Survey Administration and Respondent Groups
Twenty-one population surveys were identified that queried CAM (Table 1). Respondents in tier 1 surveys were selected from active duty and reserve corps rosters in a stratified random sample (HRB, MCS, and NMC) or from patients in Veteran Health Administration (SMW and VAOP) or military outpatient medical center (MFMP and MAMC). Patient samples also included family members. Among the tier 1 surveys, 3 included questions that would permit analysis related to ever being deployed (MCS, HRB, and SMV); 1 survey permitted longitudinal analysis (MCS). Respondents from tier 2 were selected from household members by random dial telephone interviews (CHIS, MEPS, NHIS, HRS), or taken from patient records (NHHCS), or from in-home interviews (NHANES). Tier 3 survey samples were drawn from 3 sources as described in Table 1.16,25–38
The most recent military-related (tier 1) data were collected in 2005, compared with 2012 and 2013 in other household surveys. Five surveys included CAM questions only in a supplement rather than the core, including 1 military survey, 2 civilian surveys, and 2 in tier 3.
CAM Therapies Queried
Commonly, the survey listed specific CAM options, “Did you ever use any of the following CAM therapies in past 12 months?” One survey did not query any specific CAM (SMV). In all cases, responses were yes/no. However, definitions regarding CAM varied. Some surveys combined CAM into an analytic category; for example, yoga and tai chi were combined as “movement therapy” (HRB) and kept separate in another (NHIS); Reiki and polarity were combined as energy healing (HRB) and kept separate in another (CHIS). Especially problematic was inconsistent definition of vitamins and prayer. Vitamins and dietary supplements were queried separately in 2 surveys (HRB and CHIS). Vitamins alone were queried in 1 survey (MFMP); dietary supplements alone were queried in 5 (HRS, NHIS, NHNES, MAMC, and VAOP); and neither was specifically queried in 4 (CPES, MCS, NMC, and NHHCS). Terminology regarding prayer and spiritual practices varied as well. Prayer could be listed separately or conditionally defined as “prayer for oneself,” “prayer in a group,” and “prayer for others.” Included in some surveys were “spiritual/religious healing,” “spiritual healing by others,” and “prayer/spiritual practice.” This is important to note because estimates of “any CAM” utilization may be inflated if prayer and/or spiritual practices were queried..2
Across all tier 1 and tier 2 surveys, a total of 49 different CAMs were queried. The most common CAMs queried in tier 1 surveys were acupuncture, chiropractic care, massage, megavitamin, herbal, and homeopathy. Among tier 2 surveys, the most common CAMs queried were acupuncture, megavitamins, and herbal therapy.
Utilization Estimates of CAM in Military-related Populations
Table 2 summarizes estimates of CAM utilization in past 12 months from military surveys, grouped by patient and nonpatient respondents. For comparison, the table reports on CAM therapies queried in at least 2 surveys. We combined some CAM modalities in a single category for analytic purposes: exercise with exercise therapy, music with music/art therapy, all forms of prayer, psychotherapy with self-help, and religion/spiritual with spiritual healing. “Any CAM” is the percentage of respondents reporting use of at least 1 CAM queried in the survey. Estimates on individual CAM items are a percentage of “any CAM.”
For reasons mentioned previously (lack of consistent definition of CAM and specific populations studied), the surveys report a wide range of utilization rates, with highest use generally among patient population. Overall, any CAM use ranges between 37% and 46% among nonpatient and between 27% and 72% among patient samples. The lowest estimate sampled a predominately male population that is less likely to use CAM.2 MAMC included retirees in its sample that may account for the higher utilization. Concurrent with other research, CAM estimates are higher in populations sampled from western region of the United States (MAMC and MFMP).39 Although it is likely that surveys that query more CAM therapies will report a higher percentage of “any CAM,” this table indicates otherwise. Specifically, among active duty respondents, HRB queries 20 CAM yet reports lower utilization than MCS with 12 CAM options.
Among nonpatient populations, the most common CAM used were: dietary supplements, exercise therapy, massage, prayer, and relaxation. Among the patient populations the most widely used CAM were: aromatherapy, art/music, chiropractic, herbs, massage, megavitamins, movement therapy, and relaxation. There was more consistency across surveys in the least widely used CAM with <11% using acupuncture, biofeedback, energy healing, folk remedies, homeopathy, hypnosis, naturopathy, and spiritual healing. Additional comparative estimates could be done with surveys listed in last column, especially CPES and NHIS that query most of the estimates published to date.
Associated Behavioral Health Conditions
Table 3 summarizes behavioral health conditions queried in tiers 1 and 2 surveys. Although exact wording of behavioral health syndromes varies slightly across tier 1 and tier 2 surveys, there were 11 different conditions queried. Four of 7 tier 1 and 6 of 7 tier 2 surveys queried at least 1 behavioral health condition.
Estimates are not presented due to the different denominators used (either as a percentage of respondents with the condition who use CAM, or as a percentage of CAM users with the condition). This table indicates that HRB and MCS provide the most information on behavioral health conditions that affect a large percentage of military and veteran populations. Although analyses have been conducted on HRB questions related to psychological disorders, published studies have not included associated use of CAM. Likewise, CPES queries the most psychological conditions but subpopulation analysis of military or veteran groups have not been published.
Additional CAM Questions
Generally, surveys do not query reasons for using CAM. Of the total 25 surveys originally abstracted, 9 query reasons for CAM use, including 1 military clinic-based sample. Although the question varied in other surveys, a typical phrasing was, “During the past 12 months, did you use [therapy] for your own health or treatment of [condition]?” Some government health care surveys sponsored by the National Center for Health Statistics permit associating a respondent’s survey with Medicare records, provider visit records, or another specific facility records so ICD9-CM diagnosis codes may be obtained on conditions under treatment. However, none of those surveys ask respondent about their military status.
This paper reports on a review designed to describe population surveys that provide estimates of CAM use in the military, provide estimates of CAM therapies used, and identify areas for future investigation. The findings report that estimates may be outdated and CAM questions were frequently contained on a supplement only, limiting the opportunity for tracking changes in utilization over time. In addition, surveys lacked congruence of CAM terminology and inclusion criteria, thus, findings must be viewed within the context of differences in methodology and population sampled. Surveys also varied in definition of military and whether responses were analyzed for those with specific conditions or all respondents.
Although difficult to study, the topic of CAM use among the military is important as consensus is growing in military and veterans’ health arenas that CAM interventions may have some utility as an adjunct treatment for psychological and other health conditions.6,40,41 Multiple deployments among OEF/OIF warriors and the aging of Vietnam era veterans result in a growing prevalence of musculoskeletal, traumatic brain injury,42 and psychological health conditions.43 In addition, rates of comorbidity across psychological health, pain, and brain injury are high.44 In short, we know these conditions are prevalent in military and veteran populations, but there are significant gaps in the data documenting the use of CAM to treat these conditions, implying the need for targeted studies.
Studies of civilians indicate that CAM may be filling gaps in access to conventional treatment, especially among those with psychological conditions. In 1 analysis, 42.8% of visits of respondents classified as having need for mental health care were treated with CAM.45 In addition, adults are more likely to use CAM when the cost of conventional care is less affordable.37 Similar analysis across military populations would help VA and military health systems monitor the need for workforce training and programmatic planning.
This review identified a number of challenges in understanding the use of CAM as currently documented in surveys. Few studies include the reason for CAM use, making it difficult to accurately assess the purpose that motivates CAM use. Motivation for CAM use among military personnel may be even more complex, for example, as part of a fitness regime,46 to reduce stress, or to address symptoms of a specific psychological concern or health condition. In turn, respondents may not attribute CAM use to 1 symptom or problem even when asked.
The findings from this analysis also identified several important gaps in our knowledge base. Some gaps could be remedied with incremental changes to survey questions, other gaps may require methods development, and other gaps could be addressed with additional analyses of extant data. Regarding incremental changes, surveys could include questions that distinguish military and veteran users of CAM by the condition for which they used CAM, hence making it easier to understand CAM use specifically in this population, especially for psychological conditions.
Another gap identified is that active military may be excluded from many epidemiologic surveys. Information on veteran status is sometimes present, but not consistently; this includes deployed history, years of military service, and retirement status. It is important to note that military personnel and veterans living in households are part of the general population, and as such may be sampled in general population surveys but unidentified unless veteran status is queried. This valuable information could otherwise be used to effectively inform policy and practice in military/veterans’ health services planning.
Questions about CAM obtained from surveys need further development to be more useful. It is difficult to summarize across epidemiologic studies as there are few common definitions of CAM and the lists of CAM therapies queried as “any CAM” rarely overlap. On the basis of review of existing studies, consensus should be reached on a gold standard for core questions to include in health surveys. The DoD and VA could promote discussions among key sponsors of such surveys to adopt a core list of CAM definitions. Recommendations could also be made that national surveys always include questions about CAM that are highly utilized. Surveys might also include standard questions about why the respondent uses CAM, in particular, whether a particular CAM is being used as a complement to or substitute for traditional treatment. Gathering this information is difficult in the context of a structured interview format, and methods development is necessary to collect more information about how a respondent uses CAM.
Despite these shortcomings, there are worthy analyses that could be conducted through further disaggregation of general household studies (NHIS, CPES, and CHIS). In addition, linking survey responses of veterans and military personnel with health utilization encounters (eg, Millennium Cohort Study) provides detailed information on conditions being treated by conventional medicine with self-report of CAM usage. Moreover, there is value in methods development to analyze data from different surveys jointly so that statistical comparisons with covariate controls can assess differences in the prevalence of CAM usage among military, veterans, and civilians.
Lastly, understanding how patients perceive CAM and currently use it for conditions for which they also receive conventional treatment is important information for medical practitioners. This may lead to better understanding of contraindications for CAM, including adverse interactions of CAM with traditional treatments. Therapies are often used by people completely on their own, and MDs cannot know about them unless they ask. At the very least, physicians need to be familiar with and to probe their patients on CAM that are most commonly used to treat specific ailments. Further analysis of these data beyond that already published and analyzed for this study could more completely inform the medical community on the medical and psychological conditions of CAM users.
The authors would like to acknowledge the support of Institute of Behavioral Health, Heller School, Brandeis University and additional research help from Lauren Hajjar.
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Keywords:© 2014 by Lippincott Williams & Wilkins.
military veteran; complementary alternative medicine; population survey; psychological health conditions; PTSD; survey analysis