The last several decades have witnessed mounting empirical evidence demonstrating the longterm deleterious health impacts of exposure to war-related traumatic events (1–3). Mental health outcomes, such as those associated with post-traumatic stress disorder (PTSD) and depression, have received particularly intense attention and are perhaps best documented (4–6). However, it is clear that war trauma associates with an extensive range of other adverse health outcomes and concerns that last throughout life, including such diverse domains as adverse health behaviors, functional health and disability, diagnosed chronic conditions, and general global assessments of wellbeing. These associations are either a function of the direct impact of the trauma experienced or effects mediated by other psychological causes such as PTSD (7–11).
Assessing the precise direct and indirect impacts and the possible interventions that may moderate their influences depends greatly on an ability to evaluate wartime experiences, which sometimes occurred earlier in life, quantify the degree of trauma that was encountered, and categorize these involvements in ways that allow us to understand the how different types of exposures impact upon the course of different domains of health. Since the mid-1980s, a variety of approaches and instruments have been advanced to measure wartime exposure and related war stressors (6, 12–14). Based on the diagnostic criteria for trauma, these measures tend to include items such as those that gauge threats and fear of death, being seriously injured, experiencing sexual violence, witnessing such events or threats to others such as fellow combatants, and experiencing other harmful physical conditions.
The preponderance of studies that have constructed and analyzed such measures focus on American veterans or veterans in other developed western countries fighting wars that occurred far from their communities of origin. In contrast, the measures adopted to categorize and quantify wartime exposure have less frequently been assessed for use among populations living in places where wars actually ensue. Exposure to traumatic events within the latter groups is particularly salient in guerilla warfare situations or in contemporary civil conflicts that unfold within villages, neighborhoods, and on roadways within urban and rural developing country settings. In these settings, potentially traumatic exposures might extend to death and injuries occurring among friends, relatives, and neighbors, the experience of being evacuated from one’s home due to fear of oncoming violence, and fears that accrue to civilians and paramilitary personal as well as military combatants.
The American-War fought in Vietnam presents an ideal context to develop and evaluate measures of wartime exposure for the purpose of examining the long-term impacts of war. Those who experienced wartime trauma during this period (1965–1975) today are moving into older ages where the incidence and prevalence of chronic conditions and other health problems are heightened. The conflict that they experienced was unusually brutal and was experienced by many different types of individuals, including military personnel, paramilitary, and civilian women and men. In Vietnam, exposure among non-military groups has rarely been identified, quantified, and categorized. Doing so requires access to retrospective data collected from cohorts of Vietnamese that lived through the war. This study uses a new and unique data source, the Vietnam Health and Aging Study (VHAS), with just such information. The VHAS surveyed 2,447 individuals living in several regions of northern and central Vietnam that were differentially exposed to the American War, inquiring about their wartime experiences. Using these items, we aim to develop and evaluate measures of wartime exposure that would be relevant for studying the subsequent impacts of the trauma associated with war and long-term health and other life-course outcomes among the former military, paramilitary, and civilian populations of Vietnam.
Defining Traumatic Events
Measuring the exposure to traumatic events that precede the experience of trauma and resultant mental and physical health issues requires a clear definition of “traumatic events.” The American Psychiatric Association (APA) defines trauma as “an emotional response to a terrible event like an accident, rape or natural disaster” (15). The “terrible events” of import for this study are war-related traumatic events and stressors. Researchers have long struggled to understand the precise features of traumatic stressors (16–18). Weathers and Keane (18) note that crafting a definition of trauma and traumatic events is difficult, in part, due to the many relevant dimensions of stressors, including their “magnitude (which itself varies on several dimensions, e.g., life threat, threat of harm, interpersonal loss…), complexity, frequency, duration, predictability, and controllability” (18). As such, most researchers rely on descriptions of traumatic events contained in the diagnostic criteria for PTSD (6, 18, 19). The clinical definition and diagnostic, found in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), lays out five criteria for diagnosing PTSD. The first criterion, without which there can be no diagnosis, is the exposure to an event that is universally acknowledged to be traumatic (18, 20, 21). Specifically, Criterion A requires: “[e]xposure to actual or threatened death, serious injury, or sexual violence,” by directly experiencing or witnessing the traumatic events or learning about the traumatic experiences of family and close friends (20). In this paper, we follow previous scholars in relying on the description of traumatic stressors provided in the DSM-V, specifically being wounded, seriously injured, or almost killed; witnessing acts of injury and killing; and learning about the death and injury of family members. We supplement the events outlined in Criterion A with war-related stressors validated by previous scholars, including engaging in combat duties, exposure to malevolent conditions, and witnessing the effects of war violence. We also test new stressors for their potential relevance to the Vietnam context.
Existing Warzone Stress Scales
Two broad research domains have investigated war-related traumatic stressors and how to measure them. One domain focuses on war veterans, while the other centers on refugees.
Research into traumatic events experienced by veterans has identified stressors clustering in four dimensions: combat activities, nearness to death and severe injury, moral injury, and inhospitable conditions. For many veterans, especially those deployed to combat duties, some exposure to the death and serious injury, whether to one’s self or others, is practically a foregone conclusion. As such, early scales measured exposure to war-related violence by cataloging combat experiences (6, 14, 22). However, scholars also recognized that war-related exposure to traumatic events extends beyond mere combat exposure. For example, scholars have also examined the relationship between trauma and the personal “moral injury” that can occur when one commits or witnesses the commission of atrocities (5, 21, 23, 24). For example, Laufer and his colleagues tested a model of war-related trauma that included three dimensions: combat experiences, witnessing abusive violence, and participation in abusive violence. This scale was innovative in that it accounted for the guerilla-style of warfare characteristic of the Vietnam War. Laufer’s subjects reported stress related to their inability to “distinguish between noncombatants and the enemy,” “sanctioned acts of brutality,” and the use of “cruel weapons” (24).
Scholars have also documented the important role of malevolent living conditions for the experience of trauma (5, 14, 21). King et al. (21) found that among American veterans of the Vietnam War, exposure to a malevolent environment (i.e., the undesirable food, climate, living conditions, and other chronic, low-grade hassles of warzone deployment) was the most pronounced contributor to PTSD, far surpassing the influence of combat. However, for civilians and local military residents of warzones, the conditions constituting malevolent or inhospitable living environs likely differ from those enumerated by veterans of foreign wars, a theme investigated in research on trauma in refugees.
The second domain of trauma research focuses on sources of trauma for refugees, asylees, and displaced persons. This branch of research often omits combat-related inquiries in favor of war-related stressors that might be experienced by anyone, but it adds new dimensions of stressors, including mental injury, extrajudicial operations, and displacement. In addition, this body of work adds breadth to dimensions of trauma investigated with veterans. For example, paralleling inquiries into combat activities, this domain of scholarship asked about exposure to shelling, bombing, or military attacks, as well as whether the respondent was involved in combat (25–27). Participation in combat, when asked, was asked of all respondents, regardless of whether they were officially associated with a military organization. However, this body of scholarship often neglects to ask whether the subjects were members of the formal military or paramilitary organizations. The injury and danger components of the combat dimensions are substantially broader in the refugee literature. Items are typically included that capture not only being injured or nearly killed, but also the experience of torture, assault, kidnapping, and mental injuries such as brainwashing and extortion (26, 28, 29). Most studies supplement these measures of combat and injury with assessments of potentially traumatic extrajudicial events and activities, such as detention, arrest, extrajudicial executions, household searches and occupation, and other “mopping up” operations designed to discover terrorists in civilian populations (27, 28, 30).
A notable omission in measurement scales designed for veterans is the lack of attention to evacuation and other “less than voluntary” migration experiences. This oversight likely stems from the fact that prior research focused primarily on American veterans of foreign wars. However, refugee scholarship informs us that war-related forced migration is concurrent with exposure to other traumatic events and dangers typically associated with warzones. Moreover, forced migration has been associated with subsequent mental distress (25, 31, 32) and may have both a direct and indirect connection to post-traumatic stress. To illustrate the complexity of the relationship between displacement as a traumatic event and mental health, Porter and Haslam (33) describe how refugees experience stress accumulating at multiple different stages of displacement, including preflight, flight, exile, and resettlement or repatriation. For example, the circumstances of preflight and flight exit that affect mental health include the amount of time available to prepare for departure, age at departure, family separation/unity, and resources for departure, among others. Conditions while in exile can also vary dramatically (e.g., duration, living structure, availability of food and water, family unity), affecting subsequent mental health (33, 34). Finally, conditions of return also play a key role. After surveying 1,100 households in Kosovo, Wang (2010) conducted follow-up interviews with a subset of respondents to investigate why displacement was so frequently listed as a source of trauma. They learned that “most people became traumatised after their return to Kosovo because they found their houses and property completely or partially destroyed… They often found that close relatives or friends had been killed or were missing” (27). Such conditions at each stage of displacement compounded the trauma of displacement itself.
Finally, refugee scholars detail a different set of inhospitable living conditions than those itemized in studies of trauma in veterans. This domain of research emphasizes deprivation and damage to property as the principal living conditions that are associated with trauma. Stressors include shortages of food and water, lack of access to medical care when ill or injured, and the economic and psychological stress of property damage and loss (26, 30).
This study seeks to integrate the insights of the two domains of research encapsulating traumatic events and evaluate the dimensions of stressful wartime events for their relevance as indicators of trauma in northern Vietnamese survivors of the American war. We look at the dimensions of combat activities, personal and family injury and death, witnessing death and severe injury, moral injury, inhospitable conditions, and displacement. Two recent studies noted that some scales clustering combat activities, injury, and nearness to death into distinct groups demonstrated poor divergent validity (12, 35). As such, we also explore the dimensionality of traumatic events, anticipating that the events may cluster differently than previously thought. We also test whether the dimensionality is consistent across civilians, informal military, and formal military respondents. Finally, the two principal research domains primarily (though not exclusively (36)) study people who no longer reside in the location where they were exposed to conflict, i.e., veterans of foreign wars and refugees resettled outside the warzone. Our study seeks to integrate the two conceptual domains and fill a critical gap in the research (37), investigating the nature of warzone stressors for residents of Vietnam, subgroups of whom include civilians, veterans of the formal military, and paramilitaries and others peripherally involved in war efforts.