Differential PTSD Symptom Cluster Profiles by Trauma Exposure Modality in Community-Dwelling Vietnamese Older Adults

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Whether distinct PTSD symptom cluster profiles emerge across different exposure modalities has not been examined. Methods This cross-sectional secondary analysis used data from the Vietnam Health and Aging Study (VHAS, 2021–2022). Of 296 community-dwelling adults aged ≥60 with documented trauma exposure, 147 with complete Criterion A subtype data were classified as any direct exposure (n = 130) and indirect-only exposure (n = 17). PCL-5 cluster scores were compared using Mann-Whitney U tests. Logistic regression adjusted for cumulative trauma burden examined whether exposure modality predicted clinical PTSD (PCL-5 ≥ 11). Results Total PCL-5 scores did not differ significantly between the indirect-only and any direct exposure groups (mean 8.82 ± 12.98 vs. 5.10 ± 9.68; U = 997.5, p = 0.467). In exploratory cluster-level comparisons, only Avoidance (Cluster C) differed significantly (mean 1.35 ± 2.09 vs. 0.56 ± 1.53; U = 826.5, p = 0.013). The proportion meeting clinical PTSD threshold was higher in the indirect-only group (41.2% vs. 17.7%; OR = 3.26, 95% CI: 1.12–9.45). After adjustment for cumulative trauma burden, the association persisted (AOR = 3.41, 95% CI: 1.16–10.00, p = 0.025). Conclusions Among community-dwelling older Vietnamese adults, indirect-only trauma exposure was associated with elevated avoidance symptoms (Cluster C) and approximately threefold higher odds of clinical PTSD relative to direct exposure, independent of cumulative trauma burden. Total severity did not differ, suggesting exposure modality may shape symptom structure rather than overall burden. These findings warrant cautious interpretation given the small indirect-only subgroup (n = 17), wide confidence intervals, and cross-sectional design; replication in larger prospective samples is needed before clinical recommendations can be made. 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F1000Research 2026, 15 :715 ( https://doi.org/10.12688/f1000research.180499.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Differential PTSD Symptom Cluster Profiles by Trauma Exposure Modality in Community-Dwelling Vietnamese Older Adults [version 1; peer review: awaiting peer review] Pham Thi Ngoc Bich 1 , Le Xuan Hung https://orcid.org/0000-0002-1957-8529 2 , Ho Thi Kim Thanh 1 Pham Thi Ngoc Bich 1 , Le Xuan Hung https://orcid.org/0000-0002-1957-8529 2 , Ho Thi Kim Thanh 1 PUBLISHED 12 May 2026 Author details Author details 1 Department of Family Medicine, Hanoi Medical University, Hanoi, Hanoi, 100000, Vietnam 2 School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Hanoi, 100000, Vietnam Pham Thi Ngoc Bich Roles: Conceptualization, Formal Analysis, Methodology, Writing – Original Draft Preparation Le Xuan Hung Roles: Project Administration, Resources, Validation, Writing – Review & Editing Ho Thi Kim Thanh Roles: Data Curation, Investigation, Supervision, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW Abstract Background PTSD in community-dwelling older adults remains under-recognized in post-conflict, low- and middle-income countries such as Vietnam, where mental health services have predominantly targeted direct trauma survivors. Whether distinct PTSD symptom cluster profiles emerge across different exposure modalities has not been examined. Methods This cross-sectional secondary analysis used data from the Vietnam Health and Aging Study (VHAS, 2021–2022). Of 296 community-dwelling adults aged ≥60 with documented trauma exposure, 147 with complete Criterion A subtype data were classified as any direct exposure (n = 130) and indirect-only exposure (n = 17). PCL-5 cluster scores were compared using Mann-Whitney U tests. Logistic regression adjusted for cumulative trauma burden examined whether exposure modality predicted clinical PTSD (PCL-5 ≥ 11). Results Total PCL-5 scores did not differ significantly between the indirect-only and any direct exposure groups (mean 8.82 ± 12.98 vs. 5.10 ± 9.68; U = 997.5, p = 0.467). In exploratory cluster-level comparisons, only Avoidance (Cluster C) differed significantly (mean 1.35 ± 2.09 vs. 0.56 ± 1.53; U = 826.5, p = 0.013). The proportion meeting clinical PTSD threshold was higher in the indirect-only group (41.2% vs. 17.7%; OR = 3.26, 95% CI: 1.12–9.45). After adjustment for cumulative trauma burden, the association persisted (AOR = 3.41, 95% CI: 1.16–10.00, p = 0.025). Conclusions Among community-dwelling older Vietnamese adults, indirect-only trauma exposure was associated with elevated avoidance symptoms (Cluster C) and approximately threefold higher odds of clinical PTSD relative to direct exposure, independent of cumulative trauma burden. Total severity did not differ, suggesting exposure modality may shape symptom structure rather than overall burden. These findings warrant cautious interpretation given the small indirect-only subgroup (n = 17), wide confidence intervals, and cross-sectional design; replication in larger prospective samples is needed before clinical recommendations can be made. READ ALL READ LESS Keywords posttraumatic stress disorder, PTSD symptom clusters, trauma exposure modality, older adults, Vietnam Health and Aging Study, PCL-5 Corresponding Author(s) Le Xuan Hung ( [email protected] ) Close Corresponding author: Le Xuan Hung Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2026 Thi Ngoc Bich P et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Thi Ngoc Bich P, Xuan Hung L and Thi Kim Thanh H. Differential PTSD Symptom Cluster Profiles by Trauma Exposure Modality in Community-Dwelling Vietnamese Older Adults [version 1; peer review: awaiting peer review] . F1000Research 2026, 15 :715 ( https://doi.org/10.12688/f1000research.180499.1 ) First published: 12 May 2026, 15 :715 ( https://doi.org/10.12688/f1000research.180499.1 ) Latest published: 12 May 2026, 15 :715 ( https://doi.org/10.12688/f1000research.180499.1 ) I. Introduction PTSD in older adults has been associated with reduced psychosocial functioning and elevated psychiatric comorbidity. 1 , 2 Several age-related factors may contribute to sustained or late-onset symptom burden: declining physical resilience, major life transitions, and cognitive changes that can impair emotional regulation. 1 Research indicates that cumulative traumatic events across the life course are associated with greater severity of PTSD and depressive symptoms in later life, 3 , 4 and cross-national data suggest that socioeconomic and cultural context shape how these disorders present and persist. 5 Vietnam offers a setting with documented high levels of war-related trauma exposure and an aging survivor population. Akbulut-Yuksel et al. (2024) found, using VHAS data, that Vietnamese adults who were exposed to the war as pre-teens had higher rates of late-life PTSD than those exposed at older ages, and that adverse effects on PTSD were particularly evident among female wartime children. 6 The VHAS has documented the range of stressors experienced by this cohort, from direct combat involvement to loss of family members, and their associations with health in later life. 7 A gap exists in how post-war mental health services in Vietnam and similar settings identify and support trauma survivors. Services have generally been organized around those with direct, documented exposure, primarily veterans. 7 , 8 The DSM-5, however, recognizes multiple indirect pathways to PTSD under Criterion A, including witnessing traumatic events (Criterion A3) and learning about traumatic events affecting close associates (Criterion A4). 9 , 10 Older adults whose primary wartime experiences involved witnessing the death or injury of others, or receiving news of a family member’s death, may not be captured by screening programs focused on direct personal threat. Evidence suggests that indirect exposure can precipitate clinically significant PTSD, 10 though this has been less studied in older community-dwelling populations. Avoidant coping in response to trauma reminders-the focus of Cluster C in the DSM-5 framework-has been shown to impede natural recovery and predict symptom persistence, 11 and may be particularly relevant to those exposed indirectly. The present study used data from the second wave of the VHAS among community-dwelling adults aged ≥60 years in Vietnam to characterize differential PTSD symptom cluster profiles by trauma exposure modality. Three objectives were addressed: (1) to compare trauma exposure characteristics between participants with any direct exposure and those with indirect-only exposure; (2) to examine between-group differences in severity across the four DSM-5 PTSD symptom clusters; and (3) to determine whether exposure modality independently predicted clinical-level PTSD after accounting for cumulative trauma burden. II. Methods 2.1 Study design and setting This was a cross-sectional, secondary analysis of data from the second wave of the Vietnam Health and Aging Study (VHAS), a population-based longitudinal cohort study. 7 Data were collected in 2021–2022 from rural communes in Hanoi and Quang Binh provinces, selected to represent documented variation in war-related trauma exposure across northern and central Vietnam. 2.2 Study population and sample selection Participants were community-dwelling adults aged ≥60 years enrolled in the VHAS baseline wave (2018) and followed up in the second wave. Inclusion required: (1) age ≥ 60 years; (2) residence in selected communes; (3) at least one traumatic event meeting DSM-5 Criterion A, as ascertained through structured interview; (4) capacity to complete study instruments; and (5) written informed consent. Participants were excluded for unavailability, refusal, severe cognitive impairment, or severe psychiatric conditions precluding a valid PTSD assessment. Sample derivation. Of 301 adults enrolled in the VHAS second wave, 296 completed full trauma exposure assessment and PCL-5 measurement and were considered trauma-exposed. For the present analysis, two additional pre-specified criteria were applied to this pool. First, participants required complete data on all DSM-5 Criterion A subtypes (direct personal experience, witnessing, learning about trauma, and occupational aversive details exposure), to allow unambiguous modality classification. Second, the analysis was restricted to participants who could be assigned to one of two mutually exclusive groups based on their highest level of exposure (described below). Participants with incomplete subtype data or ambiguous classification (i.e., those whose records did not permit definitive classification) were excluded. This process yielded an analytic sample of N = 147. The reduction from 296 to 147 reflects primarily the second criterion: many trauma-exposed participants had mixed or partially recorded exposure data that precluded unambiguous group assignment. This selection process may have introduced bias if excluded participants differ systematically in PTSD symptom burden. Comparisons between included and excluded participants on PTSD outcomes were not possible because excluded participants lacked the complete Criterion A subtype data required for group classification; baseline sociodemographic characteristics were comparable between the analytic sample and the full VHAS second-wave cohort (see Section 3.1). This limitation is acknowledged. Exposure group definitions. Participants were assigned to one of two pre-specified, mutually exclusive groups based on their DSM-5 Criterion A exposure profile. The direct exposure group (n = 130) comprised individuals who reported at least one episode of direct personal trauma, defined as an actual or threatened encounter with death, serious injury, or sexual violence, regardless of whether they also had concurrent indirect exposure. This group is therefore heterogeneous with respect to indirect exposure history; it is not a ‘pure direct only’ comparison group. The indirect-only exposure group (n = 17) comprised individuals whose entire documented trauma history consisted of witnessing events occurring to others, or learning about traumatic events affecting close family members or friends, with no direct personal threat of any kind. Individuals in this group reported absolutely no direct life-threatening events or direct serious injuries to themselves and endorsed no Criterion A subcategories involving personal bodily threat. The primary comparison in this study is therefore between any direct exposure (with or without concurrent indirect exposure) and indirect-only exposure, not between mutually exclusive direct-only and indirect-only groups. 2.3 Measures PTSD Checklist for DSM-5 (PCL-5). PTSD symptoms were measured with the Vietnamese-validated PCL-5, a 20-item self-report scale aligned with DSM-5 criteria. 12 Items are rated 0–4, yielding a total score of 0–80 across four clusters: intrusion (Cluster B; 5 items), avoidance (Cluster C; 2 items), negative alterations in cognition and mood (Cluster D; 7 items), and arousal and reactivity (Cluster E; 6 items). The Vietnamese version was produced using a forward-backward translation procedure and culturally adapted for older Vietnamese adults. Validation in a VHAS sub-cohort (N = 301) demonstrated strong internal consistency (α = 0.92), a four-factor structure consistent with DSM-5 domains, and good diagnostic accuracy against the CAPS-5 gold standard (AUC = 0.967; Pham et al., manuscript under review). A cutoff of ≥11 was applied, derived from the validation study to give optimal sensitivity (92.86%) and specificity (95.12%) in this population; this threshold is lower than the conventional cutoff of 31–33 used in general adult samples, reflecting the lower baseline symptom endorsement documented in older community-dwelling Vietnamese adults (Pham et al., manuscript under review). Sociodemographic and trauma characteristics. Age, sex, marital status, and education level were extracted from the VHAS structured database. Trauma type and modality of Criterion A exposure were assessed using structured interview modules developed for the VHAS. 2.4 Statistical analysis Analyses were conducted in R (version 4.3.1; R Foundation for Statistical Computing). Descriptive statistics summarized demographic and trauma characteristics. Fisher’s exact test was used to compare categorical trauma exposure due to small expected cell counts. PCL-5 cluster and total scores were positively skewed in both groups, as is typical for symptom scores in non-clinical community samples; Mann-Whitney U tests were therefore used for between-group comparisons, with rank-biserial correlation (r) reported as a standardized effect size. Results are presented as means ± SD alongside test statistics, as reported in prior VHAS analyses and for consistency with the validation dataset; readers should note the skewed distributions when interpreting these central tendency estimates. Crude odds ratios with 95% confidence intervals were calculated for the proportion meeting the PCL-5 ≥ 11 threshold. Cluster-level comparisons were treated as exploratory. No adjustment for multiple comparisons (e.g., Bonferroni) was applied across the four symptom cluster tests. This decision was based on the exploratory nature of the cluster-level analyses and the high intercorrelation among PCL-5 subscales, which would render Bonferroni correction overly conservative. 13 Results should be interpreted with this in mind, and the avoidance finding in particular requires replication before it can be considered confirmatory. A multivariate binary logistic regression examined whether indirect-only exposure independently predicted clinical PTSD (PCL-5 ≥ 11) after adjustment for cumulative trauma burden (total count of distinct Criterion A trauma types). The model was kept parsimonious, with a single covariate in addition to the exposure term, given the small number of outcome events (n = 30 clinical PTSD cases), which constrained the maximum number of predictors without risking overfitting (in line with the recommended minimum of 10 events per predictor variable). 14 Cumulative trauma burden was selected as the covariate a priori based on its theoretical potential to confound the exposure-outcome relationship; additional sociodemographic variables were not included owing to sample size constraints and are acknowledged as a limitation. Sensitivity analyses incorporating age and sex were not feasible given the limited number of outcome events (n = 30). Adjusted odds ratios (AORs) with 95% CIs are reported. All tests were two-sided; α = 0.05. 2.5 Ethical considerations Ethical approval was obtained from the Institutional Review Board of Hanoi Medical University (No. 01.18/HMU IRB, January 25, 2018) and the National Bioethics Committee of the Ministry of Health, Vietnam (No. 29/CN-HĐĐ, April 27, 2018). Written informed consent was obtained from all participants. All data were de-identified before analysis. III. Results 3.1 Sample characteristics Of the 147 participants included, 130 (88.4%) were in the any direct exposure group and 17 (11.6%) in the indirect-only group. Mean age was 73.6 years (SD = 8.0); sex distribution was approximately equal (50.5% male, 49.5% female). Most participants were married or cohabiting (70.8%), and 71.4% had completed at least lower secondary education. Approximately 75.4% reported at least one chronic disease. These characteristics are broadly consistent with the larger VHAS second-wave cohort. 3.2 Trauma exposure profiles by exposure modality Table 1 shows trauma exposure characteristics by group. As required by the group definitions, any direct exposure group had a substantially higher prevalence of personal life-threatening events than the indirect-only group (66.2% vs. 5.9%, p < 0.001). Life-threatening events affecting others were reported by a higher proportion of the indirect-only group (70.6% vs. 51.5%). However, this difference was not statistically significant (p = 0.196), consistent with the group’s observational exposure profile. Serious injury to others was common in both groups, with a non-significant trend toward higher frequency in the any direct exposure group (66.9% vs. 41.2%, p = 0.058). Variables indicating sexual violence to self (n = 1) and exposure to aversive details (n = 0) are omitted from Table 1 due to extremely low or zero frequencies; no significant between-group differences were observed for these categories (all p ≥ 0.21). Table 1. Trauma exposure characteristics by exposure group (N = 147). Trauma characteristics Any direct exposure (N = 130) n (%) Indirect only (N = 17) n (%) p-value Life-threatening events - To self 86 (66.2%) 1 (5.9%) < 0.001 - To others 67 (51.5%) 12 (70.6%) 0.196 Serious injury - To self 27 (20.8%) 1 (5.9%) 0.197 - To others 87 (66.9%) 7 (41.2%) 0.058 3.3 PTSD symptom cluster severity by exposure modality Table 2 and Figure 1 show PCL-5 cluster scores by exposure group. PCL-5 scores were positively skewed in both groups; non-parametric comparisons are the primary test, and means are presented for descriptive purposes alongside test statistics. Total PCL-5 scores did not differ significantly between the indirect-only and any direct exposure groups (mean 8.82 ± 12.98 vs. 5.10 ± 9.68; U = 997.5, p = 0.467). Table 2. PCL-5 symptom cluster scores by exposure group (N = 147). DSM-5 symptom cluster Any direct exposure a (N = 130) Mean ± SD Indirect only (N = 17) Mean ± SD U Effect size (r) p-value Intrusion (Cluster B) 2.68 ± 4.37 3.88 ± 5.10 1002.0 0.093 0.479 Avoidance (Cluster C) * 0.56 ± 1.53 1.35 ± 2.09 826.5 0.252 0.013 Negative alterations in cognition/mood (Cluster D) 0.73 ± 2.23 1.53 ± 3.52 935.0 0.154 0.098 Arousal and reactivity (Cluster E) 1.13 ± 2.48 2.06 ± 3.42 932.5 0.156 0.191 Total PCL-5 Score 5.10 ± 9.68 8.82 ± 12.98 997.5 0.097 0.467 a The any direct exposure group includes participants with direct exposure only and those with direct plus indirect exposure and is therefore heterogeneous. * Avoidance (Cluster C): the only cluster reaching p < 0.05 in exploratory comparisons; no correction for multiple comparisons was applied. Significant values (p < 0.05) are shown in bold. Figure 1. Distribution of PCL-5 symptom cluster scores by trauma exposure modality (N = 147). Box plots show scores for four DSM-5 PTSD symptom clusters in the any direct exposure group (n = 130) and the indirect-only exposure group (n = 17). The box represents the interquartile range (IQR); the horizontal line indicates the median; whiskers extend to 1.5 × IQR; and points beyond the whiskers represent outliers. In exploratory cluster-level comparisons (no adjustment for multiple comparisons), only Avoidance (Cluster C) showed a statistically significant observed difference between groups. The indirect-only group had higher mean avoidance scores than the any direct exposure group (1.35 ± 2.09 vs. 0.56 ± 1.53; U = 826.5, p = 0.013), with a rank-biserial correlation of r = 0.252, indicating a small-to-medium effect size. As shown in Figure 1 , avoidance scores in the any direct exposure group were compressed toward the lower end of the scale. In contrast, the indirect-only group showed greater dispersion, with a higher median. Scores for Clusters B, D, and E were numerically higher in the indirect-only group but did not reach statistical significance (all p > 0.05). These cluster-level findings are exploratory and should be interpreted cautiously pending replication. 3.4 Clinical PTSD risk by exposure modality Table 3 presents clinical PTSD rates by group. The proportion meeting the PCL-5 ≥ 11 threshold was higher in the indirect-only group than in the any direct exposure group (41.2% vs. 17.7%; OR = 3.26, 95% CI: 1.12–9.45, p = 0.048). Table 3. Proportion meeting clinical PTSD threshold (PCL-5 ≥ 11) by exposure group (N = 147). Exposure modality Clinical PTSD (PCL-5 ≥ 11) n (%) Subclinical/No PTSD n (%) Odds ratio (95% CI) p-value Any direct exposure (n = 130) 23 (17.7%) 107 (82.3%) 1.00 (Reference) - Indirect exposure only (n = 17) 7 (41.2%) 10 (58.8%) 3.26 (1.12–9.45) 0.048 3.5 Multivariate predictors of clinical PTSD Table 4 shows the logistic regression results. Cumulative trauma burden was not a statistically significant predictor of clinical PTSD (AOR = 1.20, 95% CI: 0.78–1.85, p = 0.410). After adjustment, the estimated association between indirect-only exposure and clinical PTSD remained statistically significant (AOR = 3.41, 95% CI: 1.16–10.00, p = 0.025). The wide confidence interval reflects the small indirect-only subgroup (n = 17) and the limited number of outcome events (n = 30). Although the lower bound exceeds 1.0, the estimate’s precision is low, and the result should be interpreted cautiously. Sociodemographic variables were not included in the model due to sample size constraints; residual confounding by age, sex, and chronic disease burden cannot be excluded. Table 4. Multivariate logistic regression: indirect-only vs. any direct exposure as predictor of clinical PTSD (PCL-5 ≥ 11), N = 147. Predictor variable AOR 95% CI (Lower - Upper) p-value Exposure modality Any direct exposure 1.00 (Reference) - - Indirect exposure only a 3.41 1.16–10.00 a 0.025 Cumulative trauma burden Total number of trauma types experienced 1.20 0.78–1.85 0.410 a Wide 95% CI (1.16–10.00) reflects a small indirect-only subgroup (n = 17) and limited events (n = 30); interpret with caution. Significant values (p < 0.05) are shown in bold. IV. Discussion This study examined differential PTSD symptom cluster profiles by trauma exposure modality among community-dwelling older adults using data from the VHAS. Three principal findings emerged: (1) the indirect-only group exhibited selectively elevated avoidance symptoms without a corresponding increase in total PTSD severity; (2) indirect-only exposure was associated with approximately threefold higher estimated odds of clinical PTSD, independent of cumulative trauma burden; and (3) the small proportion of participants classified as indirect-only (11.6%) reflects the cohort’s historically high direct exposure prevalence. Each finding is discussed below. 4.1 Distribution of trauma exposure types The high proportion of participants in the any direct exposure group with personal life-threatening events (66.2%) is consistent with documented patterns of wartime exposure in the VHAS cohort, where aerial bombardment and combat involvement were widespread among this generation. 7 The prevalence of witnessed serious injury across both groups (66.9% any direct exposure, 41.2% indirect-only) reflects the broad reach of the conflict across communities. These observations are in keeping with findings from Akbulut-Yuksel et al. (2024), 6 who reported lasting adverse health effects among older adults who were exposed to the war as children, including those without direct combat involvement. The small size of the indirect-only subgroup (n = 17, 11.6%) is consistent with the historical epidemiological context of this cohort, where direct personal threat appears to have been common. This group imbalance affects statistical precision and is discussed as a limitation in Section 4.4. 4.2 Avoidance symptoms and possible mechanisms The selective elevation of Avoidance scores (Cluster C) in the indirect-only group (p = 0.013), in the absence of a significant difference in total PCL-5 scores, was the principal exploratory finding of this study. As illustrated in Figure 1 , the distribution of avoidance scores in the indirect-only group shows a higher median and wider spread than in the any direct exposure group, where most scores were near zero. This pattern-where one symptom cluster differs between groups while global severity does not-warrants careful interpretation given the exploratory design, small subgroup size, and absence of multiple-comparison correction. Notably, despite the small sample, the between-group difference in Avoidance was not only statistically significant (p = 0.013) but also yielded the largest effect size among the four symptom clusters (r = 0.252, small-to-medium), supporting the hypothesis that indirect-only exposure may engage avoidance-specific mechanisms rather than elevating PTSD symptoms uniformly. One hypothesized interpretation involves learned helplessness. Direct life-threatening events may elicit fight-or-flight responses manifesting as hyperarousal and intrusion (Clusters E and B). In contrast, indirect trauma may instead foster perceived helplessness with no capacity for intervention. This sense of helplessness has been hypothesized to promote persistent avoidance rather than resolve through habituation. 11 This mechanism was not directly measured in the present study, and whether it accounts for the observed pattern cannot be determined from cross-sectional data. A related hypothesis concerns survivor’s guilt or moral injury-a psychological burden arising from witnessing extreme suffering without the capacity to prevent it. Such distress may manifest primarily through shame and avoidance rather than fear and may be less responsive to standard exposure-based treatments. These interpretations remain speculative: neither mechanism was measured directly, and the present data support only an association between indirect-only exposure and avoidance severity, not a causal or mechanistic pathway. Future studies with longitudinal designs and validated measures of helplessness, guilt, and moral injury are needed to test these hypotheses. 4.3 Cumulative trauma burden and exposure modality The estimated association between indirect-only exposure and clinical PTSD (AOR = 3.41, p = 0.025), in the absence of a significant contribution from cumulative trauma burden (p = 0.410), is consistent with the possibility that exposure modality may matter independently of the number of trauma types experienced. This is in contrast to cumulative dose-response models, which predict that a greater count of traumatic events will linearly increase PTSD risk. 4 These data do not support that model in this specific sample, though the small sample and wide confidence interval mean that this negative finding should not be over-interpreted. The model did not adjust for sociodemographic characteristics, and residual confounding cannot be excluded. If replicated, these findings may have relevance for trauma-related mental health screening in post-conflict settings such as Vietnam, where services have generally targeted direct exposure survivors. Routine inquiry about experiences of witnessing and interpersonal loss in geriatric primary care may help identify individuals at elevated risk not captured by screening focused on personal threat. This suggestion is tentative, given the study’s limitations. 4.4 Strengths and limitations This study has several strengths: community-based data from a well-characterized longitudinal cohort with documented trauma histories; the use of a psychometrically validated, culturally adapted PCL-5 with a population-appropriate cutoff; strict, non-overlapping group classification that helps isolate the exposure modality effect; and a parsimonious regression model with a priori covariate selection. Several limitations should be considered when interpreting these findings. First, the indirect-only subgroup was small (n = 17), which substantially limits statistical power in cluster-level analyses and produces imprecise regression estimates (AOR 95% CI: 1.16–10.00). Second, the cross-sectional design precludes causal inference. Third, the sample derivation process, reducing 296 to 147 through exposure-modality filtering, may have introduced selection bias if excluded participants differ systematically from included participants. Only pre-tabulated analytic data were available for this secondary analysis; individual-level raw data for excluded participants were not accessible, precluding a formal comparison of PTSD outcomes between included and excluded groups. Fourth, cluster-level comparisons were exploratory, and no adjustment for multiple comparisons was applied; the Avoidance finding, in particular, should be treated as hypothesis-generating. Fifth, the regression model did not adjust for sex, age, or chronic disease burden due to sample size constraints; residual confounding by these variables is possible. Sixth, retrospective self-report of trauma type and modality may introduce misclassification, particularly for events occurring decades prior. Seventh, any direct-exposure group is heterogeneous with respect to its indirect exposure history, so the between-group comparison does not isolate indirect-only exposure relative to a matched direct-only comparator. Finally, the sample is drawn from two rural Vietnamese provinces, which limits generalizability to urban settings, clinical populations, and other cultural contexts. V. Conclusions This cross-sectional study of community-dwelling older Vietnamese adults identified differential PTSD symptom cluster profiles by trauma exposure modality. Despite comparable total symptom severity, participants with indirect-only exposure exhibited selectively elevated avoidance symptoms (Cluster C) and approximately threefold higher estimated odds of clinical PTSD relative to those with any direct exposure, independent of cumulative trauma burden. These findings suggest that exposure modality may shape the structure of PTSD symptom expression rather than overall severity. These findings are preliminary. The indirect-only subgroup was small (n = 17), the regression confidence interval was wide (1.16–10.00), covariate adjustment was limited, and the cross-sectional design does not permit causal inference. Possible mechanisms-including helplessness, survivor’s guilt, and moral injury-were not directly measured and remain hypothetical in this context. If replicated, these differential symptom profiles would support routine screening for indirect trauma experiences in geriatric settings and may inform modality-specific approaches to assessment and intervention. Larger prospective studies with adequate covariate adjustment are needed to confirm these patterns across different post-conflict populations and to examine whether they have implications for treatment selection in this age group. Data availability Underlying data The raw individual-level dataset derived from the Vietnam Health and Aging Study (VHAS) contains sensitive personal health and demographic information and cannot be made publicly available due to ethical and privacy restrictions imposed by the Institutional Review Board of Hanoi Medical University (No. 01.18/HMU IRB, 25 January 2018). To support transparency and reproducibility, an anonymized analytical dataset (de-identified) supporting the findings of this study is publicly available on Figshare: https://doi.org/10.6084/m9.figshare.32050995 . 15 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Extended data Researchers requiring access to the restricted individual-level data for replication purposes may contact the corresponding author, Le Xuan Hung ( [email protected] ), or the Hanoi Medical University Institutional Review Board ( [email protected] ). Access will be considered on a case-by-case basis, subject to Institutional Review Board approval and the execution of a formal data use agreement. Acknowledgements The authors thank the participants of the Vietnam Health and Aging Study for their time and contributions, local health authorities and community leaders in Hanoi and Quang Binh provinces for support during data collection, and staff at Hanoi Medical University for administrative assistance. References 1. Averill PM, Beck JG: Posttraumatic stress disorder in older adults. J. Anxiety Disord. 2000 Mar; 14 (2): 133–156. PubMed Abstract | Publisher Full Text 2. Pietrzak RH, Goldstein RB, Southwick SM, et al. : Psychiatric comorbidity of full and partial posttraumatic stress disorder among older adults in the United States: results from wave 2 of the national epidemiologic survey on alcohol and related conditions. Am. J. Geriatr. Psychiatry. 2012 May; 20 (5): 381–390. PubMed Abstract | Publisher Full Text | Free Full Text 3. Do TTH, Correa-Velez I, Dunne MP: Trauma exposure and mental health problems among adults in central vietnam: a randomized cross-sectional survey. 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Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 12 May 2026 ADD YOUR COMMENT Comment Author details Author details 1 Department of Family Medicine, Hanoi Medical University, Hanoi, Hanoi, 100000, Vietnam 2 School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Hanoi, 100000, Vietnam Pham Thi Ngoc Bich Roles: Conceptualization, Formal Analysis, Methodology, Writing – Original Draft Preparation Le Xuan Hung Roles: Project Administration, Resources, Validation, Writing – Review & Editing Ho Thi Kim Thanh Roles: Data Curation, Investigation, Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 12 May 2026, 15:715 https://doi.org/10.12688/f1000research.180499.1 Copyright © 2026 Thi Ngoc Bich P et al . 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