered self (Sointu, 2006; Dodds et al, 2014). Consequently, even though CAM’s effectiveness is still questionable, CAM almost certainly increases users’

subjective well-being, which is an indispensable part of general well-being. Thus, it is argued

that, although the social component of consumer value has not been found to have a significant

effect on loyalty (Pura, 2005; Gallarza and Saura, 2006), qualitative studies indicate that users

deem social value as an important aspect of CAM treatments. Hence, since consumer value can

enhance long-term relationships and its social component seems to be relevant for CAM users,

it is argued that social value can promote CAM loyalty.

Hypothesis 4: Social (esteem) value has a positive effect on CAM loyalty.

 Altruistic value

According to Holbrook (1999; 2006) altruistic value is a consumer value component that is

comprised of ethics and spirituality. The author states that altruistic value is an intrinsic,

other-oriented construct, which means that a consumption experience is appreciated as an

end-in-itself and for the sake of others. Specifically, the altruistic value of a product or service derives from consumers’ engagement in ethically desirable practices or from the feeling of some sort

of spiritual ecstasy that accompanies a consumption experience (Holbrook, 2006). Dodds et al

(2014), note that spirituality and ethics are integral components of CAM and play a critical role in consumers’ evaluations of a CAM therapy. Nonetheless, ethics and spirituality have scarcely

been examined in the literature and Sanchez-Fernandez et al. (2008) argue that due to their

closely related natures the two components can be combined under the umbrella of altruistic value. Therefore, after following Holbrook’s recommendations, the authors combine these two

components into one category. This study also follows Sanchez- Fernandez et al. (2008) and

Holbrook’s (1999; 2006) advice and treats ethics and spirituality as one component, namely

Theoretical Framework|18

a. Spiritual value

The spirit is considered as the ‘life force’ by which individuals act and a dominant driver of

human behavior (Golberg, 1998) and consequently of consumption choices. Nevertheless,

spirituality as a motivation for consumption, has rarely been examined in the literature. The

first step towards a definition of spirituality, that is relevant for consumption experiences, is

conducted by Skousgaard (2006), who states that there are three main categories of spirituality:

meaning, connection and emotional transcendence. Meaning refers to consumption choices that

add a sense of meaning in life and it is associated with the concepts of purpose, hope and

personhood (Golberg, 1998). Connection is associated with consumption experiences that

involve relationships with other people, nature or a Higher Power and the connection with one’s internal selves (Holbrook 1999; Thompson and Troester, 2002). Hope, love, compassion,

trust and forgiveness act as primary influents of one’s sense of connection (Golberg, 1998).

Finally, emotional transcendence incorporates consumption decisions that create feelings of

peace, inner harmony, comfort, or a sense of security (Golberg 1998; Holbrook 1999). Meaning

and connection constitute the cognitive components of spiritually, whereas emotional

transcendence refers to the affective component of the construct (Skousgaard, 2006). A visual

representation of spirituality and its components is shown in figure 2.

Source: Skousgaard (2006)

Figure 2: Cognitive and affective components of spirituality

Spirituality

Cognitive components

Meaning

Sence of meaning in life, purpose, hope,

personhood

Connection

Connection with others, nature, Higher power and inner self. (Feelings of hope, love, compassion, trust, forgiveness)

Affective components Emotional transcendence

Peace, inner harmony, comfort, sense of

Theoretical Framework|19 For CAM the most relevant component is the emotional transcendence that users feel after their

consumption experience. Although some participants have reported a sense of connection with

their inner self or God and a way to find purpose in life (Dodds et al, 2014), feelings of peace,

harmony and balance express the dominant spiritual benefits that CAM users gain (Thomson

and Troester, 2002; Spence and Ribeaux, 2004; Sointu, 2006; Zainuddin et al, 2011). Thus,

the positive spiritual evaluation of a CAM treatment has the ability to further the continuance

of CAM.

b. Ethics (natural aspect of treatment)

Thomson and Troester (2002), argue that consumer culture is fragmented across a number of

consumption microcultures, each one with its own distinct patterns of socially shared meanings

and practices. These value systems are evident in the stories consumers say about their

consumption experiences (Thomson and Troester, 2002). One such cluster is the natural health

consumers who seek balance, flexibility, mindfulness and a knowledge of the holistic

interconnections that affect health and well-being (Thomson and Troester, 2002), and many

CAM users are a part of this post-materialistic health cluster (Bishop et al, 2007).

CAM consumers either have prior beliefs or post-purchase appreciation of the holistic approach

of CAM treatments on the body, mind, and spirit (Tataryn, 2002; Spence and Ribeaux, 2004;

Dodds et al, 2014). Furthermore, the natural aspect of CAM is what drives a substantial

proportion of users into it in the first place (Bishop et al, 2007), since many CAM users criticize

biomedicine of being too body-invasive (Sointu, 2006; Dodds et al, 2014). Many CAM users

share the faith that psychological factors have a role in the appearance of health problems

(Furnham and Kirkcaldy, 1996), therefore biomedicine is inadequate to restore and maintain

their health. Rather, the notion that CAM can support the ability of the body to heal itself

Theoretical Framework|20 continuance. Therefore, and since ethics and spirituality are united under the construct of

altruistic value, it can be argued that altruistic value is able to motivate CAM loyalty.

Hypothesis 5: Altruistic value (spirituality and ethics) has a positive effect on CAM loyalty.

 Play (leisure activities, relaxation)

Play within the consumption context is defined as a self-motivated construct, involves having

fun and is connected with people’s need for leisure (Holbrook, 1999; Sanchez-Fernandez et al,

2008). Payne et al (2010) state that the combination of health treatments with complementary

leisure activities can increase physical and psychological well-being. Furthermore, it has been

noted that leisure activities that match an individual’s personality boost well-being(Melamed

et al, 1995), increase life satisfaction, work productivity and enhance interpersonal

relationships (Mannell, 2007). However, the connection of play with health care practices,

mostly revolves around leisure activities that are advised by health providers along with an

ongoing treatment.

Some CAM therapies can be considered as leisure activities themselves (Dodd et al, 2014).

Examples could be yoga, aromatherapy, massage and reflexology. It is suggested that a part of

CAM therapies, like those mentioned above, could be seen by CAM users as leisure activities,

while practitioners advise the complementation of other CAM therapies with extra leisure

activities, such as walking in nature, to increase the effect of the treatment and to reduce stress.

Dodds et al (2014) discover that CAM users experience some CAM therapies as relaxation

activities, whereas extra leisure activities along with CAM treatments are seen as a contribution

in achieving life balance and well-being. Therefore, it is indicated that play is an important

aspect of CAM, as it most certainly advances at least subjective well-being, and thus has the

ability to promote CAM loyalty.

Theoretical Framework|21

CAM user groups

The first study to address CAM users as not a homogenous group is that of Sirois and Gick

(2002), who state that CAM users belong in two different groups: new/infrequent users and

established CAM users. Their research shows that motivations for CAM use between these two

groups are different. One the one hand, new/infrequent clients are driven into CAM due to

health aware reasons and dissatisfaction for conventional practices, whilst on the other hand established users’ behaviors can best be predicted by congruent with CAM health beliefs. They

conclude that CAM users are more sophisticated than previously thought and that they should

be studied further.

This perspective is also shared by Smuel and Shuval (2006), who demonstrate that personal

characteristics are important determinants of CAM use. Therefore, according to them, it is

better to classify persons by their user-type (CAM only or both CAM and CMT), than just by

the user/non-user classification. Congruent with the above studies, is the paper by Furnham

and Smith (1988) who categorize CAM users into three different groups: opportunists (who

use both CAM and CMT), principalists (who use only CAM), and those that are frustrated by

conventional practices.

In an effort to apprehend CAM use from a consumer behavior perspective, Spence and Ribeaux

(2004), illustrate that CAM usage patterns could be explained by the Theory of Planned

Behavior (Ajzen, 1991), identifying two different groups of CAM users: the CAM believers

(who only use CAM) and the CAM seekers (who use both CAM and CMT). This categorization

is attributed to the sick or in search of well-being CAM users, respectively, and will be adopted

as such in the remainder chapters of this research. CAM believers adopt CAM in order to

achieve general well-being, and perceive it as a hedonic consumption experience (Spence and

Ribeaux, 2004), On the contrary, CAM seekers are, on their majority, individuals with health

Theoretical Framework|22 (Rossler et al, 2006) or because of dissatisfaction or perceived inability of conventional

therapies to treat their condition efficiently (Sirois and Gick, 2002; Grzywacz et al, 2007).

Research to date has indicated that a great proportion of CAM users do so, due to their overall

health beliefs and the notion that health transcends the physiological dimension into more

abstract notions such as the mind and the spirit (Sirois and Gick, 2002; Spence and Ribeaux,

2004; Sointu, 2006; Zainuddin et al, 2011). Astin (1998) notes that a proportion of CAM users are “cultural creatives”, a group of people who are committed to feminism, environmentalism,

spirituality, personal growth and a love for the foreign and exotic.

By considering the above studies, it can be seen that there are deeper personal values and beliefs

that drive a proportion of individuals into CAM usage. Different studies have used different

names for the two user groups; however the characteristics of these groups remain the same

across all of them. The names used for the groups, as well as the group definitions adopted in

this research, are of little importance. Instead, what is of great interest is that academia has

acknowledged that CAM can be better understood under the scope of the user classification,

since the two groups are potentially driven to CAM for different reasons, and perhaps they

value their experiences divergently.

Nonetheless, value is a situational, unique to every person and of higher level of abstraction

construct (Zeithaml, 1988) and a key element of the decision to continue using a certain service.

Consequently, differences in value perceptions between seekers and believers are most

probably present, and must be taken into consideration in order to understand users’ decision

to maintain CAM use. In general, CAM seekers turn to CAM due to health issues. Therefore,

it is possible not to trust CAM or to be uncertain of its effectiveness prior to its use. However,

if a CAM therapy provides consumers with the desired outcomes, the faith in CAM

effectiveness is enhanced and this could influence their attitudes towards CAM overall, driving

Theoretical Framework|23 in CAM therapies, therefore a negative evaluation of a certain therapy or provider is capable

of influencing their decision to maintain their relationship with that provider but not strong

enough to drive them away from CAM therapies in general.

It is argued that, when value components between seekers and believers will be tested, quality

of care and efficiency of treatment will have the greatest impact on CAM loyalty for CAM

seekers, whilst altruistic value (ethics and spirituality) will be a dominant value component for

CAM believers. This argument is based on the work of Sirois and Gick (2002), Thomson and

Troester (2002), Sointu (2006), and Bishop et al (2010), and on the notion that the two groups

have different perspectives on health. One the one hand, seekers need CAM therapies to treat

a health issue, while one the other hand, believers are concerned of their general health status,

regardless of the presence of a current health problem. Therefore, the following hypotheses are

formed:

Hypothesis 7a: Consumer’s user group will moderate the relationship between quality of care

and CAM loyalty, so that the positive relationship between quality of care and CAM loyalty is

stronger for CAM seekers than for CAM believers.

Hypothesis 7b: Consumer’s user group will moderate the relationship between treatment

efficiency and CAM loyalty, so that the positive relationship between treatment efficiency and

CAM loyalty is stronger for CAM seekers than for CAM believers

Hypothesis 8: Consumer’s user group will moderate the relationship between altruistic value

and CAM loyalty, so that the positive relationship between altruistic value and CAM loyalty is

stronger for CAM believers than for CAM seekers.

An optical representation of the conceptual model and the suggested relationships can be

Research Method|24 The coming chapter presents the research method that was adopted in order to answer the

research question and test the above hypotheses, as well as a detailed explanation of the sample

recruitment and the procedure that was followed during the data collection.

Research Method

In order to test the above hypothesized relationships, a positivism research philosophy and a

deductive approach, to test the consumer value model proposed by Dodds et al (2014) and its

effect on CAM loyalty, were adopted. For the purpose of this study, the use of a questionnaire

was deemed as the most appropriate solution. Questionnaires are widely used in behavioral

sciences to measure perceptions, attitudes, behaviors and decisions and are suitable for answering “how” questions. In addition, sampling techniques are suitable for collecting data

that can be generalized to the entire population, with only testing a small sample of it. (Saunders

and Lewis, p. 116, 2012). The ability to collect a large amount of data and the ease of

comparison across respondents, due to its standardized nature, were the main advantages of

this research method and led to the decision of its adoption. However, the standardized nature Direct effect Moderating effect

Figure 3 : Conceptual Model

CAM user group (seekers/believers) Quality of care Treatment efficiency Aesthetics Social value Altruistic value Play CAM loyalty H1 H2 H3 H4 H5 H6 H8 H7b H7a

Research Method|25 of a structured survey offers limited answer flexibility, and leads, thus, to forced choices, a

limitation of the method that should be taken into account.

The sample that was tested, the procedure that was followed and the measurement of the

variables that were used, are presented, in detail, below.

The sample

A non-probability sampling technique and a self-selective sampling were used to recruit

participants. Responders were recruited both online and offline, by means of an online survey

and from CAM clinics and centers of the Amsterdam region, respectively. The aim of this

research is to test the effect of consumers’ evaluations of CAM therapies that are provided by

a practitioner, thus are not self-selected, on their loyalty towards the CAM domain.

Consequently, by recruiting respondents from CAM clinics and centers, it was ensured that all

participants were engaged in at least one CAM treatment that was administered by a

practitioner. On the other hand, the online survey is less controlled by the researcher, thus it

can be subject to bias. In order to make sure that participants who answered the online version

of the questionnaire were indeed familiar with CAM, the online version was posted on social

network pages about CAM and on CAM forums. Furthermore, to ensure that online recruited

participants were engaged in at least one CAM therapy that was provided by a practitioner, a

question was added in the online version of the questionnaire that asked them to indicate the

kind or kinds of CAM they had in mind when filling out the questionnaire. The particular

question was also added on the offline version of the questionnaire, so as to get data for the

kinds of CAM participants had in mind when answering the survey. It is argued that, all CAM

users could potentially had received more than one kind of CAM therapy within the last six

months and by indicating them on the survey, insights were provided about the spectrum of

Research Method|26 one CAM therapy that was provided by a practitioner were excluded from further research.

Thus, this way the representativeness of the online sample was controlled as much as possible.

42 CAM clinics and centers were approached for permission to include their clients in the

study. Of the 42 contacted, six agreed to administer the questionnaire to their clients: two

massage clinics, one chiropractor clinic, two acupuncture clinics and one yoga center.

Participants were given a written version of the questionnaire along with a description of the

purpose, scope, and intended outcomes of the research. Moreover, assurances of confidentiality

and anonymity were also given, in order to minimize response biases. From the 130

questionnaires that were administered, 37 were answered, which resulted in a response rate of

28,4%.

The online survey was identical with the offline version with the first page presenting the

purpose, scope and intended outcomes, as well as ensuring respondents for the confidential and

anonymous handling of their data. 189 respondents started the online survey, with 103 of them

completing it. This gave a response rate for the online version of 54,4%. Combined, from the

319 questionnaires that were given to and started by participants, 140 were completed (103

online and 37 offline surveys), resulting in a total response rate of 43,8%. The overall response

rate was lower than expected but not surprising, given the fact that response rates have fallen

over the years (de Leeuw and Heer, 2002). After eliminating respondents who failed to answer

properly the above mentioned question, a final sample of 121 participants composed the final

data set for the analysis. Based on Green (1991), the number of participants needed to test the

effect of individual predictors on a dependent variable, should exceed the number of predictors

by 104. In this research, this translates to a number of participants of at least 110 so as to test

the effect of each of the six consumer value components on loyalty. Thus, the final sample,

despite the relatively low response rate, meets the sample size requirements for the purpose of

Research Method|27

Translation-back translation procedure

The online version was written in English, since the majority of CAM forums and social

network pages were in English. Practitioners who participated in the offline research requested

a Dutch version of the questionnaire as it would be more convenient for their patients to answer

the survey in their mother language. Five out of the six clinics and centers were working with

Dutch clients, however, one was working with only non-Dutch speakers. In addition, three

more clinics had a proportion of non-Dutch speaking clients. In overall, both English and Dutch

versions of the offline questionnaire were given to four of the clinics, while the fifth and the

sixth clinic requested only Dutch and English copies of the survey, respectively.

The measurements were derived from English studies and the English version of the

questionnaire was developed first. Afterwards, a translation- back translation procedure was

adopted. Firstly, the English version was translated from English to Dutch by a native Dutch

speaker. Afterwards, a second native person re-translated the questionnaire from Dutch to

English. Both persons had an excellent knowledge of the English language, as well. A small

number of discrepancies between the two versions was detected and corrected, ensuring that

the two different versions of the questionnaire had the exact same content.

Pilot testing

Before the final administration of the questionnaire, a pilot testing with a small group of

respondents was conducted to validate that all the questions were perceived as intended and no

difficulty in answering the questions was present. The English version of the questionnaire was

administered to eight CAM users and two CAM practitioners, one chiropractor and one massage practitioner. During the pilot testing it was illustrated that, some questions’ wording

was unclear to the participants, thus the sentences were slightly changed, so as to ensure that they were totally comprehensive. In addition, the drop of the efficiency item “I had promptly

Research Method|28 received my bill and paid”, due to the indicated irrelevancy with the context, as well as the

formation of the final quality of care scale were also finalized during the pre-test, after

indications and recommendations from the respondents.

Sample demographics

Participants’ age ranged from 17 to 82 years (M=34.5, SD=13,14), with 68,5% aging between

23 and 39 years old. 79,3% of the respondents were females, whereas only 20,7% were males.

The greatest proportion of them were either holding a bachelor’s (33,9%) or a master’s degree

(43,8%), with no participant below high school level education. As far as financial status was

concerned, the majority of the respondents had a yearly income of below 25.000 € (45,5%) and 50.000 € (20,7%), respectively. One quarter of responders though (25,6%), did not wish to

disclosure their income levels. Respondents were also asked to indicate the duration and

frequency of their CAM use. The greatest part was following CAM treatments for more than

three years (38%), followed by relatively new users of one to five months (26,4%) and six to

eleven months (19%). Finally, most of the users were engaged with CAM at least once a week

(29,8%), two to three times a month (23,1%) and once every two to three months (25,6%).

From the above demographics it can be seen that the greatest percentage of respondents was

young females of higher educational levels, relatively heavy users and low yearly incomers

who engaged with CAM for a long period of time. These results are in accordance with

previous researches that indicate that females of higher educational levels are reporting higher

levels of CAM use (Eisenberg, 1993). Nevertheless, there is a contradiction of the demographic

results of this research with previous studies. Although it is indicated that older and higher

income women are more prone to CAM use (Eisenberg, 1993; Grzywacz et al, 2007), this study

showed that the majority of the respondents were below 40 years old and had an income of less

Research Method|29 turn to CAM due to the increasing financial burden of conventional medicine therapies, thus

are low income individuals. Though a substantial proportion of participants did not wish to

reveal their financial status, a fact that can have an impact on income estimations, it is argued that the overall demographic results in this study support Furnham and Forey’s (1994) view

that demographics are not the most suitable way to make conclusions about CAM use.

Finally, the respondents who participated in the study pointed out 23 different CAM kinds that

had been provided to them by a practitioner within the past six months. The greatest

percentages were for yoga (24,7%), chiropractic (13,6%), acupuncture (12,3%), massage

(11,7%), Pilates (10,5%), homeopathy (6,2%) and herbal medicine (5%). The remaining 16%

included alternative treatments provided by conventional doctors regarding nasal congestion

and urologic issues, meditation, naturopathy, reiki, reflexology, Ayurveda, mind support,

osteopathic, traditional Chinese medicine, medical biomagnetism, hair analysis, crystal therapy

and orthomolecular treatment. A list of definitions of the CAM therapies that were identified

by participants in this research is provided in Appendix 1.

Measurement of variables

In order to ensure content validity, construct validity and reliability of the measurements,

existing measurement scales, taken from the literature, were used in order to test the

hypotheses.

Consumer value

To measure the consumer value components, the scale items developed by Sanchez-Fernandez

et al (2008) were adopted. This decision was made for two reasons. Firstly, the qualitative study

of Dodds et al (2014) is based on the components identified by Holbrook (1999) as relevant

for services’ consumption. These components are the starting point of Sanchez-Fernandez and

Research Method|30 Holbrook to measure the six dimensions of consumer value within a services context

(Sanchez-Fernandez et al, 2008). Since this study also addresses the same dimensions, the scale items

were considered as the most appropriate measurement option. Secondly, although there were

other measurements that are widely used for some of the components addressed in this research,

such as the SERVQUAL scale for service quality (Parasuraman et al, 1985; 1988), which

however refers to a particular service episode (Maklan and Klaus, 2011) and was not suitable for our six months’ time span, no scale for spirituality and ethics is present in the literature.

Due to their close relationship, the lack of empirical approaches for their conceptualization and measurement and after following Holbrook’s recommendation, Sanchez-Fernandez et al

(2008) unified the two constructs into one component, namely altruistic value. Thus, due to the

lack of existing measurements for spirituality and ethics, their recommendation and

measurement approach was followed in this research, as well. In addition, social value

measurements that are developed by other researchers, such as the one by Sweeny and Soutar

(2001), were inappropriate with the social value definition that was identified by CAM users

(Dodds et al, 2014) and adopted in the research. All together, the scale items by

Sanchez-Fernandez et al (2008) were considered as the most suitable measurement for all the six

constructs. Nevertheless, items were either added or dropped after a pre-test of the

questionnaire, so as to fit in the CAM context. The items that were used are explained in detail

in the following section.

Consumer value components’ measurements

The first section of the questionnaire included the consumer value scale, which was comprised

of 30 items that represented the six value dimensions: service quality, treatment efficiency,

social value, play, aesthetics and altruistic value. All items were adapted to fit the CAM

context. Participants were asked to assess their level of agreement with the 30 items, taking

Research Method|31 months. The reason for this timeframe was that the CAM experience of only one practitioner

is not the interest of this research. Rather, what is tested is whether the value they had derived

from their engagement with one or multiple practitioners and CAM therapies had the ability to

influence their decision to engage in long-term relationships with CAM. Therefore, a six-month

time horizon was considered as an appropriate timeframe for the purpose of the study. It is

argued that people can remember their past encounters with CAM practitioners, process the

value they had derived from these encounters and reach to the decision to engage in long-term

CAM use. Furthermore, evaluations of service providers within a given timeframe rather than

a unique encounter are considered more appropriate for the services industry and have also

been applied in previous researches of service providers, including the health sector (Bitner et

al, 1990; Kelley and Davis, 1994; Stephen et al; 1998)  Quality of care

For the quality of care component, two of the original four quality items from the Sanchez-

Fernandez (2008) scale, and eight of the nine service quality items, developed by Cronin et al

(2000), were used. Cronin’s et al (2000) scale was chosen due to its similar, yet more

comprehensive and detailed nature than Sanchez-Fernandez’s et al. (2008) scale. The two items

that were dropped from the Sanchez-Fernandez et al (2008) were replaced by the more detailed eight items of the Cronin’s et al (2000) scale. One item of Cronin’s et al (2000) scale was

dropped due to its high similarity with treatment efficiency items. These final ten items were

measured on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).  Treatment efficiency

Treatment efficiency was measured with four of the five treatment efficiency items from the

Sanchez-Fernandez’s et al (2008) scale. The item “You have promptly received your bill and paid” was dropped after pre-test respondents’ indication of irrelevancy with the CAM context.