CAM Utilization Among OEF/OIF Veterans: Findings From the National Health Study for a New Generation of US Veterans

Reinhard, Matthew J. PsyD*,†; Nassif, Thomas H. PhD*,‡; Bloeser, Katharine MSW, LICSW*; Dursa, Erin K. PhD, MPH§; Barth, Shannon K. MPH§; Benetato, Bonnie PhD, FNP-BC, MBA∥,¶; Schneiderman, Aaron PhD, MPH, RN§

doi: 10.1097/MLR.0000000000000229
Original Research

Background: Complementary and alternative medicine (CAM) is increasingly seen as an adjunct to traditional plans of care. This study utilized a representative sample of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans and OEF/OIF-era veterans to explore the prevalence and characteristics of CAM users.

Research Design: The National Health Study for a New Generation of US Veterans (NewGen) is a longitudinal health study of a population-based cohort of OEF/OIF (deployed) and OEF/OIF-era (nondeployed) veterans. Data from the 2009–2011 NewGen survey (n=20,563) were analyzed to determine prevalence of CAM use by demographic and military characteristics, the types of CAM modalities used, and where the modalities were sought. Results were weighted to the entire population of OEF/OIF and OEF/OIF-era veterans.

Results: There was no statistically significant association between CAM use and deployment. Those who used Department of Veterans Affairs (VA) health care after separation were more likely to be CAM users compared with those who did not use VA care; however, the majority of veterans using CAM are using it outside the VA health care system. Massage was the most prevalent CAM modality followed by chiropractic treatment; males were less likely to use CAM than women.

Conclusions: CAM modalities are being utilized by OEF/OIF veterans for health problems mainly outside the VA. Policymakers should determine appropriate use of these modalities.

*War Related Illness and Injury Study Center (WRIISC), Washington DC Veterans Affairs Medical Center

Georgetown University Medical School, Department of Psychiatry

American University School of Education, Teaching and Health

§US Department of Veterans Affairs, Office of Public Health, Post Deployment Health, Epidemiology Program, Washington, DC

Veterans Affairs Greenville NC CBOC

East Carolina University, College of Nursing, Greenville, NC

Supported by the Department of Veterans Affairs Office of Public Health and the War Related Illness and Injury Study Center.

The authors declare no conflict of interest.

Reprints: Matthew J. Reinhard, PsyD, War Related Illness and Injury Study Center, Veterans Affairs Medical Center, Room 3B 203 (Mail Stop 127), 50 Irving St, NW, Washington, DC 20422-0002. E-mail:

Article Outline

Complementary and alternative medicine (CAM) encompasses a broad spectrum of practitioner-assisted interventions, self-care therapies, and natural products to prevent illness, treat disease, and maintain well-being.1 CAM practitioners typically focus on the nutritional, emotional, social, and spiritual contexts of illness, in addition to the physical and biochemical attributes.2 In 2007, 10 million US adults used CAM for treating illness, 32 million for health promotion, and 29 million for both purposes.1 Approximately 4 of 10 US adults in the general population2 and among military personnel3–5 used CAM in the past 12 months.

Chronic health problems are an increasing concern for veterans deployed to Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). Understanding CAM utilization patterns is important for informing health care policy decisions and medical providers delivering care to those with chronic health conditions. Among veterans receiving care at Department of Veterans Affairs (VA) facilities, 27% used CAM within a 12-month period.6 However, surveys limited to VA users do not provide an accurate representation of CAM utilization among all veterans, as only 41% of post 9/11 veterans use the VA as their primary care provider.7

Prior research suggests that CAM use is more prevalent in previously deployed veterans.8 Military CAM users also tend to be women,3–5 which is consistent with studies of the general population.9–19 Single marital status is associated with CAM use among service members5 and veterans8 but not in the general population.10,11,20 White non-Hispanics more frequently use CAM in the US military4 and in the general population,10,12,13,15,16 but many studies have found no relationship between race and CAM use.10,11,19,21,22

Poor self-reported health status has been widely demonstrated among CAM users.3,5,12,14,16,20,21,23–27 CAM utilization is associated with chronic health conditions24 including worse mental health,17,25 psychiatric disorders,11 depression,25,28 anxiety disorders,21,25 diabetes,19,29 and gastrointestinal problems.8,28 Self-reported mental health conditions and symptoms are correlated with CAM use in active duty military3,5 and veterans,8 including PTSD and depression. Active duty military and retirees most commonly used CAM for chronic pain conditions, stress, depression, health promotion, and disease prevention.30

Veterans deployed to a combat zone report poorer health than veterans not deployed.31–34 Conditions associated with CAM use including depression, anxiety, PTSD, and chronic pain are also associated with deployment to OEF/OIF.35–37 The current study examined differences in CAM usage between 2 populations [OEF/OIF (deployed) and OEF/OIF-era (nondeployed) veterans] by demographic and military characteristics, the types of CAM modalities used, and where the modalities were sought.

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Data Collection

The National Health Study for a New Generation of Veterans (NewGen) is a longitudinal cohort study to evaluate the health status of OEF/OIF veterans compared with nondeployed veterans serving during this period. Veterans reported current medical conditions and CAM utilization.

This longitudinal survey of 30,000 OEF/OIF and 30,000 OEF/OIF-era veterans was sampled from the Department of Defense (DoD) Manpower Data Center and the VA/DoD Identification Repository (VADIR), respectively. The response rate was approximately 34% (n=20,563). The permanent panel includes a population-based sample of troops from each branch of service, unit component (active duty, reserve, National Guard), and sex. Women were oversampled to provide sufficient representation in the study, comprising 20% of the sample.38

Veterans were asked if they used VA health care services after they separated from active duty. In addition, participants reported the number of alternative treatment visits in the past 12 months that were made because of health problems. If alternative treatments were used for health problems, participants were asked whether they used any of the listed treatments, the reason for the treatment, and whether it was used at the VA or elsewhere. CAM users were those who reported ≥1 visits for alternative therapy for a health problem. Treatment categories included acupuncture, biofeedback, chiropractic care, energy healing, folk remedies, herbal therapy, high-dose/megavitamin therapy, homeopathy, hypnosis, massage, relaxation, and spiritual healing. The protocol was approved by the Washington, DC Veterans Affairs Medical Center Institutional Review Board.

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Data Analysis

The χ2 analyses were conducted to determine whether the prevalence of CAM use was different between deployed and nondeployed veterans. The prevalence of CAM use was calculated and stratified by deployment status for demographic and military characteristics. Unadjusted odds ratios (OR) [with 95% confidence intervals (CI)] were calculated. The prevalence of CAM modality by location (VA or non-VA) stratified by deployment status were then calculated. All analyses were completed using SAS version 9.3 and were considered significant at the P≤0.05 level.

Weights were used to adjust for the stratified sampling design, nonresponse, and misclassification in the sampling frame to improve precision and accuracy of the population prevalence estimates. Basic weights to account for the stratified sampling design and nonresponse were developed. A proportion of the subjects identified as nondeployed by the VADIR records and part of the original population of controls when sampling occurred had deployed before or during data collection. To account for misclassification in deployment status in the sampling frame, Yoon et al39 used a technique reported by Kuha and Skinner40 to adjust the survey estimates. Yoon et al39 used a misclassification matrix, representing the misclassification error, to update the sampling frame totals to account for misclassification. Once the misclassified population counts were corrected, they raked the weights to sampling frame counts for sex, service branch, unit component, highest education, and birth year cohort and self-reported deployment status.39

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The prevalence of 12-month CAM use did not differ statistically between OEF/OIF (14.8%) and OEF/OIF-era (13.9%) veterans (P=0.103). Females were more likely than males to use CAM, with an OR of 1.64 (95% CI, 1.45, 1.86) in OEF/OIF veterans and 1.87 (95% CI, 1.59, 2.19) in OEF/OIF-era veterans (Table 1). Veterans who reported using VA health care since separation were more likely to report CAM use than those who did not in both OEF/OIF veterans (OR, 1.62; 95% CI, 1.39, 1.89) and OEF/OIF-era veterans (OR, 1.53; 95% CI, 1.37, 1.70). Single never married veterans were less likely than married veterans to use CAM among both OEF/OIF veterans (OR, 0.71; 95% CI, 0.61, 0.83) and OEF/OIF-era veterans (OR, 0.64; 95% CI, 0.52, 0.79).

Table 2 provides prevalence of CAM use by modality and location, stratified by deployment status. The majority of veteran CAM users sought services outside the VA health care system. Massage, chiropractic, and relaxation were the most commonly reported CAM modalities across both groups.

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Approximately 15% of OEF/OIF veterans and 14% of OEF/OIF-era veterans used at least 1 CAM treatment within the past 12 months for a health problem. This figure was considerably lower than other nationwide CAM prevalence studies on military personnel (37%–41%)3–5 and civilians (40%), which surveyed overall CAM use not limited to health-related treatments. It is likely that the percentage of CAM users would be higher in the present study if participants were asked about overall CAM use for health promotion, disease prevention, or leisure, which may be more common reasons for utilizing CAM. Future surveys should consider assessing these categories along with treatment of a health problem to further decipher CAM utilization and prevalence. Qualifying CAM use to the treatment of a health problem may be especially informative for health care organizations in considering how to best serve their patient population. The types of CAM modalities reported most frequently (massage, chiropractic, relaxation, spiritual healing, and herbal therapy) were consistent with previous studies on veterans and military service members,3–5,6,30 and in the US population.1

Across modalities, CAM treatment for health problems was used predominantly outside the VA, a finding that may be explained by lack of CAM access within the VA. Availability of CAM is variable across VA facilities, and in place of providing CAM services VA medical centers may utilize community resources on a fee-for-service basis. Increasing CAM offerings to veterans may provide an incentive to prospective patients considering VA care. McPherson and Schwenka30 found that 70% of active duty respondents desired CAM services to be offered at their military medical treatment facility. Likewise, 76% of veterans reported they would use CAM modalities if they were offered at their VA treatment facility,41 and VA medical centers have reported that CAM services were in high demand based upon current and past CAM use by patients.42 High rates of satisfaction with care and improvement in physical and mental health symptoms for veterans enrolled in CAM services within a VA medical setting have been demonstrated.43 Opportunities to access CAM within VA are increasing,44 and future prevalence estimates will likely reflect this growth.

No relationship was found between CAM use and deployment status. However, active duty and Navy personnel were each 20% less likely than reserve or National Guard veterans to use CAM. The finding that CAM users were more likely to have higher education was consistent with veteran and overall population studies.5,8,9,11–14,16,17,21–23 CAM use among deployed veterans was not associated with higher household income, which is consistent with other studies10,12,19–22,24 but contrasts with studies that reported higher socioeconomic status among CAM users.8,35 The decreased likelihood of CAM use among veterans of single marital status contradicts military studies, which found the opposite relationship.5,8 Our findings are perhaps supported by the research showing increased health care access and use among married individuals.45 Our results also show that veterans who used VA health care were more likely to report CAM use. We know that the VA patient population has been found to exhibit poorer health status compared with the general patient population,46,47 and it is possible that VA patients are more likely to seek CAM services because of poorer health. Finally, women were more likely to report CAM use than men, which has been observed in the general population and military.3–5

Study limitations include the following. First, our analysis did not include all possible CAM modalities,2 and frequency and dose of CAM use was not available for analysis from the survey. In addition, CAM treatment survey items did not include a description of the therapy, which may have led to misinterpretation by participants. The 34% survey response rate in this study is similar to those reported by other national studies on military personnel3,4; however, the possibility exists that the responding sample provides less than an optimal representation of the overall veteran population.

Despite these limitations, this study represents the largest nationwide sample of US veterans to describe demographic characteristics and diagnosed medical conditions among CAM users. In this study, veterans reported using herbal therapy, homeopathy, or high-dose/megavitamin therapy outside the VA for a health problem. Safety concerns about CAM therapies have emerged including pharmacological interactions, infectious complications, and organ toxicity.48–50 The VA could engage in CAM treatments under sufficient clinical supervisory control. Continued rigorous research on the effectiveness and implementation of CAM within the VA is underway and needed to build the evidence base for these CAM modalities and to ensure that health benefits outweigh health risks in veteran populations. By increasing alternative treatment offerings to veterans who otherwise might seek CAM treatments outside of the VA, the risk of harm or adverse health effects can be mitigated. This study provides useful information for health care providers and policy makers committed to providing optimal care and improving health outcomes in this population. As the largest health care system in the United States, the VA is uniquely positioned to take the lead in optimizing safe complementary treatments within an integrated patient-centered model of care.

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complementary therapies; alternative medicine; veterans health; health surveys; population characteristics; CAM

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