Introduction
Early life experiences such as poverty, emotional neglect, abuse and chronic stress are increasingly recognized as foundational to health across the lifecourse (Likhar et al. Reference Likhar, Baghel and Patil2022; Sales et al. Reference Sales, Maranhão, Ramalho, Macêdo, Souza and Maciel2024). These early exposures do not fade with time but shape physical and cognitive health trajectories, increasing the risk of chronic diseases like diabetes and cardiovascular conditions (Raphael Reference Raphael2011; McEniry Reference McEniry2013; Daines et al. Reference Daines, Hansen, Novilla and Crandall2021), as well as mental health problems and cognitive decline (Daines et al. Reference Daines, Hansen, Novilla and Crandall2021; Ding and He Reference Ding and He2021; Zhu and Liao Reference Zhu and Liao2021). A lifecourse perspective emphasizes how early disadvantages accumulate as risks compound through time and are amplified by unequal access to social, economic and environmental resources (Elder Reference Elder1998; Pearlin et al. Reference Pearlin, Schieman, Fazio and Meersman2005; Pearlin Reference Pearlin2010). The accumulation of these effects across the lifecourse has a particularly profound impact on health status in later life (George Reference George and Settersten2018). The theory of cumulative disadvantage explains how these processes contribute to widening health inequalities with age, resulting in poorer health outcomes, especially in midlife and older adulthood (Singh-Manoux et al. Reference Singh-Manoux, Ferrie, Chandola and Marmot2004).
War-related exposures are an extreme form of early-life adversity that can initiate and intensify cumulative disadvantage across the lifecourse (Levy and Sidel Reference Levy and Sidel2009; Zimmer et al. Reference Zimmer, Korinek, Young, Teerawichitchainan and Toan2022). Conflict-related trauma – including physical injury, witnessing violence, chronic fear, sleep deprivation and resource scarcity – produces lasting impacts on mental and physical health that persist long after the conflict ends (Bedard and Deschênes Reference Bedard and Deschênes2006; Davison et al. Reference Davison, Pless, Gugliucci, King, King, Salgado, Spiro and Bachrach2006; Levy and Sidel Reference Levy and Sidel2009; Wilmoth et al. Reference Wilmoth, London, Oliver, Spiro, Settersten and Aldwin2019). These effects may vary by gender. While the intensity and frequency of war exposure experienced by male combatants is related to higher incidence of post-traumatic stress disorder (PTSD) as compared to their female counterparts, women carry the mental health effects of protecting their families and participating in military and paramilitary (sometimes referred to as informal military) roles (Young et al. Reference Young, Kovnick, Korinek and Minh2022). Individuals and populations affected by armed conflict often show elevated risks of mental health disorders, such as PTSD, depression and anxiety (Solomon and Mikulincer Reference Solomon and Mikulincer2006; O’Toole and Catts Reference O’Toole and Catts2008; Yaffe et al. Reference Yaffe, Vittinghoff, Lindquist, Barnes, Covinsky, Neylan, Kluse and Marmar2010). They also experience lasting physical consequences including chronic pain, disability and functional impairment (Spitzer et al. Reference Spitzer, Wibisono, Terfehr, Löwe, Otte and Wingenfeld2014; Gasperi et al. Reference Gasperi, Afari, Goldberg, Suri and Panizzon2021; Kearney et al. Reference Kearney, Kamp, Storms and Simpson2022). Chronic stress plays a central role in these associations. Prolonged activation of stress-response systems disrupts hypothalamic-pituitary-adrenal (HPA) axis regulation, elevates cortisol levels and impairs immune functioning (Katrinli et al. Reference Katrinli, Oliveira, Felger, Michopoulos and Smith2022; Smeeth et al. Reference Smeeth, McEwen, Popham, Karam, Fayyad, Saab, Rieder, Elzagallaai, van Uum and Pluess2023; Lawrence and Scofield Reference Lawrence and Scofield2024; Rocha et al. Reference Rocha, Daniels, Chandrasekaran and Michopoulos2024). Emerging evidence suggests that war-related stress may become biologically embedded through accelerated epigenetic ageing (Raza et al. Reference Raza, Hussain, Foster, Wall, Coffey, Martin and Gomes2023).
Although wartime trauma is widely associated with adverse health outcomes, its effects are not uniform. Some individuals experience profound and enduring distress, while others maintain stable mental and physical health despite severe hardship (Murthy and Lakshminarayana Reference Murthy and Lakshminarayana2006; Litz Reference Litz2014). This heterogeneity may highlight the importance of resilience in shaping long-term health after conflict. Resilience operates at both individual and collective levels (Sousa et al. Reference Sousa, Haj-Yahia, Feldman and Lee2013) and can mitigate harmful effects of early wartime trauma across the lifecourse (Williams and Drury Reference Williams, Drury, Cook and Wall2011; Mahamid Reference Mahamid2020: Schwarzer Reference Schwarzer2024). Some research views resilience as a stable personality trait, emphasizing adaptability and coping capacity (Fleming and Ledogar Reference Fleming and Ledogar2010; Wright et al. Reference Wright, Masten, Narayan, Goldstein and Brooks2012; Masten and Cicchetti Reference Masten, Cicchetti and Cicchetti2016). Other recent works frame resilience as a dynamic, context-dependent process that emerges from interactions among biological, psychological, social and ecological systems (Fleming and Ledogar Reference Fleming and Ledogar2010; Hoffman and Kruczek Reference Hoffman and Kruczek2011; Ungar Reference Ungar2011, Reference Ungar2013; Southwick et al. Reference Southwick, Bonanno, Masten, Panter-Brick and Yehuda2014). These perspectives stress how recovery and long-term wellbeing after wartime are shaped by interactions between individual capacities and external resources (Hoffman and Kruczek Reference Hoffman and Kruczek2011; Schwarzer Reference Schwarzer2024).
Resilience is a multidimensional construct that arises from the interaction between individual capacities and broader social systems (Masten and Obradovic Reference Masten and Obradovic2008; Ungar Reference Ungar2011). At the individual level, resilience represents the ability to manage, adapt to and recover from stress through psychological resources and coping strategies developed over time (Agaibi and Wilson Reference Agaibi and Wilson2005; Clark et al. Reference Clark, Burbank, Greene, Owens, Riebe, Resnick, Gwyther and Roberto2018). Research has shown how these capacities operate in periods of armed conflict. Studies of internally displaced persons in eastern Ukraine have shown that forgiveness and emotional regulation are associated with lower levels of depression and anxiety (Kravchuk Reference Kravchuk2020; Rashid et al. Reference Rashid, van der Kaap-Deeder, Abbate and Costa2024). More broadly, maintaining a positive outlook and engaging in adaptive coping strategies such as problem-solving, cognitive reappraisal and goal-setting can strengthen individuals’ capacity to navigate prolonged uncertainty and support long-term recovery after wartime exposure (Solomon and Dekel Reference Solomon and Dekel2007; Karstoft et al. Reference Karstoft, Armour, Elklit and Solomon2015; Eshel et al. Reference Eshel, Kimhi, Marciano and Adini2023).
Supportive relationships, community networks and institutional systems play a critical role in sustaining wellbeing and facilitating recovery during periods of prolonged adversity (Masten and Obradovic Reference Masten and Obradovic2008). Community resilience refers to the collective mobilization of social structures, cultural norms and shared resources that enables groups to withstand and adapt to crises (Sousa et al. Reference Sousa, Haj-Yahia, Feldman and Lee2013; Liu et al. Reference Liu, Yu, Xu, Zhao and Guo2022). Collective efficacy, defined as a shared belief in a community’s capacity to act together, further strengthens responses to adversity by facilitating coordinated action and mutual support (Bandura Reference Bandura1997). Over time, collective memory and identity, expressed through cultural narratives of shared trauma and hope, can reinforce solidarity and provide meaning that supports long-term recovery (Landau and Saul Reference Landau, Saul, Walsh and McGoldrick2004; Walsh Reference Walsh2007; Bar-Tal Reference Bar-Tal2011). These processes show that community-level resources may interact with individual coping capacities to shape resilience after traumatic wartime experiences.
The Vietnamese context
Vietnam’s history of prolonged conflict provides a distinctive context for examining how wartime trauma may shape long-term health and resilience. The country experienced successive periods of foreign domination, most notably French colonization (1858–1954) and the American War (1965–1975), exposing generations to sustained violence and deprivation (Hirschman et al. Reference Hirschman, Preston and Loi1995; Thomas and Asselin Reference Thomas and Asselin2022). During the American War, the People’s Army of Vietnam mobilized both military and civilian populations, fostering an ethos of national unity, collective sacrifice and shared responsibility for survival (Merli Reference Merli2000; Guillemot Reference Guillemot2009; Holcombe Reference Holcombe2020). The conflict was marked by guerrilla warfare, widespread aerial bombardment and the use of chemical agents such as Agent Orange, which has been linked to lasting physical and intergenerational health consequences (Stellman et al. Reference Stellman, Stellman, Christian, Weber and Tomasallo2003; Lee et al. Reference Lee, Park, Kang, Ham, Yoon and Choi2023). Narratives of sacrifice and resilience played a central role in shaping national identity, especially in northern Vietnam, where shared wartime experiences strengthened community cohesion and collective memory (Ring et al. Reference Ring, Eyerman and Madigan2017). Women were mobilized through paramilitary organizations such as the Youth Shock Brigade (YSB) and local self-defence militias (Merli Reference Merli2000; Guillemot Reference Guillemot2009). While their contributions were framed as patriotic and emancipatory, many former YSB members were later excluded from veteran status and the social benefits given to former military personnel (Merli Reference Merli2000; Guillemot Reference Guillemot2009; Hendrich Reference Hendrich2023). These patterns of mobilization, recognition and exclusion continue to shape the health, resilience and identity of older Vietnamese adults today.
Today’s older population in Vietnam includes those who were children or young adults during the most destructive period of the American War, particularly from the mid-1960s through the mid-1970s. This demographic reality offers a unique opportunity to examine the long-term foundations of health and ageing in a population whose lifecourse has been shaped by war. Few studies have examined the long-term health consequences of wartime exposure among older Vietnamese adults. Notable exceptions include the recently initiated Vietnamese Cognitive Aging Program (Meyer et al. Reference Meyer, Farias, Whitmer, Kanaya, Harvey, Hinton, Tiet, Vuong, Gavett and Park2024), which interviews Vietnamese war survivors residing in the United States to investigate the contribution of war-related trauma to disparities in dementia risk. Additional research in Vietnam has also alluded to persistent physical and mental health consequences of bombing and chemical warfare exposure among those who remained in the country (Singhal Reference Singhal2019; Vuong et al. Reference Vuong, Chang and Palmer2021; Le et al. Reference Le, Pham and Polachek2022). Other studies have found broader associations between wartime trauma and long-term health outcomes (Korinek et al. Reference Korinek, Young, Teerawichitchainan, Chuc, Kovnick and Zimmer2020; Zimmer et al. Reference Zimmer, Korinek, Young, Teerawichitchainan and Toan2022). Taken together, this body of work demonstrates the enduring and harmful health impacts of wartime exposure in Vietnam and underscores the need for further research focused on ageing and resilience in this population.
Theoretical framework
This study is grounded in the bioecological theory of human development, which emphasizes how nested and interacting environmental systems shape individual outcomes across the lifecourse (Bronfenbrenner Reference Bronfenbrenner1979; Bronfenbrenner and Ceci Reference Bronfenbrenner and Ceci1994). Central to this framework is the biophysical system, which includes physiological and behavioural responses to environmental stressors. Through these responses, early-life exposures such as wartime trauma become biologically and socially embedded. Individual development and health are shaped by interactions within multiple interconnected systems at different levels of proximity and influence.
The microsystem includes direct interactions in immediate settings, such as relationships with family, peers and neighbours. The mesosystem captures linkages among these settings, including connections between family, community and local institutions. The exosystem encompasses broader social structures, such as healthcare systems, mass media and policy environments, that indirectly influence individuals by shaping access to resources and opportunities. The macrosystem reflects cultural, political and economic contexts, including dominant narratives of sacrifice, resilience and recognition from Vietnam’s wartime history. The chronosystem situates these systems in historical time and shows how exposure to war during critical developmental periods can have lasting consequences for health and resilience in later life.
Applying Bronfenbrenner’s bioecological framework, this study examines how personal experiences of wartime trauma interact with community and structural contexts to shape long-term health and wellbeing in later life. In this perspective, resilience is not a fixed trait but an emergent process from dynamic interactions across biological, psychological, social and institutional systems (Bronfenbrenner Reference Bronfenbrenner1979; Reference Bronfenbrenner and Ceci1994 ). This enables integrated analysis of how war survivors cope with trauma, mobilize resources and navigate ageing within complex social environments shaped by conflict.
The present study
The American War profoundly shaped Vietnamese society, yet research on its long-term health consequences has disproportionately focused on American veterans, leaving the experiences of Vietnamese survivors understudied (Pedersen Reference Pedersen2002; Jawad et al. Reference Jawad, Vamos, Najim, Roberts and Millett2019). This imbalance has created a significant gap in understanding how wartime trauma has influenced health and ageing within Vietnam. Although existing studies have linked wartime exposure to adverse long-term outcomes, including frailty, respiratory illness and cardiovascular disease (Young et al. Reference Young, Kovnick, Korinek and Minh2022; Zimmer et al. Reference Zimmer, Korinek, Young, Teerawichitchainan and Toan2022; Teerawichitchainan et al. Reference Teerawichitchainan, Zimmer, Low and Toan2023; Korinek et al. Reference Korinek, Zimmer, Teerawichitchainan, Young, Manh and Toan2024), little is known about how individuals interpret and make meaning of the war’s lasting effects on their health and wellbeing. Situated within the distinctive social and historical context of northern Vietnam, this study adopts a qualitative approach to examine these lived experiences in depth (Ungar Reference Ungar2003; Ring et al. Reference Ring, Eyerman and Madigan2017). Guided by Bronfenbrenner’s bioecological model, the analysis explores how individual experiences of wartime trauma intersect with environmental, community and societal factors to shape long-term health and wellbeing (Bronfenbrenner and Ceci Reference Bronfenbrenner and Ceci1994). The study also investigates resilience as a key mechanism underlying variation in these later-life outcomes.
Data and methods
Sample
Participants for the current qualitative analysis were drawn from the Vietnam Health and Aging Study (VHAS), a longitudinal study of adults aged 60 and older living in northern Vietnam at the time of data collection. The full VHAS sample includes 2,447 individuals born before 1959, all of whom experienced adolescence or young adulthood during the American War. The VHAS participants were recruited from four districts: Ba Vì, Yên Khánh, Bố Trạch and Đồng Hới. These districts were chosen to represent variation in wartime exposure, as indicated by differences in bombing intensity during the 1960s and 1970s (Miguel and Roland Reference Miguel and Roland2011). The present analysis involves a subsample of VHAS participants who live in Đồng Hới district in Quảng Bình province. This district was chosen for the qualitative portion of the data collection owing to its proximity to the 17th parallel, the former dividing line between North and South Vietnam, and its subsequent high exposure to wartime activity (Miguel and Roland Reference Miguel and Roland2011). Participants were purposively selected to represent individuals with moderate to high wartime exposure and variation in later-life health outcomes. To ensure that respondents could engage with interviewers for a lengthy period, respondents also had to display a minimal level of physical and cognitive health. Thus, individuals with severe physical limitations or substantial cognitive impairment were excluded from the present study.
Forty individuals were contacted for qualitative interviews. Two declined for health reasons, and two were unavailable. The final analytic sample included 36 North Vietnamese war survivors aged 64 to 92 (M = 75.2), 19 of whom were female. Participants were categorized according to their wartime participation as formal military, paramilitary or civilian. Table 1 presents individual-level characteristics of the qualitative sample, including military status, wartime exposure, select health indicators, household and family context, and intergenerational support. Table 2 summarizes aggregated descriptive characteristics by sex across key socio-demographic and health variables. Notable sex differences include higher rates of marriage, Communist Party membership and educational attainment among men. Women were, on average, slightly older and more likely to report a disability. Households of male participants also reported ownership of more assets, suggesting higher socio-economic status. Additional details on the VHAS study design, sampling procedures and measurement protocols are provided elsewhere (Korinek et al. Reference Korinek, Teerawichitchainan, Zimmer, Brindle, Nguyen, Nguyen and Tran2019).
Participants’ demographic characteristics
Table 1 Long description
The table lists 36 older participants with sex, age, military status, wartime exposure score, frailty score, lifetime posttraumatic stress symptoms, recent psychological distress, and household and family support indicators. Ages span mid 60s to late 80s, with both men and women and a mix of civilian, formal military, and paramilitary histories. Wartime exposure varies widely, from very low to very high, and higher exposure often appears alongside higher trauma symptoms and distress, though this pattern is not consistent for every individual. Frailty ranges from very low to high, indicating substantial variation in health deficits across participants. Lifetime posttraumatic stress symptoms range from none to high, and psychological distress ranges from none to elevated, with the highest distress observed in a participant who also has high frailty. Most participants are married and live with family members, but a small number live alone or with nonfamily only. Household size and assets vary, and most participants report satisfaction with relationships with children and receiving financial and instrumental support, although several report no financial support and a few report no satisfaction or no support.
Notes: 1 Wartime exposure score reflects the summed total of 26 war-related exposure items capturing intensity of bombing, forced displacement, illness and deprivation, injury and fear, witnessing death or severe injury, and combat-related experiences; items were coded 0–2 (or 0–4 for family deaths), with higher scores indicating greater exposure.
2 Frailty was calculated using a deficit accumulation approach representing the proportion of deficits across 58 items spanning 15 health domains; scores provide an indicator that proxies biological ageing.
3 Lifetime post-traumatic stress symptoms (PTSS) are measured using a nine-item adapted PTSD checklist based on DSM-5 criteria (range = 0–27).
4 Psychological distress is measured using the ten-item Self-Reporting Questionnaire (SRQ-10), representing the weighted sum of affirmative responses in the past 30 days.
5 Household assets represent a count of household ownership of the following eight assets: television, phone, refrigerator, air conditioner, motorcycle, car, computer and home internet.
6 Satisfaction with relationship, financial support and instrumental support refer to participants’ relationship with and support received from children.
Descriptive characteristics of the study sample by sex
Table 2 Long description
The table summarizes counts and average characteristics for 36 participants, split by sex (17 males, 19 females) and overall. Women report disability more often than men (10 vs 3), while men are much more likely to be Communist Party members (9 vs 1). More men are married (16 vs 11) and currently working (10 vs 8). Women more often report a heart condition (6 vs 4), and arthritis is common in both groups (13 women, 12 men). Military service is similar by sex (13 women, 11 men), and only women report having a living parent (3 vs 0). On average, women are older (76.3 vs 74.1) and have fewer years of formal education (7.3 vs 10.1) and fewer household assets (4.1 vs 5.4). Average chronic health conditions are slightly higher for women (2.3 vs 2.0), and women report more living children (4.1 vs 3.6) while men report more living siblings (7.9 vs 6.6). Findings are descriptive for this small sample and may not generalize beyond it.
Notes: 1 Based on activities and instrumental activities of daily living (ADL and IADLs, respectively).
2 Count of the number of the following eight assets owned by the household: TV, phone, refrigerator, air conditioner, motorcycle, car, computer, home internet.
3 Based on the sum of 12 diagnosed physical chronic health conditions, including heart disease and arthritis.
Interview procedure
Ethics approval was obtained from the institutional review boards of the University of Utah, Mount Saint Vincent University, Singapore Management University and Hanoi Medical University. All participants provided informed consent before participating. All research team members received standardized training in research ethics, consent procedures and qualitative interviewing techniques. Special attention was given to developing and translating interview questions to ensure conceptual equivalence in Vietnamese and to use open-ended probes to elicit detailed narratives. Briefing profiles summarizing each participant’s wartime experiences and current health conditions were created from the 2018 VHAS survey data and provided to interviewers before each interview. These profiles helped tailor follow-up questions while maintaining a flexible, participant-led approach.
Data were collected through in-depth, semi-structured interviews conducted in Vietnamese by two research collaborators from Hanoi Medical University. While interviewers did not know participants personally, they were familiar with the sample from earlier phases of the VHAS. Interviews used a semi-structured guide to explore participants’ perceptions of wartime trauma, resilience and long-term health outcomes. The guide was developed by an international team of principal investigators with input from key stakeholders and consultants and refined through three pilot interviews. Each interview began with an informal conversation to build rapport, followed by open-ended questions such as: ‘Can you tell me what your typical day is like?’, ‘Please tell me about your health’, ‘Can you share your war experiences as you remember them?’ and ‘What were the things that helped you cope during and after the war?’. Interviewers then used clarifying and probing questions to encourage deeper reflection.
Interviews took place in private, familiar settings to foster a sense of comfort and openness. Sessions averaged 89 minutes, ranging from 70 to 115 minutes. All interviews were audio-recorded with participants’ consent and transcribed verbatim for analysis. Field notes were taken after each interview to summarize key themes and capture contextual details not evident in the recordings. Participants received 100,000 Vietnamese đồng as compensation upon completing the interview.
Translation
Audio recordings were first transcribed in Vietnamese then professionally translated into English. All analyses were conducted in English, the primary language of the data analysis team. Although this approach introduces potential challenges, including the risk of losing culturally embedded meanings (van Nes et al. Reference van Nes, Abma, Jonsson and Deeg2010; Aloudah Reference Aloudah2022), several strategies were employed to mitigate these limitations. Bilingual researchers were consulted throughout the analytic process to assess translation accuracy and cultural nuance. Key Vietnamese terms and phrases were retained in the transcripts, and translators provided annotations to clarify culturally specific idioms and metaphors. Through ongoing collaboration among bilingual researchers, English-speaking analysts and professional translators, the study sought to ensure conceptual equivalence across languages and to preserve the original intent and meaning of participants’ accounts (Choi et al. Reference Choi, Kushner and Lai2012).
Analysis
Final English-language transcripts were imported to MAXQDA 2022 (Release 22.8.0) for systematic qualitative analysis. Thematic analysis was used to identify, organize and interpret patterns in the data following Braun and Clarke’s (Reference Braun and Clarke2021) six-phase approach. The analyst repeatedly read the transcripts to become familiar with the data, then used inductive coding to capture salient ideas and recurring patterns in participants’ accounts. Codes were examined and organized using Bronfenbrenner’s bioecological systems framework, situating themes across micro-, meso-, exo-, macro- and chronosystem levels. For example, codes about family relationships and interpersonal support were assigned to the microsystem, while themes capturing cultural narratives or institutional processes were assigned to the macrosystem. Through an iterative process, themes were reviewed, refined and consolidated to ensure that they accurately captured patterns of interaction within and across systems. In the final analytic phase, themes were clearly defined and labelled to reflect their central organizing concepts. The resulting thematic structure aligns with the bioecological framework, providing an integrated account of how wartime trauma, resilience and ageing are experienced across multiple levels of context.
Results
Table 2 provides descriptive characteristics of the study sample. Table 3 displays the final subthemes identified from participant narratives, along with the number of participants associated with each subtheme. Because many participants described experiences spanning multiple subthemes, the total number of coded excerpts exceeds the sample size. Table 4 organizes themes and subthemes into broader thematic categories based on Bronfenbrenner’s bioecological framework. This table numbers these themes to correspond with the discussion of results that follow. The analysis also explores how participants described and navigated these experiences across different social and material contexts (e.g. gender, household size, family support levels). Descriptive patterns are reported only when meaningful differences are observed.
Subthemes of ecological factors and coping strategies, categorized using the bioecological system framework
Table 3 Long description
The table lists subthemes of ecological factors for 35 participants and coping strategies for 36 participants, with totals plus the share who were female and who lived in households of four or fewer people. Among ecological factors, community support systems were most common at 97.1%, followed by lingering psychological distress and family support systems at 80.0% each, and economic policies and resources at 82.9%. Physical health challenges were also frequent at 74.3%, while collective identity and resilience was least common at 45.7%. For coping strategies, proactive health management was reported by all participants at 100.0%, and adherence to collective ideals was also very high at 97.2%; practicing gratitude and access to financial assistance were each 94.4%, and acceptance of uncertainty was 91.7%. Lower-frequency coping strategies included forward-focused coping at 77.8%, reuniting with former comrades at 66.7%, intergenerational storytelling at 52.8%, and intentional forgetting at 50.0%. Female representation within subthemes generally clustered around about half, ranging from 37.5% for collective identity and resilience to 57.9% for intergenerational storytelling. The share living in below-mean household size varied by subtheme, from 31.0% for economic policies and resources to 61.5% for physical health challenges, and these percentages are within-subtheme distributions rather than overall population rates.
Notes: Percentages for female participants and household size are calculated from the total within each subtheme. Household size refers to the number of individuals in the household (sample mean = 4.25). A below-mean household size indicates four or fewer members. Gender and household size distributions are presented to contextualized heterogeneity within the sample.
Organization of subthemes into overarching themes
Table 4 Long description
The table organizes five overarching qualitative themes and lists the subthemes that make up each theme. Theme 1, on cumulative health effects of early-life wartime trauma, includes physical health challenges and lingering psychological distress. Theme 2, on coping strategies, contains five subthemes: proactive health management, practicing gratitude, acceptance of uncertainty, forward-focused coping, and intentional forgetting, making it the most detailed theme. Theme 3, on resilience supported by family and community, includes family support systems, intergenerational storytelling, community support systems, and reuniting with former comrades. Theme 4 focuses on systemic economic transition inequities and includes economic policies and resources plus access to financial assistance. Theme 5 frames collective resilience as foundational for individual resilience and includes collective identity and resilience and adherence to collective ideals. The table presents a thematic structure rather than counts or rankings, so it does not indicate frequency or strength of evidence for any subtheme.
Biophysical system
Theme 1: early-life wartime trauma exerts cumulative effects on health
Subtheme 1.1: physical health challenges
Participants reported a range of physical consequences resulting from early-life wartime trauma, which worsened with age and contributed to declining health. They attributed chronic conditions to bombings, demanding labour, exposure to chemical agents and prolonged resource scarcity. Many highlighted the persistent and episodic nature of these effects, noting that environmental triggers such as weather changes could reactivate pain from past injuries. As one participant explained:
‘I often get sick. Whenever the weather changes, my old injuries flare up. I experience body aches, discomfort, and fatigue … I was trapped in a tunnel that collapsed due to a bomb … Now every time the weather changes, I feel pain’ (ID 33).
Former members of the YSB also described long-term musculoskeletal problems from extreme physical demands during the war. One participant linked daily heavy lifting to degenerative spinal conditions:
I used to carry [bags of rice] on my shoulders all the time, for a year straight, so now I have degenerative cervical spine issues … Carrying 50 to 100-kilo bags of rice every day, along with carrying wounded soldiers, led to a degenerated lumbar spine. One of my vertebrae collapsed, and I started to feel pain this year. (ID 36)
Participants reported exposure to chemical agents, including Agent Orange and napalm, and articulated concerns regarding both immediate and intergenerational health consequences. One former military member recounted,
‘I was scared I was pregnant once. I had an abortion because I was afraid of giving birth … planes bombed and poisoned the hill where I was staying … Since then, my health has been poor. I’ve had various health issues, from stomach problems to thyroid disease’ (ID 33).
Severe deprivation during and after the war further exacerbated these physical health challenges. One former militia member emphasized that prolonged exposure to inadequate nutrition and harsh living conditions could result in lasting illness:
‘We didn’t have food to eat or clothes to wear … I had severe gallbladder inflammation … The joint pain, headaches, sinus issues, and vestibular disorders all stem from the war … staying in the trenches and dealing with rain and storms have left lasting impacts’ (ID 10).
Subtheme 1.2: lingering psychological distress
Participants reported enduring psychological effects resulting from early-life wartime trauma. Recurring nightmares and intrusive memories were prevalent, indicating persistent post-traumatic stress that continued for decades following the war. One participant described vivid and recurrent dreams of aerial bombardment:
I dream of bombs and aircraft attacking me, running and seeing people dying … Sometimes when I’m asleep, I dream that I’m sleeping in one place and the aircraft strikes right next to me … I can still see the smoke and fire vividly, and I wake up startled, realizing it was just a dream. (ID 19)
Psychological distress was frequently intensified by unresolved grief and disrupted mourning processes. One former militia member recalled being unable to return home when their parent died:
‘I couldn’t return immediately [when my father passed away]. By the time I got back home, he had already been gone for six or seven days’ (ID 8).
Among former military personnel, unresolved loss often manifested as survivor’s guilt, expressed through recurring dreams of fallen comrades: ‘I dream about my comrades returning … They ask why I haven’t brought them back. I say that I couldn’t find where they were’ (ID 6). For participants who lost a parent in childhood, psychological distress was closely linked to the premature assumption of adult responsibilities. One former militia member described the emotional burden of bereavement and forced maturity:
Losing my mother was the hardest because I was only nine years old … I was very sad, but with my mother gone, there was so much work to do. I had to work hard, taking care of a herd of 20 pigs. I also had a younger sister to look after. I just worked and went to school [crying]. I could only go to school two or three times a week. It was very hard. (ID 15)
Theme 2: individuals use diverse coping strategies to mitigate long-term effects
Participants reported using various strategies to manage their psychological distress and promote wellbeing. These strategies included proactive health management, expressions of gratitude, acceptance of uncertainty, maintaining a forward-focused mindset and, in some cases, deliberately avoiding painful memories. While these approaches provided short-term or situational relief, participants’ accounts showed that sustained resilience depended more on access to broader familial, community and institutional supports.
Subtheme 2.1: proactive health management
Many participants described engaging in proactive health management, including regular symptom monitoring, following medical advice and adjusting diet and daily routines. Several combined biomedical care with traditional remedies, often favouring natural options such as herbal teas, honey, turmeric and locally used medicinal plants like khoi and sim. One former military veteran emphasized the importance of physical activity to protect long-term health after wartime trauma:
‘I practise tai chi. I practise old martial arts techniques and do some light exercises. I used to run long distances, but now I avoid it because it can be dangerous. Instead, I run a short distance and do exercises to stay fit’ (ID 1).
Participants consistently acknowledged the importance of proactive health management, but its feasibility varied. For some, available resources and family support enabled symptom monitoring, dietary changes and adherence to treatment. For others, financial constraints, limited time or restricted access to care made maintaining these practices challenging. Gender also influenced motivations for sustained engagement. Men more frequently emphasized disciplined adherence to maintain their independence, while women described proactive health management as a prerequisite for maintaining care-giving and household responsibilities.
Subtheme 2.2: practising gratitude
Practising gratitude was identified as an important meaning-making strategy that supported participants’ psychological wellbeing. Participants described deep appreciation for surviving the war, ongoing family support and the opportunity to rebuild their lives. Rather than minimizing loss, this outlook allowed individuals to place past trauma within a broader life perspective, which helped temper its ongoing emotional impact. One former military veteran explained how reframing their experiences had contributed to a more positive outlook despite significant losses:
‘There are still some negative impacts, but the good outweighs the bad, and I feel very fortunate to enjoy the life I have. Many of my comrades are still missing but I consider myself lucky to be in this situation. I don’t have any complaints’ (ID 31).
Subtheme 2.3: acceptance of uncertainty
Acceptance of uncertainty was a recurring theme in participants’ narratives. Many individuals, shaped by prolonged exposure to unpredictable conflict, highlighted the importance of focusing on controllable factors rather than external circumstances. This perspective reflected a pragmatic adjustment of expectations rather than resignation. As one former YSB member stated:
‘It often comes down to fate … Sometimes circumstances beyond our control prevent us from achieving our goals … Even if life is tough initially, with persistence and support, people can eventually succeed’ (ID 4).
This acceptance enabled participants to sustain their determination and a sense of purpose despite ongoing personal and structural challenges.
Subtheme 2.4: forward-focused coping
Participants frequently reported adopting a forward-focused mindset, emphasizing present and future responsibilities rather than dwelling on past traumatic experiences. Involvement in work, community activities and care-giving provided both a sense of purpose and a practical strategy to limit the emotional impact of distressing memories. For many, this orientation constituted a deliberate choice rather than a lack of remembrance. One female civilian explained how focusing on current responsibilities supported their emotional wellbeing:
Some people hold only negative feelings, but I’ve let go of it all … If I keep remembering all those things, it will only make my mind and body suffer. I remember the war and those who died, but now I prefer to focus on the present. Of course, the past is important, but it’s better to move on and only talk about it occasionally with friends … When we meet, we reminisce, but then we agree we should focus on the life we have now: our families, our children and just keep going. (ID 26)
Forward-focused coping was common among participants, but its meaning and rationale varied across social contexts. Men typically characterized this strategy as a conscious effort to avoid the past, emphasizing personal resolve and self-discipline. Women tended to see forward focus as necessary for maintaining care-giving and household routines. Material circumstances also shaped these perspectives. In settings with limited resources, prioritizing the present was seen as essential for managing daily pressures and ongoing constraints. Conversely, participants with greater material stability reported more opportunities to reflect on past experiences while addressing present and future responsibilities.
Subtheme 2.5: intentional forgetting
Some individuals reported intentionally limiting their engagement with traumatic memories to manage psychological distress. Rather than indicating denial or lack of awareness, intentional forgetting was described as a way to create emotional distance from overwhelming experiences. This approach was often seen as necessary to support daily functioning, with participants noting that revisiting wartime memories would only extend suffering. Forgetting was viewed as a means of moving forward without being burdened by the past. However, participants also recognized the limitations and potential costs of this strategy. For some, efforts to forget offered temporary relief but limited opportunities to process trauma more thoroughly or to access formal support systems. One participant who served in both the YSB and a militia described this tension:
During the war, there were many times when bombs and bullets exploded right next to me … I was only 24 or 25 years old then, and I couldn’t avoid it. I just sat down in the gap between the two piles of rice and escaped death … Sometimes I just think about it in my head and don’t speak it out loud [cries] … That is why I don’t participate in veteran support programmes. (ID 14)
Micro- and mesosystem levels
Theme 3: family and community facilitate individual resilience
Participants identified two primary sources of support that contributed to their resilience. Family support from spouses, children and close relatives provided emotional and material assistance, as well as opportunities for intergenerational storytelling. Because of its immediate and ongoing influence on daily wellbeing, family support was considered part of the microsystem. Community support, such as veteran associations, neighbourhood groups and cultural institutions, enhanced resilience by broadening social networks and facilitating reconnection with former comrades to process shared experiences of trauma. This support extended beyond the household and was considered part of the mesosystem.
Subtheme 3.1: family support systems
Participants often identified family as their primary source of emotional and practical support. Strong family networks facilitated emotional stability and eased reintegration into civilian life:
‘I was reunited with my family and reintegrated into the community. I considered my homeland, neighbours and descendants to be the solid rear of support I needed, which helped me stop dwelling on the fear of death’ (ID 20).
As participants aged, culturally embedded expectations of filial piety reinforced participants’ reliance on family members, with adult children providing household assistance, financial support and help with health-care needs. This support was often described with great appreciation and pride, reinforcing participants’ sense of belonging and security:
‘When [my children] come home, they check the pantry and buy anything that is missing without waiting for us to ask. For instance, they sometimes buy supplements and medicines … I’m proud of that because, in general, one relies on their children’ (ID 1).
In addition to practical assistance, family relationships provided emotional grounding and a renewed sense of purpose. Many participants described care-giving, particularly for grandchildren, as a meaningful daily role that supported wellbeing and facilitated recovery from past hardships. However, some participants expressed ambivalence regarding increased dependence on family, especially when it limited their autonomy or capacity to contribute economically. As one former YSB member explained:
‘Even if someone offered me a job like washing dishes in a restaurant, my children wouldn’t allow it. They say I’m too old to be doing such jobs and are concerned it might affect my health’ (ID 23).
Family support varied among participants. Individuals with smaller, more distant or strained family relationships reported limited emotional support, even when practical assistance was present. In some cases, discussing wartime experiences within the family was challenging, reducing opportunities for emotional processing at home. Participants with weaker family support often depended more on community connections, especially with former comrades and veteran network. These groups offered shared understanding, implicit recognition and relief from bearing these experiences alone. Such relationships were considered essential for sustaining resilience in later life.
Subtheme 3.2: intergenerational storytelling
Close family relationships provided participants with opportunities for intergenerational storytelling. These exchanges enabled participants to reflect on and preserve their wartime memories while transmitting cultural, moral and experiential knowledge to their children and grandchildren. Storytelling helped participants make sense of the past and provided younger generations with insight into the hardships that shaped their ancestors’ lives. One former militia member described the challenges of conveying these experiences to younger family members:
Now that [my children] are grown up and starting their own lives … it is hard for them to understand. The younger ones don’t really know about these experiences and don’t listen much. I focus on teaching them about revolutionary ethics and my own way of living. It is difficult for them to grasp these historical matters now. (ID 10)
Participants’ accounts highlighted how intergenerational storytelling could be used to transmit values such as perseverance, solidarity and moral responsibility to younger generations. However, it often became a source of tension when generational distance or shifting priorities reduced younger family members’ engagement with these stories. Several participants observed declining interest among younger generations, which limited opportunities to share their wartime experiences.
Subtheme 3.3: community support systems
Many participants emphasized the importance of reconnecting with former comrades through community networks to process their wartime experiences. Participation in veteran associations, neighbourhood groups and informal social gatherings created spaces for shared remembrance, mutual understanding and emotional connection, which participants sometimes found difficult to achieve within their families. As one former YSB and militia member noted: ‘We often reminisce about the old days, the bombings, and share laughs about it. It is a way to remember and connect’ (ID 28). As participants aged, maintaining these relationships became increasingly challenging owing to declining health, mobility limitations and the loss of peers. Some adapted by using digital platforms such as Zalo and Facebook to maintain contact when in-person visits were not feasible. However, access to and familiarity with these technologies varied. Several participants reported that limited digital literacy among older peers restricted participation in online networks, resulting in new forms of social exclusion even as technology offered alternative means of connection.
Subtheme 3.4: reuniting with former comrades
Reuniting with former comrades was identified as a critical source of social connection and emotional validation. For many participants, these gatherings offered rare opportunities to share wartime memories with others who had similar experience. Such opportunities were often unavailable within families or across generations. One former military veteran explained that veteran meetings were among the few settings where recalling battlefield experiences felt possible:
‘The only opportunities for me to talk about my battlefield experiences are during veteran meetings, where we can reminisce together about our shared memories’ (ID 20).
In addition to fostering social connection, reunions were associated with tangible psychological benefits. Several participants described these encounters as providing emotional relief and, in some cases, reducing trauma-related distress. As one veteran noted, reconnecting with surviving comrades coincided with the cessation of recurring war-related dreams:
‘After dreaming about bombs for a long time, there was a moment when I met my comrades again, and from then on I stopped having those dreams … My comrades who survived and returned; after meeting them again, I suddenly stopped having those dreams’ (ID 36).
The significance of these reunions varied depending on household context and the availability of family support. Participants with limited family support, or who struggled to discuss their wartime experiences with family, were more likely to see reunions as a primary source of recognition, solidarity and emotional validation. Those with substantial family support tended to view reunions as supplementary, helping maintain a sense of identity surrounding their wartime experiences rather than serving as a main coping resource.
Exosystem level
Theme 4: economic transitions and systemic inequities undermine collective resilience
Subtheme 4.1: economic policies and programmes
Participants reported that post-war economic policies were crucial in shaping their capacity to sustain their livelihoods and adapt to changing economic conditions. During the post-war subsidy period, the state centralized the distribution of essential goods to promote equality. However, participants noted that this system constrained individual economic agency and limited opportunities for personal advancement. One former military veteran reflected on the transition following the end of this period:
‘During the subsidy period, life was more restricted and challenging … Now that the subsidy period has ended, the government says that the more you work, the more you will benefit. Before, the state provided everything’ (ID 13).
Following the dissolution of collectivized agricultural cooperatives, many participants pursued alternative livelihoods within an increasingly unstable market economy. One former militia member recounted working in a cooperative until it closed owing to declining productivity:
‘I worked in a cooperative … I was involved in harvesting broomcorn … I left because the cooperative dissolved. The broomcorn industry wasn’t thriving, so the cooperative shut down’ (ID 7).
Some participants adapted by engaging in small-scale trading or informal labour, while others faced challenges with the rising cost of living, shifting market demands and unstable income. One former militia member described leaving market trading after several years because ‘the cost of living had increased, and the demand for goods was higher. I couldn’t keep up’ (ID 34). Despite the widespread hardship during this transitional period, participants described gradual improvements in state support over time. One former militia member contrasted earlier conditions with more recent economic developments, explaining that after discharge they had received minimal assistance but ‘nowadays, the government is more caring … they now provide health care and other benefits’ (ID 30). While these changes were welcomed, participants’ accounts alluded to how institutional support had lagged behind post-war economic restructuring, creating uneven pathways to resilience.
Subtheme 4.2: access to financial assistance
Economic disparities grew owing to unequal access to state financial assistance. Formal military veterans and civil servants were generally prioritized for benefits, while paramilitary forces and civilians faced more restricted or uncertain support. Eligibility often depended on documentation, health assessments and navigating complex bureaucratic procedures, which many participants found opaque and hard to access. One former military veteran described how these processes limited equitable compensation for wartime injuries:
I received compensation for my injuries … but it is a modest amount. I was granted a pension for 44 per cent disability based on the examination after I healed. If I had been examined while I was still injured, the percentage might have been higher … I had heard that I could go to Hanoi or another place for a re-evaluation of my injuries to potentially receive a higher disability percentage. However, I didn’t know where to go … so I didn’t pursue it. (ID 33)
These disparities generated frustration among veterans and, at times, strained the solidarity that had previously characterized their relationships. Participants reported that uneven benefits led to perceptions of unfairness and resentment, particularly when individuals with similar wartime experiences received notably different levels of support. Nonetheless, expressions of loyalty to the state coexisted with these grievances. One former military veteran explained how unequal assistance had influenced collective memory and identity among veterans:
‘I was fortunate to have a good position and a pension, but many didn’t … Ten years later, some of them are very bitter about the situation and say they should have just surrendered … They are just expressing their frustration, but their hearts are still loyal’ (ID 1).
Experiences of financial assistance varied by gender, socio-economic status and family support. Men often regarded benefits as an entitlement for their military service, while women more often characterized this support as limited, unreliable or insufficient. Participants with fewer household assets were particularly vulnerable to payment delays or gaps and had limited alternatives when eligibility was unclear. Those with greater material resources were less affected by these challenges, but still spoke of documentation and evaluation processes that disproportionately disadvantaged others. Robust family support networks also helped to mitigate the effects of inadequate assistance, while more limited family support could intensify the consequences of scarce resources.
Macrosystem level
Theme 5: collective resilience serves as the foundation for individual resilience
Subtheme 5.1: collective memory and identity
The American War was pivotal in shaping Vietnam’s national identity. Participants characterized the war as a shared hardship that reinforced social cohesion and functioned as a psychological buffer against personal trauma. One former militia member reflected on the fulfilment derived from contributing to a collective cause:
My joy came from my work. During the war, I served and contributed my efforts to the national victory and that made me happy. Now that I’m retired, I have a pension, and I have a happy life with my children. I participate in community activities and do whatever tasks they assign me. That is living with an ideal, living for the people. (ID 11)
Participants described how their commitment to a collective good motivated them during wartime and continued to support their health and wellbeing later in life. By viewing personal sacrifice as part of a broader national struggle, they found meaning that helped to mitigate the impact of fear, loss and social isolation. Another former YSB member also emphasized duty and shared responsibility as central to their wartime experience and later reflections:
Being a youth volunteer was first about freeing the country and then about driving out enemies to protect our sovereignty … As a young person, you had to volunteer and go where you were needed. That was our duty, just like it was for the soldiers. As women, we had to run and carrying ammunition, doing our part. Now that I’m old and have survived, I’m just grateful to heaven and earth. (ID 26)
Across narratives, the normalization of extreme hardship through shared experience became integral to participants’ identities. This process reinforced their resilience by situating personal suffering within a broader historical and moral context.
Subtheme 5.2: adherence to collective ideals
Commitment to collective ideals, shown through selflessness, solidarity and national duty, enabled participants to see suffering and sacrifice as meaningful contributions to a shared cause. This framing provided psychological support, easing emotional distress and helping individuals endure challenging circumstances. One male civilian succinctly expressed this sentiment:
‘I feel pride in our Vietnamese people … During war, a young person must be brave and lead the fight to protect their country’ (ID 3).
Pride in collective identity fostered trust, cooperation and a sense of moral clarity, anchoring resilience during and after conflict. Several participants emphasized how this collective mindset turned hardship into enduring strength. A former military veteran recalled:
‘I was happy for the country and the people, for participating in the common cause … With this mindset, I was able to move forward’ (ID 11).
Another veteran similarly reflected on shared suffering as a source of personal growth:
‘Not only did I suffer, but the whole country did … My personal contributions, despite being tough, made me wiser and more resilient in everyday life. I learned the value of community and the love of my comrades and friends, which is very precious’ (ID 31).
Some participants observed that the solidarity underpinning collective resilience had gradually diminished after the war. One former militia member expressed nostalgia for earlier unity, contrasting it with contemporary social and economic pressures:
The sense of community was warmer back then … Today, people are driven by the pursuit of wealth and competition … Back then, people were carefree because they had nothing to compete for. Even if there was competition or wealth, it didn’t matter much in the face of bombs and death. (ID 34)
This perceived transition from collective solidarity to a more competitive, economically driven society underscores tensions between traditional collective ideals and modern pressures. It raises questions about how resilience strategies rooted in shared purpose may be sustained or transformed over time.
Discussion
This study highlights the lasting physical and psychological effects of early-life wartime trauma among North Vietnamese war survivors, emphasizing resilience as a key factor in later-life health, particularly for older adults. Consistent with lifecourse and cumulative disadvantage perspectives, the findings show that wartime trauma is an ongoing process, with effects that build and intensify over time. Participants reported that early, prolonged exposure to chronic stress, extreme physical labour, chemical agents and material deprivation became biologically and psychologically embedded, contributing to declining health as they aged. These exposures often led to musculoskeletal degeneration, episodic and chronic pain, and ongoing psychological distress, such as intrusive memories, nightmares and unresolved grief, that lasted for decades after the conflict.
The present findings are consistent with previous research that links early-life adversity to poorer health outcomes in later life. Substantial evidence demonstrates that adverse childhood experiences are associated with an increased risk of chronic disease and psychological distress in later adulthood and old age (Raphael Reference Raphael2011; McEniry Reference McEniry2013). Previous research on war-exposed populations has documented long-term mental and physical health consequences, though studies using primary qualitative data from survivors remain relatively limited. Studies of European populations exposed to World War II have shown lasting effects on mental health (Akbulut-yuksel et al. Reference Akbulut-Yuksel, Tekin and Turan2024) and physical functioning (Ramirez and Haas Reference Ramirez2021). Broader research across conflict-affected settings has linked war exposure to chronic pain, reduced physical fitness, increased cardiovascular risk, frailty and even accelerated biological ageing and epigenetic changes (Wang et al. Reference Wang, Pacolli, Rushiti, Rexhaj and Modvig2010; Korinek et al. Reference Korinek, Young, Teerawichitchainan, Chuc, Kovnick and Zimmer2020; Zimmer et al. Reference Zimmer, Korinek, Young, Teerawichitchainan and Toan2022; Raza et al. Reference Raza, Hussain, Foster, Wall, Coffey, Martin and Gomes2023). This study supports this literature and contributes to it by demonstrating how and that early wartime trauma becomes embedded not only in survivors’ bodies but broadly in their lives over decades, influencing health outcomes in later adulthood.
The present findings also contribute by indicating how resilience serves as a central mechanism influencing the health impacts in older age of early-life war trauma. Resilience is neither uniform nor solely individual. Participants described a range of coping strategies, including proactive health management, gratitude, acceptance of uncertainty and maintaining a forward-focused mindset, which contributed to reduced psychological distress and supported daily functioning. Nevertheless, these strategies were not universally accessible or sustainable. Survivors lacking family support or sufficient resources often experienced persistent emotional distress, which exacerbated physical health challenges. This variability underscores the importance of sustained social and institutional support systems in promoting long-term resilience. Consistent with cumulative stress perspectives, the continued presence of chronic pain, degenerative conditions and psychological symptoms throughout the lifespan demonstrates the enduring impact of wartime trauma, particularly when individual coping is not reinforced by broader social and structural systems (Ferraro and Shippee Reference Ferraro and Shippee2009; Haas and Ramirez Reference Haas and Ramirez2024).
Bronfenbrenner’s bioecological model provided a useful framework for understanding the complex, multi-level dynamics present in survivors’ experiences. At the biophysical level, participants reported chronic conditions from wartime exposure, including musculoskeletal degeneration, chronic pain and persistent psychological distress, which continued to affect their health and wellbeing in later life. At the micro- and mesosystem levels, family and community networks, especially veteran associations, fostered resilience by offering emotional support, shared remembrance and collective meaning-making through intergenerational storytelling and peer connection (Bandura Reference Bandura1997; Masten and Obradovic Reference Masten and Obradovic2008; Norris et al. Reference Norris, Stevens, Pfefferbaum, Wyche and Pfefferbaum2008; Ungar Reference Ungar2011). At the exosystem level, post-war economic restructuring and uneven access to pensions, health care and financial assistance limited survivors’ perceptions of equity, particularly among women and paramilitary veterans who were often overlooked by state support systems. At the macrosystem level, shared ideals of sacrifice, unity and heroism enabled many participants to find meaning in wartime suffering, fostering a sense of pride, collective identity and psychological endurance. These narratives served as an important cultural resource, reducing distress and reinforcing social cohesion. However, many participants noted that rapid economic modernization and increased individualism had eroded this shared moral framework. Many expressed concerns about declining community cohesion and reduced engagement among younger generations with wartime histories (Ring et al. Reference Ring, Eyerman and Madigan2017; Hirschberger Reference Hirschberger2018). Although the chronosystem was not analysed as a distinct analytical category, its influence was clear across ecological levels. Historical developments like post-war reconstruction, the Đổi Mới economic reforms and evolving collective memory combined with age-related changes to influence survivors’ health and wellbeing (Ferraro and Shippee Reference Ferraro and Shippee2009).
These findings indicate that resilience is a dynamic, context-dependent process rather than a static individual trait. While personal coping strategies supported daily functioning and emotional regulation, long-term wellbeing in later life largely depended on a collective identity, community relationships and culturally embedded narratives of shared sacrifice and purpose (Ring et al. Reference Ring, Eyerman and Madigan2017; Hirschberger Reference Hirschberger2018). Participants’ concerns about declining social cohesion suggest that these cultural and communal resources were increasingly at risk amid ongoing social and economic changes, which may have important implications for the future sustainability of resilience among later generations of war survivors (Wilson Reference Wilson2012).
These findings have important implications for health policy, social services and future research in Vietnam and other post-conflict societies. Interventions to support ageing war survivors should be culturally responsive and integrative, addressing both the physical consequences of wartime exposure and the psychological and social dimensions of early wartime trauma. Programmes that strengthen family cohesion, support intergenerational communication, community and veteran networks and promote digital inclusion among older adults may enhance resilience and social connectedness in later life (Orazani et al. Reference Orazani, Reynolds and Osborne2023; Whear et al. Reference Whear, Campbell, Rogers, Sutton, Robinson-Carter, Sharpe, Cohen, Fergy, Garside, Kneale, Melendez-Torres and Thompson-Coon2023; Jung et al. Reference Jung, Lee and Nam2025). At the structural level, policies that address inequities in access to health care, pensions and veteran benefits, particularly for women and paramilitary survivors, are essential for reducing long-term disparities. Efforts to document, preserve and publicly recognize wartime narratives may also reinforce collective memory and social cohesion, supporting psychological wellbeing across generations (Holtorf Reference Holtorf2018; Fajic Reference Fajic2024).
At the same time, advancing these policy and practice goals requires research designs that can better capture how lived experiences of wartime trauma translate into health trajectories over time. Future studies would do well to integrate qualitative narrative data with longitudinal quantitative measures of health and ageing. Connecting themes like chronic pain, psychological distress, family support, community engagement and access to institutional resources to data sources like the Vietnam Health and Aging Study clarify how wartime trauma relates to physical and mental health and functional decline. Mixed-methods approaches can identify which forms of resilience are most protective in different social and institutional contexts. Because meaning-making and collective memory shape these processes, ongoing attention to language, translation and cultural interpretation is essential. Although rigorous translation procedures were used in this study, future research combining qualitative narratives with longitudinal health measures may further validate observed patterns and ensure culturally relevant interpretations.
In summary, the findings of the present study demonstrate that early-life wartime trauma continues to affect both physical and psychological health among North Vietnamese survivors into later adulthood. Resilience is identified as a dynamic, multi-level process rather than a static individual trait. The integration of cumulative disadvantage theory with Bronfenbrenner’s bioecological model indicates that long-term health outcomes are shaped by personal coping strategies and by interactions among family relationships, community networks, cultural narratives and institutional support systems. While shared ideals of sacrifice, solidarity and collectivism have historically provided protection and meaning, participants’ accounts suggest that these collective resources are increasingly undermined by economic transformation, social change and generational shifts. These findings underscore the importance of culturally grounded approaches that foster intergenerational connection, promote community-based care and recognize and preserve wartime experiences to support resilience and address the enduring health consequences of war in ageing populations.
Acknowledgements
This analysis uses data from the Vietnam Health and Aging Study (VHAS). The VHAS was funded by the National Institutes of Health under Award Number R01AG052537. For more information, please refer to www.vhas.utah.edu.
Author contributions
All authors were involved in the conceptualization and design of the study. Then SI Hamm conducted the qualitative analysis and drafted the manuscript. Each author participated in the interpretation of results and reviewed and approved the final manuscript.
Financial support
This work was supported by the Canadian Institutes for Health Research (CIHR), project title ‘The Long-Term Effects of War on Biological Aging: The Case of Vietnam’, project number (175309). Partial support to D Norris and Z Zimmer came from a Standard Internal Research Grant from Mount Saint Vincent University to the Department of Family Studies and Gerontology. No financial sponsor played a role in the design or implementation of this research project.
Competing interests
The authors declare no potential competing interests concerning the research authorship and/or publication of this article.
Ethical standards
Ethical approval for the Vietnam Health and Aging Study was provided by the University of Utah’s Institutional Review Board (IRB_00099861), Mount Saint Vincent University’s Research Ethics Board (2018–047), Singapore Management University’s Independent Review Board (IRB-18-031-A034(318)) and Hanoi Medical University’s Independent Review Board in Bio-medical Research (IRB No. 00003121).
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