Research: Perceptions of CIH Vary at the VA

By Martha Brown Menard, Ph.D., LMT, July 2, 2018

The Study Question: Massage therapy has been shown to be a popular form of health care among veterans and is now actively recommended and promoted by the Veterans Administration, along with other complementary and integrative health care (CIH) therapies such as acupuncture, mindfulness and yoga. However, implementation of these therapies across the VA health care system has been inconsistent. This study explored whether perceptions among providers and administrators regarding CIH at one VA medical center (VAMC) were similar to perceptions from a sample of other VAMCs.

The Study Methods: The researchers first designed an exploratory qualitative study using a structured interview, focused on respondents’ views about CIH therapies in general and within the VA in particular. People who were perceived to be supportive as well as those who were skeptical of CIH were deliberately included.

The initial sample of 28 participants was recruited from the Ann Arbor VAMC in Michigan. An additional 22 participants from 15 purposefully selected, geographically diverse VAMCs across the U.S. were also recruited using snowball sampling, and this study reports their perceptions and beliefs in relation to the results from the initial sample. A disproportionate number of females participated— 20 of the 22 additional participants. To preserve respondents’ anonymity, demographic data regarding ethnicity was not collected.

Each VAMC was represented by two to seven participants. All interviews took place by phone between April 2014 and July 2014, and were recorded, transcribed and checked for accuracy by the principal investigator. The data were analyzed using thematic analysis with NVivo software.

The Results: Interview responses covered a wide range of topics that were classified under the broad categories of barriers and facilitators. According to the authors, these categories illustrate the multiple challenges to VA administrators and providers—as well as the benefits to veterans and staff—of implementing CIH across the VA. Results were grouped according to types of barriers and facilitators and whether they occurred at the personal, facility or system-wide level.

Barriers included logistical challenges, such as finding available space and designing procedures for charting, and variable access to CIH therapies across institutions. For example, some CIH programs offered several therapies while others offered just one or two. Many were funded by grants or run by volunteers, generally employees, who took time out from other responsibilities to offer therapies. There appears to be little funding for dedicated CIH positions, and credentialing of CIH practitioners poses challenges.

Facilitators included the VA’s recent directive to reduce the prescription of opioids, and the perception of improved pain management from incorporating CIH therapies. A surprising facilitator was the institutional willingness to accept varying spiritual practices as a part of promoting holistic healing, particularly in areas where larger numbers of Native Americans are present. Perceptions of improved mental health treatment for patients and improved staff morale were also considered positive facilitators by respondents. Employees appreciated the option to receive access to CIH therapies as part of employee wellness programs.

When participants were asked to list the top three to four therapies they believed were most important for the VA to offer patients, massage therapy was the most frequently cited therapy, specified by 50 percent of participants. Other important therapies mentioned were acupuncture (41 percent), chiropractic (32 percent), and meditation, music, pet therapy and yoga (27 percent each).

The authors also interviewed Tracy Gaudet, M.D., the director of the VA Office of Patient Centered Care and Cultural Transformation. She agreed with many of the same issues identified by study respondents, and cited both philosophical and practical barriers to adoption of CIH in the VA system. For example, the biomedical model is still considered the ideal by many providers in the VA, and on a practical level, there is a lack of job descriptions that prevents hiring of CIH practitioners. There is also a need for additional research that supports the use of CIH therapies. In terms of facilitators, she sees the enthusiasm of providers, patients and members of Congress for a more holistic approach to health care as a positive for promoting CIH in the VA. She cites acupuncture, mind–body approaches, movement therapies and massage therapy as specific examples of CIH therapies that should be included in the VA system.

Limitations of the Study: As a qualitative study, this study is not intended to be generalized to any specific institution, but instead describes a wide range of possible perceptions among hospital providers and administrators. The findings reported in this paper are preliminary and may be limited by the small number of sites involved and self-selection of respondents due to their interest in CIH. More research is needed to determine if these are systemic issues across the VA or limited to particular institutions.

Implications for Evidence-informed Practice: This study provides useful information for any massage therapist who may be considering applying for a formal position or is interested in volunteering at a VA facility. Such candidates should be aware of these potential barriers and facilitators at a given institution. Individual therapists who have clients who are veterans may also gain a better understanding of the VA system.