Med Care. 2014 (Dec); 52 (12 Suppl 5): S83–90 ~ FULL TEXT
Margot T. Davis, PhD, Norah Mulvaney-Day, PhD, Mary Jo Larson, PhD,
Ronald Hoover, PhD, and Danna Mauch, PhD
Heller School for Social Policy and Management,
Institute for Behavioral Health,
Brandeis University, Waltham, MA
BACKGROUND: Recent reports reinforce the widespread interest in complementary and alternative medicine (CAM), not only among military personnel with combat-related disorders, but also among providers who are pressed to respond to patient demand for these therapies. However, an understanding of utilization of CAM therapies in this population is lacking.
OBJECTIVE: The goals of this study are to synthesize the content of self-report population surveys with information on use of CAM in military and veteran populations, assess gaps in knowledge, and suggest ways to address current limitations.
RESEARCH DESIGN: The research team conducted a literature review of population surveys to identify CAM definitions, whether military status was queried, the medical and psychological conditions queried, and each specific CAM question. Utilization estimates specific to military/veterans were summarized and limitations to knowledge was classified.
RESULTS: Seven surveys of CAM utilization were conducted with military/veteran groups. In addition, 7 household surveys queried military status, although there was no military/veteran subgroup analysis. Definition of CAM varied widely limiting cross-survey analysis. Among active duty and Reserve military, CAM use ranged between 37% and 46%. Survey estimates do not specify CAM use that is associated with a medical or behavioral health condition.
CONCLUSIONS: Comparisons between surveys are hampered due to variation in methodologies. Too little is known about reasons for using CAM and conditions for which it is used. Additional information could be drawn from current surveys with additional subgroup analysis, and future surveys of CAM should include military status variable.
Key Words: military veteran, complementary alternative medicine, population survey, psychological health conditions, PTSD, survey analysis
From the FULL TEXT Article:
There is a growing interest in complementary and alternative
medicine (CAM) use in general including among
veterans and military personnel. CAM use is growing, in part
to alleviate physical and psychological disorders and to increase
wellness. [1, 2] Adding to our knowledge about effectiveness
of CAM, a number of reports by the Veterans
Administration (VA) and the Department of Defense (DoD)
have reviewed the research evidence for CAM related to
specific psychological conditions including post-traumatic
stress disorder (PTSD), [3, 4] depression, and anxiety,  and as part
of a broad review on the evidence for mind-body practices. 
These reports reinforce the widespread interest in CAM among
military personnel and veterans dealing with combat-related
Despite this interest, the extent of CAM use among
military personnel and veterans is not well documented. Although
practitioner surveys within military and VA health
systems were recently completed,  many CAM therapies are
not monitored because they are not practitioner based (eg,
herbal treatments). Even CAM that is administered by practitioners
may not generate insurance claims thereby limiting
independent sources of data for analysis. One recent study
found that when CAM was provided in the VA, a procedure
code was assigned only 40% of the time.  Because therapies,
such as massage or high-dose megavitamins, are not typically
included in covered benefits,  the majority of CAM use is
possibly independent of the military health system and the VA
and therefore outside claims data analysis. Hence, obtaining
generalizable estimates of the extent of CAM utilization in
both military and civilian populations is dependent on selfreport
from population surveys.
CAM use is driven by several factors. As with the
general public, use is partly driven by lack of access to adequate
specialty mental health treatment and to stigma associated
with psychiatric conditions. [9, 10] Veterans who seek
professional care often find their symptoms may not be alleviated
by more traditional behavioral therapies.  Among the
military, rates of PTSD and chronic pain are high [12-14] and the
chronic nature of these conditions leads many to explore CAM
as adjuncts to conventional treatment [15-17]. Given that a recent
study found that military personnel use CAM 2.5–7 times more
frequently than civilians,  more reliable and efficient means of
assessing their use among military personnel through population
surveys is important for practitioners and for health
Challenges in identifying cam use through population-based surveys
The study of CAM utilization using survey methodology
presents 3 major challenges. First, investigations differ
regarding the definition or scope of CAM, especially when a
broad rubric is applied, and it can be difficult to classify which
treatments have moved from “alternative” to “mainstream”
categories. [18, 19] Even if investigators agree on a CAM list, it is
unwieldy to include all in a single survey. Secondly, the purpose
of CAM use is frequently not knowable. Determining
whether CAM use constitutes treatment for a specific health
condition can be difficult to assess, especially in cases when
CAM is delivered by providers outside of organized or licensed
medical settings (eg, massage). CAM may be used for
preventive and restorative purposes, [19, 20] as stand-alone conventional
treatment, as an alternative to conventional treatment,
or to complement conventional treatment.  Lastly,
defining and understanding dose is challenging. For example,
many herbal treatments are not regulated and strength of an
active ingredient may not be labeled.
Challenges in identifying military personnel and veterans in population surveys
Military personnel/veterans are a heterogenous group,
encompassing active duty, reserve, National Guard, retirees,
and veterans from peacetime and wartime eras. Definitional
issues exist even in surveys of military members and veterans.
Because of the differences in the way military and
veterans are defined both within and outside formal military
establishments, it is challenging to specify the analytic
group. For example, combat veterans can include current
military, only those separated from service, or restricted to
those entitled to VA benefits. Second, timing of survey is
critical as responses may vary due to war experience  especially
with regard to psychological conditions. Veterans
who served in combat in Iraq are likely to have different
needs and conditions than veterans who were not deployed.
Surveys generally do not query these 2 important measures
regarding military experience.
Because of the growth in utilization of CAM therapies,
the Military Operational Medicine Research Program of the
US Army Medical Research and Material Command
(USMRMC) requested an analysis on CAM and its use for
treatment of PTSD in military personnel.  The current
study, presents findings from the synthesis of CAM utilization
estimates prepared for the USMRMC project.
The present study was conceived as a gap analysis
through synthesis of literature regarding CAM utilization
among military personnel and veterans. The aims of this
paper are 3-fold: (1) describe population and self-report
surveys that provide estimates on CAM utilization; (2)
identify among these surveys the CAM therapies utilized in
the military population; and (3) identify areas for future investigation
through an analysis of questions asked on surveys,
especially ones that query psychological conditions
and reasons for use. The literature provides analysis of civilian
population surveys that focus on CAM,  but none to
date have been done of military surveys. With a focus on the
military, this analysis will add to our knowledge of CAM use
as well as document gaps in research and limitations of
current survey designs.
To accomplish these aims, a research team conducted a
literature search to identify population surveys. We extracted
content on relevant topics, and assessed gaps in the information
reported and available on CAM use among military
personnel and veterans. Survey analysis was approved
by Abt Associates Internal Review Board, Cambridge, MA.
Identification of Population Surveys and Inclusion Criteria
Three team members conducted independent online
search for household survey databases. First, we searched abstracts
in electronic databases for the literature that reported
estimates on CAM utilization from population-based, general
household, or military self-report surveys (Fig. 1). The electronic
databases PubMed, CINAHL, Embase, Psycinfo, Pilots,
Embase, Google scholar, and The Cochrane Library were accessed
to identify appropriate articles, as described in original
study report.  Searches were conducted between January and
June 2012 and updated on January 2014. No time frame was
imposed on survey administration. Keywords included: “CAM,”
“complementary medicine,” “alternative medicine,” “household
survey,” “population survey,” and “probability survey.” We also
searched selected Web sites to discover articles and reports that
did not result in peer review publications, including DoD,
Military and Veterans Health Administration, World Health
Organization, and National Center of Health Statistics.
Abstracts and reports were included if the survey was
population based (or used random selection of military respondents)
and queried at least 1 CAM. We utilized the National
Center for Complementary and Alternative Medicine’s
classification of CAM  for inclusion criteria. CAM therapies
are classified into: (1) biologically based practices, (2) mind/
body practices, (3) manipulative and body-based practices, (4)
energy-based interventions, and (5) whole medical systems.
Some private surveys could not be included as the results are
proprietary and perceived to be less relevant to our purposes.
Survey instruments were located from survey sponsors documentation
when available, or from the authors’ description.
To facilitate analysis, we created a data collection instrument
for extracting information from the retrieved survey
documentation and publications. If CAM questions were
administered in multiple years, we abstracted information
from the most recent survey. Elements extracted included
survey year, sponsor, study design, population sampled,
specific CAM questions, variables that define military/veteran
status, and main CAM results. Estimates on CAM utilization
were taken from peer-reviewed literature, or in some
cases, the sponsoring Web site if data were not published.
Team members reviewed all documentation manuals, read
main reports and publications, and consulted study’s Web
site. A third team member reviewed survey information to
ensure its completeness and clarity.
For analytic purposes we divided surveys with CAM
items into 3 tiers (Table 1). Tier 1 was defined as surveys of
military-related populations or patients including military
members, their dependents, and/or veterans. Tier 2 was defined
as surveys that queried general household members or
patients and included a question to identify the respondent’s
military or veteran status. Tier 3 was defined as surveys of
general household members or patients without a question on
veteran or military status. The main comparisons presented
here are between surveys in tiers 1 and 2.
To compare and summarize data we developed 3
tables. Table 1 provides surveys identified in all 3 tiers. For
brevity, we attached initials to identify each survey. It should
be noted that even though many of the third tier surveys are
widely used to report CAM use, we did not include them in
our other analyses because they could not provide information
regarding military-related use. Table 2 compares
the percentage of military/veterans who used CAM during a
prior 12-month period. For this table, we created patient and
nonpatient respondent subgroups. For gap analysis we included
a list of tier 2 household surveys that could offer
additional military-related data through subpopulation
analysis. Table 3 presents self-report behavioral health conditions
queried on tier 1 and tier 2 surveys.
Population Surveys With
CAM Questions, by Knowledge
of Military Status
Estimates of Percentage
of Military/Veteran Population With
CAM Utilization; Household Surveys
With Military Status Question
Health Conditions Queried on Surveys:
Military/Veteran and Household
With Military Status
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. 
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.  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).  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
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,  and psychological health conditions.  In addition,
rates of comorbidity across psychological health, pain, and
brain injury are high.  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.  In addition, adults are
more likely to use CAM when the cost of conventional care
is less affordable.  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,  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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