Complementary/integrative healthcare utilization in US Gulf-War era veterans: Descriptive analyses based on deployment history, combat exposure, and Gulf War Illness

While generally considered to be “complementary and alternative” due to their nonmainstream status, treatment approaches such acupuncture, Tai Chi, yoga, and chiropractic care have gained traction in becoming evidence-based treatments [1]. The Veterans Health Administration (VHA) has been at the forefront of turning “complementary and alternative medicine” into “complementary and integrative health” (CIH) by increasing its utilization of non-pharmacological treatment options for physical and mental health conditions common among U.S. military veterans [2]. In 2011, 89% of Veterans Affairs (VA) medical facilities offered at least one of 31 practices considered to be complementary and alternative [3]. From 2017 to 2018, over half of VA sites offered at least five or more CIH approaches [4]. Additionally, the VHA standard medical benefits package has recently expanded the CIH modalities covered to include: acupuncture, therapeutic massage, biofeedback, hypnotherapy, Tai Chi, yoga, meditation, and chiropractic care [5]. Understanding patterns of engagement and utilization of CIH modalities will further inform expansion efforts in the VHA. Specifically, understanding CIH user profiles may assist clinicians in discussing evidence based CIH approaches for particular health conditions.

Uptake of CIH by veterans has been high, and interest in services is growing. In a national survey, over half of veterans reported that they used one of 26 CIH approaches in 2017, and 84% reported interest in trying or learning about CIH treatments [5]. Symptom severity may drive this interest: compared to veterans who did not utilize CIH, veterans who did have higher gastrointestinal symptoms, insomnia, asthma [7–9,49], physical pain [6] and physical injury [7], as well as higher anxiety and stress [[7], [8], [9], [10]]. Gulf War era veterans (GWE; defined in this study as veterans who served in 1990–1991 Gulf War era military operations) represent a subpopulation of veterans that report a higher burden of health conditions compared to other veterans [11].

“Gulf War Illness” or “Chronic Multisymptom Illness” [12,13] is the signature illness/injury of the GWE and describes a diverse set of medically unexplained symptoms, characterized by: persistent pain, fatigue, gastrointestinal problems, skin abnormalities, cognitive problems, and sleep disturbance [[14], [15]]. However, interventions for the estimated 25–32% of GWE veterans who developed GWI are lacking [16] and are critically needed [17]. CIH modalities, such as acupuncture, meditation, yoga, and herbal supplements have shown promise for relieving a broad range of GWI symptoms [18]. Given emerging evidence on the benefits of CIH treatments for these symptoms, and the need to identify treatment options for GWI, it is important to understand psychosocial characteristics of those who utilize CIH services, and how CIH has been used to treat GWI symptoms. To date, only one study has investigated CIH utilization in the GWE veteran population [16]. Holliday and colleagues (2014) examined how general stress, pain, insomnia, and depression symptom severity impacts CIH utilization (i.e., group and individual acupuncture, iRest Yoga Nidra meditation, and integrated health education classes). Contrary to the literature, results revealed that GWE veterans did not endorse significantly higher symptom severity than non-GWE veterans. Participation across CIH services was generally consistent between the groups, although GWE veterans attended significantly fewer sessions of group acupuncture.

The purpose of the present research was to expand on previous work on CIH utilization in GWE veterans in several ways. First, this study combined guiding questions from Ref. [16] and other studies (e.g. Refs. [5,7], to examine the influence of demographic characteristics, military experiences, and GWI symptom severity on CIH utilization. Second, previous studies examined isolated symptoms of GWI (e.g., insomnia, stress, pain), rather than GWI as a constellation of symptoms or diagnosis. The current study followed evidence-based guidelines to establish criteria for GWI, and for symptom severity. We also examined differences in CIH utilization between GWE veterans with and without GWI. Furthermore, we assessed whether veterans utilized CIH to specifically treat GWI symptoms.

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