1 15 22 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 066 Folder The folder containing the original item. 1800 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clippings: USA Today - The Nation's Newspaper - Gives Its Op-Ed Page to Vietnam Trauma, September 1, 1983 Subject The topic of the resource veteran psychological health public opinion popular press ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/c846a4bf774c356f6f5a1fe329c688c6.pdf ff42ea3db1e2d641de5746de90cdded7 PDF Text Text Item ID Number 01747 Author Corporate Author Center for Environmental Health and Injury Control, CD Roport/Articlo TltlO Health Status of Vietnam Veterans, I. Pyschological Characteristics, The Center for Disease Control Vietnam Experience Study Journal/Book Title JAMA Year 1988 Month/Day Ma 13 Color ^ Numboronmagos 7 v Descrmtoii Notes Monday, June 11, 2001 Page 1748 of 1793 �Reprinted from JAMA *• The Journal of the American Medical Association May 13, 1988, Volume 259 Copyright 1988, American Medical Association Original Contributions Health Status of Vietnam Veterans I. Psychosocial Characteristics The Centers for Disease Control Vietnam Experience Study The Vietnam Experience Study was a multidimensional assessment of the health of Vietnam veterans. From a random sample of enlisted men who entered the US Army from 1965 to 1971,7924 Vietnam and 7364 non-Vietnam veterans participated in a telephone interview; a random subsample of 2490 Vietnam and 1972 non-Vietnam veterans also underwent a comprehensive health examination, including a psychological evaluation. At the time of the study, the two groups of veterans were similar in terms of level of education, employment, income, marital status, and satisfaction with personal relationships. Certain psychological problems, however, were significantly more prevalent among Vietnam veterans than among non-Vietnam veterans. These included depression (4.5% of Vietnam veterans vs 2.3% of non-Vietnam veterans), anxiety (4.9% vs 3.2%), and alcohol abuse or dependence (13.7% vs 9.2%). About 15% of Vietnam veterans experienced combat-related posttraumatic stress disorder at some time during or after military service, and 2.2% had the disorder during the month before the examination. (JAMA 1988;259:2701-2707) MANY veterans are concerned that military service in Vietnam may have adversely affected their health and, perhaps, that of their children. Little objective evidence has been available, See also pp 2708 and 2715. as yet, regarding Vietnam veterans' health compared with that of other veterans of similar age and background. To address these concerns, Congress directed that appropriate epidemiologic studies be conducted (Veterans Health Programs Extension and Improvement From the Center for Environmental Health and Injury Control, Centers for Disease Control, Public Health Service, Department of Health and Human Services, Atlanta. Reprint requests to Centers for Disease Control, 1600 Clifton Rd (F-16), Atlanta, GA 30333 (Frank DeStefano, MD). JAMA, May 13, 1988—Vol 259, No. 18 Act of 1979, Public Law 96-151 [HR 3892], 93 STAT 1092-1098; and Veterans' Health Care, Training, and Small Business Loan Act of 1981, Public Law 97-72 [HR 34997], 95 STAT 1047-1063). One study, conducted by the Centers for Disease Control in response to this congressional mandate, was the Vietnam Experience Study (VES). The VES assessed health effects related to the general Vietnam military experience; it did not focus on exposure to herbicides such as Agent Orange. The health of a sample of male US Army Vietnam veterans was compared with the health of a similar group of US Army veterans who did not serve in Vietnam. The study included an analysis of postservice mortality, which has been published previously,1'2 a telephone interview, medical examination and psychological testing, and an evaluation of reproductive outcomes and child health. Comprehensive accounts of the latter three components can be found in a five-volume monograph.8"7 Information in these five volumes is summarized in a series of three reports in this issue of THE JOURNAL. In this first report, we focus on current psychosocial characteristics; in the second,8 on physical health; and in the third,9 on reproductive outcomes. SUBJECTS AND METHODS Participant Selection Study participants were selected from a random sample of male US Army veterans who served during the Vietnam era (Fig 1). To increase comparability between those who served in Vietnam and those who served elsewhere, we selected only veterans who (1) entered military service for the first time between January 1965 and December 1971, (2) served only one term of enlistment, (3) had at least 16 weeks of active service, (4) earned a military occupational specialty other than "trainee" or "duty soldier," and (5) had a pay grade no higher than E-5 (sergeant) when discharged from active duty. Tracing and Interviewing All veterans not known to have died were eligible for the telephone interview (Fig 1). With the assistance of a private contractor, all eligible veterans were traced using mailings, telephone directory assistance, credit bureau searches, driver's license and motor vehicle registration records, city directories, local records, and personal field visits. Overall, 87% of Vietnam veterans (7924) and 84% of non-Vietnam veterans (7364) were successfully located CDC Vietnam Experience Study—Psychosocial Characteristics 2701 �Vietnam-Era US Army Personnel Records Filed at NPRC ~4.9 Million Vietnam 9558 Died on Active Duty 234 •H Died on Active Duty 34 4 Studv Cohort Died Between Discharge and Dec 31,1983 Mortality Study Died Between Discharge and Dec 31,1983 246 Vietnam 200 Non-Vietnam that is designed to assess the prevalence of certain psychiatric conditions according to the DSM-HI11 criteria of the American Psychiatric Association. The DIS was administered by specially trained psychology technicians under the supervision of licensed clinical psychologists. Technicians generally did not know whether a veteran had served in Vietnam until the end of the interview, when questions about posttraumatic stress disorder (PTSD) were asked. Since we focused on current status, veterans were considered to have a condition of interest (generalized anxiety, depression, alcohol abuse or dependence, drug abuse or dependence, and PTSD) if they reported a pattern of symptoms in the past month that met the full DSM-HI criteria for that condition. When we analyzed the occurrence of conditions over a veteran's lifetime, the prevalences of all conditions increased but the relative differences between Vietnam and non-Vietnam veterans generally remained the same.6 The MMPI is a self-administered questionnaire that provides a quantitative evaluation of personality, emotional status, and level of psychopathology.12 Elevations on the standard MMPI clinical scales were defined as T scores of 70 or higher, which represents 2 SDs above the mean for the population on which the scales were developed. Data Analysis Multivariate analyses were performed by using logistic regression13 to compute odds ratios and 95% confidence intervals. As a general approximation, if a 95% confidence interval excludes 1.0, the odds ratio estimate can be considered to be statistically significant (ie, Fig 1.—Number of veterans in each component of Vietnam Experience Study. NPRC indicates National Personnel Records Center. P<.05). In the results presented herein, all odds ratios have been adjusted for six characteristics that were considered a priori to be potential confounders or modifiers of associations between place and interviewed by telephone. Among Examination and Testing of service and current health. These Vietnam veterans located but not interA random subsample of veterans was "entry characteristics" were age at viewed, 31 were incarcerated and nine were physically or mentally handi- selected to participate in a comprehen- entry into the army, race, score on the capped; the corresponding figures for sive medical and psychological examina- enlistment general technical test (a non-Vietnam veterans were 32 and 11, tion in addition to the telephone inter- measure of mental aptitude), enlistview (Fig 1). Of those invited, 75% of ment status (drafted or volunteered), respectively. A structured questionnaire was the Vietnam veterans (2490) and 63% of year of entry into the army, and priadministered by trained interviewers the non-Vietnam veterans (1972) partic- mary military occupational specialty using a computer-assisted telephone ipated. All examinations and tests were (tactical or nontactical). For nearly all interview system. Before the telephone performed at one medical facility. Par- conditions, unadjusted estimates were interview and all other components 'of ticipants' expenses—including travel, similar to estimates that were adjusted the VES, participants were given a spe- meals, lodging, and a nominal stipend— for the six entry characteristics as well as to estimates that were adjusted for cial assurance of confidentiality. Inter- were paid from study funds. Psychological health was assessed by additional characteristics, such as eduviewers could not distinguish Vietnam veterans from other veterans until late using the Diagnostic Interview Sched- cation and marital status." We also evalin the interview when Vietnam veter- ule (DIS) and the Minnesota Multipha- uated interactions between entry charans were asked about various experi- sic Personality Inventory (MMPI). The acteristics and place of service. When DIS10 is a standardized questionnaire final models included significant interences unique to Vietnam. I. Psychological Characteristics II. Physical Health III. Reproductive Outcomes 2702 JAMA, May 13, 1988—Vol 259, No. 18 CDC Vietnam Experience Study—Psychosocial Characteristics �action terms, odds ratios were standardized to the distribution of the interaction variable in both cohorts combined.14'15 In the VES we had no objective measure of the amount of combat experienced by individual veterans. We did, however, use tactical military occupational specialty as an indirect indicator of which men were likely to have participated in direct combat. We realize, however, that some men with nontactical military occupational specialties would have experienced heavy combat and vice versa. As part of the psychological testing, we administered a combat exposure questionnaire16 that relied on men's recollections of events that occurred 15 to 20 years earlier. Both of these indicators of combat exposure are thus imperfect, although they probably are related to some extent to actual combat experienced. Vietnam veterans with tactical military occupational specialties did have higher self-reported combat exposure scores (mean, 34 [of a possible 72]) than those with nontactical military occupational specialties (mean, 18). Since we tried to use objective information as much as possible, we relied on military occupational specialty category as the indicator of leVel of combat for the present analysis. A summary analysis was performed to determine which of the entry characteristics, including place of service, were associated with current "poor psychological status." A veteran was considered to have a poor psychological status if he met full DIS criteria for generalized anxiety, depression, or substance abuse in the past month and if he had elevations on at least two of eight clinical scales (scales 1 through 4 and 6 through 9) from the MMPI. In a clinical setting, such findings would typically lead to further psychological or psychiatric evaluation and, perhaps, treatment. RESULTS Participant Characteristics Among those who were interviewed, the age and racial distributions of the Vietnam and non-Vietnam groups were similar (Table 1). The two groups also were similar with respect to age at entry into the army, enlistment status, and having had any absent without leave or confinement time while in the army. Non-Vietnam veterans tended to have higher entry general technical test scores while more Vietnam veterans entered the army before 1969, were assigned tactical military occupational specialties, and served in units associated with direct combat activity. Smaller proportions of Vietnam than JAMA, May 13, 1988—Vol 259, No. 18 Table 1.—Comparison of Selected Demographic and Military Characteristics Among Vietnam and NonVietnam Veterans Veterans Interviewed Characteristic* Mean age at interview, y Race, % white (not Hispanic) Mean age at enlistment, y Year of enlistment, % before 1969 Enlistment status, % volunteers Mean score on enlistment GT test Primary MOS.t % tactical operations Type of unit,:): % combat unit AWOL or confinement time, % with some Type of discharge,! % nonhonorable Pay grade at discharge, %E1-E3|| Examined Vietnam (N=7924) Non- Vietnam (N = 7364) Vietnam (N = 2490) Non-Vietnam (N = 1972) 37.5 37.4 37.4 37.4 83.2 82.0 82.5 81.1 19.8 20.1 19.8 20.1 72.0 60.6 70.5 60.5 35.6 32.8 38.3 35.1 103.9 106.6 104.6 107.6 34.2 26.9 34.0 25.3 57.0 44.8 55.9 45.0 10.0 10.5 9.4 10.8 1.8 6.2 1.9 6.5 9.3 15.9 9.4 16.4 "Unknown values are excluded from the results shown here. GT indicates general technical; and AWOL, absent without leave. tMOS indicates primary military occupational specialty—the job for which the man was trained in the army. Tactical operations includes jobs such as infantryman, armored vehicle crewman, artillery crewman, and combat engineer. ^Refers to the principal unit recorded in the military record for the man's foreign assignment (or US assignment if no foreign service was performed). Combat units include infantry, artillery, armor, cavalry, and engineer. §Also called character of service. Nonhonorable includes underhonorable, other than honorable, undesirable, general-underhonorable, bad conduct, and dishonorable. IIGrades E1 through E3 correspond to the various ranks of private. non-Vietnam veterans were discharged nonhonorably or at lower pay grades. The characteristics of the subsample of veterans examined were similar to those of the telephone interview participants (Table 1). Additional information that was available only for the examination participants indicated that childhood (younger than age 15 years) behavioral problems, as reported by the veterans, were not different in the two groups. In each group, about 12% had been expelled or suspended from school, 3% had run away from home, and 6% had been arrested. At the time of the study, the socioeconomic characteristics of Vietnam and non-Vietnam veterans were generally similar among the telephone interview participants and those examined (Table 2). Marital status was similar in the two cohorts: about 60% of ever-married veterans were currently married to their first wives. Non-Vietnam veterans tended to have more education and higher household incomes, but these differences almost disappeared after adjusting for differences in the six entry characteristics. More than 90% of the veterans in both groups were currently employed. The types of jobs the veterans held also were similar, although more non-Vietnam veterans were in executive, managerial, and professional specialty occupations. Information from those examined indicated that more than 90% of Vietnam and non-Vietnam veterans felt satisfied with their current personal relationships. Psychological Evaluation Vietnam veterans were more likely than non-Vietnam veterans to meet DIS criteria for alcohol abuse or dependence, generalized anxiety, and depression (Table 3). Few men in either group met DIS criteria for drug abuse or dependence. Vietnam veterans were significantly more likely to meet criteria for at least one of the conditions or for two or more of the conditions. Analyses of combat-related PTSD were restricted to Vietnam veterans since non-Vietnam veterans had little opportunity to experience combat. About half of Vietnam veterans reported experiencing one or more symptoms related to a traumatic combat event, and 15% met DIS diagnostic criteria for combat-related PTSD at CDC Vietnam Experience Study—Psyohosocial Characteristics 2703 �Table 2.—Comparison of Selected Socioeconomic Characteristics Among Vietnam and Non-Vietnam Veterans Veterans, % Examined Interviewed Characteristic* Marital status at interview Married Divorced, separated, or widowed Never married Education! Less than high school High school graduate Some college College graduate Usual occupation Executive and managerial Professional specialties Office, clerical, and sales Service and transportation Precision work, craft, and repair Operator and laborer Farmer, forester, and fisherman Unemployed at interview Income, $i <10000 10000-29999 30000-49999 >50000 Vietnam (N=7924) Non- Vietnam (N=7364) Vietnam (N=2490) Non-Vietnam (N = 1972) 74.2 74.5 73.2 73.8 17.1 16.6 18.1 17.7 8.7 8.9 8.7 8.5 14.1 11.6 13.7 10.1 39.6 37.9 37.2 35.8 28.5 28.9 30.3 29.1 17.8 21.7 18.9 25.0 18.5 20.5 19.6 21.8 11.0 14.0 11.3 15.0 7.8 7.7 8.0 6.8 13.5 12.4 15.3 13.7 25.7 24.5 24.0 24.4 20.6 18.1 18.9 16.3 2.9 2.8 2.8 2.4 9.5 8.5 9.6 9.1 9.7 9.4 10.0 10.0 46.6 45.0 47.1 45.1 33.4 33.3 32.9 32.5 10.3 12.4 10.0 12.4 *Men with unknown values for a particular variable were excluded from the analysis of that variable. fHighest grade or year of regular schooling attained as of interview. ^Combined family (gross) income for the calendar year immediately preceding the year of interview. some time during or after service (Table 4). In the month before examination, 79% of Vietnam veterans had no symptoms and 21% had one or more symptoms, with 2% meeting full diagnostic criteria for combat-related PTSD. Meeting DIS diagnostic criteria for combat-related PTSD was associated with having a tactical military occupational specialty. The odds ratio for tactical vs nontactical military occupational specialties was 2.0 (95% confidence interval, 1.5 to 2.5) for "ever" meeting DIS diagnostic criteria and 1.7 (95% confidence interval, 1.0 to 3.0) for meeting diagnostic criteria in the month before examination. Veterans who met criteria for PTSD were also more likely to meet DIS criteria for other psychiatric conditions. Among those who met DIS criteria for combat-related PTSD during the month before examination, 66% also met DIS criteria for anxiety or depression and 39% met criteria for alcohol abuse or dependence. 2704 JAMA, May 13, 1988—Vol 259, No. 18 The MMPI provided further information about the veterans' current psychological status. The reliability of each veteran's responses was evaluated by using the standard MMPI validity scales (L, F, and K) and two additional scales (Carelessness and Test-Retest). The same proportion of veterans in the two cohorts (11%) showed questionable or invalid profiles on the basis of elevations on these scales (T scores 5*70 on the L scale; 5*80 on the F scale; or >70 on the K, Carelessness, or Test-Retest scales). Analyses conducted with and without exclusions of questionable profiles yielded essentially the same results; questionable profiles have been excluded from the results presented herein. A larger proportion of Vietnam than non-Vietnam veterans showed MMPI indications of psychological problems (Table 5). Significantly more Vietnam veterans had elevations on scales 1,2,3, and 7 (which provide the MMPI's best indication of anxiety, somatization, and depression) as well as on scale 8 (which indicates unusual thoughts or behaviors, usually related to distress or psychopathology). Other clinical scales, including 4 and 9 (which are commonly associated with characteristics of addictive or antisocial personality) and 5 and 0 (both of which are of little clinical relevance), did not differ between Vietnam and non-Vietnam veterans. Overall, about half the participants in each group showed no elevation on any clinical scales, but elevations on two or more clinically relevant scales (scales 1 through 4 and 6 through 9) were significantly more frequent among Vietnam veterans. Current poor psychological status was also more prevalent among Vietnam veterans (Table 6). The increased prevalence of current poor psychological status, however, was more prominent among those veterans who entered the army before 1968. Regardless of whether a veteran had served in Vietnam, current poor psychological status was more prevalent in veterans who were not white, who had been young (younger than age 19 years) at enlistment, or who had lower general technical test scores at enlistment. The other entry characteristics, including military occupational specialty category, were not associated with current poor psychological status. The prevalence of current poor psychological status among Vietnam veterans was 13% for those with tactical military occupational specialties and 12% for those with nontactical military occupational specialties. The same proportional increase in current poor psychological status associated with service in Vietnam was found within different subgroups defined by race, age at enlistment, and enlistment general technical test score (Fig 2). Although proportional differences remained the same, absolute differences in risk of current poor psychological status between Vietnam and non-Vietnam veterans necessarily varied as the underlying risk changed. Thus, the absolute differences in risk between Vietnam and non-Vietnam veterans diminish as the risk moves downward from nonwhite veterans who had been young and had had low general technical test scores at enlistment to white veterans who had been older and had had high general technical test scores at enlistment. COMMENT Since the time of the conflict to the present, veterans and others have been concerned about the psychological health of American military personnel who served in Vietnam and about their CDC Vietnam Experience Study—Psychosocial Characteristics �Table 3.—Vietnam and Non-Vietnam Veterans Who Met DIS Criteria for Selected Psychiatric Conditions* Veterans, % Condition Alcohol abuse or dependence Drug abuse or dependence Generalized anxiety§ (with or without depression) Depression (with or without generalized anxiety) Total No. of above conditions >1 >2 Vietnam (N=2490) Non-Vietnam (N = 1972) Odds Ratlof 95% Confidence Interval 13.7 9.2 1.5 1.2-1.8 0.4 0.5 0.9$ 0.4-2.0 4.9 3.2 1.5 1.1-2.1 4.5 2.3 2.0 1.4-2.9 19.2 13.1 1.5 3.5 1.8 1.9 1.3-1.8 1 .2-2.8 *DIS indicates Diagnostic Interview Schedule. Veterans must have met DIS criteria in the month before examination. t Adjusted for the six entry characteristics. fCrude odds ratio presented because the number of cases is not sufficient for an adjusted estimate. §For clinical purposes, depression is considered the primary diagnosis for individuals with both depression and anxiety Of Vietnam veterans, 2.8% had generalized anxiety alone and 2.1% had generalized anxiety and depression; of non-Vietnam veterans, 2.2% had generalized anxiety alone and 1.0% had generalized anxiety and depression. Table 5.—Vietnam and Non-Vietnam Veterans With Elevated MMPI Clinical Scales (T score >70)* Veterans, % MMPI Scale Vietnam (N=2221)f Non- Vietnam (N = 1754)f Odds Ratio* 1.7 95% Confidence Interval 1.4-2.1 1.3-1.8 1.2-2.0 0.9-1.2 0.9-1.3 1.0-1.7 1 15.6 9.1 2 25.1 17.3 1.6 3 8.9 5.9 1.5 4 15.7 14.7 1.0 5 12.7 12.9 1.1 6 9.1 7.2 1.3 7 16.5 10.9 1.6 1 .3-1 .9 8 16.3 9.2 2.0 9 13.7 13.5 1.1 0 11.0 8.3 1.3 1.6-2.4 0.9-1.3 1.0-1.6 51.5 59.6 0.7 48.5 40.4 1.3 28.2 20.8 1.5 No scales elevated§ 21 scales elevated§ 2:2 scales elevated§ Table 4.—Vietnam Veterans Who Ever Met DIS Criteria for Combat-Related PTSD and Those Who Met Full Criteria in the Month Before Examination* 0.7-0.8 1.2-1.5 1.2-1.7 *MMPI indicates Minnesota Multiphasic Personality Inventory; a T score of 70 or higher represents 2 SDs above the standardization sample mean. fVeterans with questionable profiles are not included in this analysis. ^Adjusted for the six entry characteristics. §Excluding scales 5 and 0. adaptation to civilian life after their return home.17'20 In this study, 15 to 20 years after army service, Vietnam veterans seem to be functioning socially and economically in a manner similar to army veterans who did not serve in Vietnam. At the time of the study, few men in either group of veterans were in jail, institutionalized, or mentally or physically incapacitated. In both groups, three fourths of the men were married at the time of interview, with similar proportions married to their first wives. In addition, more than 90% expressed satisfaction with their family JAMA, May 13, 1988—Vol 259, No. 18 and other personal relationships. More than 90% were also currently employed. After differences that were present at induction into the army (such as general technical test score) had been accounted for, the educational levels, types of occupations, and household incomes of the two groups were similar. Although the outward indications are that the two groups of veterans have made similar adaptations to civilian life, the study results also indicate that more Vietnam veterans than non-Vietnam veterans currently are experiencing psychological problems. The current Vietnam Veterans, % (N=2490) Type of Symptoms Combat-related PTSDf Criterion B Recurrent thoughts or dreams Felt as if event recurring Criterion C Lost ability to care about others or lost interest in usual activities Criterion D Jumpy or easily startled Trouble sleeping Ashamed of being alive Forgetful or trouble concentrating Avoids situations that remind Symptoms get worse in situations that remind No symptoms Month Before Ever Examination 14.7 2.2 32.4 7.6 1.9 9.4 17.1 5.1 45.1 34.6 8.1 10.6 3.4 1.9 13.6 0.4 28.8 7.9 17.3 49.9 3.9 79.2 *DIS indicates Diagnostic Interview Schedule; and PTSD, posttraumatic stress disorder. fTo meet DIS criteria for combat-related PTSD, a veteran had to report a combat-related traumatic event (criterion A), at least one reexperiencing symptom (criterion B), a numbing symptom (criterion C), and at least two symptoms of autonomic arousal (criterion D). All symptoms were related specifically to the traumatic event. psychological problems of Vietnam veterans, as determined by the DIS, mainly involve (1) alcohol abuse or dependence, affecting about 14% of Vietnam veterans compared with 9% of nonVietnam veterans; (2) anxiety, 5% vs 3%; and (3) depression, 5% vs 2%. The MMPI results, although they do not provide information on discrete diagnostic categories, were generally in accord with the DIS results. Also, according to DIS criteria, about 15% of Vietnam veterans have ever experienced combat-related PTSD, and about 2% experienced the disorder during the month before the examination. Fewer than 1% in either cohort met DIS criteria for current drug abuse or dependence. The mortality analysis of the VES cohorts suggested that drugrelated deaths were higher among Vietnam veterans throughout the approximately 13 years of follow-up.1'2 The VES telephone interviews and examinations, however, indicate that current regular use of illicit drugs was similar among Vietnam and non-Vietnam veterans. Drug use, typically involving only marijuana, was reported by about 10% of Vietnam and 8% of non-Vietnam veterans.1 Use of illicit drugs other than marijuana was reported by about 2% to 3% in each group." To identify the participants who could be considered to have the poorest current psychological status, we combined CDC Vietnam Experience Study—Psychosocial Characteristics 2705 �Table 6.—Risk Factors Associated With Current Poor Psychological Status Prevalence of Poor Psychological Status Factor Year of entry and place of service 1965-1967 Non- Vietnam Vietnam 1968-1971 Non- Vietnam Vietnam Other risk factors Race White Nonwhitef Age at enlistment, y <19 % Odds Ratio* No. 5.6 51 163 Referent 1.6-3.2 1.0 13.0 2.3 8.8 93 134 1.3 8.8 322 1.0 14.7 119 Referent 0.8-2.0 1.0 10.9 1.4 16.3 105 8.7 326 12.7 10 1.4 <88 16.0 142 1.9 88-101 102-113 114-124 12.4 110 1.3 9.5 88 1.0 8.1 70 0.8 3.4 29 1.5-2.4 Referent 0.7-2.8 1.0 >24 Referent 1.1-1.8 1.9 19-24 95% Confidence Interval 0.6 Enlistment GT test secret >124 1.6-2.2 1.2-1.4 Referent 0.7-0.8 0.5-0.7 * Adjusted for all other risk factors in table. tNonwhite includes blacks, Hispanics, American Indians, Asians, and Pacific Island Americans. tGT indicates general technical. 40 40 o 30 o 30 £20 20 10 10 70 80 90 100 110 120 130 140 Enlistment GT Score 70 80 90 100 110 120 130 140 Enlistment GT Score Fig 2.—Predicted probability of poor psychological status by place of service, age at enlistment, race, general technical (GT) test score, and year of entry into military service. Left, Veterans who entered service between 1965 and 1967. Right, Veterans who entered service between 1968 and 1971. V indicates Vietnam; N, non-Vietnam; solid lines, nonwhite and younger than 19 years old; and dotted lines, white and between 19 and 24 years old. findings from the DIS and the MMPI. Among veterans who entered the army from 1965 to 1967, the prevalence of current poor psychological status for Vietnam veterans was about double the prevalence for veterans who did not serve in Vietnam; among those who entered later, the prevalences were similar. This suggests that some change occurred around 1968, but we cannot specify what the change may have been. The range of possibilities includes not 2706 JAMA, May 13, 1988—Vol 259, No. 18 only changes in the nature of the Vietnam conflict, but also changes in American societal attitudes and perceptions about the conflict and changes in the attitudes or expectations of men entering the army. Compared with veterans who entered the army before 1968, the prevalence of current poor psychological status decreased among Vietnam veterans but increased among nonVietnam veterans who entered in 1968 or later. When military occupational specialty category was used as an indicator of the extent of direct combat likely to have been experienced, the only psychological condition that showed a strong association with level of combat was combatrelated PTSD. Vietnam veterans with tactical military occupational specialties were nearly twice as likely as those with nontactical military occupational specialties to have ever experienced combat-related PTSD. For all the other psychological conditions, the increased relative risk associated with service in Vietnam was evident in both military occupational specialty categories. This suggests that those Vietnam veterans who had tactical military occupational specialties were not at any greater relative risk of having these subsequent psychological problems than those who had nontactical military occupational specialties. For most psychological conditions, the relative effect of service in Vietnam was the same regardless of such characteristics as race, age at entry into the army, enlistment status, and induction general technical test score, as well as military occupational specialty category. This suggests that the effect of Vietnam service, at least for those who entered the Army between 1965 and 1967, was a general one for which most veterans who served in Vietnam may have been at risk. The increased prevalence of current psychological problems among Vietnam veterans does not seem to have been due to the characteristics of the men who were sent to Vietnam. From all available information, the characteristics of the two groups seemed to be similar. In particular, the racial distributions and the prevalences of reported childhood behavioral problems were nearly identical. Also, preservice prevalences of psychiatric symptoms, including anxiety, depression, and substance abuse, were similar in the two groups.6 The only difference in known entry characteristics was that those with higher entry general technical test scores seemed less likely to serve in Vietnam. This difference, however, was small and did not account for the differences in psychological findings between Vietnam and non-Vietnam veterans. A potential concern with the study is the possibility of participation bias. Examination participation rates for Vietnam veterans were higher than those for non-Vietnam veterans. Detailed analyses of the factors that influenced participation showed that those examined were similar to those interviewed by telephone.5 Thus, participa- CDC Vietnam Experience Study—Psychosocial Characteristics �tion bias is not likely to have had a large influence on the study results. The higher prevalence of psychological problems among Vietnam veterans does not seem to be related to their being in worse current physical health. In the medical examination component of the VES, few differences were found between Vietnam and non-Vietnam veterans in terms of neuropsychological performance, neurological findings, or other objective measures of current physical health.5'8 Military service in Vietnam was, undoubtedly, an emotionally and psychologically difficult experience for many US servicemen. Fifteen to 20 years afterward, more Vietnam veterans have psychological and emotional problems compared with veterans who did not serve in Vietnam. These psychological problems, however, are not of a magnitude that has resulted in Vietnam veterans' having, as a group, lower social and economic attainment. This report was prepared by the following: Drue H. Barrett, MA; Coleen A. Boyle, PhD; Pierre Decoufle, ScD; Frank DeStefano, MD, MPII; Owen J. Devinc, MS; Robin D. Morris, PhD (Centers for Disease Control and Georgia State University, Atlanta); Mark J. Scally, MPA; Nancy E. Stroup, PhD; Scott F. Wetterhall, MD; and Robert M. Worth, MD, PhD. Other VES staff members include the following: Charles L. Adams, MPH; Joseph L. Annest, PhD; Andrew L. Baughman, MPH; Edward A. Brann, MD, MPH; Eugenia E. Calle, PhD; Elizabeth A. Cochran; Karen S. Colberg; Robert C. Diefcnbach; Barbara Dougherty; Sandra S. Emrich; W. Dana Flanders, MD, DSc; Anthony S. Fowler; Robert R. German; Patricia Holmgreen, MS; Martha I. Hunter; M. Riduan Joesoef, MD, PhD; John M. Karon, PhD; Muin J. Khoury, MD, PhD; Marcie-jo Kresnow, MS; Heather D. McAdoo; Brcnda R. Mitchell; Linda A. Moyer; Thomas R. O'Brien, MD, MPH; and Joseph B. Smith. Current and former Centers for Disease Control staff members who also made important contributions include the following: Robert J. Delaney; John J. Drescher; J. David Erickson, DOS, PhD; Melin- JAMA, May 13, 1988—Vol 259, No. 18 da L. Flock, MSPH; John J. Gallagher; Jerry G. Gentry, MSPH; Michael E. Kafrissen, MD, MSPH; Marilyn L. Kirk; Peter M. Layde, MD, MSc; Maurice E. LeVois, PhD; Peter J. McCumiskey; Daniel L. McGee, PhD; Terryl J. Meranda, MS; Daniel A. Pollock, MD; Melvin W. Ralston; Philip H. Rhodes, MS; Richard K. Rudy, MD; Paul D. Simpson, MS; and Dennis M. Smith, MD. Consultants who made important contributions to this study component include the following: Lee N. Robins, PhD (Washington University, St Louis), and Marjorie A. Speers, PhD (Division of Chronic Disease Control, Center for Environmental Health and Injury Control, Centers for Disease Control). Many other individuals and organizations have provided invaluable support to the study. These include the following: the Agent Orange Working Group and its Science Panel; the Congressional Office of Technology Assessment; the Army Reserve Personnel Center, US Army and Joint Services Environmental Support Group, Department of Defense; Equifax Inc; the General Services Administration; the Internal Revenue Service; Lovelace Medical Foundation; the National Personnel Records Center, National Archives and Records Administration; the National Center for Health Statistics; the Institute of Medicine, National Academy of Sciences; Research Triangle Institute; the Social Security Administration; the Veterans Administration; and other staff members of the Centers for Disease Control and outside consultants. Leaders of Veterans Service Organizations provided important input and support to the study, and participation by Vietnam-era veterans made the study possible. References 1. Boyle CA, Decoufle P, Delaney RJ, et al: Poatservice Mortality Among Vietnam Veterans. Atlanta, Centers for Disease Control, 1987. 2. Centers for Disease Control Vietnam Experience Study: Postservice mortality among Vietnam veterans. JAMA 1987;257:790-795. 3. Centers for Disease Control Vietnam Experience Study: Health Status of Vietnam Veterans: I. Synopsis. Atlanta, Centers for Disease Control, in press. 4. Centers for Disease Control Vietnam Experience Study: Health Status of Vietnam Veterans: II. Telephone Interview. Atlanta, Centers for Disease Control, in press. 5. Centers for Disease Control Vietnam Experience Study: Health Stains of Vietnam Veterans: III. Medical Examination. Atlanta, Centers for Disease Control, in press. 6. Centers for Disease Control Vietnam Experience Study: Health Status of Vietnam Veterans: IV. Psychological and Neuropsychological Evaluation. Atlanta, Centers for Disease Control, in press. 7. Centers for Disease Control Vietnam Experience Study: Health Status of Vietnam Veterans: V. Reproductive Outcomes and Child Health. Atlanta, Centers for Disease Control, in press. 8. Centers for Disease Control Vietnam Experience Study: Health status of Vietnam veterans: II. Physical health. JAMA 1988;259:2708-2714. 9. Centers for Disease Control Vietnam Experience Study: Health status of Vietnam veterans: III. Reproductive outcomes and child health. JAMA 1988;259:2715-2719. 10. Robins LN, Helzer JE, Cottier LB, et al: The Diagnostic Interview Schedule, Version III-A, Training Manual. St Louis, Veterans Administration, 1987. 11. Diagnostic and Statistical Manual, ed 3. Washington, DC, American Psychiatric Association, 1980. 12. Dahlstrom WG, Welsh GS, Dahlstrom LE: An MMPI Handbook: Clinical Interpretation, revised edition. Minneapolis, University of Minnesota Press, 1972, vol 1. 13. Engelman L: Stepwise logistic regression, in Dixon WJ, Brown MB, Engelman L, et al (eds): BMDP Statistical Software. Berkeley, University of California Press, 1983, pp 330-344. 14. Wilcosky TC, Chambles LE: A comparison of direct adjustment and regression adjustment of epidemiologic measures. J Chronic Dis 1985;38:849-856. 15. Flanders WD, Rhodes PH: Large sample confidence limits for regression standardized risks, risk ratios, and risk differences. / Chronic Dis 1987;40:697-704. 16. Egendorf A, Kadushin C, Laufer RS, et al: Legacies of Vietnam: Comparative Adjustment of Veterans and Their Peers, publication V101. Washington, DC, Center for Policy Research Inc, 1981, pp 134-630. 17. Helzer JE, Robins LN, Wish E, et al: Depression in Vietnam veterans and civilian controls. Am J Psychiatry 1979;136:526-529. 18. Blank AS: Stresses of war: The example of Vietnam, in Goldberg L, Breznitz S (eds): Handbook of Stress: Theoretical and Clinical Aspects. New York, Free Press, 1982, pp 631-643. 19. Laufer RS, Gallops MS, Frey-Wouters E: War stress and trauma: The Vietnam veteran experience. J Health Soc Behav 1984;25:65-85. 20. Robins LN, Davis DH, Goodwin DW: Drug use by U.S. Army enlisted men in Vietnam: A follow-up on their return home. AmJEpidemiol 1974;99:235249. CDC Vietnam Experience Study—Psycho-social Characteristics Printed and Published in the United States of America 2707 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 065 Folder The folder containing the original item. 1747 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Description An account of the resource <strong>Corporate Author: </strong>Center for Environmental Health and Injury Control, CDC, Public Health Service, DDHS, Atlanta, Georgia Source A related resource from which the described resource is derived JAMA Date A point or period of time associated with an event in the lifecycle of the resource May 13 1988 Title A name given to the resource Health Status of Vietnam Veterans, I. Psychological Characteristics, The Center for Disease Control Vietnam Experience Study Subject The topic of the resource Vietnam Experience Study veteran psychological health PTSD study protocol ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/eda1ab0ba8cd79035b18e79b26b04f62.pdf cd6d46a606e7b3f8913bfe99ef4a1cbc PDF Text Text Item ID Number 01742 Author Corporate Author RopOrt/ArtiClB TitlO Postservice Mortality Among Vietnam Veterans: The Centers for Disease Control Vietnam Experience Study Journal/Book Titlo JAMA Year 1987 Month/Day February 13 Color n Number of ImaDBS 28 DOSCTiptOn NOtOS Includes an undated, pre-publication typescript of the article. Monday, June 11, 2001 Page 1743 of 1793 �Reprinted from the JAMA" Journal of the American Medical Association February 13, 1987, Volume 257 Copyright 1987, American Medical Associatbn Postservice Mortality Among Vietnam Veterans The Centers for Disease Control Vietnam Experience Study The postservice mortality (through December 1983) of a cohort of 9324 US Army veterans who served in Vietnam was compared with that of 8989 Vietnam-era Army veterans who served in Korea, Germany, or the United States. Over the entire follow-up period, total mortality in Vietnam veterans was 17% higher than for other veterans. The excess mortality occurred mainly in the first five years after discharge from active duty (rate ratio, 1.45; 95% confidence interval, 1.08 to 1.96) and involved motor vehicle accidents, suicide, homicide, and accidental poisonings. Thereafter, mortality among Vietnam veterans was similar to that of other Vietnam-era veterans, except for drug-related deaths, which continued to be elevated. An unexpected finding was a deficit in deaths from diseases of the circulatory system among Vietnam veterans. The excess in postservice mortality due to external causes among Vietnam veterans is similar to that found among men returning from combat areas after World War II and the Korean War. (JAMA 1987;257:790-795) MANY Vietnam veterans have been concerned that their health, and that of their children, has been affected by their service in Southeast Asia and possible exposure to the herbicide Agent Orange. To address these concerns, the US Congress directed that appropriate epidemiologic studies be conducted.1'2 The Centers for Disease Control (CDC) has proposed three complementary efforts to assess the health of Vietnam veterans: the Agent Orange Study, the Selected Cancers Study, and the Vietnam Experience Study (VES).3 The VES is a historical cohort study designed to identify the possible adverse health effects of having served in the military in Vietnam. It has three components: (1) an assessment of postservice mortality, (2} a detailed health interview, and (3) a comprehensive medical, psychological, and laboratory evaluation. Although Agent Orange is among the many factors that could have From the Center for Environmental Health. Centers for Disease Control, Atlanta. Reprint requests to Centers for Disease Control, 1600 Cliflon Rd (C-25), Atlanta, GA 30333 (Coloon A. Boyle, PhD). 790 JAMA, Feb 13,1987—Vol 257, No. 6 adversely affected those who served in Vietnam, it is not the main focus of this study. This report is an abbreviated version of the results of the postservice mortality component, published in detail elsewhere.4 SUBJECTS AND METHODS Study Participants Participation was restricted to men who served in the US Army. To increase comparability between those who served in Vietnam and those who served elsewhere, we selected only veterans who (1) entered military service for the first time between January 1965 and December 1971, (2) served only one term of enlistment, (3) had at least 16 weeks of active service time, (4) earned a military occupational specialty (MOS) other than "trainee" or "duty soldier," and (5) had a pay grade no higher than E5 on discharge from active duty. To be eligible for the Vietnam cohort, a veteran had to have served at least one tour of duty in Vietnam. For the comparison cohort, tours of duty were limited to the United States, Germany, or Korea. The VES was designed principally to assess morbidity associated with ser- vice in Vietnam; mortality was examined for completeness. Thus, the sample size for the VES, about 9000 Vietnam and 9000 non-Vietnam veterans, was based on statistical power requirements for the morbidity components.3 Nevertheless, this sample size provides statistical power of 90% for detecting a 30% relative increase in allcause mortality, but more limited power for detecting cause-specific increases, particularly for deaths due to natural causes, which in this age group are rare.'1 Potential participants were randomly selected from almost 5 million US Army veterans whose service records were received by the National Personnel Records Center (NPRC) between September 1964 and June 1977. Personnel of the NPRC believe that this group includes the vast majority of US Army Vietnamera veterans who fulfill the study criterion of a single term of enlistment. The Figure outlines the process of participant selection. To achieve the desired sample size of 18 000 veterans with the above study criteria (proportion estimated from a pretest), we randomly selected 48 513 service records. Of the 47158 records located and reviewed, 60.6% were excluded during the qualification process; these included less than 200 records that did not contain critical data needed to determine eligibility. Characteristics of eligible men as of entry into service and details of their military experience were abstracted from the records. Altogether, 9558 Vietnam and 9023 non-Vietnam veterans qualified for the study. The 234 Vietnam and 34 non-Vietnam veterans who had died during active duty were excluded. Vital Status Ascertainment Follow-up began the day the veteran was discharged alive from active duty CDC Vietnam Experience Study—Postservice Mortality �Vietnam-Era Army Personnel Records Filed at NPRC, Sept 1964-June 1977 (About 4.9 Million) I I Random Sample (48 513) [Records Not Found'(1355)j [ Qualified for Study (18581)] Vietnam (9558) I Not Qualified (28577) [Non-Vietnam (9023)[ I Died on Active Duty (34) Died on Active Dutyt (234) I 34)] Vietnam Cohort (9324) [ I Non-Vietnam Cohort (8989) Selection of study group. NPRC indicates National Personnel Records Center; asterisk, excluded from study; and dagger, 83% (N = 194) of active-duty deaths among Vietnam veterans were due to war-related activities. ratio (RR) was formed by dividing the crude mortality rate among Vietnam veterans by that for non-Vietnam veterans. The 95% confidence intervals (CIs) for the RRs were computed using procedures described by Laird and Oliver.7 The Cox proportional hazards regression model8 was used to consider possible effect modification and confounding by selected covariates. Adjusted RRs were obtained from Cox models stratified on primary MOS and enlistment status (volunteer or draftee), and adjusted for other selected covariates. Two MOS categories were used in the model and can be described roughly as "tactical" (infantry, armor, artillery, and combat engineers) and "other" (all other specialties). Additional covariates considered in the Cox models, chosen on the basis of their associations with mortality in the univariate analyses," included race, age at discharge, Army General Technical Test score (a general aptitude test taken at entry into the service), pay grade at discharge, and year of discharge. Comparisons were also made between the mortality experience of each veteran cohort and that of the US male population utilizing Monson's software package.9 Results are expressed as a standardized mortality ratio (SMR) adjusted for age, race, and calendar year. RESULTS and ended on the date of his death or Dec 31, 1983, whichever came first. To identify those who had died after discharge, we checked files of the US Army, Veterans Administration (Beneficiary Identification and Record Locator Subsystem), Social Security Administration, Internal Revenue Service, and National Center for Health Statistics (National Death Index). For the interview component of the VES, an attempt was made to locate and contact all veterans not identified as deceased by the above sources. Through this method, vital status was confirmed for 93.6% of Vietnam veterans and 91.9% of those who served elsewhere. Entry and military service characteristics of Vietnam veterans whose vital status was uncertain were similar to those of non-Vietnam veterans with uncertain vital status. All men with uncertain vital status were assumed to be alive at the end of 1983. For all but nine of the 446 men reported to have died after discharge, copies of official death certificates were obtained. The other nine deaths were confirmed through other sources. Underlying causes of death were coded according to both the eighth and ninth revisions6'6 of the International Classification of DisJAMA, Feb 13,1987—Vol 257, No. 6 eases (ICD) by an experienced nosologist at the National Center for Health Statistics who had no knowledge of whether the decedent had served in Vietnam. Medical Review Panel To address limitations of death certificate-based diagnoses, a review panel of two physicians determined the underlying cause of death, using pertinent medical and legal documents describing the nature and circumstances of each of 426 deaths for which additional information could be obtained. Sources included hospitals, law enforcement agencies, coroners or medical examiners, and private physicians. All causes of death and other significant conditions were coded by the medical review panel according to the Ninth Revision of the ICD. To estimate the influence of substance abuse on mortality in this study, special categories of alcohol- and drug-related deaths were developed, and deaths were so classified by the review panel when appropriate. Analyses Crude death rates were based on person-years at risk since discharge from active duty. An unadjusted rate There were some differences in both preinduction and military service characteristics between the Vietnam and non-Vietnam cohorts (Table 1). In general, however, the preinduction differences were small. Differences in some of the military service characteristics, such as a greater percentage of Vietnam veterans with tactical MOS classifications and infantry unit assignments, reflect war-related military requirements in Vietnam. All-Cause Mortality Over the entire follow-up period, the mortality among Vietnam veterans was 17% higher than the rate among nonVietnam veterans (Table 2). Most of this excess, however, was due to higher mortality among Vietnam veterans during the first five years of follow-up (RR, 1.45; 95% CI, 1.08 to 1.96). By the sixth year, the two cohorts had similar mortality rates that remained so through the end of follow-up (RR, 1.01; 95% CI, 0.79 to 1.28). Because of the variation in relative mortality with time, time-specific results will be presented when appropriate. To determine whether the association between Vietnam service and mortality was uniform or varied across different CDC Vietnam Experience Study—Postservice Mortality 791 �Table 1.—Differences in Selected Characteristics Between Vietnam and Non-Vietnam Veterans at Entry Into Service and During Military Service Table 3.—Number of Deaths Among Vietnam and Non-Vietnam Veterans and Unadjusted Rate Ratios (RRs), by Selected Characteristics and Years Since Discharge From Active Duty, 1965 Through 1983 Vietnam (N=9324) At entry into service Race,* % white Age at entry (mean) Enlistment status,* % draftee Year of entry into service, % before 1969 Non-Vietnam (N=8989) 86.8 86.5 20.3 Characteristic 20.5 Characteristic* 65.6 Race White 63.7 Years Since Discharge From Active Duty s5 Nonwhite 72.1 Army General Technical Test score (mean, scaled to 100) During military service Primary military occupational specialty, t % tactical operations 60.6 105.5 Type of discharge, % honorable 34.3 27.4 26.6 Type of unit, % infantry 97.2 91.0 88.5 79.8 Year of discharge, % before 1970 48.1 44.6 *Race and enlistment status were the only two characteristics that were not significantly different (P>.05) between the Vietnam and the non-Vietnam groups. tThe job specialty for which the man was trained in the Army. No. RR No. RR 79 1.09 111 0.91 190 0.98 104 1.80 152 1.06 256 1.31 GT test scoref 97 1.42 141 0.90 238 1.08 <100 100 + 83 1.43 119 1.07 202 1.20 Duty MOSt 63 1.19 Tactical 89 1.04 152 1.10 Other 120 1.58 174 0.97 294 1.18 Age at discharge <21 47 1.83 42 0.67 89 1.14 14.6 Pay grade at discharge, % E4 or E5 RR All Years 146 1.50 193 0.99 339 1.18 37 1.30 70 1.07 107 1.14 Enlistment status Volunteer Draftee 103.1 No. 6+ 21 + 136 1.41 221 1.10 357 1.21 Pay grade at discharge E4-E5 125 1.50 183 1.10 308 1.24 E1-E3 58 1.95 80 1.16 138 1.44 Year of discharge 79 2.05 122 0.96 201 1.27 <1970 104 1.16 141 1.06 245 1.10 1970 + "There was no evidence of statistically significant effect modification for any of these characteristics (P>.OS). tArmy General Technical Test (GT) scores were missing for six veterans. ^Determined from principal military occupational specialty (MOS) held while on tour of duty. Table 2.—Number of Deaths, Person-Years, and Death Rates Among Vietnam and Non-Vietnam Veterans and Unadjusted RRs by Years Since Discharge From Active Duty, 1965-1983* Non-Vietnam Vietnam ==5 No. of Deaths PersonYears Ratef No. Of Deaths PersonYears 95% Cl 46350 2.4 73 44747 Ratef 1.6 RR 110 Years Since Discharge 1.45 1.08-1.96 6+ 136 81547 1.7 127 76582 1.7 1.01 0.79-1.28 All years 246 127897 1.9 200 121 329 1.7 1.17 0.97-1.41 *RR indicates rate ratio; Cl, confidence interval. tCrude death rate per 1000 person-years. subgroups of veterans, separate analyses were done within these groups (Table 3). Although the results indicated a consistent pattern of elevated mortality associated with Vietnam service limited to the first five years after discharge, there was some variation in the RR among various subgroups of veterans. Tests for effect modification, however, were not statistically significant (P>.05). Possible confounding by selected covariates (age at discharge, race, Army General Technical Test score, pay grade at discharge, and year of discharge) was assessed by including them in stratified Cox models. In the first five years after discharge, adjustment for these characteristics increased the RR to 1.58 (95% Cl, 1.16 to 2.14). In the later 792 JAMA, Feb 13,1987—Vol 257, No. 6 follow-up period, adjustment changed the RR to 1.04 (95% Cl, 0.81 to 1.33). Results from the Cox model also indicated that Vietnam service had a greater effect on mortality among those who were discharged before age 21 years than those discharged at age 21 years or older (P = .02) and among veterans discharged before 1970 compared with those discharged during 1970 or later (P = . 05). Cause-Specific Mortality Death Certificates.—Only four major cause-of-death categories contained sufficient numbers of deaths for formal analysis (Table 4). Rates for Vietnam veterans appeared to differ from rates for non-Vietnam veterans in two of these categories: diseases of the circu- latory system (51% decrease in the death rate) and external causes of death (25% increase in the death rate). The deficit in circulatory disease deaths was evident regardless of time since discharge and type of circulatory disease. There were no differences in mortality from mental disorders or neoplasms. Deaths from specific types of neoplasms were too few for meaningful comparisons. The excess in external causes of death is examined further in Table 5. Vietnam veterans had significantly higher mortality from motor vehicle accidents (MVAs) (RR, 1.48; P = .03) than nonVietnam veterans. The excess was most pronounced in the first five years after discharge from active duty (RR, 1.93; P = .01). After that period, MVA rates were similar in the two cohorts (RR, 1.16). The RRs for suicide and homicide were somewhat increased in the early postdischarge period but not in the later years of follow-up. Accidental poisoning deaths (mostly by drugs) were substantially more common among Vietnam veterans than other veterans over the entire follow-up period (RR, 2.47; P = .08). No postservice deaths were attributed to war injuries (ICD-9, E990-E999). Adjustment for selected covariates did not materially alter the pattern of cause-specific mortality, except for suicide in the earlier follow-up period, where the adjusted RR was 2.59 (95% Cl, 1.09 to 6.17). Medical Review Panel.—The medical review analysis was based on 233 (95%) of Vietnam veteran deaths and 193 (97%) of deaths among non-Vietnam veterans. On average, slightly fewer supplemental medical and legal records were recovered for each Vietnam veteran death (mean, 3.3 records) than for each non-Vietnam veteran death (mean, 3.7 records). Overall agreement between the medical review panel diagnoses and death certificate diagnoses, however, was good (82%; K = 0.79) and did not differ significantly between the two veteran cohorts. The medical review analyses indicated differences in only two ICD-9 categories that were not evident from the death certificate analysis. The RR for mental disorders from the medical review panel analysis was 2.85 (95% Cl, 0.92 to 8.82) compared with 0.95 from the death certificate analysis. Most mental disorder deaths were related to alcohol or drugs and are examined in more detail in Table 6. The RR for neoplasms based on medical review panel diagnoses was 1.21 (95% Cl, 0.55 to 2.66) compared with 0.82 based on death certificates. This difference was CDC Vietnam Experience Study—Postservice Mortality �Table 4.—Number of Deaths by Cause (From Death Certificate), Death Rates Among Vietnam and NonVietnam Veterans, and Unadjusted RRs, 1965 Through 1983* Vietnam Underyllng Cause of Death (/CD-9)t Non-Vietnam No. Rate* Infectious and parasitic diseases (001 -139) No. 95% Cl RR§ Rate* 1 0.8 1 0.8 12 9.4 14 11.5 0.82 0.38-1 .76 Mental disorders (290-31 9) 7 5.5 7 5.8 0.95 0.33-2.70 Diseases of nervous system (320-389) 0.49 0.25-0.99 Neoplasms (140-239) 2 1.6 1 0.8 Diseases of circulatory system (390-459) 12 9.4 23 19.0 Diseases of respiratory system (460-51 9) 5 3.9 4 3.3 Diseases of digestive system (520-579) 5 3.9 3 2.5 Diseases of genitourinary system (580-611) 4 3.1 0 Congenital anomalies (740-759) 1 0.8 1 0.8 Symptoms, signs, and ill-defined conditions (780-799) 2 1.6 1 0.8 188 147.0 143 117.9 External causes (E800-E999) General Population Comparison 1 .25 1 .00-1 .55 2 7 No death certificate *RR indicates rate ratio; Cl, confidence interval. f/CD-9 indicates International Classification of Diseases, ninth revision. No deaths were categorized to diseases of blood and blood-forming organs; endocrine, metabolic or nutritional diseases; diseases of the skin; or diseases of the musculoskeletal system. Therefore, these categories are not shown. tCrude death rate per 100000 person-years. §lf the total number of deaths for a cause-of-death category in both groups combined was less than ten, RRs are not shown. Table 5.—Number of Deaths From Specific External Causes (From Death Certificate) Among Vietnam and Non-Vietnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, 1965 Through 1983* Years Since Discharge From Active Dutyt All Years 64- External Cause of Death (/CD-9) No. RR 95% Cl Motor vehicle accident (E810-E825, E929.0) 66 1.93 1.16-3.22 further refinement of the later follow-up period suggests the upward trend in drug-related mortality continues into the most recent years. Further, Vietnam service seems to be associated with an especially high rate of drug-related mortality among those drafted into service, those whose jobs were in tactical or combat operations, and those who served during 1969. Again, as in the death certificate results, adjustment for selected covariates increased the RR for suicide in the early follow-up period to 2.56 (95% Cl, 1.11 to 5.87). No other RR presented in the medical review results was materially altered by adjustment. No. RR 95% Cl No. RR 95% Cl 67 1.16 0.72-1.87 133 1.48 1.04-2.09 Both groups of veterans had a significantly lower overall mortality rate for "natural causes" than the general US male population (Table 7). During the first five years after discharge, Vietnam veterans had a higher death rate from external causes, whereas non-Vietnam veterans have a lower rate relative to the general population. In the later time period both groups of veterans showed a similar deficit in external cause mortality. Although these data are not presented in Table 7, over the entire followup period, Vietnam veterans had a striking deficit of circulatory disease deaths (SMR, 0.48; 95% Cl, 0.25 to 0.85), whereas non-Vietnam veterans had only a slight deficit (SMR, 0.87; 95% Cl, 0.54 to 1.34). Accidental poisoning (E850-E869, E929.2) 11 1.69 0.49-5.77 7 ... ... 18 2.47 0.88-6.92 COMMENT Other accidents* 23 1.05 0.46-2.37 39 0.89 0.48-1.67 62 0.95 0.58-1 .56 Suicide (E950-E959) 25 1.72 0.76-3.88 32 0.64 0.32-1.30 57 0.98 0.58-1.65 Homicide (E960-E969) 18 1.52 0.59-3.91 33 0.78 0.39-1.55 51 0.99 0.57-1.71 10 3.79 0.81-17.87 The intent of this study was to assess the effect of military service in Vietnam on subsequent mortality. The "Vietnam experience" includes a wide variety of possible health-influencing factors such as psychological stresses associated with war, infectious diseases prevalent in Vietnam, and exposure to the herbicide Agent Orange. The modest excess of deaths among Vietnam veterans was concentrated in the first five years after discharge, where all-cause mortality was 45% higher than in the non-Vietnam group. External causes accounted for most of this increase, with the largest elevation in relative mortality due to MVAs. A more detailed examination of MVA deaths did not indicate any particular factor that could explain the overall excess in Vietnam veterans. The increased risk did not appear to be related to elevated blood alcohol levels at the time of death, and the excess was apparent across various types of MVAs. Drug-use information on MVA victims was limited; the medical review panel Undetermined intentlonality (E980-E989) 4 6 *RR indicates rate ratio; Cl, confidence interval; /CD-9, International Classification of Diseases, ninth revision. tTime-specific RRs are not presented for categories with less than ten deaths in both Vietnam and non-Vietnam groups combined. ^Includes /CD-9 categories E800 to E807, E826 to E849, E870 to E928, E929.1, E929.3 to E929.9, E930 to E949, E970 to E978, and E990 to E999. primarily the result of two deaths from neoplasms among non-Vietnam veterans being reclassified elsewhere by the medical review panel and the opposite occurrence among Vietnam veterans. There was no particular type of neoplasm in excess in the Vietnam cohort. Supplemental information collected for the medical review allowed further exploration of MVA deaths. Single- and multiple-vehicle crash deaths as well as daytime and nighttime events all occurred more frequently among Vietnam veterans during the early postdischarge period. Vietnam veterans had a modest excess of alcohol-related MVA deaths JAMA, Feb 13,1987—Vol 257, No. 6 during this period (RR, 1.35; 95% Cl, 0.60 to 3.04). Alcohol-related natural causes of death were too few for formal analysis in the early postdischarge period, but the RR in the later period showed no difference between the two groups (Table 6). A modest elevation in alcohol-related traumatic deaths among Vietnam veterans was limited to the first five years after discharge. For drug-related deaths, the RR was slightly elevated during the early postdischarge period and more elevated during the later follow-up period. Although the number of deaths is too small for formal analysis, CDC Vietnam Experience Study—Postservice Mortality 793 �Table 6.—Number of Deaths From Alcohol and Drug-Related Causes (From Medical Review) Among Vietnam and Non-Vietnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, 1965 Through 1983* Years Since Discharge From Active Duty s5 Cause of Death Alcohol-related natural causesf Alcohol-related traumatic causes:): Drug-related causes§ No. All Years 6+ RR 95% Cl No. 95% Cl No. RR 95% Cl 25 5 RR 0.87 0.40-1.90 30 1.08 0.53-2.22 42 1.29 0.70-2.37 61 1.04 0.63-1.71 103 1.13 0.77-1 .67 18 1.21 0.48-3.06 22 2.01 0.82-4.94 40 1.58 0.83-3.00 'RR indicates rate ratio; Cl, confidence interval. tincludes the following diagnoses determined to be the underlying or contributing cause of death: alcoholic psychoses (291.0 to 291.9); alcohol dependence syndrome (303); nondependent alcohol abuse (305.0); alcoholic polyneuropathy (357.5); alcoholic cardiomyopathy (425.5); alcoholic gastritis (535.3); alcoholic liver disease (571.0 to 571.3); and excessive blood level of alcohol (790.3). ^Includes deaths in which the underlying cause is accidental poisoning by alcohol (E860.0 to E860.9) or any traumatic death (E800 to E989) in which either nondependent abuse of alcohol (305.0) or excessive blood level of alcohol (790.3) is a contributing cause of death. §Deaths for which one of the following drug-specific diagnoses is the underlying or contributing cause of death: drug psychoses (292.0 to 292.9); drug dependence (304.0 to 304.9); nondependent abuse of drugs (305.2 to 305.9); accidental poisoning by drugs (E850.0 to E850.2, E850.5, E850.8, E851-E854, E855.1 to E855.2, E866.6, and E869.0); suicide by drugs (E950.0 to E950.5); and poisoning by drugs, intentionality undetermined (E980.0 to E980.5). Table 7.—Observed and Expected Numbers of Deaths by Cause Among Vietnam and Non-Vietnam Veterans and SMRs, by Years Since Discharge From Active Duty, 1965 Through 1983* Years Since Discharge -~5 Cause of Deathf (ICDA-8) All natural causes (000-796) External causes (E800-E999) 6+ All natural causes (000-796) External causes (E800-E999) All years All natural causes (000-796) External causes (E800-E999) Observed Expected^ SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Observed Expected SMR 95% Cl Vietnam 13 Non- Vietnam 24.2 23.4 0.54 0.29-0.92 16 0.68 0.39-1.11 92 55 72.5 69.4 1.27 1.02-1.56 0.79 0.60-1.03 38 39 65.8 63.4 0.58 0.41-0.79 96 102.7 0.93 0.76-1.14 0.62 0.44-0.84 88 96.6 0.91 0.73-1.12 51 55 90.0 86.8 0.57 0.42-0.75 0.63 0.48-0.82 188 143 175.2 166.0 1.07 0.93-1.24 0.86 0.73-1.01 *SMR indicates standardized mortality ratio; Cl, confidence interval; and ICDA-8, International Classification of Diseases, Adapted for Use in the United States, eighth revision. •(•Excludes nine deaths (seven Vietnam, two non-Vietnam) for which death certificates were not recovered. ^Expected number is based on the mortality rates among US men, standardized for age, calendar year, and race. identified only one drug-related MVA death. Suicide and homicide also occurred somewhat more frequently among Vietnam veterans during the early postdischarge period. Accidental poisoning deaths (mainly by drugs) were elevated throughout the entire follow-up period, although the number of such deaths was small. By the sixth year after discharge, 794 JAMA, Feb 13,1987—Vol 257, No. 6 both all-cause and external-cause mortality among Vietnam veterans had fallen to levels found in the non-Vietnam group, except for deaths due to drug abuse, where the rate was actually higher in the more recent follow-up period. These findings are unlikely to be the result of a serious flaw in study design or execution. The study groups were selected in a manner that minimized dif- ferences in their preservice characteristics; vital status was verified for 93% of all participants; death certificates were recovered for 98% of deaths; and supplemental medical and legal documents, which allowed an independent assessment of cause of death by standardized criteria, were obtained for 96% of deaths. Moreover, the pattern of excess deaths was remarkably consistent across various subgroups of Vietnam veterans and appears not to be an artifact of confounding. It should be noted, however, that sample size constraints limited our ability to detect excesses in mortality in subgroups of veterans and for the less frequent causes of death in this relatively young group. Our findings can be viewed against the results of five previous mortality studies of Vietnam veterans. Four10'13 are proportional mortality studies, which may not be directly comparable with this study because of incompleteness of data and inherent limitations of this analytic method.14 The fifth, a cohort study of Australian Vietnam veterans, is very similar in design to our study and thus is a more appropriate comparison.16 The US Air Force "Ranch Hand" study is not discussed here, since its principal concern is the adverse health effects of herbicide exposure in a unique group of veterans.16 The 30% excess of external-cause mortality among Australian Vietnam veterans relative to non-Vietnam veterans is similar to what is seen here.16 Although the Australian investigators did not examine external cause mortality by time since discharge, there was a suggestion of a decline in relative mortality with increasing time since discharge in their all-cause mortality results. Deaths from suicide, homicide, and accidental poisoning also occurred more frequently among their Vietnam veterans. Mortality from MVA was not elevated overall, but an excess in the youngest age group was suggested. Findings for external-cause mortality from the four proportional mortality studies are not consistent with our results. A nonsignificant increase in deaths from MVA among Vietnam veterans relative to other veterans was present in only one of the studies.12 The relative frequencies of suicide and homicide were not unusual, although there was one instance of a nonsignificant increase in both of these causes." Accidental poisonings were analyzed in only one of the studies, and the result was a small, nonsignificant elevation among Vietnam veterans.11 Australian Vietnam veterans had an excess of deaths from alcohol-related CDC Vietnam Experience Study—Postservice Mortality �natural causes, but no increases in deaths from alcohol-related external causes or drug-related mortality. These discordant findings may reflect differences in in-service use of drugs and alcohol by American and Australian troops. In contrast to the reportedly heavy use of illicit drugs by American troops in Vietnam,17'18 drug use among Australian soldiers was reported to be uncommon and alcohol use, heavy.15 Our finding of increased mortality from drug-related causes in the later followup period was not consistent with surveys indicating little or no influence of Vietnam service or combat exposure on postdischarge drug use.18'19 The lower mortality from cardiovascular diseases (CVDs) among Vietnam veterans is surprising. The lower rate might be explained as a by-product of some kind of selection process taking place in the final assignments to Vietnam, which might correlate with cardiovascular fitness established during basic or advanced training. Indeed, the SMR results suggest that the CVD deficit may be the result of an unusually high rate in the comparison group; CVD mortality in the non-Vietnam cohort was only slightly below that of the general population, whereas we expected it to be much lower.20 A completely opposite result was found in the Australian study, where CVD mortality was 90% higher among Vietnam veterans than non-Vietnam veterans.15 Various indexes, of CVD morbidity measured in the other components of the VES may help in further elucidating the mortality findings. In the Australian study most of the excess in all-cause mortality among Vietnam veterans was confined to members of the Engineer Corps.15 This pattern was not found in the present study, but the number of men assigned to engineer units was relatively small. Furthermore, possible differences between US and Australian engineering units in training and composition may make this comparison inappropriate. The excess in postservicc externalcause mortality among Vietnam veterans seen here could be due to some peculiarity in the assignment of men to Vietnam whereby those who were sent tended to have characteristics that placed them at increased risk of dying from external causes after discharge from active duty. This explanation appears doubtful for several reasons. Most importantly, if Vietnam veterans tended to have an inherent predisposition to traumatic events, it might be expected to manifest itself in increased mortality from such causes throughout the period of observation, not just in the first few years, as observed here. Alternatively, our findings may reflect consequences of the unique environment and experience of serving in Vietnam and returning to an unsupportive and sometimes hostile climate in the United States. This explanation might seem plausible given the unique military and social environment of the Vietnam conflict. However, the present results are similar to previous observations of postservice mortality in Army veterans. Indeed, increased mortality from external causes has been seen in two groups of World War II combat veterans and one group of Korean War combat veterans, when compared with the general US male population, even though older men and officers were included.21 In contrast, broader cross-sections of World War II veterans, including combat and noncombat groups, showed no difference or even a deficit in postdischarge traumatic deaths,20'21 as did non-Vietnam veterans in our study. Although the influence of factors specific to the Vietnam experience cannot be completely ruled out, our findings and previous studies suggest that the postservice excess of traumatic deaths among Vietnam veterans is probably due to unusual stresses endured while stationed in a hostile fire zone. The mortality assessment of Vietnam veterans presented here is an incomplete evaluation of the health experience of this group. Additional data on the present and past health status of living Vietnam veterans will be forthcoming from the health interview and medical, psychological, and laboratory evaluation components of the VES. Because this group of veterans has not yet reached the age where chronic diseases have an important impact on mortality, continued monitoring of mortality among VES participants may provide additional insights. The VES Mortality Study Staff consisted of Coleen A. Boyle, PhD, Pierre Decoufle, ScD, Robert J. Delaney, Frank DeStefono, MD, Melinda L. Flock, MSPH, Martha I. Hunter, M. Riduan Joesoef, MD, PhD, John M. Karon, PhD, Marilyn L. Kirk, Peter M. Layde, MD, Daniel L. McGee, PhD, Linda A. Moyer, RN, Daniel A. Pollock, MD, Philip Rhodes, MS, and Robert M. Worth, MD, PhD. Many other individuals and organizations provided invaluable support to the study. These include The Agent Orange Working Group and its Science Panel; Army Reserve Personnel Center, US Army and Joint Services Environmental Support Group, Department of Defense; NPRC, National Archives and Records Administration; General Services Administration; Veterans Administration; National Center for Health Statistics; Social Security Administration; Internal Revenue Service; National Academy of Sciences; other staff members of the CDC; and outside consultants who contributed their unique expertise. A more comprehensive report of the findings from this study has been published in the form of a monograph by the CDC. Copies can be obtained from the CDC, Atlanta, GA 30333. References 1. Veterans Health Programs Extension and Improvement Act of 1979, Public Law 96-151 (HR 3892), Dec 20, 1979, 93 STAT 1092-1098. 2. Veterans' Health Care, Training, and Small Business Loan Act of 1981, Public Law 97-72 (HR 3499), Nov 3, 1981, 95 STAT 1047-1063. 3. Protocol for Epidemiologic Studies of the Health of Vietnam Veterans. Atlanta, Centers for Disease Control, November 1983. 4. Post-service Mortality Among Vietnam Veterans. Atlanta, Centers for Disease Control, 1987. 5. International Classification of Diseases, Adapted for Use in the United States, rev 8, PHS publication 1693. US Dept of Health, Education, and Welfare, 1967. 6. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, rev 9. Geneva, World Health Organization, 1977. 7. Laird N, Oliver D: Covariance analysis of censored survival data using log-linear analysis techniques. JAmStatAssoc 1981;76:231-241. 8. Cox DR, Oakes D: Analysis of Survival Data. London, Chapman & Hall, 1984. 9. Monson RR: Analysis of relative survival and proportional mortality. Comp Biomed Res 1974;7: JAMA, Feb 13,1987—Vol 257, No. 6 325-332. 10. Anderson IIA, Hanrahan LP, Jensen M, et al: Wisconsin Vietnam Veteran Mortality Study. Madison, Wis, Wisconsin Division of Health, 1985. 11. Lawrence CE, Reilly AA, Quickenton P, et al: Mortality patterns of New York State Vietnam veterans. Am J Public Health 1985;75:277-279. 12. Kogan MI), Clapp RW: Mortality Among Vietnam Veterans in Massachusetts, 1972-1983. Boston, Massachusetts Dept of Public Health, 1985. 13. Holmes AP: West Virginia Vietnam-Era Veterans Mortality Study. Charleston, WVa, West Virginia Health Dept, 1986. 14. Wong 0, Decoufle P: Methodological issues involving the standardized mortality ratio and proportionate mortality ratio in occupational studies. J Occup Med 1982;24:299-304. 15. Fott MJ, Dunn M, Adena MA, et al: Australian Veterans Health Studies: The Mortality Report: Part I. A Retrospective Cohort Study of Mortality Among Australian National Servicemen of the Vietnam Conflict Era, and an Executive Summary of the Mortality Report. Canberra, Australia, Australian Government Publishing Service, 1984. 16. Lathrop GD, Moynahan PM, Albanese RA, et al: Project Ranch Hand II. An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides: Baseline Mortality Study Results. San Antonio, Tex, Brooks Air Force Base, US Air Force School of Aerospace Medicine, 1983. 17. Ritter C, Clayton RR, Voss HL: Vietnam military service and marijuana use. Am J Drug Alcohol Abuse 1985;11:119-130. 18. Robins LN, Helzer JE, Davis DH: Narcotic use in Southeast Asia and afterward. Arch Gen Psychiatry 1975;32:955-961. 19. Yager T, Laufer R, Gallops M: Some problems associated with war experience in men of the Vietnam generation. Arch Gen Psychiatry 1984; 41:327-333. 20. Seltzer CC, Jablon S: Effects of selection on mortality. Am J Epidemiol 1974;100:367-372. 21. Nefzger MD: Follow-up studies of World War II and Korean War prisoners: I. Study plan and mortality findings. Am J Epidemiol 1970;91: 123-138. CDC Vietnam Experience Sludy— Postsorvice Mortality Printed and Published in the United States of America 795 �Postservice Mortality Among Vietnam Veterans The Centers for Disease Control Vietnam Experience Study Published in February 13, 1987 issue of The Journal of the American Medical Association. �ABSTRACT The postservice mortality (through December 1.983) of a cohort of 932.4 US Army veterans who served in Vietnam was compared with that of 0989 Vietnam-era Army veterans who served in Korea, Germany, or the United States. Over the entire follow-up period, total mortality in Vietnam veterans was 17% higher than for other veterans. The excess mortality occurred mainly in the first five years after discharge from active duty (rate ratio,.1.45; 95% confidence interval, 1.08 to 1.96) and involved motor vehicle accidents, suicide, homicide, and accidental poisonings. Thereafter, mortality among Vietnam veterans was similar to that of other Vietnam-era veterans, except for drug-related deaths, which continued to be elevated. An unexpected finding was a deficit in deaths from diseases of the circulatory system among Vietnam veterans. The excess in postservice mortality due to external causes among Vietnam veterans is similar to that found among men returning from combat areas after World War II and the Korean War. �INTRODUCTION Many Vietnam veterans have been concerned that their health, and that of their children, has been affected by their service in Southeast Asia and possible exposure to the herbicide Agent Orange. To address these concerns, the US Congress directed that appropriate epidemiologic studies be conducted.1'^ The Centers for Disease Control (CDC) has proposed three complementary efforts to assess the health of Vietnam veterans: the Agent Orange Study, the Selected Cancers Study, and the Vietnam Experience Study (VES).^ The VES is a historical cohort study designed to identify the possible adverse health effects of having served in the military in Vietnam. It has three components: 1) an assessment of postservice mortality, 2) a detailed health interview, and 3) a comprehensive medical, psychological, arid laboratory evaluation. Although Agent Orange is among the many factors that could have adversely affected those who served in Vietnam, it is not the main focus of this study. This report is an abbreviated version of the results of the postservice mortality component, published in detail elsewhere"./l �SUBJECTS AMD METHODS Participation was restricted to men who served in the US Army. To increase comparability between those who served in Vietnam and those who served elsewhere, we selected only veterans who 1) entered military service for the first time between January 1965 and December 1971, 2) served only one term of enlistment, 3) had at least 16 weeks of active service time, 4) earned a military occupational specialty (MOS) other than "trainee" or "duty soldier," and 5) had a pay grade no higher than E5 on discharge from active duty. To be eligible for the Vietnam cohort, a veteran had to have served at least one tour of duty in Vietnam. For the comparison cohort, tours of duty were limited to the United States, Germany, or Korea. The VES was designed principally to assess morbidity associated with service in Vietnam; mortality was examined for completeness. Thus, the sample size for the VES, about 9000 Vietnam and 9000 non-Vietnam veterans, was based on statistical power requirements for the morbidity components. 3 Nevertheless, this sample size provides statistical power of 90% for detecting a 30% relative increase in all-cause mortality, but more limited power for detecting cause-specific increases, particularly for deaths due to natural causes, which in this age group are Potential participants were randomly selected from almost 5 million US Army veterans whose service records were received by the National Personnel Records Center (IMPRC) between September 1964 and June 1977. Personnel of the WPRC believe that this group includes the vast majority of US Army Vietnam-era veterans who fulfill the study criterion of a single term of enlistment. The figure outlines the process of participant selection. To achieve the desired sample size of 18000 veterans with the above study criteria (proportion estimated from a pretest), we randomly selected 48513 service records. Of the 47158 records located and reviewed, 60.6% were excluded during the qualification process; these included less than 200 records that did not contain critical data needed to determine eligibility. Characteristics of eligible men as of entry into service and details of their military experience were abstracted from the records. Altogether, 9558 Vietnam arid 9023 non-Vietnam veterans qualified for the study. The 234 Vietnam and 34 non-Vietnam veterans who had died during active duty were excluded . Follow-up began the day the veteran was discharged alive from active duty and ended on the date of his death or Dec 31, 1983, whichever came first. To identify those who had died after discharge, we checked files of the US Army, Veterans Administration (Beneficiary Identification and Record Locator Subsystem), Social Security Administration, Internal Revenue Service, and National Center for Health Statistics (National Death Index). For the interview component of the VES, an attempt was made to locate arid contact all veterans not identified as deceased by the above sources. Through this method, vital status was confirmed for 93.6% of Vietnam veterans arid 91.9% of those who served elsewhere. Entry and military service �characteristics of Vietnam veterans whose vital status was uncertain were similar to those of non-Vietnam veterans with uncertain vital status. All men with uncertain vital status were assumed to be alive at the end of 1983. For all but nine of the 446 men reported to have died after discharge, copies of official death certificates were obtained. The other nine deaths were confirmed through other sources. Underlying causes of death were coded according to both the Eighth and Ninth Revisions'1"-1' ^ of the I.nJ;£mat_i_onal Q.3^As..ific.ati_qn......of.....Diseases ....ID1 by an experienced nosologist at the National ...(C. Center for Health Statistics who had no knowledge of whether the decedent had served in Vietnam. To address limitations of death certificate-based diagnoses, a review panel of two -physicians determined the underlying cause of death, using pertinent medical and legal documents describing the nature and circumstances of each of 426 deaths for which additional information could be obtained. Sources included hospitals, law enforcement agencies, coroners or medical examiners, and private physicians. All causes of death and other significant conditions were coded by the medical review panel according to the Ninth Revision of the I.QQ' T° estimate the influence of substance abuse on mortality in this study, special categories of alcohol- and drug-related deaths were developed, and deaths were so classified by the review panel when appropriate. Analyses Crude death rates were based on person-years at risk since discharge from active duty. An unadjusted rate ratio (RR) was formed by dividing the crude mortality rate among Vietnam veterans by that for non.....Vietnam veterans. The 95% confidence intervals (CIs) for each RRs were computed usiricj the procedures described by Laird and Oliver.''' The Cox proportional hazards regression model8 was used to consider possible effect modification and confounding by selected covariates. Adjusted RRs were obtained from Cox models stratified on primary MOS and enlistment status (volunteer or draftee), arid adjusted for other selected covariates. Two MOS categories were used in the model and can be described roughly as "tactical" (infantry, armor, artillery, arid combat engineers) arid "other" (all other specialties). Additional covariates considered in the Cox models, chosen on the basis of their associations with mortality in the univariate analyses, ^ included race, age at discharge, Army General Technical Test score (a general aptitude test taken at entry into the service), pay grade at discharge, and year of discharge. Comparisons were also made between the mortality experience of each veteran cohort and that of the US male population utilizing Morisori's software package.9 Results are expressed as a standardized mortality ratio (SMR) adjusted for age, race, and calendar year. �RESULTS There were some differences in both pre induction and military service characteristics between the Vietnam and non-Vietnam cohorts (Table 1). In general, however, the preinduction differences were small, Differences in some of the military service characteristics, such as a greater percentage of Vietnam veterans with tactical MOS classifications arid infantry unit assignments, reflect wai— related military requirements in Vietnam. Over the entire follow-up period, the mortality among Vietnam veterans was 17% higher than the rate among non-Vietnam veterans (Table 2). Most of this excess, however, was due to higher mortality among Vietnam veterans during the first five years of follow.....up (RR, 1.45; 95% CI, 1.08 to 1.96). By the sixth year, the two cohorts had similar mortality rates that remained so through the end of follow-up (RR, 1.01; 95% CI, 0.79 to 1.28). Because of the variation in relative mortality with time, time— specif ic results will be presented when appropriate . To determine whether the association between Vietnam service and mortality was uniform or varied across different subgroups of veterans, separate analyses were done within these groups (Table 3). Although the results indicated a consistent pattern of elevated mortality associated with Vietnam service limited to the first five years after discharge, there was some variation in the RR among various subgroups of veterans. Tests for effect modification, however, were not statistically significant (P>.05). Possible confounding by selected covariates (age at discharge, race, Army General Technical Test score, pay grade at discharge, and year of discharge) was assessed by including them in stratified Cox models. In the first five years after discharge, adjustment for these characteristics increased the RR to 1.58 ( . % CI, 1.16 to 2.14). In the later follow-up period, adjustment 95 changed the RR to 1.04 (95% CI, 0.81 to 1.33). Results from the Cox model also indicated that Vietnam service had a greater effect on mortality among those who were discharged before age 2.1. years than to those discharged at age 21 years or older (P=.02) and among veterans discharged before 1970 compared with those discharged during 1970 or later (P=.05). Death Certificates. -• Only four major cause— of-death categories contained sufficient numbers of deaths for formal analysis (Table 4). Rates for Vietnam veterans appeared to differ from rates for non-Vietnam veterans in two of these categories: diseases of the circulatory system (51% decrease in the death rate) and external causes of death (25% increase in the death rate). The deficit in circulatory disease deaths was evident regardless of time since discharge and type of circulatory disease. There were no differences in mortality from mental disorders or neoplasms. Deaths from specific types of neoplasms were too few for meaningful comparisons. The excess in external causes of death is examined further in Table 5. Vietnam veterans had significantly higher mortality from motor vehicle accidents (MVAs) (RR, 1.48; P=.03) than non-Vietnam veterans. The excess was most pronounced in the first five years after discharge from active duty �(RR, 1,93; P-.Ol). After that period, MVA rates were similar in the two cohorts (RR, 1.16). The RRs for suicide and homicide were somewhat increased in the early postdischarge period but not in the later years of follow-up. Accidental poisoning deaths (mostly by drugs) were substantially more common among Vietnam veterans than other veterans over the entire follow up period (RR, 2.47; P-.08). No postservice deaths were attributed to war injuries (ICD-9, E990-E999). Adjustment for selected covariates did riot materially alter the pattern of cause-specific mortality, except for suicide in the earlier follow-up period, where the adjusted RR was 2.59 (95% CI, 1.09 to 6.17). Medical Review Panel, ••••• The medical review analysis was based on 233 (95%) of Vietnam veteran deaths and 193 (97%) of deaths among non Vietnam veterans. On average, slightly fewer supplemental medical and legal records were recovered for each Vietnam veteran death (mean, 3.3 records) than for each non-Vietnam veteran death (mean, 3,7 records). Overall agreement between the medical review panel diagnoses and death certificate diagnoses, however, was good (82%; kappa = 0.79) and did not differ significantly between the two veteran cohorts. The medical review analyses indicated differences in only two ICID 9 categories that were not evident from the death certificate analysis. The RR for mental disorders from the medical review panel analysis was 2.85 (95% CI, 0.92 to 8.82) compared with 0.95 from the death certificate analysis. Most mental disorder deaths were related to alcohol or drugs and are examined in more detail in Table 6. The RR for neoplasms based on medical review panel diagnoses was 1,21 (95% CI, 0.55 to 2.66) compared with 0.82 based on death certificates. This difference was primarily the result of two deaths from neoplasms among non Vietnam veterans being reclassified elsewhere by the medical review panel and the opposite occurrence among Vietnam veterans. There was no particular type of neoplasm in excess in the Vietnam cohort. Supplemental information collected for the medical review allowed further exploration of MVA deaths. Single- and multiple-vehicle crash deaths as well as daytime and nighttime events all occurred more frequently among Vietnam veterans during the early postdischarge period. Vietnam veterans had a modest excess of which were alcohol-related MVA deaths during this period (RR, 1.35; 95% CI, 0,60 to 3.04). Alcohol-related natural causes of death were too few for formal analysis in the early postdischarge period, but the RR in the later period showed no difference between the two groups (Table 6). A modest elevation in alcohol-related traumatic deaths among Vietnam veterans was limited to the first five years after discharge. For drug-related deaths, the RR was slightly elevated during the early postdischarge period and more elevated during the later follow up period. Although the number of deaths is too small for formal analysis, further refinement of the later follow-up period suggests the upward trend in drug related mortality continues into the most recent years. Further, Vietnam service seems to be associated with an especially high rate of drug-related mortality among those drafted into service, those whose jobs were in tactical or combat operations, and those who served during 1969. �Again, as in the death certi Ficate results, adjustment for selected covariates increased the RR for suicide in the early follow-up period to 2.56 (95% CI, 1.11 to 5,87), No other RR presented in the medical review results was materially altered by adjustment. Gener.aJ Both groups of veterans had a significantly lower overall mortality rate for "natural causes" than the general US male population (Table 7). During the first five years after discharge, Vietnam veterans had a higher death rate from external causes, whereas non-Vietnam veterans have a lower rate relative to the general, population. In the later time period both groups of veterans showed a similar deficit in external cause mortality. Although these data are not presented in Table 7, over the entire follow.....up period, Vietnam veterans had a striking deficit of circulatory disease deaths (SMR, 0,48; 95% CI, 0.25 to 0.85), whereas non.....Vietnam veterans had only a slight deficit (SMR, 0.87; 95% CI, 0.54 to 1.34). �COMMENT The intent of our study was to assess the effect of military service in Vietnam on subsequent mortality. The "Vietnam experience" includes a wide range of possible health influencing factors such as psychological stresses associated with war, infectious diseases prevalent in Vietnam and exposure to the herbicide Agent Orange. The modest excess of deaths among Vietnam veterans was concentrated in the first five years after discharge, where all-cause mortality was 45% higher than in the non-Vietnam group, External causes accounted for most of this increase, with the largest elevation in relative mortality due to MVAs. A more detailed examination of MVA deaths did not indicate any particularfactor that could explain the overall excess in Vietnam veterans. The increased risk did not appear to be related to elevated blood alcohol levels at the time of death, and the excess was apparent across various types of MVAs. Drug-use information on MVA victims was limited; the medical review panel identified only one drug-related MVA death. Suicide and homicide also occurred somewhat more frequently among Vietnam veterans during the early postdischarge period. Accidental poisoning deaths (mainly by drugs) were elevated throughout the entire follow-up period, although the number of such deaths was small. By the sixth year after discharge, both all-cause and external-cause mortality among Vietnam veterans had fallen to levels found in the non-Vietnam group, except for deaths due to drug abuse, where the rate was actually higher in the more recent follow-up period. These findings are unlikely to be the result of a serious flaw in study design or execution. The study groups were selected in a manner that minimized differences in their preservice characteristics; vital status was verified for 93% of all participants; death certificates were recovered for 98% of deaths; and supplemental medical and legal documents, which allowed an independent assessment of cause of death by standardized criteria, were obtained for 96% of deaths. Moreover, the pattern of excess deaths was remarkably consistent across various subgroups of Vietnam veterans and appears not to be an artifact of confounding. It should be noted, however, that sample size constraints limited our ability to detect excesses in mortality in subgroups of veterans and for the less frequent causes of death in this relatively young group. Our findings can be viewed against the results of five previous mortality studies of Vietnam veterans. Four10""1^ are proportional mortality studies, which may not be directly comparable with this study because of incompleteness of data and inherent limitations of this analytic method. 1 ^ The fifth, a cohort study of Australian Vietnam veterans, is very similar in design to our study and thus is a more appropriate comparison.^ The US Air Force "Ranch Hand" study is not discussed here, since its principal concern is the adverse health effects of herbicide exposure in a unique group of veterans.16 The 30% excess of external cause mortality among Australian Vietnam veterans relative to non-Vietnam veterans is similar to what is seen here.^ Although the Australian investigators did riot examine external cause mortality by time since discharge, there was a suggestion of a decline in relative �mortality with increasing time since discharge in their all-cause mortality results. Deaths from suicide, homicide, and accidental poisoning also occur more frequently among their Vietnam veterans, Mortality from MVA was not elevated overall, but an excess in the youngest age group was suggested. Findings for external-cause mortality from the four proportional mortality studies are not consistent with our results. A nonsignificant increase in deaths from MVA among Vietnam veterans relative to other veterans was present in only one of the studies.^ The relative frequencies of suicide and homicide were not unusual, although there was one instance of a nonsignificant increase in both of these causes .•*••'• Accidental poisonings were analyzed in only one of the studies, and the result was a small, nonsignificant elevation among Vietnam veterans.^ Australian Vietnam veterans had an excess of deaths from al.cohol--reJ.ated natural causes, but no increases in deaths from alcohol related external causes or drug-related mortality. These discordant findings may reflect differences in in-service use of drugs and alcohol by American arid Australian troops. In contrast to the reportedly heavy use of illicit drugs by American troops in Vietnam, I'7'-'-^ drug use among Australian soldiers was reported to be uncommon and alcohol use, heavy.^ Our finding of increased mortality from drug-related causes in the later follow-up period was not consistent with surveys indicating little or no influence of Vietnam service on postdischarge drug use. ^ ^ ' The lower mortality from cardiovascular diseases (CVDs) among Vietnam veterans is surprising. The lower rate might be explained as a by-product of some kind of selection process taking place in the final assignments to Vietnam, which might correlate with cardiovascular fitness established during basic or advanced training. Indeed, the SMR results suggest that the CVD deficit may be the result of an unusually high rate in the comparison group; CVD mortality in the non-Vietnam cohort was only slightly below that of the general population, whereas we expected it to be much lower.20 A completely opposite result was found in the Australian study, where CVD mortality was 90% higher among Vietnam veterans than non-Vietnam veterans.^ Various indexes of CVD morbidity measured in the other components of the VES may help in further elucidating the mortality findings. In the Australian study most of the excess in all-cause mortality among Vietnam veterans was confined to members of the Engineer Corps.^ This pattern was not found in the present study, but the number of men assigned to engineer units was relatively small. Furthermore, possible differences between US and Australian engineering units in training and composition may make this comparison inappropriate. The excess in postservice external-cause mortality among Vietnam veterans seen here could be due to some peculiarity in the assignment of men to Vietnam whereby those who were sent tended to have characteristics that placed them at increased risk of dying from external causes after discharge from active duty. This explanation appears doubtful for several reasons. Most importantly, if Vietnam veterans tended to have an inherent predisposition to traumatic events, it might be expected to manifest itself in increased mortality from such causes throughout the period of observation, not just in the first few years, as observed here. �10 Alternatively, our findings may reflect consequences of the unique environment arid experience of serving in Vietnam and returning to an unsupportive and sometimes hostile climate in the United States. This explanation might seem plausible given the unique military and social environment of the Vietnam conflict. However, the present results are similar to previous observations of postservice mortality in Army veterans. Indeed, increased mortality from external causes has been seen in two groups of World War II combat veterans and one group of Korean War combat veterans, when compared with the general US male population, even though older men and officers were included. 21 In contrast, broader cross-sections of World War II veterans, including combat and noncombat groups, showed no difference or even a deficit in postdischarge traumatic deaths,20,21 as (-j-jd non-Vietnam veterans in our study. Although the influence of factors specific to the Vietnam experience cannot be completely ruled out, our findings and previous studies suggest that the postservice excess of traumatic deaths among Vietnam veterans is probably due to unusual stresses endured while stationed in a hostile fire zone. The mortality assessment of Vietnam veterans presented here is an incomplete evaluation of the health experience of this group. Additional data on the present and past health status of living Vietnam veterans will be forthcoming from the health interview and medical, psychological, and laboratory evaluation components of the VES. Because this group of veterans has not yet reached the age where chronic diseases have an important impact on mortality, continued monitoring of mortality among VES participants may provide ad d i t i o na1 i n s i g h t s . �11 ACKNOWLEDGEMENTS The VES Mortality Study Staff consisted of Coleen A. Boyle, PhD, Pierre Decoufle, ScD, Robert J. Delaney, Frank DeStefano, MD, Melinda L. Flock, MSPII, Martha I. Hunter, M. Riduan Joesoef, MD, PhD, John M. Karon, PhD, Marilyn L. Kirk, Peter M. Layde, MD, Daniel L. McGee, PhD, Linda A. Moyer, RIM, Daniel A. Pollock, MD, Philip Rhodes, MS, and Robert M. Worth, MD, PhD. Many other individuals and organizations provided invaluable support to the study. These include The Agent Orange Working Group and its Science Panel; Army Reserve Personnel Center, US Army and Joint Services Environmental Support Group, Department of Defense; MPRC, National Archives and Records Administration; General Services Administration; Veterans Administration; National Center for Health Statistics; Social Security Administration; Internal Revenue Service; National Academy of Sciences; other staff members of the CDC, and outside consultants who contributed their unique expertise. A more comprehensive report of the findings from this study has been published in the form of a monograph by the CDC, Copies can be obtained from the CDC, Atlanta, GA 30333. �12. REFERENCES H e . a lt-h !^t.99.ra!M .il^Grision and Improvement Act of 1979, Law96-~15'l.......( M R......3li?2)"......6e"c~20"........1979",.......93......STAT ...... ~ 2. Public Veterans' Health _......___......_^ , and . _ Business _ _ Act of 1981, „ . . _.....— —.......Care,, Tra i n i rig....._......._Small ......„_....... Loan . .......... _.. „ . _ _ 3 , [r°.t..9I t°L iEMi!M£l9<3.ic Studies of the Health of Vinetnam yc|tejrans . !...-9£.. Atlanta, Centers for Disease Control, November i.983. . ... .. c3 r Disease Control, 1987, States, rev 8, Welfare, 1967. PUS publication .1.693. i.ec! for Use in_..the Unitecl US Dept of Health, Education, and ..9f ..i...l0t r n a t i o n a 1 S t a t i s ti. c a 1 C la s s if i c a t i o n o f D i s e as e s , ... ..be,...e _.a!.ldjl§.y.?..§A...9f P.?a.th, rev 9. Geneva, World Health Organization, 97..................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 7. Laird l\l, Oliver D; Covariance analysis of censored survival data using log-linear analysis techniques . .J_Am Stat Ass_oc 1981; 76 : 231.....2.41 . 8. Cox DR, Oakes D: Ajlollisi.s_.....9.f. itlC.y,i.V..al Q.a.t.a.- London, Chapman and Hall, 1984. 9. Monson RR: Analysis of relative survival and proportional mortality. s. 1974; 7: 325-3 32. Qomg 10. Anderson HA, l-lanrahan LP, Jensen M, et al: W..ij.conj_ij;i^V]i^^nami Veteran Mortality/ S.ty_dy . Madison, Wise, Wisconsin Division of Health, 1985. 11. Lawrence CE, Reilly AA, Quickenton P, et al: Mortality patterns of l\lew York State Vietnam veterans, Am_J.....PubllS.......Health 1985; 75 : 277-2.79 . 12. Kogan MD, Clapp RW: Mortality Amoj'ig Vietnam yeterans; in..Massiacjui]Sj3t1;;_si, l Z 2 i 9 3 . Bos ton , M ! a h s ! t l.r.8 a7TVe:^ ....... •——••- 1 3 . HO ime s AP : Charleston, W VA, West Virginia Health Department, 1986. 14. Wong 0, Decoufle P: Methodological issues involving the standardized mortality ratio and proportionate mortality ratio in occupational studies. 1 9 8 2. ; 2 4 : 2, 9 9.....3 04 , 15. Fett MJ, Dunn M, Aderia MA, et al: .CL^ ...^ Ay.st;ra_l.ian_ Vete_ra_ri_3......Health......S_tyd_i_e_sj:......The . . . . . ^ St_u_(iy_ of Q9b9C a a a e - 6 L t b ? ! ! . . £ s . . t Re po r; t . Canberra, A u s t ra 1 i a , . . . . !!9L<.i.l Australian Government Publishing Service, 1984. �13 16. Lathrop GD, Moynahan PM, Alfoanese RA, et al: £roj.ectRanch Hand II. An ! [ i i . 5 i . 9 i I D 5 ! ^ l : i . i £ °f...ii?!.l?.i.tb...JLffl;i!.£i5 illD...LCQiCS.® E§lisonnej. iE^!!.9l£c ..i..l.3^iD Foil owing Ex.J2£l^ureto..JJ..Ii-^rM.9..M£.?....;. !3<as£l.ine.!J£!r.^£il.tl......S..t.y..dj/ !l§..s.y.lt_s. San Antonio, Tex, Brooks Air Force Base, US Air Force School of Aerospace Medicine, 1983. 17. Ritter C, Clayton RR, Voss ML: Vietnam military service and marijuana use, Am J D.ru_g_Alcoh£ 1__Abuse 1985; 11: 119•-130. 18. Robins l...l\l, Helzer JE, Davis DH: Narcotic use in Southeast Asia and afterward . .Arch .Gen Psychiatry 1975; 32 : 955 961. 19. Yager "I", Laufer R, Gallops M: Some problems associated with war experience in men of the Vietnam generation. A.r_cJ;i__Gen Psjf£hia_t_r\f 1984; 41:327-333 . 2.0. Seltzer CC, Jablon S: Effects of selection on mortality. Am J Epjidemio1 1974;!00:36 7-372. 21. Wefzger MD: Follow up studies of World War II and Korean War prisoners. I. Study plan and mortality findings. Am J_.E£_ideipi_o_l 1970; 91: 123-138 . �VIETNAM-ERA ARMY PERSONNEL R E C O R D S FILED AT NPRC BETWEEN SEPT 1964 AND JUNE 1977 Approx. 4,900,000 RANDOM SAMPLE 48,513 QUALIFIED FOR STUDY 18,581 RECORDS NOT FOUND 1,355 Ll NOT Q U A L I F I E D 28,577 NON-VIETNAM 9,023 DIED ON ACTIVE OUT 234 DIED ON ACTIVE DUTY 34 VIETNAM COHORT 9,324 NON-VIETNAM COHORT 8,989 Selection of s t u d y g r o u p , NPRC indicates N a t i o n a l Personnel Records Center; a s t e r i s k , excluded f r o m s t u d y ; and dagger, eighty-three percent (N=194) of a c t i v e d u t y deaths among V i e t n a m veterans were due to war-related activities. �fable 1. Differences in Selected Characteristics Between Vietnam and Won Vietnam Veterans at Entry Into Service and During Military Service Character:!, stic Vietnam (N=9324) Won-Vietnam (N=8989) _Ate_ntry_...into service Race/' (% white) 86.8 86.5 Age at entry, (mean) 20.3 20.5 Enlistment status/' ( draftee) % 63.7 65.6 Year of entry into service, (% before 1969) 72.1 60.6 103.1 105.5 Army General Technical Test score (mean, scaled to 100) During military service Primary mi 1 itary occupational specialty"1" % tactical operations 34 .3 27, ,4 Type of unit, % infantry 26..6 14,.6 Type of discharge, % honorable 97, 2 , 91, 0 Pay grade at discharge, % E4 or E5 88,,5 79, ,8 Year of discharge, % before 1970 ,1 48, 44. 6 Race and enlistment status were the only two characteristics that were not significantly different (P>.05) between the Vietnam and the non-Vietnam groups, + The job specialty for which the man was trained in the Army. �Table 2, Years Since Discharge Number of Deaths, Person-Years, and Death Rates Among Vietnam and Won Vietnam Veterans and Unadjusted RRs by Years Since Discharge From Active Duty, 1965--1983'x' 6-1- All years V i §t na m Person-years 110 <5 l\lo. of deaths _ 46,350 2.4 73 44,747 1.6 1.45 1.08 1.96 136 81,547 1.7 127 76,582 1.7 1.01 0.79-1.28 246 127,897 1.9 200 121,32.9 1.7 1.17 0.97-1.41 Rate'1" l\lo. deaths _N o n;-V let n am. Person-years Rate4' RR indicates rate ratio; CI, conPidence interval. "'" Crude death rate per 1000 person years. RR 95% CI �Table 3, Number of Deaths Among Vietnam and Won Vietnam Veterans and Unadjusted Rate Ratios (RRs), by Selected Characteristics and Years Since Discharge from Active Duty, 1965-1903 Y e a r s S i nee D i s c h a r < From Active Duty 30 <5 All years 6-1- Characteristic 'K' No. RR No. RR No. RR Race White Won white 146 37 1 .50 1 .30 193 70 0.99 1 .07 339 107 1 .18 1 .14 Enlistment status Volunteer Draftee 79 104 1 .09 1 .80 11 1 152 0 .91 1 .06 190 256 0 .98 1 .31 97 83 1 .42 l .43 141 1:1.9 0.90 1 .07 238 202 1 .08 1 ,2.0 63 120 l .'19 l ,58 89 174 1 .04 0,97 152 294 1 . 10 1. 1 8 47 136 l .83 l ,41 42 221 0.67 1 , 10 89 357 1 .14 1 .2.1 125 58 l .50 l . 95 183 80 1 .10 1 .16 308 138 1 .24 1 .44 79 2.05 122 0.96 201 1.27 104 1.16 141 1 .06 2.45 1. 10 GT test score"'" < .1.00 100+ Duty MOS + Tactical Other Age at discharge 21+ Pay grade at discharge E4 - E5 El - E3 Year of discharge <1970 1970-1- There was no evidence of statistically significant effect modification for any of these characteristics (P>0.05). Army General Technical Test (GT) scores were missing for six veterans. + Determined from principal military occupational specialty (MOS) held while on tour of duty. �Table 4. Number oP Deaths by Cause (from Death Cerlif'icato), Death Rates Among Vietnam and Won Vietnam Veterans, and Unadjusted RRs, 1965 190;i'K Underlying cause of death (ICD 9)+ Infectious and parasitic diseases (001 139) Vietnam No. Won Vietnam Rate? No. Rate + RR§ 95% CI 1 0.8 1 0.8 12 9.4 14 11.5 0.82 0.38-1.76 Mental disorders (290-319) 7 5.5 7 5.8 0.95 0.3 3 --2. 70 Diseases of nervous system (320 389) 2 1.6 J. Diseases of circulatory sy s tern (390 459) 12 9,4 23 19.0 0.49 0.25--0.99 Diseases of respiratory system ' (460 519) 5 3.9 4 3.3 Neoplasms (140 239) Diseases of digestive system (520-579) 3.9 Diseases of genitourinary system (580-611) 0.8 ri ft \J , O 3.1 Congenital anomalies (740-759) ! 2.5 0.8 �Table 4. Number of Deaths by Cause (From Death Certificate), Death Rates ftrnong Vietnam and Won.....Vietnam Veterans, and Unadjusted R R s , 1965.....1903* (continued) Symptoms, signs, and :i. 1 !-•d e f i ne d c o n d i t i o n s (780.....799) External causes (E800-E999) 0.8 1.6 188 147.0 143 117.9 1.25 1.00.....1.55 l\lo death certificate \f. RR indicates rate ratio; CI, confidence interval, + ICD 9 indicates International Classification of Diseases, ninth revision. l\lo deaths were categorized to diseases of blood and blood-forming organs; endocrine, metabolic or nutritional diseases; diseases of the skin; or diseases of the rnusculoskeletal system. Therefore, these categories are not shown. T Crude death rate per 100,000 person-years. § If the total number of deaths for a cause-of-death category in both groups combined was less than ten, RRs are not shown. �Table 5. Number of Deaths From Specific External Cause:; (K'rom Death Certificate) Among Vietnam and Won Vietnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, .1.96.5-1983*' External cause of d e <5 a t Years Since Q_i_3charge From Acti ye Duty+ 6+ h ~ ~ Motor vehicle accident (E810--E825, E929.0) 66 1.93 1.16--3.22 67 Accidental poisoning (E8SO-E869, E92.9.2) 11 1.69 0.49 5.77 Other , accidents+ 23 1.05 Suicide (E950 E959) 25 Homicide (E960 E969) 18 Undetermined intentional:!, ty (E980 E989) 4 All Years 1.16 0.72-1.87 133 1.48 1.04 2.09 7 - - 18 2.47 0.88 6.92 0.46 2.37 39 0.89 0.48 1.67 62 0.95 0.58 1.56 1.72 0.76-3.88 32 0.64 0.32 1.30 57 0.98 0.58 1.65 1.52 0.59 3.91 33 0.78 0.39-1.55 51 0.99 0.57-1.71 - 6 - 10 3.79 0.81-17.87 *' RR indicates rate ratio; CI, confidence interval; ICO-9, International Classification of Diseases, ninth revision. "'" Time-specific RRs are not presented for categories with less than 10 deaths in both Vietnam and non-Vietnam groups combined. £ Includes ICD-9 categories E800 to E807, E826 to E849, E870 to E928, E92.9.1, E929.3 to E929.9, E930 to E949, E970 to £978, and E990 to E999. �"fable 6. Number of Deaths From Alcohol and .Drug-Related Causes (From Medical Review) Among Vietnam and Mori-Vie tnam Veterans and Unadjusted RRs, by Years Since Discharge From Active Duty, 1965.....1983* ............... Years_ S.ln£g_P_i^_chair3_e From Active Duty <5 6-1fill Years Cause of death o Alcohol.....related natural causes"1" 5 ..... Alcohol.....related traumatic causes t 42 1,29 Drug related causes§ 18 1.2.1. * + ~ ••••• " 25 0.87 0.40.....1.90 30 0.70-2.37 61 1.04 0.63-1.71 103 0.48 3.06 22 2.01 0.82-4.94 40 1.08 0.53-2.22 1.13 0.77.....1.67 1.58 0.83-3.00 RR indicates rate ratio; C.I, confidence interval. Includes the following diagnoses determined to be the underlying or contributing cause of death: alcoholic psychoses (291.0 to 291,9); alcohol dependence syndrome (303); nondependent alcohol abuse (305.0); alcoholic polyneuropathy (357.5); alcoholic cardiomyopathy (42.5.5); alcoholic gastritis (535.3); alcoholic liver disease (571.0 to 571.3); and excessive blood level of alcohol (790.3). + Includes deaths in which the underlying cause is accidental poisoning by alcohol (E860.0 to E860.9) or any traumatic death (E800--E989) in which either nondependent abuse of alcohol (305.0) or excessive blood level of alcohol (790.3) is a contributing cause of death. § Deaths for which one of the following drug-specific diagnoses is the, underlying or contributing cause of death; drug psychoses (292.0 to 292.9); drug dependence (304.0 to 304.9); nondependent abuse of drugs (305.2 to 305.9); accidental poisoning by drugs (E850.0 to E850.2, E8S0.5, E850.8, E851-E8S4, E855.1 to E855.2, E866.6 and E869.0); suicide by drugs (E950.0 to E950.5); and poisoning by drugs, intentionality undetermined (E980.0 to E980.5). �Table 7. Years since discharge Observed and Expected Numbers of Deaths by Cause Among Vietnam and Mori Vietnam Veterans and SMRs, y by Years Since Discharge From Active Duty, 1965--1983 Cause of De ath+ (ICOA--8) Vietnam Won Vietnam 16 23 . 4 0.68 0.39-1. 11 13 24 . 2 0 . 54 0.29 0.92 Observed Expected SMR 95% CI 92 72.5 1 . 2.7 1.02-1.56 55 69.4 0.79 0.60 1.03 All natural causes (000 796) Observed Expected SMR 95% CI 38 65.8 0.58 0.41-0.79 39 63.4 0.62 0.44-0.84 Observed Expected SMR 95% CI 96 .1.02 . 7 0.93 0.76-1.14 88 96.6 0,91 0.73-1.12 All natural causes (000 796) Observed Expected SMR 95% CI 51 90.0 0,57 0.42 0.75 55 86.8 0.63 0.48 0.82 External causes (E800-E999) All years Observed Expected IJI SMR 95% CI External causes (E800--E999) 6+ All natural causes (000 796) External causes (E800 E999) <5 Observed Expected SMR 95% CI 188 175.2 1 . 07 0,93-1.24 143 166.0 0.86 0.73-1.01 SMR indicates standardized mortality ratio; CI, confidence interval; and ICDA 8, International Classification of Diseases, Adapted for Use in the United States, eighth revision. "'" Excludes nine deaths (seven Vietnam, two non Vietnam) for which death certificates were not recovered. T Expected number is based on the mortality rates among US men, standardized for age, calendar year, and race. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 064 Folder The folder containing the original item. 1742 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Source A related resource from which the described resource is derived JAMA Date A point or period of time associated with an event in the lifecycle of the resource February 13 1987 Title A name given to the resource Postservice Mortality Among Vietnam Veterans: The Centers for Disease Control Vietnam Experience Study Subject The topic of the resource Vietnam Experience Study mortality trends veteran psychological health ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/5c140e22c8d7d24ef37434af119f2257.pdf b8454b7701c4b71972c1e75dd07576b9 PDF Text Text Item ID Number 01732 Author Corporate Author Report/Article TltlB RTI Gets JOIirnal/BOQk Title Occupational Health & Safety Letter Year 1984 Month/Day October a Color Number of Images Veterans $3-6 Million to Study Adjustment of Vietnam n 2 Descrlpton Notes Monday, June 11, 2001 Page 1733 of 1793 �•6 Occupational Health & Safety Letter, October 8, 1984 LOCKHEED REQUIRES ALL EMPLOYEES TO JOIN HMO FOR AT LEAST A YEAR: Lockheed Corp. now requires all of its employees at three major divisions to join a Health Maintenance Organization for at least one year. The divisions are in Burbank, Cal., Sunnyvale, Cal., and Marietta, Ga. HMO enrollees will pay no deductibles or co-payments. All full-time employees and part time-employees who work at least 20 hours a week will be covered. Other related developments: * Mallinckrodt Inc., St. Louis, has signed a contract with the UAW calling for 100 percent reimbursement for pre-certification, outpatient diagnostic testing and second surgical opinions. If an employee does not use the covered services, reimbursement is reduced to 50 percent. * General Motors' agreement with UAW gives workers the right to choose between traditional coverage, an HMO or preferred provider organization coverage. The latter is a hew innovative health benefit package. * Enrollment in HMOs sponsored by Blue Cross-Blue Shield increased by 32 percent between June 30, 1983 and June 30, 1984, a significant gain over the 23 percent increase reported in the preceding 12 months. As of mid-1984, 41 Blue Cross and Blue Shield plans were sponsoring 57 HMOs, enrolling 1.8 million members. HEALTH CARE EMPLOYEES UNION CERTIFIED BY AFL-CIO: The National Union of Hospital & Health Care Employees has received a charter as an AFL-CIO affiliate and declared a priority goal of organizing health care workers in every part of the country. "Our job is to organize the unorganized, help them win salaries and working conditions in keeping with the vital work they do, and strive to make decent patient care available to all Americans," said president Henry Nicholas. The hospital employees union had previously been a division of the Retail, Wholesale and Department Store Union. But the largest segment of the hospital and health care workers — District 1199 of New York City — will remain with the retail union as a consequence of an internal organization problem. The newly chartered union will continue to maintain headquarters in New York. A number of AFL-CIO affiliates now represent hospital and nursing home workers, one of the fastest growing areas of labor activity. A Hospital Workers Organizing Committee was established in 1968 as part of the Retail, Wholesale and Department Store Union and was made a division of that union in 1971. Note: Some confusion in identification is bound to develop as a result of District 1199 remaining as part of the Retail Store union. This is because many of the members of the new union belong to such locals called 1199C, 1199E, 1199/New England, etc. They are all offshoots of the New York local, which is not part of the new national union. RTI GETS $3.6 MILLION TO STUDY ADJUSTMENT OF VIETNAM VETERANS: The Veterans Administration has awarded a $3.6 million contract to Research Triangle (NC) Institute to study post-traumatic stress disorder (PTSD) and other readjustment problems among Vietnam-era veterans. Both male and female veterans will be included in the large-scale study. "The study findings should help us determine how many Vietnam-era veterans have these problems and evaluate the effectiveness of our programs for providing assistance to them," said VA Administrator Harry N. Walters. The study will focus on veterans who now have or have had readjustment problems, as well as those who made the transition to civilian life with little or no difficulty. Approximately 2,900 persons throughout the United States will be interviewed. Data derived from the interviews will provide national estimates of the extent to �Occupational Health & Safety Letter, October 8, 1984 7 which their psychological and health status can be applied to the entire Vietnam-era veteran population. It is the first time that such a full-scale, in-depth study on this subject has been attempted, the VA said. Groups to be interviewed include Vietnam veterans, Vietnam-era veterans, women veterans, minority group veterans, incarcerated veterans, those living in rural and urban areas, those seeking treatment at VA facilities, those with physical disabilities and a special control group of non-veterans. Families of veterans will also will be interviewed. VA said it had long recognized the need for such a study and had been planning it for more than a year. The full study, mandated by Congress last November, is expected to be completed by February 1988. However, the first phase will provide the basis for an initial report to Congress by October 1, 1986. Meanwhile, the first phase of a mammoth $100 million study by no less than eight Federal agencies on the exposure of Vietnam veterans to Agent Orange is about to get under way, under direction of the Centers for Disease Control in Atlanta. So vast is the project that new buildings to house the staff, scientific instruments and computers for the Agent Orange study are under construction in suburban Chamblee, Ga. Dr. Peter M. Layde, a CDC researcher, is in charge of the project. Another key figure is Dr. Barclay M. Shepard, director of Agent Orange studies for the VA. More than 100,000 veterans have already received some form of treatment in VA hospitals for conditions they say are related to dioxin exposure. The number is growing steadily, and some psychologists have contended that even the fear that they may have been exposed has caused emotional problems among some Vietnam veterans. As part of the new studies, physical examinations will be given to 10,000 former servicemen, and many more thousands will be given questionnaires on their health status, both physical and emotional. The objective, said Dr. Layde, is to rule out the uncertainty which has marked preliminary findings of studies in the last few years. In a nutshell, those findings can be summarized as: we don't see proof of physical harm from the exposure, but we're not certain that there isn't. Almost 150,000 veterans have already been examined as part of an Agent Orange registry program launched by the VA in 1978. SILICA EXPOSURE IN NORTH CAROLINA UNDER STUDY: Industrial hygiene researchers have been studying for the last four years the environmental conditions which lead to the development of silicosis in North Carolina miners and mineral processors. The research is being conducted in cooperation with the North Carolina State Industrial Commission, the occupational health branch of the North Carolina Division of Health Services and the occupational health studies group of the University of North Carolina. It is funded by NIOSH and by a DuPont Fellowship grant to the UNC Department, of Environmental Sciences and Engineering. Industrial processes with potential silica dust exposure include the quarrying of building stone for dressing and crushing, the mining and milling of metallic and non-metallic minerals, and foundry work. The current occupational standard for exposure to silica dust is based largely on a series of studies of exposure-disease relationships in the Vermont granite industry. This detailed work documents employee exposures to airborne dust since the late 1920s. The occupational history and health status of the workers have been periodically updated since 1937. A similar program of environmental and health surveillance has been carried out by North Carolina since 1935. In that state the dusty trades include granite � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 064 Folder The folder containing the original item. 1732 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Source A related resource from which the described resource is derived Occupational Health & Safety Letter Date A point or period of time associated with an event in the lifecycle of the resource October 8 1984 Title A name given to the resource RTI Gets $3.6 Million to Study Adjustment of Vietnam Veterans Subject The topic of the resource PTSD veteran psychological health ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 080 Folder The folder containing the original item. 2071 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Date A point or period of time associated with an event in the lifecycle of the resource 1985-05-01 Title A name given to the resource Australian and American Newspaper Clippings on veteran lifestyle and ten year anniversary of war's end, May 1985 Subject The topic of the resource veteran psychological health popular press Australia Agent Orange controversy ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 080 Folder The folder containing the original item. 2070 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Date A point or period of time associated with an event in the lifecycle of the resource 1985-05-01 Title A name given to the resource Australian and American Newspaper Clippings on attitudes towards veterans and ten year anniversary of war's end, May 1985 Subject The topic of the resource veteran psychological health popular press Australia Agent Orange controversy ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 080 Folder The folder containing the original item. 2069 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Date A point or period of time associated with an event in the lifecycle of the resource 1985-04-01 Title A name given to the resource Australian and American Newspaper Clippings on attitudes towards veterans and ten year anniversary of war's end, April 1985 Subject The topic of the resource veteran psychological health popular press Australia Agent Orange controversy ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 079 Folder The folder containing the original item. 2054 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Date A point or period of time associated with an event in the lifecycle of the resource 1984 Title A name given to the resource Australian Newspaper Clippings on Australian Royal Commission Hearings, February, March, and September 1984. Subject The topic of the resource Australian Royal Commission Hearings popular press veteran psychological health veteran health and hygiene ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 076 Folder The folder containing the original item. 1975 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Date A point or period of time associated with an event in the lifecycle of the resource January 19 1984 Title A name given to the resource Transcript of Proceedings: Royal Commission on the Use and Effects of Chemical Agents on Australian Personnel in Vietnam, 19 January 1984 Subject The topic of the resource Australian Royal Commission Hearings herbicide application spray equipment veteran psychological health ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 073 Folder The folder containing the original item. 1926 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Description An account of the resource <strong>Corporate Author: </strong>Parliament of the Commonwealth of Australia, Senate Standing Committee on Science and the Environment, Canberra, Australia Date A point or period of time associated with an event in the lifecycle of the resource 1982-11-01 Title A name given to the resource Pesticides and the Health of Australian Vietnam Veterans: First Report, November 1982 Subject The topic of the resource Australian Parliamentary hearings mortality trends morbidity trends veteran psychological health ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 055 Folder The folder containing the original item. 1468 Series The series number of the original item. Series III Subseries II Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Description An account of the resource <strong>Corporate Author: </strong>Vietnam Veterans of America Title A name given to the resource Includes itinerary for Vietnam Veterans of America's Second Delegation to Vietnam, May 28, 1982 through June 3, 1982; listing and short biographies for members of the delegation; three articles related to delegation, "Hanoi Trip: Gains Seen By Ex-G.I.'s" Subject The topic of the resource Southeast Asia veteran psychological health Agent Orange Controversy ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/cbab1174662d647631846a03a4c59196.pdf 510bf5c8921eebaac2d86b36b5e391ed PDF Text Text Item D Number °1856 Author True Wi||iam Corporate Author Veterans Administration ' R- Report/Article Title Stress Symptomology Among Vietnam Veterans: Analysis of the Veterans Administration Survey of Veterans II Journal/Book Tltto Year °00° Month/Day Color a Number of hnaaos 37 DOSCdpton NOtBS Funding from Cooperative Studies Program, Study #256, Veterans Administration Medical Research Service. An earlier version of this paper was presented at the Soceity for Epidemiological Research meetings in Pittsburgh, PA in June 1986. Wednesday, July 11,2001 Page 1857 of 1870 �STRESS SYMPTOMATOLOGY AMONG VIETNAM VETERANS: ANALYSIS OF THE VETERANS ADMINISTRATION SURVEY OF VETERANS II WILLIAM R. TRUE1, JACK GOLDBERG2, SETH A. EISEN3 �STRESS SYMPTOMATOLOGY True et al. 2 1 Psychiatry and Research Services (151A-JB), VA Medical Center, St. Louis, MO 2 63125. (Reprint requests to Dr. True.) University of Illinois, School of Public Health, and the Cooperative Studies Coordinating Center, VA Medical Center, Hines, IL 60141. 3 Medical and Research Services, VA Medical Center, St. Louis, MO 63125. Running Head: Acronym: STRESS SYMPTOMATOLOGY PTSD = Post Traumatic Stress Disorder Acknowledgement of Funding: Cooperative Studies Program, Study # 256, Veterans Administration Medical Research Service The authors acknowledge the contribution of Dr. A. J. Singh, Director, Statistical Policy and Research Service, office of Information Management and Statistics, Veterans Administration, Washington, D.C. who provided the data tape and documentation, and consulted with the authors. Mr. Edward Barnes, programmer at the Cooperative Studies Coordinating Center, Veterans Administration Medical Center, Hines, IL, and Dr. Sharon Homan, Assistant Professor of Community Health, St. Louis University Center for Health Services Research and Education, St. Louis MO, provided assistance. Dr. Joel Royalty, Murray State University, Murray KY, developed preliminary approaches to the data. An earlier version of this paper was presented at the Society for Epidemiological Research meetings in Pittsburgh, PA in June 1986. �STRESS SYMPTOMATOLOGY True et al. 3 ABSTRACT True, William R. (VA Medical Center, St. Louis, MO 63125), J. Goldberg, and s. A. Eisen. Stress symptomatology among Vietnam veterans: Analysis of the Veterans Administration Survey of Veterans II. In 1979, the Veterans Administration conducted a health survey of 11,236 veterans. The present analysis of this data focuses on the effects of service in Vietnam and combat on stress symptomatology among the 1,787 Vietnam era veterans who entered the Army, Navy, Marines, or Air Force between 1965 and 1975. In the unadjusted analysis, both service in Vietnam and combat were related to the prevalence of nightmares, sleep problems, troubled memories, depression, temper control, life goal indecision, guilt feelings and confusion. After controlling for length of active military service, year of discharge, branch of service, rank at discharge, draft status, age at discharge, race, and educational attainment at discharge, combat exposure remained strongly associated with all eight measures of Post Traumatic Stress Disorder symptomatology. Because the data were collected prior to the current controversy about the potential psychological and physical health effects of exposure to Agent Orange, the likelihood of response bias is reduced. The analysis demonstrates that combat continues to have profound effects on veterans' psychological health years after the conclusion of military service. Stress disorders, post traumatic; Vietnam; Veterans �STRESS SYMPTOMATOLOGY True et al. 4 Controversy about the effect of war stress on the current well-being of Vietnam veterans have been prominent in popular, policy, and scientific literature for some years. Since the end of the war, there have been eight major (1-8) studies of the psychological effects of the Vietnam experience. Debate about the validity of their conclusions has turned upon the relative strength of the research designs, the importance of pre-military risk factors, and the nature and methods of measuring war stress experiences and post-service outcomes. Vietnam experience research studies can be divided into two major design categories: those based on convenience or volunteer samples (1-3) and those based on cross-sectional of defined target populations sample is the work of Wilson (4-8). random samples Typical of a convenience (3) who identified a comprehensive set of stress symptomatology markers which he related to Vietnam service and combat exposure. consisted of a self-selected However, Wilson's study sample set of Vietnam era veterans seeking help for psychological problems. Of greater methodological sophistication are the cross-sectional surveys. Robins (4) and Card (8) both selected samples based upon chronological criteria. Robins used Army examinations to identify servicemen with positive drug screens who left Vietnam in September, 1971. Control subjects were drug-free soldiers from the same group. Card selected veterans and controls from the 1974 Project Talent follow-up study, a national longitudinal project which in 1960 administered an extensive battery of tests to a randomly selected �STRESS SYMPTOMATOLOGY True et al. cohort of 375,000 9th and 12th graders (9). 5 The Egendorf study (7) used an unusual "snowball" sampling technique in which a contacted household without a qualifying subject referred the study personnel to veterans in the extended kin network (cousins, nephews, etc.) who met study criteria. The Harris (6) survey used its national panel to identify a sample of Vietnam era veterans. While differing dramatically in scope and objectives, each of these studies has contributed to our knowledge of the psychological health of Vietnam era veterans. The present study follows in the tradition of these crosssectional sample surveys of Vietnam era veterans by examining the association between military service in Vietnam and subsequent Post Traumatic Stress Disorder (PTSD) symptomatology in the national Survey of Veterans II (5). MATERIALS AND METHODS Study population; Survey of Veterans II The Survey of Veterans II, performed in 1979, was designed to collect data by self-report on men who were veterans of active duty military service. The Veterans Administration and the Bureau of the Census created an interagency agreement to conduct the survey. The Bureau of the Census drew the sample from households which had been recently retired from the Current Population Survey, an ongoing random sample of households throughout the United States. Men in the Current Population Survey who answered that they �STRESS SYMPTOMATOLOGY True et al. 6 had served in the United States armed forces further responded to a detailed personal interview lasting approximately 45 minutes. The questionnaire covered a wide range of topics related to the veteran's health and well-being including sources of medical care, psychological health, pension benefits, education, rehabilitation, loans and burial benefits. The sample originally consisted of 11,236 men. From this sample, 492 persons were found to be non-veterans, six were outof-scope, and 803 were non-interviews. Therefore, 9,929 veterans completed interviews for a response rate of 93 per cent. Veterans who served during the Vietnam era (August 5, 1965 through May 7, 1975) identified themselves by their responses to the question, "What periods did you serve on active duty in the U. S. Armed Forces?" The investigators identified a total of 2,458 Vietnam era veterans. From this group, veterans whose active military service began prior to August 5, 1965 (650 men) or who served in the Coast Guard or National Guard (21 men), were excluded. Thus, the final study sample of 1,787 servicemen was limited to veterans of the Army, Navy, Marines or Air Force who entered service after August 4, 1965. Measure s of mi1itary service A variety of approaches exist for measuring the stresses of war. The present study used two: 1) the simple dichotomy of service in the war zone obtained from the question: "Were you stationed in Vietnam, Laos, or Cambodia; in the waters in or around these countries; or fly in missions over these areas?", �STRESS SYMPTOMATOLOGY True et al. 7 and 2) a multi-dimensional index of exposure to combat as specified in the responses to a set of nine 'Yes/No1 items asked of all veterans who served in Vietnam. These items include the following combat roles and experiences: Fired on the enemy, flew in aircraft over war area, stationed at a forward observation post, received incoming fire, encountered mines and booby traps, received sniper or sapper fire, ambushed by the enemy, or was engaged in a firefight with either Vietcong, guerilla, or North Vietnamese Army. These items are quite similar to those used by Egendorf (7) in the Legacies of Vietnam study. A summary index of combat exposure was constructed from the nine questions on combat roles and experiences. response to an item scored one point. Each positive The combat exposure index is the summation over the nine combat roles and experiences. The mean value of the combat exposure index is 3.43 (n=771). Cronbach's coefficient alpha, used to provide an indication of the internal consistency of the combat exposure index, was 0.85. The nine-point scale was coded for analysis into the ordinal categories: a) non-Vietnam, b) Vietnam-no combat, c) Vietnam-low combat, d) Vietnam-medium combat, and e) Vietnam-high combat. Other military experience variables in the Survey of 'Veterans II reflect factors which have been extensively analyzed in the Vietnam stress literature (10). These include mode of entry into service (drafted or enlisted), branch of service (Air Force, Army, Navy, and Marines), rank or grade at discharge (officer or non-officer), length of service (coded in the �STRESS SYMPTOMATOLOGY True et al. 8 original questionnaire as less than two years or 2-20 years), and year of discharge (before or after 1968). This last point was analyzed because of claims (11) that soldiers discharged after the Tet offensive in 1968 suffered increased stress reactions. The variable length of service was more inclusive than would have been preferred, but further categorization was impossible. Three further demographic factors were examined in the analysis of the Survey of Veterans II: race (white or non- white), years of education at discharge (less than 12 and at least 12), and age at discharge (less than 22, 22 to 24, and 25 and older). This grouping of age at discharge reflects the evidence in the literature (3) that adolescents exposed to war stress may suffer from increased PTSD symptoms. Measures of stress symptomatology Traumatic stress was measured with a eight-item checklist using specific symptoms. form: Questions were stated in the following "Since your LAST release from active military service, have you had . . . a) frightening dreams or nightmares, b) sleep problems, c) troubled memories, d) depression, e) temper control problems, f) life goal indecision, g) guilt feelings, h) confusion?" The items asked for overall prevalence during the years since discharge. There was no probe for timing of the symptom. Sufficient data were not available to make a presumptive diagnosis of Post-Traumatic Stress Disorder. The items included in the Survey of Veterans II represent the symptom list which in �STRESS SYMPTOMATOLOGY True et al. 9 1979 was associated in the clinical literature with the psychological consequences of combat and subsequently have been largely incorporated as the core criteria for the Diagnostic and Statistical Manual III (12) diagnosis of PTSD. These include nightmares, sleep problems, and guilt feelings. Implied in the PTSD diagnosis are the further items of life goal indecision, troubled memories, confusion, depression and temper control. Statistical analysis The statistical analysis of the relationship between military service and post-traumatic stress symptomatology is done in stages. The first stage uses simple contingency table analyses to examine whether service in Vietnam, and specifically exposure to combat, is associated with increased levels of post traumatic stress symptomatology. Prevalence odds ratios and 95 per cent confidence intervals are calculated for each measure of post-traumatic symptomatology. The second stage of analysis examines each of the eight measures of post-traumatic stress in more detail. in particular, logistic regression is used to determine if the association between Vietnam service and stress symptomatology is confounded by military service or demographic factors. Factor adjusted logistic odds ratios and 95 per cent confidence intervals are presented for each of the military service and demographic variables examined. �STRESS SYMPTOMATOLOGY True et al. 10 RESULTS Post traumatic stress disorder symptoms, Vietnam service and combat exposure Table 1 presents the relationship between service in Vietnam and exposure to combat with the eight symptoms of PTSD. For each of the eight symptoms a positive association is observed for Vietnam service. The most striking findings are found for nightmares and troubled memories. Veterans who served in Vietnam are nearly four times more likely (f = 3.74, 95 per cent C.I. 2.88-4.87) to have experienced nightmares compared to veterans who did not serve in Vietnam. Likewise, Vietnam service veterans were three and a half times more likely to have reported troubled memories of military service than non-Vietnam veterans. Several other symptoms such as sleep problems, temper control problems, life goal indecision, and confusion are one and a half to two times more common in Vietnam service veterans compared to veterans who did not serve in Vietnam. The weakest association (though the 95 per cent C.I.'s do not include unity) with Vietnam service is found for depression ( f = 1.47) and guilt feelings (f • 1.39). The prevalence of each of the eight PTSD symptoms with increasing levels of combat intensity. increases The most dramatic association with combat exposure was observed for nightmares and troubled memories. Veterans who were exposed to high intensity combat were eight times more likely than veterans who did not serve in Vietnam to report nightmares since discharge from active �STRESS SYMPTOMATOLOGY duty. True et al. 11 Similarly, reports of troubled memories about experiences in the military were more than seven and a half times more common in high combat exposure Vietnam veterans compared to non-Vietnam service veterans. Odds ratios for the association of combat with temper control problems, guilt feelings, confusion, sleep problems, and depression all display a strong trend with combat exposure. A minimum of a twofold increase in the prevalence of each symptom was found with high combat exposed veterans who were compared to the non-Vietnam veterans. Only for the symptom life goal indecision does the high combat exposed group display an odds ratio of less than two. A closer examination of the relationship of combat with the PTSD symptoms is revealing. For troubled memories, the prevalence odds ratios increase monotonically and sharply beginning with the Vietnam service non-combat group. An equally steady progression in prevalence is observed for nightmares. Several of the symptoms such as sleep problems, depression, life goal indecision, guilt problems and confusion, show a relatively small increase in prevalence among the Vietnam non-combat group and Vietnam low combat group. It is only when combat exposure reaches the medium and high levels that the prevalence odds ratios for these conditions rise appreciably. PTSD symptoms - Multiple logistic regression analysis of military service and demographic factors Table 2 presents a multiple logistic regression analysis of the relationship of nightmares to six military service and three �STRESS SYMPTOMATOLOGY demographic factors. True et al. 12 As in the unadjusted analysis, combat exposure remains strongly associated with the prevalence of nightmares in Vietnam era veterans; a four unit change in combat produces nearly an eight-fold increase in the frequency of reported nightmares. None of the other military service factors are associated with the prevalence of nightmares. Age at discharge and race demonstrate significant associations with the prevalence of nightmares. Non-white veterans are nearly twice as likely as white veterans to report troubling dreams or nightmares. Age at discharge displays a negative association with the frequency of nightmares; men who were discharged after the age of 25 report problems with nightmares 0.64 less often than men discharged prior to age 22. The relationship of the military service and demographic factors with depression is examined in table 3. Significant associations are observed for combat exposure, age, race and education at discharge from active duty. Combat exposure is positively related to the prevalence of depression. Vietnam service high combat veterans report depression more than twice as frequently as non-Vietnam veterans. Though not significant, veterans who served in the Army, Navy, or Marines show a trend toward a lower frequency of depression compared to Air Force veterans, after the adjustment for combat exposure. Older age at time of discharge is associated with a diminished prevalence of depression. Conversely, the factor adjusted prevalence odds ratio for race indicates that depression is increased in non- �STRESS SYMPTOMATOLOGY whites. True et al. 13 Education is also related to the prevalence of depression; veterans discharged with less than 12 years of education are more than one and a half times more likely to report problems with depression. Table 4 presents the results of the logistic regression analysis for the symptom guilt feelings. The combat exposure index is significantly related to the prevalence of guilt feelings, even after adjustment for military service and demographic variables. Several of the military service factors exhibit unexpected relationships with the prevalence of guilt feelings. Veterans released after 1968 are less likely to report guilt feelings than veterans released prior to 1969. Likewise, veterans who served in the Army, Navy or Marines display a trend toward reporting feelings of guilt about activities during military service less often than veterans who served in the Air Force, though this is not significant. Each of the three demographic factors are associated with the presence of guilt feelings in veterans. Age at discharge from active duty displays an inverse association with the prevalence of guilt feelings; men who were discharged from active duty after the age of 24 were 0.68 less likely to report guilt feelings compared to men who were discharged prior to age 22. Non-white veterans complain of guilt feelings more frequently than white veterans ( f = 1.59, 95 per cent C.I. 1.11-2.28). Veterans who had not completed high school when they were released from active duty are one and a half times more likely to report guilt feelings compared to �STRESS SYMPTOMATOLOGY True eh al. 14 veterans who had completed at least a high school education. Factor adjusted prevalence odds ratios examining the relationship between troubled memories and the six military service factors and three demographic factors are presented in table 5. Most striking is the strong association troubled memories and combat exposure. between A four unit change on the grouped combat exposure index produces a more than seven-fold increase in the prevalence of troubled memories after adjustment for covariates. None of the remaining military service factors are associated with the prevalence of troubled memories. Of the demographic factors examined, both age and race are related to troubled memories. Men who are discharged at an older age are less likely to report troubled memories. Non-white veterans are more likely to report troubled memories. Table 6 examines the relationship between military service and demographic factors and temper control problems. The combat index is positively related to the prevalence of temper control problems which are nearly three times more common in veterans who experienced high levels of combat exposure compared to nonVietnam service veterans. Of the military service covariates examined, only length of service and rank at discharge are found to be marginally related to the prevalence of temper control problems. However, marginal associations are observed for both length of service and rank at discharge. For length of service, veterans who served less than two years are less likely to report temper control problems than veterans who served between 2 and 20 �STRESS SYMPTOMATOLOGY years. True et al. 15 A twofold increase in the frequency of temper control problems is found for veterans discharged as non-officers compared to veterans discharged as officers. Of the demographic factors examined, age and years of education at discharge are both independently associated with temper control problems. Older age at discharge (25 or above) is associated with a reduced prevalence of temper control problems compared to younger age at discharge (21 and under). Also, men with less than a high school education complained of temper control problems more frequently than those who completed high school. Factors associated with the prevalence of the PTSD symptom life goal indecision are examined in table 7. Combat exposure demonstrates a positive relationship with the prevalence of life goal indecision. High combat Vietnam veterans are 1.85 times more likely to report problems with life goal indecision compared to non-Vietnam veterans. Among the remaining military service factors, a significant association with life goal indecision is found for rank at discharge and whether the veteran was drafted or enlisted. For branch of service, Marines, Army and Navy veterans report problems with life goal indecision more commonly than Air Force veterans; this difference is only marginally significant (P < 0.10). Veterans who are non-officers are twice as likely to complain of problems with life goal compared to veterans who are officers. indecision Veterans who are drafted into military service are less likely to report problems with life goal indecision than veterans who enlisted into the �STRESS SYMPTOMATOLOGY military. True et al. 16 Both age and years of education at release are related to the prevalence of life goal indecision. Age at discharge is negatively related to life goal indecision, with older age at discharge associated with a lower prevalence. Veterans with less than 12 years of education report life goal indecision problems more frequently than veterans with at least 12 years of education ( 7 «= 1.44, 95 per cent C.I. 1.01-2.03). Table 8 presents factor adjusted prevalence odds ratios for sleep problems. Combat exposure shows a positive relationship with reporting of sleep problems. dose-response A four unit change on the grouped combat scale produces a twofold increase in the prevalence odds ratio. None of the other military service factors are significantly associated with the prevalence of sleep problems. Of the demographic factors, only years of education is related to sleep problems. As was found for many of the previously examined PTSD symptoms, less education is associated with a higher prevalence of sleep problems. marginally associated with sleep problems. Age at discharge is Consistent with other PTSD symptoms, age is negatively related to sleep disorders. Table 9 presents the results from a logistic regression analysis of confusion with the military service and demographic factors. A positive and significant association the intensity of combat exposure. is found with Age at discharge is negatively associated with confusion as veterans discharged over the age of 24 complain of difficulties with confusion about half as frequently as veterans discharged prior to age 22. Non-white �STRESS SYMPTOMATOLOGY True et al. 17 veterans are more than twice as likely to report this symptom compared to white veterans. Educational level is related to the prevalence of confusion, with the less educated (under 12 years of schooling) more likely to report this problem than veterans with at least 12 years of education. DISCUSSION The analysis of the Survey of Veterans II has demonstrated a marked correlation between eight symptoms of PTSD and military service and combat experience in Vietnam. The advantages of this study include a large random sample (n=l,787) selected from the total U. S. population, an excellent interview response rate (93 per cent), and the collection of data prior to the recent controversy surrounding the issue of the health effects of possible exposure of Vietnam veterans to Agent Orange. The analysis excluded men who served in the military prior to 1965; thus, the results are uncontaminated by military service prior to the Vietnam era. An ordinal index of combat exposure was constructed which demonstrated a high level of internal consistency. One disadvantage of the study was the incidence-prevalence bias of cross-sectional studies. It was not possible to determine if the elevation of PTSD symptomatology found for Vietnam veterans, and especially for those exposed to combat, existed prior to military service. Pre-military service risk factors, prominent in much of the literature about PTSD (4, 8, �STRESS SYMPTOMATOLOGY True et al. 11) were unavailable on the survey. 18 Likewise, there were no measures of post military service traumatic events. Another disadvantage is that the measures of PTSD symptomatology included in the Survey of Veterans II were not sufficiently complete to make the specific psychiatric diagnosis. A summary of the associations among the eight PTSD symptoms and the nine military service and demographic variables is presented in table 10. The relationship of each factor with each symptom is indicated by a plus or a minus sign. For nominal factors the reference category is indicated to assist interpretation. Four factors are consistently symptomatology: associated with PTSD combat exposure index, age at discharge, race, and years of education at discharge. Only combat was associated with an increased prevalence in all eight symptoms. Age at discharge was found to be inversely associated with the prevalence of seven stress symptoms. discharge was inversely associated Years of education at with six symptoms. white) correlated positively with five symptoms. Race (non- None of the remaining military service factors demonstrated a consistent association with the PTSD symptoms. That combat shows such a positive correlation with all symptoms is consistent with other studies (8, 6, 7,). Indeed, the first evidence in the literature of the presence of marked psychologic symptomatology came in clinical studies which investigated the influence of combat These early studies, however, were not controlled. (13). �STRESS SYMPTOMATOLOGY True et al. 19 A rnonotonic increase in the prevalence of several PTSD symptoms was observed with combat exposure in the unadjusted analysis. For example, for the symptom nightmares, prevalence odds ratios increase from 1.32 (no combat) to 2.49 (low combat), 5.49 (medium combat), and 8.19 (high combat). troubled memories increases from 1.73 combat), to 5.29 Similarly, (no combat), to 2.02 (medium combat) and to 7.85 (low (high combat). The other symptoms show consistent but lesser magnitudes of change. Although there is considerable consistency in reporting strong effects of elevated war stress experiences, some studies (4, 14, 15) have not found these risks to outweigh the role of predispositional risk factors. The original Robins (4) study included a seven-point combat scale, but as combat did not show any association with psychological presented. outcomes, the data were not Helzer's work (14, 15) derived from the same cohort, interviewed veterans one and three years after their return to the United States. The study found an association between combat and depression in the first survey, with 27 per cent of the Vietnam veterans reporting at least some depression, which had largely evaporated by the second survey. in the Helzer studies, combat was a three-level ordinal scale, and the measurement of depression covers only a portion of the symptoms now included under the broader category of PTSD. Card (8) used a nine-item combat scale, plus a special measurement for being wounded, and found that 8 of the 10 combat experiences were significantly associated with the PTSD scale she �STRESS SYMPTOMATOLOGY devised, True et al. 20 card scored PTSD as present if two symptoms existed in each of the symptom categories of re-experiencing trauma, numbing, and miscellaneous. This is a somewhat idiosyncratic definition not conforming with the Diagnostic and Statistical Manual ill (12). Further, her analysis of the stress symptoms was limited because all symptom data were reduced to an additive scale, thus losing the ability to look at individual symptoms. Harris (6) also used a nine-point combat index, but the results of the analysis are not comparable to the Survey of Veterans II because the study's only symptom is the simple statement 'Have you had. . Mental or emotional problems?" While there were three-fold increases in 'problems' due to combat, no refined analysis was conducted. Egendorf et al. (7) used an 11-point combat scale, the most extensive of the measurements of war stress in the major surveys using random sampling. Their major finding was that more than a third of heavily combat exposed veterans showed significant stress symptoms compared to less than 20 per cent of other veterans. In later analyses of this study, Laufer (16, 17) focused attention on the importance of exposure to and participation in abusive violence and atrocities, which appear to markedly enhance stress reactions. The importance of the combat exposure index is highlighted by a comparison to the simple dichotomy of Vietnam versus nonVietnam service. This comparison can be seen in table 1, where prevalence odds ratios for Vietnam service are not pronounced for �STRESS SYMPTOMATOLOGY True et al. the symptoms such as guilt feelings (1.39, 95 per cent C.I. 21 1.10- 1.74) and sleep problems (1.53, 95 per cent C.I. 1.20-1.94). However, a distinct gradient in the prevalence of these symptoms is observed with increasing levels of the combat exposure index. Previous studies (7, 8) have found that service in Vietnam itself did not induce .PTSD symptoms. Analysis of the variable race reveals that non-whites have a pattern of increased risk for suffering PTSD symptoms. This pattern was present for five of the eight symptoms, with nonwhites suffering more nightmares, troubled memories, depression, guilt feelings, and confusion than whites. Kadushin (18) found that being white attenuated war stress, and that blacks showed twice the prevalence of stress symptomatology with exposure to high combat. However, Card (8) did not find a correlation between PTSD (as defined by her) and race. Card dichotomized PTSD into present or absent while Kadushin analyzed stress as a continuous scale. Veterans discharged from service with less than 12 years of education are more likely to suffer from sleep problems, depression, temper control problems, life goal indecision, guilt, and confusion, independent of the effects of combat. The Legacies study (18) found that low educational attainments were correlated with increased stress. Helzer (14) found a significant correla- tion in the prevalence of depression at one year after discharge with educational attainment, defined as in the Survey of Veterans II. However, these differences had resolved by the time of the �STRESS SYMPTOMATOLOGY three-year follow-up. True et al. 22 Card (8) had the most exhaustive data on educational attainment, but did not use education at enlistment or discharge as a covariate in the analysis of war stress and PTSD symptomatology. Age at discharge is negatively related to PTSD symptoms, with older age being protective. The only symptom not associated with age at release is sleep problems. Greater maturity during war service appears to be protective against later symptomatology. Wilson and Krauss (3) found suffering traumatic stress during the formative late adolescent years to be especially predictive of higher stress symptom outcomes. Further support for the increased psychological vulnerability of younger Vietnam experienced veterans to the development of PTSD symptomatology is provided by the postservice mortality study of conducted by the Centers for Disease Control (19). The authors found an increased mortality rate in the 5 years following discharge among Vietnam veterans, and particularly those discharged before age 21. causes of death were the following: The principal accidents, suicide, homicide, and poisonings, including drug-related incidents. The present study did not identify any consistent association of stress symptoms with enlistment status (volunteered or drafted), length of service, branch of service, or rank at discharge. Year of discharge (before or after 1968— the Tet Offensive) appears not to have the importance reported by Laufer (11). Only the symptom guilt is correlated with year of �STRESS SYMPTOMATOLOGY True et al. 23 discharge, with post 1968 service suggesting a protective effect ( f = 0.64, 95 per cent C.I. 0.44-0.93). Card (8) examined this point as well, and also found no support for the distinction between service before and after 1968. Evidence has been presented of the presence of traumatic stress symptomatology for a randomly selected sample of veterans studied in 1979, a time preceding recent controversies about Agent Orange and war effects. That these symptoms are magnified by combat exposure confirms clinical experience and other research. �True et al. 24 STRESS SYMPTOMATOLOGY TABLE 1 The association of the Vietnam service and combat exposure with the eight measures of post-traumatic stress symptomatology Symptoms of Post-Traumatic Stress Service in Vietnam ? No n Nightmares Yes No Prevalence Odds Ratios (95% CI) 85 925 1.00 Yes Non-Vietnam Vietnam No Combat n n n 85 925 Combat Exposure Index Vietnam Vietnam Low Combat Medium Combat 13 107 197 573 3.74 (.848) 28-.7 n 60 262 1.00 1.32 (7-.5 .124) 2.49 (1.76-3.53) 160 851 21 99 56 266 n 60 119 5.49 (.678) 38-.1 Vietnam High Combat n 64 85 8.19 (.71.4 57-16) Sleep Problems Yes No Prevalence Odds Ratios (95% CI) 160 851 1.00 172 599 . 15 .3 (.019) 12-.4 1*00 1.13 (6-.6 .818) 105 906 20 100 1.12 (8-.6 .015) 43 136 1.68 (.524) 11-.6 52 98 2.82 (.640) 19-.7 Troubled Memories Yes No Prevalence Odds Ratios (95% CI) 105 906 1.00 220 549 34 .6 (.044) 27-.3 1.00 1.73 (.328) 10-.9 61 260 68 111 2.02 5.29 (.428) (.774) 14-.4 37-.1 71 78 7.85 (5.58-11.05) Depression Yes No Prevalence Odds Ratios (95% CI) 312 699 1.00 306 465 1.47 (.117) 12-.9 312 699 41 79 1.00 1.16 (7-.4 .817) 110 212 1.16 (8-.2 .915) 83 96 1.94 (.126) 14-.7 72 78 2.07 (.729) 14-.1 �True et al. 25 STRESS SYMPTOMATOLOGY TABLE 1 The association of the Vietnam service and combat exposure with the eight measures of post-traumatic stress symptomatology (Continued) Symptoms of Post-Traumatic Stress Service in. Vietnam ? No n Yes Non—Vietnam Vietnam No Combat n n Combat Exposure Index Vietnam Vietnam Low Combat Medium Combat n 15 105 n n Vietnam High Combat n Temper Control Problems Yes No Prevalence Odds Ratios (95% CD 144 868 176 595 144 868 1.00 1.78 (.022) 14-.7 1.00 0.86 (4-.2 .915) 225 786 231 539 225 786 34 86 62 260 49 130 1.44 2.27 (.419) (.832) 10-.9 15-.8 50 100 3.01 ( . 8 4 .36) 20-, Life Goal Indecision Yes No Prevalence Odds Ratios (95% CI) 1.00 1.50 (.118) 12-.5 1.00 1.38 (9-.1 .121) 191 821 188 583 191 821 23 97 1.00 1.39 (.017) 11-.4 1.00 1.02 (6-.5 .316) 148 864 163 607 148 864 1.00 1.57 (.320) 12-.0 1.00 92 230 57 122 48 101 1.40 1.63 1.66 1 1 - 4) ( . 5 1 8 ) ( . 6 2 3 ) ( . 5 2. 1 10-.5 11-.1 Guilt Feelings Yes No Prevalence Odds Ratios (95% CI) 65 257 1.09 (7-.9 .914) 49 130 51 99 2.21 1.62 15-. ( . 3 2 3 ) ( . 4 3 19) 11-.3 Confusion Yes No Prevalence Odds Ratios (95% CD 19 101 1.10 (6-.5 .518) 60 262 1.34 (9-.6 .618) 44 135 40 109 2.14 1.90 14-. ( . 0 2 7 ) ( . 4 3 18) 13-.8 �STRESS SYMPTOMATOLOGY True et al. 26 TABLE 2 Factor adjusted prevalence odds ratios for nightmares Military Service and Demographic Factors Logistic Regression Beta Coefficients Factor Adjusted Prevalence Odds Ratios 95% CI Military Service Factors Combat Exposure .5181 1 Non-Vietnam Vietnam no combat Vietnam low combat Vietnam medium combat Vietnam high combat Length of Service 2 to 20 years less than 2 years Year of Discharge Before 1968 1968 and after Branch of Service Air Force Army Navy Marines 1.00 1.68 2.82 4.73 7.94 (1.53-1.8 (2.33-3.4 (3.55-6.3 (5.41-11. 1.00 .97 ( .69-1.3 1.00 1.44 ( .87-2.41 1.00 1.07 .75 .98 ( .68-1.6} ( .45-1.24 ( .56-1. 7j 1.00 1.19 ( .61-2.31 1.00 1.00 ( .68-1.48 1.00 .80 .64 ( .65- .99 ( .42- .99 1.00 1.96 (1.31-2.92 1.00 1.28 ( .84-1.96 -.0256 .3657 .0649 -.2926 -.0179 Rank of Discharge Officer Non-Officer .1716 Enlisted vs. Drafted Enlisted Drafted .0041 Demographic Factors Age at Discharge 21 and younger 22 - 24 25 and older Race White Non- white Years of Education at Discharge At least 12 yrs of education Less than 12 years -.2232 .6722 .2490 �STRESS SYMPTOMATOLOGY True et al. 27 TABLE 3 Factor adjusted prevalence odds ratios for depression Military Service and Demographic Factors Logistic Regression Beta Coefficients Factor Adjusted Prevalence Odds Ratios 95% CI Military Service Factors Combat Exposure Non-Vietnam Vietnam no combat Vietnam low combat Vietnam medium combat Vietnam high combat .1930 1.00 1.21 1.47 1.78 2.16 1.00 .98 ( .63-1.25) 1.00 .68 .85 .74 ( .50- .94) ( .61-1.19) ( .48-1.13) 1.00 1.53 ( .93-2.51) 1.00 1.08 ( .80-1.44) 1.00 .77 .60 ( .66- .91) ( .43- .82) 1.00 1.57 ( 1.13-2.18) 1.00 1.58 (1 .14-2.19) -.0236 Year of Discharge Before 1968 1968 and after ( .76-1.25) 1.00 .89 Length of Service 2 to 20 years less than 2 years ( 1.12-1.31) ( 1.26-1.71) (1.42-2.24) ( 1.60-2.93) -.1167 Branch of Service Air Force Army Navy Marines -.3831 -.1603 -.3018 Rank of Discharge Officer Non-Officer .4239 Enlisted vs. Drafted .0740 Enlisted Drafted Demographic Factors Age at Discharge 21 and younger 22 - 24 25 and older Race White Non-white Years of Education at Discharge At least 12 years of education Less than 12 years -.2587 .4508 .4583 �True et al. 28 STRESS SYMPTOMATOLOGY TABLE 4 Factor adjusted prevalence odds ratios for guilt feelings Military Service and Demographic Factors Logistic Regression Beta Coefficients Factor Adjusted Prevalence Odds Ratios 95% CI Military Service Factors Combat Exposure Non-Vietnam Vietnam no combat Vietnam low combat Vietnam medium combat Vietnam high combat .1828 1.00 1.20 1.44 1.73 2.08 Length of Service 2 to 20 years less than 2 years -.0800 Year of Discharge Before 1968 1968 and after (1.10-1.31) (1.21-1.71) (1.34-2.24) (1.48-2.92) -.4446 Branch of Service Air Force Army Navy Marines Rank of Discharge Officer Non-Officer Enlisted vs. Drafted Enlisted Drafted 1.00 .92 ( .69-1.23) 1.00 .64 ( .44- .93) 1.00 -.3951 -.3524 -.4697 .67 .70 .63 ( .47- .96) ( .48-1.03) ( .38-1.02) .4276 1.00 1.53 ( .85-2.78) -.1096 1.00 .90 ( .64-1.26) Demographic Factors Age at Discharge 21 and younger 22 - 24 25 and older Race White Non- white Years of Education at Discharge At least 12 years of education Less than 12 years -.1954 1.00 .82 .68 ( .68- .99) ( .47- .98) .4640 1.00 1.59 (1.11-2.28) 1.00 1.50 (1.04-2.15) .4035 �STRESS SYMPTOMATOLOGY True et al. 29 TABLE 5 Factor adjusted prevalence odds ratios for troubled memories Military Service and Demographic Factors Logistic Regression Beta Coefficients Factor Adjusted Prevalence Odds Ratios 95% CI Military Service Factors Combat Exposure Non-Vietnam Vietnam no combat Vietnam low combat Vietnam medium combat Vietnam high combat Length of Service 2 to 20 years less than 2 years Year of Discharge Before 1968 1968 and after Branch of Service Air Force Army Navy Marines .5015 1.00 1.65 2.73 4.50 7.43 (1.51-1.81) (2.27-3.27) (3.43-5.91) (5.17-10.69) 1.00 .85 ( .62-1.17) 1.00 1.26 ( .79-2.02) 1.00 1.16 1.20 .97 ( .76-1.78) ( .76-1.88) ( .56-1.67) 1.00 1.19 ( .65-2.19) 1.00 1.05 ( .72-1.51) 1.00 .81 .66 ( .66- .99) ( .44- .98) 1. 00 1.56 (1.05-2.32) 1.00 .96 ( .63-1.47) -.1682 .2339 .1513 .1797 -.0353 Rank of Discharge Officer Non-Officer .1727 Enlisted vs. Drafted Enlisted Drafted .0456 Demographic Factors Age at Discharge 21 and younger 22-24 25 and older Race White Non-white Years of Education at Discharge At least 12 years of education Less than 12 years -.2105 .4472 -.0397 �STRESS SYMPTOMATOLOGY True et al. 30 TABLE 6 Factor adjusted prevalence odds ratios for temper control problems Military Service and Demographic Factors Logistic Regression Beta Coefficients Factor Adjusted Prevalence Odds Ratios 95% CI Military Service Factors Combat Exposure Non-Vietnam Vietnam no combat Vietnam low combat Vietnam medium combat Vietnam high combat .2695 1.00 1.31 1.71 2.24 2.94 1.00 .75 ( .56-1.29) 1.00 1.04 .98 1.09 ( .69-1.56) ( .64-1.52) ( .65-1.83) 1.00 2.13 ( .99-4.62) 1.00 .93 ( .65-1.35) 1.00 .64 .41 ( .52- .79) ( .27- .62) 1.00 .69 ( .44-1.09) 1.00 1.82 (1.26-2.64) -.2932 Year of Discharge Before 1968 1968 and after ( .54-1.02) 1.00 .85 Length of Service 2 to 20 years less than 2 years (1.20-1.43) (1.43-2.05) (1.71-2.94) (2.05-4.22) -.1631 Branch of Service Air Force Army Navy Marines Rank of Discharge Officer Non-Officer Enlisted vs. Drafted Enlisted Drafted .0345 -.0186 .0874 .7576 -.0678 Demographic Factors Age at Discharge 21 and younger 22 - 24 25 and older Race White No n- white Years of Education at Discharge At least 12 years of education Less than 12 years -.4452 -.3652 .6001 �STRESS SYMPTOMATOLOGY True et al. 31 TABLE 7 Factor adjusted prevalence odds ratios for life goal indecision Military Service and Demographic Factors Logistic Regression Beta Coefficients Factor Adjusted Prevalence Odds Ratios 95% CI Military Service Factors Combat Exposure Non-Vietnam Vietnam no combat Vietnam low combat Vietnam medium combat Vietnam high combat Length of Service 2 to 20 years less than 2 years Year of Discharge Before 1968 1968 and after .1541 1.00 1.17 1.36 1.59 1.85 (1.08-1.27) (1.16-1.60) (1.24-2.03) (1.34-2.57) 1.00 .82 ( .62-1.07) 1.00 1.25 ( .84-1.85) 1.00 .92 .80 .0 6 ( .66-1.28) ( .56-1.15) ( .47- .76) 1.00 2.00 (1.13-3.55) 1.00 .65 ( .47- .90) 1.00 .72 .52 ( .60- .86) ( .36- .74) 1.00 1.00 ( .69-1.44) 1.00 1.44 i(1.01-2.03) -.2052 .2207 Branch of Service Air Force Army Navy Marines Rank of Discharge Officer Non-Officer Enlisted vs. Drafted Enlisted Drafted -.0878 -.2178 -.5178 .6935 -.4308 Demographic Factors Age at Discharge 21 and younger 22 - 24 25 and older -.3281 Race White Non-white -.0015 Years of Education at Discharge At least 12 years of education Less than 12 years .3616 �STRESS SYMPTOMATOLOGY True et al. 32 TABLE 8 Factor adjusted prevalence odds ratios for sleep problems Military Service and Demographic Factors Logistic Regression Beta Coefficients Factor Adjusted Prevalence Odds Ratios 95% CI Military Service Factors Combat Exposure Non-Vietnam Vietnam no combat Vietnam low combat Vietnam medium combat Vietnam high combat .1908 Length of Service 2 to 20 years less than 2 years .0961 Year of Discharge Before 1968 1968 and after Branch of Service Air Force Army Navy Marines 1.00 1.21 1.46 1.77 2.15 (1.11-1.32) (1.23-1.75) (1.36-2.31) (1.51-3.05) 1.00 1.10 ( .82-1.48) 1.00 .88 ( .59-1.32) 1.00 1.17 .85 1.55 ( .78-1.75) ( .54-1.33) ( .94-2.56) 1.00 .99 ( .56-1.74) 1.00 .93 ( .65-1.31) 1.00 .83 .70 ( .69-1.01) ( .47-1.03) 1.00 1.28 ( .87-1.89) 1.00 1.60 (1.11-2.31) -.1256 .1578 -.1621 .4397 Rank of Discharge Officer Non-Officer -.0142 Enlisted vs. Drafted Enlisted Drafted -.0774 Demographic Factors Age at Discharge 21 and younger 22 - 24 25 and older Race White Non-white Years of Education at DischargeAt least 12 years of education Less than 12 years -.1816 .2474 .4726 �STRESS SYMPTOMATOLOGY True et al. 33 TABLE 9 Factor adjusted prevalence odds ratios for confusion Military Service and Demographic Factors Logistic Regression Beta Coefficients Factor Adjusted Prevalence Odds Ratios 95% CI Military Service Factors Combat Exposure Non-Vietnam Vietnam no combat Vietnam low combat Vietnam medium combat Vietnam high combat .2057 Length of Service 2 to 20 years less than 2 years .1174 Year of Discharge Before 1968 1968 and after Branch of Service Air Force Army Navy Marines Rank of Discharge Officer Non-Officer. Enlisted vs. Drafted Enlisted Drafted 1.00 1.23 1.51 1.85 2.28 (1.12-1.35) (1.25-1.82) (1.41-2.45) (1.57-3.29) 1.00 1.12 ( .83-1.53) 1.00 .82 ( .54-1.24) 1.00 .98 1.15 .99 ( .65-1.49) ( .74-1.78) ( .58-1.70) 1.00 1.51 ( .74-3.04) 1.00 .90 ( .62-1.30) 1.00 .74 .55 ( .60- .91) ( .37- .83) 1.00 2.09 (1.45-3.03) 1.00 1.75 (1.20-2.54) -.1950 -.0191 -.1405 -.0081 .4089 -.1030 Demographic Factors Age at Discharge 21 and younger 22 - 24 25 and older Race White Non-white Years of Education at Discharge At least 12 years of education Less than 12 years -.2974 .7395 .5575 �STRESS SYMPTOMATOLOGY True et al. 34 . TABLE 10 Summary of analyses of PTSD symptoms PTSD SYMPTOMS Military Service and Demographic Factors Combat Nightmares *** Sleep Problems *** Troubled Memories *** Degression *** Temper Control Problems *** Life Goal Indecision ** * Guilt Feelings *** Confusion *** Length of Service (2-20 yrs) Year of Release (Before 1968) _* Branch (Air Force) Rank at Discharge (Officer) Drafted (Enlisted) Age of Discharge Race (White) Years of Education (M2 yrs) ** *** *** ** *** ** ** ** ** ** *p£.05 **p£.01 ***p£.001 i" Positive and inverse associations between each military service and demographic factor and PTSD symptom are represented by plus ( ) and minus (-) signs, respectively. + �STRESS SYMPTOMATOLOGY True et al. 35 REFERENCES 1 Borus JF. Reentry II. "Making It" Back in the States. American Journal of Psychiatry 1973;130(8):850-854. 2 Nace EP, O'Brien CP, Mintz J, et al. Stress Disorders Among Vietnam Veterans. C. R. Figley, New York: Brunner/Mazel, 1978:71-128. 3 Wilson JP, Krauss GE. Post-Traumatic Stress Disorder and the War Veteran Patient, in William E. Kelly, New York: Brunner/Mazel, 1985:102-147. 4 Robins LN, Davis DH, Goodwin DW. Drug Use by U.S. Army Enlisted Men in Vietnam: A Follow-Up on Their Return Home. American Journal of Epidemiology 1974;99(4):235-249. 5 Veterans Administration. 1979 National Survey of Veterans, Summary Report. 1980. 6 Harris L. Myths and Realities: A Study of attitudes toward Vietnam era Veterans. Washington, DC 1980. Submitted to the Committee on Veterans' Affairs. 7 Egendorf A, Kadushin C, Laufer RS, et al. Summary of Findings. New York City: The Center for Policy Research, Inc., 1981. A Study Conducted for the Veterans Administration. 8 Card JJ. Lives after Vietnam. Lexington, Massachusetts Toronto: Lexington Books, D.C. Heath and Company, 1983. 9 Wise LL, McLaughlin DH, Steel L. The Project TALENT Data Bank Handbook. Palo Alto: American Institutes for Research, 1979. �STRESS SYMPTOMATOLOGY True et al. 10 Boulanger G and Kadushin C, eds. 36 The Vietnam Veteran Redefined: Fact and Fiction. Hillsdale, NJ: Lawrence Erlbaum Associates, 1986. 11 Laufer RS, Yager T, Frey-Wouters E, et al. Post-War Trauma: Social and Psychological Problems of Vietnam veterans in the aftermath of the Vietnam War. New York: Center for Policy Research, 1981. The final report to the Veterans Administration. 12 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders III (DSM-III). Washington, DC 1980. 13 Shatan CF. The Grief of Soldiers: Vietnam Combat Veterans' Self-Help Movement. American Journal of Orthopsychiatry 1973;43(4):640-653. 14 Helzer JE, Robins LN, Davis DH. Depressive Disorders in Vietnam Returnees. The Journal of Nervous and Mental Disease 1976;163(3):177-185. 15 Helzer JE, Robins LN, Wish E, et al. Depression in Viet Nam Veterans and Civilian Controls. American Journal of psychiatry 1979;136(4B):526-529. 16 Laufer RS, Gallops MS, Frey-Wouters E. War Stress and Trauma: The Vietnam Veteran Experience. Journal of Health and Social Behavior 1984;25(1):65-85. 17 Laufer RS, Brett E, Gallops MS. Dimensions of Posttraumatic Stress Disorder among Vietnam Veterans. The Journal of Nervous and Mental Disease 1985;173(9):538-545. �STRESS SYMPTOMATOLOGY True et al. 37 IB Kadushin C, Boulanger G, Martin J. Long Term Stress Reactions: Some Causes, Consequences, and Naturally Occurring Support Systems. Center for Policy Research, Inc., 1981. 19 The Centers for Disease Control Vietnam Experience Study. Postservice Mortality Among Vietnam Veterans. JAMA 1987;257(6). � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 069 Folder The folder containing the original item. 1856 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource True, William R. Jack Goldberg Seth A. Eisen Description An account of the resource <strong>Corporate Author: </strong>Veterans Administration Title A name given to the resource Stress Symptomology Among Vietnam Veterans: Analysis of the Veterans Administration Survey of Veterans II Subject The topic of the resource veteran psychological health PTSD study protocol ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 079 Folder The folder containing the original item. 2041 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Stibbard, K. Date A point or period of time associated with an event in the lifecycle of the resource 1984 Title A name given to the resource Why is Publicity Given to Vietnam Veterans? Subject The topic of the resource veteran psychological health public opinion popular press ao_seriesIII https://www.nal.usda.gov/exhibits/speccoll/files/original/584708fa5dd2df0381e6bf11d2fb7306.pdf cb5ddd9d56fe48449073f6aad7ee94a8 PDF Text Text Item ID Number °1849 Author McKinlay, Sonja M. Corporate Author ^ew England Research Institute, Inc., Watertown, Mass ROpOrt/ArtldB Title Women's Vietnam Veterans Health Study Protocol Development, Questionnaire, Deliverable C Journal/Book Tltto Year 000 ° Month/Day Color D Number of Images 42 DeSCrlptOfl Notes Contract No. V101(93)P-1138 Wednesday, July 11, 2001 Page 1850 of 1870 �WOMEN'S VIETNAM VETERANS HEALTH STUDY PROTOCOL DEVELOPMENT CONTRACT NO. V101(93)P-1138 QUESTIONNAIRE DELIVERABLE C SUBMITTED BY NEW ENGLAND RESEARCH INSTITUTE, INC. PRINCIPAL INVESTIGATOR SONJA M. MCKINLAY, Ph.D. NEW ENGLAND RESEARCH INSTITUTE, INC.' 42 Pleasant Street Watertown, Massachusetts 02172 (617)923-7747 �QUESTIONNAIRE CONSTRUCTION Several instruments were reviewed for possible inclusion in the Women Veterans Health Study. Whenever possible, questions were taken from other health studies (in particular the National Health Interview Survey) to assure high validity and reliability. This is most evident in the general health section as well as the reproductive history, social support, lifestyle, and demographics sections. Since much of the life history events data is open-ended, a format used successfully in the Framingham Heart Study for hospitalizations and surgical procedures was expanded for use in the civilian employment, military history, and marital history sections. The pertinent hospitalizations and surgeries, as well as the military history, will be validated using hospital and military records respectively. The same format was used to collect employment and military history on the father of each pregnancy and the conception partner sections. These have been pre-tested extensively and have worked very well. Several questions regarding current PTSD have been buried throughout the instrument purposefully as part of the study design. The CESD scale was also included as a reliable means of assessing depression for these women in general. In addition, a short military experience section also gathers information relating to PTSD. The instrument by Dr. Robert Stretch, "Vietnam-Era Nurses Adjustment Survey" provided the basis for this section, and several questions in Stretch's instrument were used here. This instrument is based on the Vietnam-Era Veterans Adjustment Survey (VEVAS), which has been used in research on other veterans, and has established reliability. �In addition, all of the following were reviewed for this section: • The Stress Event Survey; Problem Checklist and Stress Event Test (Pearce, 1985) • The Youthful Liability Scale (Laufer, 1985) • Independent Variable and Demographic Questionnaire (Frye, 1982) • Post-Traumatic Stress Disorder Checklist (Ellen Frank, University of Pittsburgh, School of Medicine, Department of Psychiatry, 1987) • Post-Traumatic Stress Disorder questionnaire from the Diagnostic Interview Schedule (L.N. Robins, J.E. Helzer and J.L. Croughan) • Psychiatric Epidemiology Research Interview (PERI; Laufer, 1985) These instruments listed above (except for the problem checklists which are duplicative of several other instruments), were excluded due to the difficulty of administration (several must be done in an in-person interview and/or require a clinician's assessment) and the length of time required to administer them. Also, given that the primary focus of this study is on female reproductive outcomes, the scope of the study must be limited for feasibility and to meet the time limits of a telephone interview. Several general health studies as well as studies of Vietnam Veterans were reviewed for the instrument design: • • • • • • The Veterans Health Survey Questionnaire for CDC (conducted by RTI, 1985) The Survey of Female Veterans for the VA (conducted by Louis Harris and Associates, 1985) The Vietnam Era Twin Study Survey of Health The Vietnam Veterans History Questionnaire for the VA (Foy, 1986) The Ranch Hand Study for the USAF (1982) The National Health Interview Survey for the U.S. Public Health Service (1984) �The Australian Veterans Health Studies for the Australian Government (Australian Royal Commission, 1985) Thesis by Gregory Paul Korgeski for the University of Minnesota (1987) on "The Psychological, Neurological and Medical- Correlates of Self-Reported and Objective Ratings of Herbicide Exposure among Vietnam Veterans." The Women Vietnam Era Veteran's Social History Form (Butler and Samson) A Guide to Obtaining a Military History from Vietnam Veterans (Scorfield and Blank) In addition to all of those listed above, several other instruments were reviewed specifically for the reproductive history section. These instruments together formed the basis for this section and pertinent topics addressed in these instruments are covered in the protocol. In addition to instruments developed by this project's Principal Investigator on studies of female reproductive functioning and social support networks the following were reviewed: • The Reproductive Health Questionnaire for NCHS • National Survey of Family Growth Cycles III and IV for HHS • Menstrual Distress Questionnaire (Moos, 1968) • Social Support Questionnaire (Norbeck, 1983) For the nursing section, the following were very helpful and formed the basis for questions included in this section: • Protocol from the Vietnam Nurse Veteran Project (Paul and O'Neill, 1984) • The Staff Burnout Scale for Health Professionals by J.W. Jones (Cronin-Stubbs, 1985) • The Nursing Stress Scale by Gray-Toft (CroninStubbs, 1985) • Questionnaire for Rating Stressful factors in the ICU/CCU developed by Dr. L. Huckabay, (Norbeck, 1985) �These instruments were provided directly from the researchers through correspondence. �PRE-TEST REPORT The pre-test was conducted with 37 interviewees in four distinct groups: (1) twenty-seven Red Cross women who served in Vietnam; (2) one non-military nurse who served in Vietnam with AID; (3) seven Vietnam-era veterans (both nurses and non-nurses); and (4) two Vietnam veteran nurses. The majority of the 37 interviews were conducted with former Red Cross volunteers for two major reasons: (1) the similar exposure (i.e., Vietnam experience) and, (2) the fact that this group will not be eligible for the Women Veterans Health Study and therefore would not reduce the sample of interest. In order to pre-test the specific military and nursing sections however, a small number of Vietnam and Vietnam-era veterans were included. These names were made available through consultants on the project who are Vietnam and Vietnam-era veterans themselves. The names came from veterans organizations and the American Nurses' Association. The number of women from these groups was purposely small so that very few would have to be eliminated from the proposed study. The instrument went through several different modifications during the pre-test, and feedback was requested from interviewers and interviewees in an effort to improve the instrument. On the whole, the interview was well-received. Respondents felt that it was thorough, comprehensive and neither offensive nor intrusive. The utilization of professionally-trained interviewers with several years of interviewing experience was certainly an important factor in this assessment. �The interview was always conducted at a convenient time for the respondent and for the majority, a specific appointment time was made due to the length of time required to administer the initial versions of the instrument. The average length of time required to administer the instrument across all four groups was 69.61 minutes. The average was 71.20 for the Red Cross group; 85 minutes for the two Vietnam veteran nurses; 44 minutes for the one AID nurse; and 63 minutes for the seven Vietnam-era veterans (nurses and non-nurses). �INSTRUMENT BIBLIOGRAPHY NOTE: The articles cited in this Bibliography provided the basis for correspondence with the individual researchers. We requested copies of the actual questionnaires or instruments used in their research. The researchers were extremely helpful and provided us with copies of their protocols for our review. �REFERENCES Australian Royal Commission, "Royal Commission on the use and effects of chemical agents on Australian personnel in Vietnam", Australian Govt. Publish. Serv., Canberra, 1985. Cronin-Stubbs, D., Schaffner, J.W., "Professional impairment: Strategies for managing the troubled nurse", NAQ. 1985, 9(3), 44-54. Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides; Baseline Questionnaire, USAF School of Aerospace Medicine (1982). Foy, D.W., Sipprelle, R.C., Rueger, D.B., Carroll, E.M., "Etiology of posttraumatic stress disorder in Vietnam veterans: Analysis of premilitary, military, and combat exposure influences", Jnl. of Consulting & Clinical Psychology. 1984, 52, 79-87. Frye, J.S., Stockton, R.A., "Discriminant analysis of posttraumatic stress disorder among a group of Vietnam veterans", Am. J. Psychiatry, 1982, 139(1), 52-56. Gray-Toft, P., Anderson, J.G., "Stress among hospital nursing staff: Its causes and effects", Soc. Sci. and Med.. 1981, 15A, 639-647. Korgeski, G.P., Leon, G.R., "Correlates of self reported and objectively determined exposure to Agent Orange", American Journal of Psychiatry. 1983, 140(11), 1443-1449. Laufer, R., "War trauma and human development: The Vietnam experience", The Trauma of War: Stress & Rec in V. Vets., Sonnenberg, S.M., Blank, A.S., Talbott, J.A., Am. Psychiatric Press Inc., 1985, 33-55. Moos, Rudolf H., "The Development of a Menstrual Distress Questionnaire", Psychosomatic Medicine. Vol. XXX, No. 6, 1968. Norbeck, J.S., Tilden, V.P., "Life stress, social support, and emotional disequilibrium in complications of pregnancy: A prospective, multivariate study", Jnl. of Health and Social Behavior. 1983, 24, 30-46. Norbeck, J.S., "Perceived job stress, job satisfaction, and psychological symptoms, in critical care nursing", Research in Nursing and Health. 1985, 8, 253-259. Paul, E.A., "Wounded healers: A summary of the Vietnam nurse project", Military Medicine. 1985, 150(11), 571-576. �Pearce, K.A., "A study of posttraumatic stress disorder in Vietnam veterans", J. of Clinical Psychology. 1985, 41(1), 9-14. Robbins, L.N., Helzer, J.E., "Drug use among Vietnam veterans three years later", Med. World News. 1975, Oct. 27, 44-49. Robins, L.N., Helzer, J.E., Davis, D.H., "Narcotic use in Southeast Asia and afterward", Archives of General Psychiatry. 1975, 32, 955-961. Robins, L.N., Helzer, J.E., Croughan, J., Ratcliff, K.S.: "The NIMH Diagnostic Interview Schedule": Archives of General Psychiatry. 1981, 38, 381-389. Stretch, R.H., Vail, J.D., Maloney, J.P., "Posttrauraatic stress disorder among army nurse corps in Vietnam veterans", J. of Consulting & Clinical Psych.. 1985, 53(5), 704-708. �WOMEN'S VETERAN HEAIJIH STODY QUESTIONNAIRE �GENERAL HEALTH SECTION First, I have some general health questions to ask you. 1. Would you say your health in general is: 1. Excellent 2. Very good 3. Good 4. Fair, or 5. 9. 2. Poor DK Overall, how much do you worry about your health: 1. Not at all 2. Very little 3. Some of the time, or 4. Most of the time 9. DK In the past 2 weeks, have you had any illness, accident or injury which has restricted your usual activities? YES 1. NO 2. 9. DK 3.1 How many days altogether were your usual activities restricted by illness, accident or injury in the past 2 weeks? DAYS 3.2 What was the reason (or reasons) for this limitation? �I will read you a list of common problems which affect us from time to time in our daily lives. Thinking back over the past two weeks. have you been bothered by any of the following? EQ IBS £K a. Dizzy spells 1 2 9 b. 1 2 9 c. Diarrhea d. Constipation e. Persistent cough 1 1 1 2 2 2 9 9 9 f. Feeling blue or depressed 1 2 9 g. Backaches or lower back pain 1 2 9 h. Anxiety i. Upset stomach 1 1 2 2 9 9 j . Headaches 1 2 9 k. Night sweats 1. Aches/stiffness in joints 1 1 2 2 9 9 m. 1 2 9 n. Sore throat o. Loss of appetite p. Menstrual problems 1 1 1 2 2 2 9 9 9 q. Fluid (water) retention r. Difficulty in concentrating 1 1 2 2 9 9 s. Nervous tension 1 2 9 t. Urinary tract/bladder infections 1 2 9 u. Trouble with bladder control/frequency 1 2 9 v. Rapid heartbeat 1 2 9 w. Hot flushes/flashes 1 2 9 x. Nightmares 1 2 9 y. Trouble sleeping or insomnia 1 2 9 z. 1 2 9 aa. Depression 1 2 9 bb. Forgetfulness 1 2 9 Lack of energy 'Pins and needles' in hands or feet Irritability IF YES TO ANY ASK: Why do you think you've had these problems lately? �5. Compared with persons of your own age and sex, how would you rate your risk of having a heart attack or stroke within the next ten years? 1. 2. 3. 4. 5. 9. Much lower than average Somewhat lower than average About average Somewhat higher than average, or Much higher than average DK 6. Do you know approximately what your blood pressure is? SYSTOLIC DIASTOLIC DK - 999 DK - 999 7. Do you know approximately what the level of cholesterol in your blood is? mg/dl DK - 999 8. How tall are you in your stocking/bare feet without shoes? round to the nearest inch. FT. IN. DK - 999 Please INCHES 9. How much do you weigh in light indoor clothing without shoes? round to the nearest pound. POUNDS DK - 999 Please �10. Excluding weight gains due to pregnancy, since you were 21, have you ever weighed 20 or more pounds over your current weight? 1. NO 2. YES 10.1 When was that? (PROBE FOR YEAR(S) AND CIRCUMSTANCES) 10.2 What is the most you have ever weighed? POUNDS DK - 999 11. Since you were 21, have you ever weighed 20 or more pounds under your current weight? 1. NO 2. YES 11.1 When was that? (PROBE FOR YEAR(S) AND CIRCUMSTANCES) 11.2 What is the least you have ever weighed? POUNDS DK - 999 �CIVILIAN EMPLOYMENT HISTORY In order to get a complete picture of you as an individual, we need to collect a complete history on several areas of your life. I'd like to start with your civilian employment history. 1. What have you been doing for most of the past 12 months -- were you in the military, working at a non-military job for pay, going to school, or doing something else? 1. SOMETHING ELSE 2. 3. IN THE MILITARY I GOING TO SCHOOL 4. WORKING AT A JOB FOR PAY V 1. What were you doing? 01. RETIRED 02. LAID OFF 03. LOOKING FOR WORK 04. KEEPING HOUSE 05. ILL 06. DISABLED 07. VOLUNTEER WORK 08. OTHER (SPECIFY): 2. Excluding active duty while in the military, have you ever worked at a job for pay? 1. NO 9. DK V SKIP TO NEXT SECTION 2. YES 2.1 Excluding jobs before you were 21 years old and excluding active duty in the military, let's begin with your first job after you reached 21. IF NO PAID JOBS AFTER 21 YEARS OF AGE SKIP TO NEXT SECTION �2.1 FOR EACH JOB ASK: (a) What were the dates of your employment for that job? (b) Was that full-time (35 hours or more per week) or part-time «35 hours per week)? (c) What type of work did you do? What, specifically, were your job duties? FOR NURSES ASK: What was your specialty? What type of ward did you work on? (d) What type of an organization did you work for? (Was it a hospital, company, university, etc.?) And, in what city and state was it located? (e) IF NOT CURRENTLY WORKING AT THAT JOB, ASK: Why did that job end? (b) FT PT (a) DATE S JOB # 1 TO MONTH YEAR MONTH YEAR MONTH YEAR MONTH MONTH YEAR MONTH YEAR MONTH 2 YEAR YEAR MONTH YEAR 1 3 2 1 2 1 2 1 TO 2 1 TO 2 V. 4 TO MONTH YEAR MONTH YEAR MONTH YEAR 5 ' TO TO 6 MONTH YEAR (c) TYPE OF WORK �IF NURSE: SPECIALTY WARDS (d) ORGANIZATION CITY, STATE (e) WHY LEFT �2. (CONT.) FOR EACH JOB ASK: (a) What were the dates of your employment for that job? (b) Was that full-time (35 hours or more per week) or part-time « 35 hours per week)? (c) What type of work did you do? What, specifically, were your job duties? FOR NURSES ASK: What was your specialty? What type of ward did you work on? (d) What type of an organization did you work for? (Was it a hospital, company, university, etc.?) And, in what city and state was it located? (e) IF NOT CURRENTLY WORKING AT THAT JOB, ASK: Why did that job end? 7 (b) FT FT (a) DATE S JOB # 1 MONTH 1 8 YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR 9 1 1 MONTH 2 YEAR 1MONTH YEAR MONTH YEAR MONTH YEAR TO 12 2 YEAR TO 11 2 1 MONTH TO 10 2 YEAR TO MONTH 2 1 MONTH 2 1 TO YEAR TO (c) TYPE OF WORK �(d) IF NURSE: SPECIALTY WARDS 10 11 12 ORGANIZATION CITY, STATE (e) WHY LEFT �2. (CONT.) FOR EACH JOB ASK: (a) What were the dates of your employment for that job? (b) Was that full-time (35 hours or more per week) or part-time «35 hours per week)? (c) What type of work did you do? What, specifically, were your job duties? FOR NURSES ASK: What was your specialty? What type of ward did you work on? (d) What type of an organization did you work for? (Was it a hospital, company, university, etc.?) And, in what city and state was it located? (e) IF NOT CURRENTLY WORKING AT THAT JOB, ASK: Why did that job end? (b) FT PT (a) DATES JOE # 13 TO MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR ] MONTH YEAR MONTH YEAR 14 MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR 1MONTH YEAR MONTH YEAR TO 15 1 1 16 17 18 TO 2 1 TO 2 1 TO 2 1 TO 2 2 (c) TYPE OF WORK �(e) IF NURSE: SPECIALTY WARDS 13 14 15 16 17 18 ORGANIZATION CITY, STATE WHY LEFT �MARITAL HISTORY The next section asks for a complete marital history. 1. Have you ever been legally married? 1. NO 2. YES 1.1 What is your current marital status, are you: 1. Married and living with your spouse 2. Separated 3. Divorced, or 4. Widowed 1.2 How many times have you been legally married in your entire life? ENTER # GO TO MARITAL HISTORY SECTION AND RECORD MARRIAGES UNTIL YOU REACH THE # ENTERED ABOVE. �2. (a) What were the dates of your marriage? (b) IF NOT CURRENTLY IN THAT MARRIAGE, ASK: Did that marriage end in divorce, a legal separation, the death of your spouse, or in some other way? REPEAT FOR ALL MARRIAGES. (b) (a) MARRIAG E # DA REASON FOR END OF MARRIAGE TO (1) MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR TO (2) TO (3) TO () 4 TO (5) TO () 6 �REPRODUCTIVE HISTORY The next set of questions ask for a complete reproductive history. 1. Have you ever taken any form of birth control pills? 1. NO 9. D,K SKIP TO QUESTION # 2 2. YES l.la How old were you when you first began taking birth control pills? (b) What year was that? YEARS (a) 1.2 (b) 19 Are you taking birth control pills now? 1. NO 2. YES 1.2a What brand are you currently using? (BRAND NAME) I SKIP TO QUESTION # 1.4 I 1.3 How long ago did you last take birth control pills? 01.< 1 MONTH 02.> 1 MONTH; <; 1 YEAR AGO 03.> 1 YEAR; <; 5 YEARS AGO 04.> 5 YEARS; < 10 YEARS AGO 05.> 10 YEARS; <^ 20 YEARS AGO 06.> 20 YEARS AGO 1.4 As best as you can remember, I'd like to know all of the specific years or time periods when you used birth control pills, and the brand you used. �2. Have you ever used an IUD? 1. NO 9. DK SKIP TO QUESTION # 3 2. YES 2.la How old were you when you first used an IUD? (b) What year was that? (a) 2.2 YEARS (b) 19 How long ago did you last use an IUD? 01. CURRENTLY USING; < 1 MONTH 02. > 1 MONTH; < 1 YEAR AGO 03. > YEAR; <5 YEARS AGO 04. > 5 YEARS; < 10 YEARS AGO 05. > 10 YEARS; < 20 YEARS AGO 06. > 20 YEARS AGO 2.3 As best as you can remember, I'd like to know all of the specific years or time periods when you used an IUD, and the brand you used. �3. Have you ever tried to conceive a child for a period of 12 months or more and been unable to get pregnant? 1. NO 9. 2. YES DK I I SKIP TO Q # 4.1 I 4. Have you ever been in a relationship where you were having intercourse regularly (on a weekly basis) without using birth control for a period of 12 consecutive months or more without conceiving? 1. NO 2. I 4.1 YES 4 old were you when this first happened? How IF NO TO Q # 3 +4 SKIP TO QUESTION # 8 YEARS 4.2 How long did this continue for? MONTHS 4.3 1. 1. YEARS Did you or your partner ever discuss this with a health professional or have any testing to determine why you did not conceive? NO 2. YES i 4.3a 4.4 OR What types of tests did you and/or your partner have? Were you or your partner ever treated by a health professional for this? NO 2. YES ,1. 4T4a As best as you can remember, I'd like to know what types of treatments were prescribed for you and/or for your partner? 4.4b What was the outcome of the treatments? �CONCEPTION PARTNER SECTION I'd like to ask you a few questions about the man you were in a relationship with when you did not conceive after 12 months. [REPEAT QUESTIONS 1 - 7 FOR EACH MAN WITH WHOM RESPONDENT WAS IN A RELATIONSHIP FOR 12 MONTHS WITHOUT CONCEPTION.] * AT END, ASK: Did you ever try to conceive for 12 months or more with any other man or were you having regular intercourse for 12 consecutive months (on a weekly basis) with any other man without using birth control and without becoming pregnant? (IF YES, REPEAT CONCEPTION PARTNER SECTION.) 1. What is his date of birth? First the month, then the day and year. 9. DAY MONTH DK YEAR 2. Did he ever serve in the military? 1. NO 9. DK \ 2. YES I 2.1 Did he ever serve in Vietnam? 9. I DK SKIP TO QUESTION # 3 Now, I'd like to get his complete military service history while in Vietnam, for each tour of duty, beginning with his first tour in Vietnam. Please tell me where he served and for how long. Please include both temporary and permanent tours of duty. (REPEAT UNTIL COMPLETE MILITARY HISTORY FOR ALL BRANCHES SERVED IN) �2.1 (a) What branch did he serve in? 2.1 (b) Where was he stationed? (COUNTRY AND AREA) 2.1 (c) For how long? 2.1 (d) What was his rank during that time? 2.1 (e) What was his assignment? 2.1 (f) FOR DOCTORS, NURSES AND MEDICS, ASK: What was his military occupational specialty? What hospital was he assigned to? What type of ward did he work on? (a) BRANCH (d) RANK (c) TIME (b) WHERE TO MONTH MONTH YEAR YEAR TO MONTH YEAR MONTH YEAR TO MONTH YEAR MONTH YEAR TO MONTH YEAR MONTH YEAR TO MONTH YEAR MONTH YEAR MONTH YEAR TO MONTH YEAR �(f) FOR DOCTORS/ NURSES AND MEDICS: (e) ASSIGNMENT SPECIALTY HOSPITAL NAME TYPE OF WARD 1 �3. Did he ever work in the manufacture or packaging of chemicals? 1. 9. NC DB 2. SKIP TO QUESTION # 4 YES (a) What were the dates of his employment in that type of occupation? (b) Was that full-time (35 hours or more per week) or part-time « 35 hours per week)? (c) What type of work did he do? What, specifically, were his job duties? (d) What was the name of the company he worked for? (e) What was the address of the company he worked for? I need the street, the city, state, and zip code, if you know it. (a) DATES JOB (b) FT PT TO MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR 1 TO 2 1 TO 2 1 TO 2 1 TO 2 () c TYPE OF WORK �(d) NAME OF COMPANY (e) STREET ADDRESS (CITY, STATE, ZIP) �4. Did he ever work in the field of agriculture? 1. 9. YES Np DK SKIP TO QUESTION # 5 I (a) What were the dates of his employment in that type of occupation? (b) Was that full-time (35 hours or more per week) or part-time « 35 hours per week)? (c) What type of work did he do? What, specifically, were his job duties? (d) What was the name of the company he worked for? (e) What was the address of the company he worked for? I need the street, the city, state, and zip code, if you know it. (a) DATE S JOB (b) FT PT TO MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR 1 1 2 1 2 1 2 YEAR MONTH 2 YEAR MONTH 2 1 MONTH YEAR TO TO TO MONTH YEAR MONTH YEAR TO (c) TYPE OF WORK �(d) (e) NAME OF COMPANY STREET ADDRESS (CITY, STATE, ZIP) �5. Did he ever work In forestry? 1. N,0 9. DK YES SKIP TO INTERVIEWER CHECK AT THE TOP OF QUESTION # 6 I (a) What were the dates of his employment in that type of occupation? (b) Was that full-time (35 hours or more per week) or part-time « 35 hours per week)? (c) What type of work did he do? What, specifically, were his job duties? (d) What was the name of the company he worked for? (e) What was the address of the company he worked for? I need the street, the city, state, and zip code, if you know it. (a) JOB (b) FT PT DATES 1 YEAR MONTH YEAR MONTH YEAR MONTH YEAR 1 MONTH YEAR 1 YEAR MONTH YEAR 2 YEAR MONTH 2 YEAR MONTH 2 YEAR MONTH 2 1 MONTH 2 1 TO MONTH TO TO TO TO (c) TYPE OF WORK �(d) NAME OF COMPANY (e) STREET ADDRESS (CITY, STATE, ZIP) �INTERVIEWER NOTE! ASK ONLY IF CURRENTLY MARRIED TO THIS MAN 6. What Is his most recent occupation? What specifically does he do? 7. What was his usual occupation for most of the past 20 years? specifically did he do for most of that time? What �8. Have you ever been pregnant? 1. NO 9. DK SKIP TO MENSTRUAL HISTORY 2, YES I 8.1 Are you currently pregnant? 1. NO I 9. DK YES * 8.la What month of the pregnancy are you in? 2. WEEKS MONTH 8.2 Altogether, how many times (including this pregnancy) have you ever been pregnant? INTERVIEWER NOTE: TIMESIF CURRENTLY PREGNANT FOR THE FIRST TIME. SKIP TO MENSTRUAL HISTORY SECTION, GO TO PREGNANCY HISTORY AND RECORD PREGNANCIES UNTIL YOU REACH THE # ENTERED ABOVE �PREGNANCY HISTORY I'd now like to ask you a series of questions about your pregnancy. time? 1. In what year did you become pregnant for the 19 YEAR 2. How long did the pregnancy last? WEEKS 3. What was the outcome of this pregnancy? 1. ECTOPIC PREGNANCY 3. STILL BIRTH 4. LIVE BIRTH 5. *SKIP TO.QUESTION # 3 . 1 MISCARRIAGE (SPONTANEOUS ABORTION) 2. [CODE RED] INDUCED ABORTION: *SKIP TO QUESTION # 14 SKIP TO QUESTION # 4 (a) Could you please tell me why you had the abortion, or how you came to the decision to have the abortion? (b) Was there any indication that the fetus was malformed? 1. NO 9. DK SKIP TO QUESTION # 14 2. YES [CODE RED] �(c) Could you please tell me when the abortion took place? 19 MONTH YEAR (d) I'd also like to know the name and address of the hospital and the doctor who treated you. HOSPITAL NAME STREET ADDRESS CITY STATE ZIP STATE ZIP DOCTOR'S NAME STREET ADDRESS CITY SKIP TO QUESTION # 14 �3.1 Were you told by a physician that the miscarriage was caused by: [READ a - b] NO YES DK a . A congenital malformation? 2 9 b . A hydatidiform mole? 3.2 1 1 2 9 I'd also like to know the name and addresses of the hospital and the doctor who treated you. HOSPITAL NAME STREET ADDRESS CITY STATE ZIP DOCTOR'S NAME STREET ADDRESS CITY STATE ZIP �3.3 Were you or your partner given any information by a physician about why you may have had the miscarriage? 1. NO 9. DK 2. YES I 3.3.1 What were you told? 3.4 Did you or your partner ever go for genetic counseling or have any tests to determine why you had the miscarriage? 1. NO 9. DK 2. YES i 3.4.1 What types of tests were done and what was the outcome of the testing? 3.5 Did this miscarriage occur after amniocentesis or other similar test procedures? 1. NO 9. DK 2. YES * 3.5.1 What tests were you given? 1. AMNIOCENTESIS 2. OTHER (SPECIFY: 3.6 Why do you think you had the miscarriage? 9. DK SKIP TO QUESTION # 14 �INTERVIEWER NOTE: FOR MULTIPLE BIRTHS (TWINS, TRIPLETS, ETC.) RECORD FOR EACH CHILD. 4. Was this child male or female? 1. MALE 2. FEMALE 5. How much did the child weigh at birth? POUNDS OUNCES 6. Did this child have any birth defects or abnormalities when s/he was born? 1. NO 2. YES 6.1 Please describe the birth defect or abnormality. (any others?) 6.2 Could I please have the name, address, city, state and zip code of the physician who diagnosed your child's abnormality or handicap, and the hospital at which the diagnosis was made? NAME OF DOCTOR ADDRESS CITY STATE ZIP STATE ZIP NAME OF HOSPITAL ADDRESS CITY �7. Was this a forceps delivery? 1. NO 2. YES 9. DK 8. Did you smoke at all during this pregnancy? 1. NO I 9. DK 2. YES v 8.1 How many cigarettes per day on the average did you smoke during this pregnancy? CIGARETTES PER DAY 9. Did you drink alcoholic beverages at all during this pregnancy? 1. NO 2. YES 9. DK 9.1 About how often did you drink alcoholic beverages on the average during this pregnancy? 1. 2. 3. 4. 5. Less Less 1 or 3 or 5 or than once a month than once a week 2 days a week 4 days a week more days a week 10. Did you have any of the following complications during this pregnancy, as a result of the pregnancy? [READ a-d, FOR EACH YES, ASK: During which month or months of the pregnancy did you have this?] PK N_Q YES a. Toxemia 1 2 9 b. Diabetes 1 2 9 c. High Blood Pressure 1 2 9 d. Spotting (Vaginal bleeding)... 1 2 9 MONTHS �11. Did you have any other complications during this pregnancy? 1. NO I 9. DK 2. YES * 11.1 What complications? INTERVIEWER NOTE: FOR STILLBIRTHS, SKIP TO QUESTION # 14 �QUESTIONS 12 AND 13 FOR LIVE BIRTHS ONLY: 12a. How old is this child now? OR 8. DECEASED YEARS MONTHS v 12.1 How old was your child when s/he died? YEARS MONTHS 13. Did this child ever develop any abnormalities, handicaps or learning disabilities which were diagnosed? 1. NO 2. 9. 13.1 DK I SKIP TO QUESTION # 14 YES I you told that your child had a learning disorder or Were disability of any type? 1. NO 2. YES 9. DK 13.1.1 How old wsis the child wh appeared? * SKIP TO Q # 13.2 OR MONTHS YEARS �13.1.2 What specific type of disability were you told your child had? [CIRCLE ALL THAT APPLY] a. HYPERACTIVITY b. EXCITABILITY c. ATTENTION DEFICIT DISORDER d. DYSLEXIA e. OTHER (SPECIFY): 13.1.3 In what specific area of learning is the disability? 13.1.4 Who diagnosed the problem? [CIRCLE ALL THAT APPLY] 01. SPECIAL EDUCATION TEACHER 02. PEDIATRICIAN 03. PH.D. CLINICAL PSYCHOLOGIST 04. SCHOOL PSYCHOLOGIST (M.A.) 05. NEUROLOGIST 06. CHILD PSYCHIATRIST 07. OTHER (SPECIFY:; �13.1.5 Could I please have the name, address, city, state and zip code of the professional who diagnosed your child's learning abnormality, and the year in which the diagnosis was made? NAME OF DOCTOR ADDRESS CITY ZIP STATE 1 9 YEAR DIAGNOSED 13.1.6 Were you told that your child's disability was neurologically based? 1. NO 2. YES 9. DK 13.1.7 Were you told that your child's disability was emotionally based? 1. NO 2. YES 9. DK 13.1.8 What were you told was the cause of the learning disability? �13.2 Were you told that your child had any abnormalities or handicaps other than learning disabilities? 1. NO 2. YES 9. DK 13.2.1 How old was the child when this first appeared? I 4- 13.2.2 What abnormalities or handicaps did s/he develop? 13.2.3 What were you told was the cause of the abnormality or handicap? 13.2.4 Who diagnosed the problem? [CIRCLE ALL THAT APPLY] 01. PEDIATRICIAN 02. NEUROLOGIST 03. CHILD PSYCHIATRIST 04. OTHER (SPECIFY:) 13.2.5 Could I please have the name, address, city, state and zip code of the professional who diagnosed your child's abnormality or handicap, and the year in which the diagnosis was made? NAME OF DOCTOR ADDRESS CITY STATE 19 ZIP YEAR DIAGNOSED �ASK EVERYONE 14. Were you or your partner using any form of birth control when you became pregnant the time? 1. NO 9. DK 2. YES I 14.1 What type of birth control were you or your partner using at the time? (CIRCLE ALL THAT APPLY) 01. BIRTH CONTROL PILLS 02. IUD 03. DIAPHRAGM 04. SPERMICIDAL JELLY 05. SPERMICIDAL FOAM 06. CONDOMS 07. CERVICAL CAP 08. CERVICAL SPONGE 09. DOUCHING AS A FORM OF BIRTH CONTROL 10. NATURAL FAMILY PLANNING (BASAL TEMPERATURE AND/OR CERVICAL MUCUS TEST) 11. RHYTHM 12. TUBAL LIGATION 13. VASECTOMY 14. OTHER (SPECIFY): GO TO FATHER OF PREGNANCY SECTION �FATHER OF PREGNANCY SECTION I'd like to ask you a few questions about the man who fathered the pregnancy. 1. What is the father's date of birth? First the month, then the day and year. MONTH YEAR DAY INTERVIEWER CHECK: IF SAME MAN AS PREVIOUS PREGNANCY, CHECK BOX AND SKIP TO NEXT PREGNANCY. AT END OF PREGNANCY SECTION, SKIP TO MENSTRUAL HISTORY. 2. Did he ever serve in the military? 1. NO 9. DK I 2. YES ^ 2.1 Did he ever serve in Vietnam? 1. NO 2. YES * \/ 9. DK SKIP TO QUESTION # 3 Now, I'd like to get his complete military service history while in Vietnam, for each tour of duty, beginning with his first tour in Vietnam. Please tell me where he served and for how long. Please include both temporary and permanent tours of duty. (REPEAT UNTIL COMPLETE MILITARY HISTORY FOR ALL BRANCHES SERVED IN) �2.1 (a) What branch did he serve in? 2.1 (b) Where was he stationed? (COUNTRY AND AREA) 2.1 (c) For how long? 2.1 (d) What was his rank during that time? 2.1 (e) What was his assignment? 2.1 (f) FOR DOCTORS, NURSES AND MEDICS, ASK: What was his military occupational specialty? What hospital was he assigned to? What type of ward did he work on? (a) BRANCH (b) (d) (c) TIME WHERE RANK TO MONTH MONTH YEAR MONTH MONTH YEAR YEAR YEAR TO MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR TO TO MONTH YEAR TO MONTH YEAR MONTH YEAR TO �(f) FOR DOCTORS/ NURSES AND MEDICS: (e) ASSIGNMENT | SPECIALTY HOSPITAL NAME TYPE OF WARD �3. Did he ever work in the manufacture or packaging of chemicals? 1. NO 2. YES DK SKIP TO QUESTION # 4 v (a) What were the dates of his employment in that type of occupation? (b) Was that full-time (35 hours or more per week) or part-time « 35 hours per week)? (c) What type of work did he do? What, specifically, were his job duties? (d) What was the name of the company he worked for? (e) What was the address of the company he worked for? I need the street, the city, state, and zip code, if you know it. (a) DATE S JOB (b) FT PT 1 1 1 MONTH MONTH YEAR MONTH YEAR MONTH YEAR YEAR MONTH YEAR 2 YEAR MONTH YEAR 2 YEAR TO MONTH 2 YEAR MONTH 2 1 MONTH YEAR 2 1 TO MONTH TO TO TO (c) TYPE OF WORK �(d) NAME OF COMPANY (e) STREET ADDRESS (CITY, STATE, ZIP) �4. Did he ever work in the field of agriculture? 1. NO 9. 2. YES DK SKIP TO QUESTION # 5 (a) What were the dates of his employment in that type of occupation? (b) Was that full-time (35 hours or more per week) or part-time « 35 hours per week)? (c) What type of work did he do? What, specifically, were his job duties? (d) What was the name of the company he worked for? (e) What was the address of the company he worked for? I need the street, the city, state, and zip code, if you know it. (a) JOB (b) FT FT DATES TO MONTH YEAR MONTH YEAR 1 1 1 MONTH YEAR MONTH YEAR 2 1 TO YEAR 2 2 YEAR TO MONTH 2 YEAR MONTH 2 1 MONTH MONTH YEAR MONTH YEAR MONTH YEAR TO TO (c) TYPE OF WORK �(d) NAME OF COMPANY (e) STREET ADDRESS (CITY, STATE, ZIP) �5. Did he ever work in forestry? 1. NO 9. 2. YES DK v \U SKIP TO INTERVIEWER CHECK AT TOP OF QUESTION # 6 (a) What were the dates of his employment in that type of occupation? (b) Was that full-time (35 hours or more per week) or part-time « 35 hours per week)? (c) What type of work did he do? What, specifically, were his job duties? (d) What was the name of the company he worked for? (e) What was the address of the company he worked for? I need the street, the city, state, and zip code, if you know it. (a) DATES JOB (b) FT PT TO MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR- MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR 1 TO 2 1 TO 2 1 TO 2 1 TO 2 (c) TYPE OF WORK �(d) NAME OF COMPANY (e) STREET ADDRESS (CITY, STATE, ZIP) �INTERVIEWER NOTE! ASK ONLY IF CURRENTLY MARRIED TO THIS MAN 6. What is his most recent occupation? What specifically does he do? 7. What was his usual occupation for most of the past 20 years? specifically did he do for most of that time? What �MENSTRUAL HISTORY I'd now like to get a complete menstrual history from you. l.a. How old were you when your period (or menstrual cycles) started? year was that? YEARS (b) What 19 2.a. When you first began menstruating, did you experience any of the following? [READ a - k] 2.b. Over the course of your menstrual history have you experienced any of the following? 2.c. FOR EACH YES TO 2.b, ASK: When was this most severe? NO (2a) YES DK NO (2b) YES DK a. Severe cramps . 1 2 9 1 2 9 b A heavy flow . 1 2 9 1 2 9 o. Nausea or vomiting. . . . 1 . 2 9 1 2 9 d. A very short period (3 days or less) . 1 2 9 1 2 9 A very lengthy period . 1 (7 or more days) 2 9 1 2 9 e. f. Periods of Amenorrhea (loss of periods not caused by pregnancy)... 1 g. A regular but very short cycle « 28 days) 1 9 h. A regular but very long cycle (>35 days). 1 9 i. j. k. An irregular menstrual cycle anywhere between 26 - 40+ days apart with no pattern 1 2 2 Clotting during your period 2 2 1 Premenstrual symptoms (such as breast tenderness or irritability).. 1 <2c) YEARS �3. Have you had a period in the past 12 months? 1. NO 2. YES V 3.1 About how long ago was your last period? 01. HAVING IT NOW \ 02.< 1 MONTH AGO OR SLIGHTLY LONGER THAN 30 DAYS BUT STILL REGULARLY MENSTRUATING. 03.> 1; < 3 MONTHS AGO 0 . 3; <. 6 MONTHS AGO 4> 05.> 6; <.9 MONTHS AGO 06.> 9; _< 12 MONTHS AGO SKIP TO QUESTION # 6 4. V Have your periods stopped? 1. NO 2. YES 4.1 What caused your periods to stop? 01. PREGNANCY/LACTATION 02. SURGERY 03. NATURAL (NON-SURGICAL) MENOPAUSE 04. RADIATION OR CHEMOTHERAPY 05. OTHER CAUSE (SPECIFY): 99. DK �5. About how old were you when you had your last period? YEARS 6. What was the date your last period started? MONTH DAY YEAR 7. When was the last time you had a Pap Test (Pap Smear)? 1. NEVER 9. MONTH 9. DK YEAR DK 8.1 SKIP TO NEXT SECTION How often do you usually have a Pap Test? 01. AT LEAST ONCE EVERY 6 MONTHS; 02. AT LEAST ONCE A YEAR; 03. AT LEAST ONCE EVERY OTHER YEAR; 04. AT LEAST ONCE EVERY FIVE YEARS; 05. AT LEAST ONCE EVERY TEN YEARS; 06. AT LEAST ONCE EVERY 20 YEARS; 07. OTHER (SPECIFY): �MEDICAL HISTORY I'd now like to get a complete medical history from you. 1. (a) Has a doctor or other health professional ever told you that you had any of the following? [READ a - f f . ] FOR EACH YES, ASK: (b) When was this first diagnosed? (YEAR) (c) Do you still have: ? (d) Have vou been treated for in the tiast 6 months? (a) NO (b) DK YES (c) HAS (d) TREATMENT (YEAR) NO YES DK NO YES DK a. High blood pressure (hypertension) 1 9 2 1 2 9 1 2 9 b. Heart disease (inc., heart attack, heart failure, rapid heart, angina) 1 9 2 1 2 9 1 2 9 c. Diabetes (high blood sugar) 1 9 2 1 2 9 1 2 9 1 2 9 1 2 9 d. Stroke or hemorrhage o f t h e brain e. Convulsions o r seizures 1 9 2 1 9 2 1 2 9 1 2 9 f. A n y disease o f t h e pancreas 1 9 2 1 2 9 1 2 9 g- Arthritis o r rheumatism 1 9 2 1 2 9 1 2 9 h. Non-Hodgkins lymphoma 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 j . Fibrocystic breast disease 1 9 2 1 2 9 1 2 9 k. A pelvic infection or pelvic inflammatory disease (PID) 1 9 2 1 2 9 1 2 9 1 2 9 1 2 9 i. Cancer (IF YES, SPECIFY) 1. Abnormal P a p Smear 1 9 2 �(a) NO DK YES (YEAR) (d) (c) HAS (b) NO YES TREATMENT DK NO YES DK m. Gonorrhea 1 9 2 1 2 9 1 2 9 n. Syphilis 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 t. Urinary tract infections 1 9 2 1 2 9 1 2 9 u. Gallstones or any gall bladder problems 1 9 2 1 2 9 1 2 9 Any chronic stomach problems (ulcer, gastrointestinal bleeding, colitis) 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 z. Skin rashes 1 9 2 1 2 9 1 2 9 aa. Asthma 1 9 2 1 2 9 1 2 9 bb. Acne or chloracne 1 9 2 1 2 9 1 2 9 cc. Alcoholism 1 9 2 1 2 9 1 2 9 0. Genital herpes P- Any other sexually transmitted disease (IF YES, SPECIFY:) q- Trichomoniasis r. Vaginal warts s . Recurrent vaginal infections V. w. Allergies X. y. Any liver problems (SPECIFY) Thyroid problems (SPECIFY) �(a) (d) (c) (b) TREATMENT HAS NO DK YES (YEAR) NO YES DK NO YES DK dd. Drug Addiction 1 9 2 1 2 9 1 2 9 ee. Hepatitis 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 1 9 2 1 2 9 1 2 9 ff. Any others (SPECIFY) �We also need to know if you have ever used medications. of common medications. I am going to read a list 2. For each one, please tell me if you have ever taken it. If you have taken it, I'd like to know when you took it and for how long. (From when to when?) [READ a - z] NEVER WHEN YES, TAKEN MONTH (a) Medicine for your heart or heartbeat YEAR MONTH 2 TO 1 2 TO (c) Medicine for your blood pressure... 1 2 TO (b) Medicine for cholesterol or fats in your blood (d) Diuretic or water pills 1 TO (e) Aspirin, Tylenol or a similar non-prescription pain reliever 1 TO (f) Medication prescribed for migraine headaches 1 TO (g) Any other pain reliever needing a prescription 1 TO (h) Sleeping pills 1 TO (i) Diet pills 1 TO ( ) Pills to relax you which required a j a prescription (valium, librium)... 1 (SPECIFY:) TO (k) Medication for depression (SPECIFY:) TO 1 (1) Hormone pills for menopause or aging symptoms (premarin, DES, estrace, estrogen, etc. ) 1 (SPECIFY:) (m) Hormone treatments for any other problems (SPECIFY PROBLEM AND TREATMENT:) 1 TO TO YEAR �NEVER YES, TAKEN WHEN MONTH (n) Any antimalarial medication 1 (o) Medicine for menstrual problems.... 1 (p) Insulin 1 (q) Calcium/Turns 1 (r) Vitamins, iron supplements or other minerals 1 (s) Thyroid pills 1 (t) Medicine for an upset stomach 1 (u) Herbs or teas for medicinal purposes 1 (v) Medicine for allergies (including injections) 1 (w) Prescription medication for arthritis or rheumatism 1 (x) Prescription medication for other muscle/joint problems 1 (y) Laxatives 1 (z) Antibiotics 1 (aa.) Any others? (SPECIFY): 1 YEAR MONTH YEAR �3. Have you ever had any surgery as an in-patient or on an outpatient basis since 1960? 1. NO 2. YES 9. DK FOR EACH SURGERY, ASK: 3.1 GO TO CHECKLIST AT END OF THIS SECTION QUESTION # 4 SURGERY # [CODE RED] (a) When did you have the surgery? (b) What was the diagnosis (or for what reason were you operated on)? (c) Please give me the name and address of both the hospital where you were operated on and the surgeon who performed the operation. [RECORD EACH SURGERY, THEN GO TO CHECKLIST] (a) DATE () 1 MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR (2) (3) (5) (b) DIAGNOSIS �(c) HOSPITAL NAME ADDRESS CITY, STATE, ZIP SURGEON'S NAME ADDRESS CITY, STATE, ZIP �(SURGERIES CONTINUED) FOR EACH SURGERY, ASK: 3.1 (a) When did you have the surgery? (b) What was the diagnosis (or for what reason were you operated on)? (c) Please give me the name and address of both the hospital where you were operated on and the surgeon who performed the operation. [RECORD EACH SURGERY, THEN GO TO CHECKLIST] (a) SURGERY # DATE (6) MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR () 7 () 8 (9) (10) (b) DIAGNOSIS �(c) HOSPITAL NAME ADDRESS CITY, STATE, ZIP SURGEON'S NAME ADDRESS CITY, STATE, ZIP �(SURGERIES CONTINUED) FOR EACH SURGERY, ASK: 3.1 (a) When did you have the surgery? (b) What was the diagnosis (or for what reason were you operated on)? (c) Please give me the name and address of both the hospital where you were operated on and the surgeon who performed the operation. [RECORD EACH SURGERY, THEN GO TO CHECKLIST] (a) SURGERY # DATE (11) MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR (12) (13) (4 1) (15) (b) DIAGNOSIS �(c) HOSPITAL NAME ADDRESS CITY, STATE, ZIP SURGEON'S NAME ADDRESS CITY, STATE, ZIP �SURGERY CHECKLIST INTERVIEWER: AFTER RESPONDENT LISTS ALL HER SURGERIES PROBE ONLY FOR THOSE NOT MENTIONED ABOVE IN SURGERY SECTION. 4. Have you ever had any of the following operations or procedures? [READ a - i] m YES NOT SURE (a) Removal of the uterus 1 2 9 (b) Removal of left ovary only 1 2 9 (c) Removal of right ovary only 1 2 9 (d) Removal of both ovaries 1 2 9 (e) Tubal ligation (having your tubes tied) 1 2 9 (f) Dilation and curettage (a D&C, scraping of the uterus) 1 2 9 (g) Breast surgery for cysts or benign tumors 1 2 9 ( h ) Breast surgery f o r cancer (i) Any pelvic surgery 1 1 (IF YES, SPECIFY REASON: FOR EACH YES THAT HAS NOT BEEN RECORDED IN SURGERY SECTION, GO BACK AND COMPLETE QUESTIONS 3.1 a - c 2 2 9 9 �5. Have you ever been treated for any type of cancer or leukemia with either radiation or chemotherapy? 1. NO 9. DK 2. YES [CODE RED] V [FOR EACH SET OF TREATMENTS, ASK:] 5.1 SKIP TO QUESTION #6 (a) When were you treated? (b) What was the diagnosis (or type of cancer)? (c) Please give me the name and address of the hospital and the doctor who treated you. (b) DIAGNOSIS (a) DATE CANCER # TO (1) MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR TO (2) TO (3) TO () 4 TO (5) �(c) HOSPITAL NAME ADDRESS CITY, STATE, ZIP DOCTOR'S NAME ADDRESS CITY, STATE, ZIP �6. Have you ever been hospitalized on an in-patient or an out-patient basis for any reason (besides what we've just discussed)? Please include any hospitalization for emotional or psychiatric problems as well. 1. NO 9. 2. YES DK [CODE RED] [FOR EACH HOSPITALIZATION, ASK:] 6.1 SKIP TO QUESTION # 7 (a) When were you hospitalized? (b) What was the diagnosis (or for what reason were you hospitalized)? (c) Please give me the name and address of the hospital and the doctor who treated you. (a) DATE HOSPITAL # (b) DIAGNOSIS TO (1) MONTH MONTH MONTH MONTH YEAR YEAR MONTH YEAR YEAR MONTH YEAR YEAR MONTH YEAR MONTH MONTH YEAR YEAR MONTH YEAR TO (2) TO (3) TO TO (5) �(c) HOSPITAL NAME ADDRESS CITY, STATE, ZIP DOCTOR'S NAME ADDRESS CITY, STATE, ZIP �(HOSPITALIZATION CONTINUED) [FOR EACH HOSPITALIZATION, ASK:] 6.1 (a) When were you hospitalized? (b) What was the diagnosis (or for what reason were you hospitalized)? (c) (b) DIAGNOSIS (a) DATE HOSPITAL # TO (6) MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR TO (7) MONTH YEAR MONTH YEAR (8) (9) Please give me the name and address of the hospital and the doctor who treated you. TO L MONTH TO YEAR MONTH . YEAR TO (10) MONTH YEAR MONTH YEAR �(c) HOSPITAL NAME ADDRESS CITY, STATE, ZIP DOCTOR'S NAME ADDRESS CITY, STATE, ZIP �7. Have you ever seen a counselor or mental health professional for any reason? 1. NO I 2. 9. 7.1 SKIP TO QUESTION # 8 YES i [FOR EACH, ASK:] (a) When was that? (b) What was the reason you went? [PROBE: Any other times?] (a) DATE (b) REASON TO ( D MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR (2) MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR TO TO (3) TO TO (5) �8. Have you ever been part of a support group or therapy group led by a licensed therapist or a certified counselor, such as a licensed social worker, a psychologist or a psychiatrist? 1. NO 9. DK 2. YES * [FOR EACH GROUP, ASK:] 8.1 (a) When was that? (b) What was the reason you went? SKIP TO NEXT SECTION [PROBE: Any other groups?] (b) REASON (a) DATE TO (1) MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR TO (2) TO (3) TO () 4 TO () 5 �SOCIAL SUPPORT NETWORK The next questions concern contact with other people. 1. Are there any groups or organizations that you attend regularly, such as church groups, political groups, unions, clubs, veterans groups, exercise or sports groups, neighborhood or school associations, etc.? 1. N(o 9. 2. YES DK SKIP TO Q # 2 1.1 What is the first group that comes to mind? 1.2 How frequently do you attend it? (RECORD RESPONSES TO BOTH QUESTIONS ON THE FIRST LINE BELOW, THEN PROBE: Is there another group? How frequently do you attend it? RECORD RESPONSE ON THE SECOND LINE BELOW. REPEAT PROBE UNTIL ALL LINES ARE FILLED OR THE RESPONDENT CANNOT THINK OF ANYMORE GROUPS.) NAME OR TYPE OF GROUP AT LEAST AT LEAST AT LEAST ONCE A ONCE A ONCE EVERY 3 MONTHS WEEK AT LEAST ONCE EVERY LESS THAN ONCE EVERY 6 MONTHS 6 MONTHS 1 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2. 2 2 3 4 5 Now I have some questions about people who may be close to you. Do you have anyone who you can go to with problems or from whom you can get advice, help or emotional support? You may include your spouse, partner or other members of your immediate family, other relatives, friends, neighbors, or people with whom you work. 1. 9. NO DK SKIP TO NEXT SECTION 2. YES �2.1 Who is the first person that comes to mind? (PROBE 2 TIMES: Is there anyone else?) PERSON 1 PERSON 2 PERSON 3 IF THREE PEOPLE ARE LISTED, ASK: How many others? SIZE OF NETWORK (GRAND TOTAL): # ABOVE + Now I would like to ask you a few questions about each of the people you just mentioned. 2.2 Is (USE NAME/RELATIONSHIP GIVEN BY RESPONDENT) 1. Male 2. Female 2.3 Approximately how old is (RECORD ANSWER IN YEARS) 2.4 Is 1. 2. 3. 4. 5. Never married Married and living with spouse Separated Divorced Widowed 9. DON'T KNOW 2.5 Is currently working? [IF YES ASK, part time or full time?; 1. NO 2. 3. 9. YES,PART TIME < 35 HOURS PER WEEK YES, FULL TIME >. 35 HOURS PER WEEK NOT SURE/DON'T KNOW 2.6 Approximately how long have you known (RECORD ANSWER IN YEARS - ROUND TO NEAREST YEAR) �2.7 's ethnic background? What is 01. IRISH 09. NO PARTICULAR ETHNIC BACKGROUND 10. OTHER (SPECIFY:) (1) 02. ENGLISH 03. FRENCH OR FRENCH CANADIAN 04. GREEK 05. ITALIAN 06. BLACK, AFROAMERICAN 07. JEWISH 08. HISPANIC 2.8 What is [CIRCLE ALL MENTIONED] () 2 (3) 77. REFUSED 99. NOT SURE/DK 's relationship to you? 01 02 03 04 05 06 SPOUSE OTHER IMMEDIATE FAMILY MEMBER LIVING IN HOUSEHOLD OTHER RELATIVE NOT LIVING IN HOUSEHOLD FRIEND NEIGHBOR CO-WORKER 07. CLERGYMAN/DOCTOR/OTHER/PROFESSIONAL, ETC. 08. OTHER 2.9 live: Does 1. In your neighborhood (or within 1 mile) 2. In your town/city (within 10 miles of you) 3. Elsewhere in your state, or 4. Out-of-state 2.10 How do you and 01. 02. 03. 04. 05. 06. usually contact each other? In person, By telephone, By mail, In person and over the telephone By telephone and mail, or All three (PERSON, TELEPHONE, MAIL) 2.11 How often do you and 01. 02. 03. 04. 05. 06. contact each other in this way? AT LEAST ONCE A DAY AT LEAST ONCE A WEEK AT LEAST ONCE A MONTH AT LEAST ONCE EVERY THREE MONTHS AT LEAST ONCE EVERY SIX MONTHS LESS THAN ONCE EVERY SIX MONTHS 2.12 Who usually makes the contact? 1. Do you make the contact most of the time, does 2. make the contact most of the time or does 3. Each of you make the contact equally SKIP TO Q #3 �3. Among the other? 1. NO 9. (NUMBER) people you have named, do any of them know each 2. YES DK ASK FOR EACH PAIR 1 Does [PERSON #1] know [PERSON #2]? Does [PERSON #2] know [PERSON #3]? RECORD NAMES BELOW [PERSON #3]? NO YES NOT SURE/DK a. 1 WITH 2 1 2 9 b. 1 WITH 3 1 2 9 c. 3.2 NUMBERS OF PAIRS 2 WITH 3 1 2 9 Are these people likely to contact each other independently of you, about something which does not have to do with you? NO 2. YES DK 3.2.1 [ASK ONLY FOR PAIRS WHO KNOW EACH OTHER] Would [INSERT PAIRS] contact each other independently of you about something which does not have to do with you? RECORD NAMES BELOW NUMBERS OF PAIRS fip_ YES a . 1 WITH 2 1 9 9 2 9 2 9 b. 1 WITH 3 1 c. 2 WITH 3 1 NOT SURE/DK �LIFESTYLE SECTION This next section asks several questions about lifestyle habits, LIFESTYLE: ALCOHOL 1. On the average, do you drink alcoholic beverages: 1. Daily; 2. At least once a week; 3. SKIP TO CM 2 At least once a month; 4. Less than once a month; or 5. 1.1 Not at all 9. DK 4, 4Have you ever drunk any alcoholic beverages? 1. 1.2 NO 2. YES Are there any particular reasons why you don't drink (now)? [RECORD VERBATIM] [CIRCLE ALL THAT APPLY] a. b. c. d. e. f. g. h. i. j. k. I'VE NEVER DRUNK IN MY LIFE. RELIGIOUS/MORAL REASONS/DON'T BELIEVE IN IT/BROUGHT UP NOT TO DRINK. FOR DIET/MEDICAL/HEALTH REASONS. (FAMILY) PROBLEMS CAUSED BY OTHERS WHO DRINK. PERSONAL/FAMILY/JOB/SCHOOL PROBLEMS CAUSED BY OWN DRINKING. I'M AN ALCOHOLIC; I HAVE A DRINKING PROBLEM/I NEEDED TO STOP DRINKING/I WAS SPENDING TOO MUCH TIME DRINKING/I JOINED AA. SOCIAL/PEER FAMILY PRESSURE TO STOP DRINKING/OTHER SOCIAL CIRCUMSTANCES/OTHERS DON'T DRINK. PERSONAL PREFERENCE/I DON'T LIKE THE TASTE/DIDN'T DRINK MUCH & DECIDED TO QUIT. TOO EXPENSIVE TO DRINK/TOO MUCH MONEY, PREGNANT. OTHER: SKIP TO INTERVIEWER CHECK AT TOP OF QUESTION # 5 �2. How often do you usually drink beer? 0. Never I 9. DK 1. Less than once a month, 2. Less than once a week, i 3. I or 2 days a week, 4. 3 or 4 days a week, or SKIP TO QUESTION # 3 5. 5 or more days a week. 2.1 Thinking of all the times you have had beer recently, when you drink beer, how many do you usually drink each time? 2.2 When you drink beer, what is the most you drink? BEERS 2.3 About how often do you drink this much beer? 1. Less than once a month, 2. Less than once a week, 3. 1 or 2 days a week, 4. 3 or 4 days a week, or 5. 5 or more days a week. �3. How often do you usually drink wine, or a punch containing wine? 0. Never I 9. DK 1. Less than once a month, 2. Less than once a week, 3. 1 or 2 days a week, y 4. 3 or 4 days a week, or SKIP TO QUESTION # 4 5. 5 or more days a week. 3.1 Thinking of all the times you have had wine recently, when you drink wine, how many glasses do you usually drink each time? GLASSES 3.2 When you drink wine, what is the most you drink? GLASSES 3.3 About how often do you drink this much wine? 1. Less than once a month, 2. Less than once a week, 3. 1 or 2 days a week, 4. 3 or 4 days a week, or 5. 5 or more days a week. �4. How often do you usually have drinks containing liquor (such as martinis, manhattans, highballs, or straight drinks)? 0. Never 1. Less than once a month, 9. DK 2. Less than once a week, J 3. 1 or 2 days a week, 4. 3 or 4 days a week, or SKIP TO QUESTION # 5 5. 5 or more days a week. 4.1 Thinking of all the times you have had liquor recently, when you have drinks containing liquor, how much do you usually drink each time? 4.2 When you have drinks containing liquor, what is the DRINKS 4.3 About how often do you drink this much liquor? 1. Less than once a month, 2. Less than once a week, 3. 1 or 2 days a week, 4. 3 or 4 days a week, 5. 5 or more days a week. �[INTERVIEWER CHECK: IF RESPONDENT NEVER DRANK. SKIP TO LIFESTYLE: TOBACCO] 5. I'm now going to ask you some questions about personal experiences you may have had when drinking. DK NO YES a. Did drinking ever cause you to have an accident or injury of any kind? 1 2 9 b. Have you ever been arrested for drunk driving? 1 2 9 c. Have you ever been arrested because of anything connected with your drinking alcohol (aside from drunk driving arrests? 1 2 9 Have you ever lost or quit a job because of your drinking alcohol? 1 2 9 Have your ever lost a close friendship because of your drinking alcohol? 1 2 9 Has your drinking alcohol ever been a cause of trouble in your household? 1 2 9 Have you ever been separated or divorced because of your drinking alcohol? 1 2 9 1 2 9 d. e. f. g. h. Have you ever gotten into arguments or fights while drinking alcohol? 6. Have your drinking patterns changed at all from the time you were 18 up until now? 1. NO 2. YES I 9. DK 6.1 Did you drink more or less when you were 18 than you do now? 1. MORE 2. LESS 9. DK 6.2 What were your drinking patterns when you were 18 and how have they changed since that time? 6.3 When (during what years) did the changes occur and why did they occur? �] LIFESTYLE: TOBACCO AND OTHER . Do you: A. smoke cigarettes? 1. NO 2. YES B. smoke cigarillos? 1. NO 2. YES C. smoke a pipe? 1. NO 2. YES D. smoke cigars? 1. NO 2. YES E. chew tobacco? 1. NO 2. YES F NO TO ALL F A THRU E IF YES TO ONLY ONE OF A THRU E IF YES TO MORE THAN ONE OF A THRU E I 1.1 SKIP TO QUESTION # 2 Which do you do most often? [CIRCLE ONE] 1. Smoke cigarettes? 2. Smoke cigarillos? 3. Smoke a pipe? 4. Smoke cigars, or 5. Chew tobacco? 1.2 (REFER TO MOST FREQUENT ABOVE) When you smoke/chew , about how many do you smoke/chew in a day (cigarettes, pipefuls, plugs) UNITS 1.3 In what year did you first smoke/chew? DK - 99 1.4 Have you tried to quit in the past 12 months? 1. NO 2. YES 9. DK �1 . 5 Have your smoking/chewing patterns changed at all from the time you began up until now? 1. NO I 9. DK 2. YES 1.5.1 Did you smoke/chew more or less when you began than you do now? 1. MORE 2. LESS 9. DK 1.5.2 What were your smoking/chewing patterns when you began and how have they changed since that time? 1.5.3 When (during what years) did the changes occur and why did they occur? -SKIP TO QUESTION # 3- �2. Have you ever smoked cigarettes, cigarillos, a pipe, cigars, or chewed tobacco? 1. NO 9. DK SKIP TO QUESTION # 4 2. YES I 2.1 Which did you do most often? 1. Smoke cigarettes? 2. 3. Smoke cigarillos? Smoke a pipe? 4. 5. [CIRCLE ONE] Smoke cigars, or Chew tobacco? [REFER TO MOST FREQUENT ABOVE] ., about how many did you 2.2 When you smoked/chewed smoke/chew in a day? (cigarettes, pipefuls, plugs)? UNITS 2.3 In what year did you first smoke/chew? 99. DK 2.4a. How long ago did you quit smoking/chewing tobacco? (b) What year was that? MONTHS or (b) 19 YEARS AGO �3. Over your entire lifetime, for how long have you smoked/chewed altogether? MONTHS OR YEARS 99 . DK 4. Does anyone else live with you who smokes cigarettes at home everyday? 1. NO 2. YES 9. DK 5. Do you work, on a daily basis with coworker(s) who smoke cigarettes around you everyday? 1. NO 2. YES 9. DK 6. Have you ever used any of the following substances? [READ a - h] (IF YES to a - h, READ QUESTIONS 6.1 - 6.3 FOR THAT ITEM) 6.1 In what year did you first try it or start using it? 6.2 Do you ever use it now? 6 .3 Did you ever have a problem with vour use of IF YES, ASK: Whe n (during what years)? YEAR TRIED NO YES DK NOW USE ? PROBLEM USE YEARS NO YES DK NO YES DK ( a ) Marijuana 1 2 9 1 9 1 2 9 1 2 9 ( b ) Hashish 1 2 9 1 9 1 2 9 1 2 9 ( c ) Barbiturates (Downers) 1 2 9 1 9 1 2 9 1 2 9 ( d ) Amphetamines (Uppers) 1 2 9 1 9 1 2 9 1 2 9 ( e ) Hallucinogens 1 such as LSD or mescaline 2 9 1 9 1 2 9 1 2 9 ( f ) Cocaine 1 2 9 1 9 1 2 9 1 2 9 ( g ) Heroin 1 2 9 1 9 1 2 9 1 2 9 ( h ) Opiates 1 2 9 1 9 1 2 9 1 2 9 �7. Have you ever had a gambling problem? 1. NO 9. 2. YES I 7.1 During what years did you have that problem? DK TO 19 8. Have you ever contemplated suicide? 1. NO 2. YES I 9. DK SKIP TO NEXT SECTION 8.1 Have you ever attempted suicide? 2. YES i 8.2 How many times? 1. NO I 9. DK SKIP TO NEXT SECTION ENTER # 8.3 Could you please tell me: (a) In what year(s) you made the attempt(s)? (b) And, what was going on in your life at that time? (a) #1 # 2. #3 19 (b) �QUALITY OF LIFE SECTION 1. I am going to read ycm a list of ways you might have felt or behaved. Please tell me on hovj many different days you have felt this way during the past week: ON AT MOST ()N UP TO ON 3-4 ON 5-7 During the past week: 1 DAY 2 DAYS DAYS DAYS I was bothered by thi.ngs that usually don't be>ther me . . . . 1 2 3 4 I did not feel like €.at ing; my appetite was poor 1 2 3 4 I felt that I could rlot shake off the blues even w: .th help from my family or fri ends 1 2 3 4 I felt I was just as good as other people 1 2 3 4 I had trouble keepingr, my mind on what I was dc inE 1 2 3 4 I felt depressed 1 2 3 4 I felt that everything I did was an effort 1 2 3 4 I felt hopeful about the future 1 2 3 4 I thought my life had been a failure 1 2 3 4 I felt fearful 1 2 3 4 My sleep was restless 1 2 3 4 I was happy 1 2 3 4 I talked less than usual 1 2 3 4 I felt lonely 1 2 3 4 People were unfriendl 1 2 3 4 I enjoyed life 1 2 3 4 I had crying spells . . 1 2 3 4 I felt sad 1 2 3 4 I felt that people dislike m e . . . 1 2 3 4 I could not cet "eoine" 2 3 4 1 �2. In general, how pleased are you with the way your life has gone so far? 1. Very Pleased, 2. Pleased, 3. You wish some things were different but are generally happy, 4. Unhappy, or 5. Very Unhappy 9. DK 3. Now looking towards the future, how do you feel about the rest of your life? 1. Very Optimistic, 2. Somewhat Optimistic, 3. Unsure, 4. Somewhat Pessimistic, or 5. Very Pessimistic 8. DO NOT THINK ABOUT IT 9. DK �MILITARY HISTORY Let's go next to your military history. 1. Have you ever served either on active duty, or in the reserves in any branch of the United States armed forces? 2. YES i 1.1 Did you serve in the (READ a-d)? FOR EACH YES ASK: During which years? YES YEAR(S) ra a. National Guard or Reserves 1 2 b. Army 1 2 c. Navy 1 2 d. Air Force 1 2 e. Marines 1 2 1.2 Were you ever in ROTC? 2. YES 1. NO 9. DK 1.2.1 When was that? (PROBE FOR YEARS) 1.2.2 What college were you in when you joined ROTC and what city and state was it in? NAME OF COLLEGE CITY 2. STATE Now, could you please tell me whether you are currently on active duty, in the reserves, retired or whether you have been permanently discharged? 1. ACTIVE DUTY 3. RETIRED 2. RESERVES A. PERMANENTLY DISCHARGED 2.1. In what year did you retire (were you discharged)? [IF>1 BRANCH, ASK FOR EACH BRANCH] ^ 19 (YEAR) BRANCH 19 (YEAR) BRANCH v �3. In what year did you first enter the armed forces? 19 YEAR 4. What was the highest grade of school that you had completed when you first entered the military? 1. 1-11 2. 12 (HIGH SCHOOL DIPLOMA OR GED) 3. 13-15 (SOME COLLEGE, TECHNICAL SCHOOL, ASSOCIATE'S DEGREE) 4. 16 (BACHELOR'S DEGREE) 5. 17+ (GRADUATE/PROFESSIONAL SCHOOL) 9. DK 5. What is the highest grade of school that you have completed up until now? 1. 1-11 2. 12 (HIGH SCHOOL DIPLOMA OR GED) 3. 13-15 (SOME COLLEGE, TECHNICAL SCHOOL, ASSOCIATE'S DEGREE 4. 16 (BACHELOR'S DEGREE) 5. 17+ (GRADUATE/PROFESSIONAL 9. DK SCHOOL) 6. Why did you decide to enter the armed forces? Any others?) (PROBE: Any other reasons? �FIRST BRANCH JOINED Why did you choose that particular branch of the service? (PROBE: ANY OTHER REASONS? ANY OTHERS?) [NOTE: ASK ONLY IF NOT CURRENTLY IN BRANCH 1]: Why did you leave that particular branch of the service: (PROBE: ANY OTHER REASONS? ANY OTHERS?) INTERVIEWER CHECK: IF RESPONDENT ONLY SERVED IN ONE BRANCH, SKIP TO NEXT SECTION. IF > 1 BRANCH CONTINUE. SECOND BRANCH JOINED Why did you choose that particular branch of the service? (PROBE: ANY OTHER REASONS? ANY OTHERS?) [NOTE: ASK ONLY IF NOT CURRENTLY IN BRANCH 2]: Why did you leave that particular branch of the service: (PROBE: ANY OTHER REASONS? ANY OTHERS?) �THIRD BRANCH JOINED Why did you choose that particular branch of the service? (PROBE: ANY OTHER REASONS? ANY OTHERS?) [NOTE: ASK ONLY IF NOT CURRENTLY IN BRANCH 3]: Why did you leave that particular branch of the service: (PROBE: ANY OTHER REASONS? ANY OTHERS?) FOURTH BRANCH JOINED Why did you choose that particular branch of the service? (PROBE: ANY OTHER REASONS? ANY OTHERS?) [NOTE: ASK ONLY IF NOT CURRENTLY IN BRANCH 4]: Why did you leave that particular branch of the service: (PROBE: ANY OTHER REASONS? ANY OTHERS?) �This next question deals with your tours of duty, beginning with your entry in the armed services. Please tell me where you served and for how long. Please include basic trainif^ and both temporary and permanent tours of duty. When you first joined the (BRANCH): (REPEAT UNTIL COMPLETE MILITARY HISTORY FOR ALL BRANCHES SERVED IN.) _ * NOTE: m AT END OF THE SECTION, FOR NURSES WHO SERVED IN VIETNAM SELECT THE LONGEST VIETNAM TOUR OF DUTY. IF 1 VIETNAM TOUR OF EQUAL LENGTH, SELECT THE FIRST/SECOND TOUR FOR ALL OTHER NURSES, SELECT THE LONGEST TOUR OF DUTY BETWEEN 1965 - 1972 T EXCLUDING ANY TOURS OF DUTY WHILE A STUDENT AND GO TO NURSING SECTION. ™ 7. (a) Where were you stationed? (COUNTRY, CITY, STATE, AND AREA) And, what unit were yen __ attached to? 4p 7.(b) For how long? (From when to when?) -• -2 7.(c) What was your rank during that time? • I 7.(d) What was your assignment and your primary military occupational specialty? _ 7.(e) FOR NURSES, ASK: What hospital were you assigned to? What type of ward did you work on? 7.(*f) FOR SELECTED TOUR, ASK: May I please have the name and address of another woman who served with you on that tour of duty? (b) (c) TIME (a) WHERE BRANCH RANK • • TO (1) MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR (UNIT) TO (2) (UNIT) (*f) NAME STREET ADDRESS CITY STATE ZIP �(d) ASSIGNMENT/MOS (e) (NURSES) HOSPITAL, WARD �TOURS OF DUTY CONTINUED * NOTE: AT END OF THE SECTION, FOR NURSES WHO SERVED IN VIETNAM SELECT THE LONGEST VIETNAM TOUR OF DUTY. IF 1 VIETNAM TOUR OF EQUAL LENGTH, SELECT THE FIRST/SECOND TOUR^, FOR ALL OTHER NURSES, SELECT THE LONGEST TOUR OF DUTY BETWEEN 1965 - 1972 ^ EXCLUDING ANY TOURS OF DUTY WHILE A STUDENT AND GO TO NURSING SECTION. 7.(a) Where were you stationed? (COUNTRY, CITY, STATE, AND AREA) And, what unit were yen _J attached to? ** 7.(b) For how long? (From when to when?) _, « 7.(c) What was your rank during that time? 7.(d) What was your assignment and your primary military occupational specialty? ^>. ^ 7.(e) FOR NURSES, ASK: What hospital were you assigned to? What type of ward did you work on? 7.(*f) FOR SELECTED TOUR, ASK: May I please have the name and address of another woman who served with you on that tour of duty? (b) (a) WHERE BRANCH (c) RANK TIME TO (3) MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR (UNIT) TO (4) (UNIT) . (*f> NAME STREET ADDRESS CITY STATE ZIP �(d) ASSIGNMENT/MOS (e) (NURSES) HOSPITAL, WARD �TOURS OF DUTY CONTINUED * NOTE: AT END OF THE TOUR OF DUTY. FOR ALL OTHER EXCLUDING ANY SECTION, FOR NURSES WHO SERVED IN VIETNAM SELECT THE LONGEST VIETNAM IF 1 VIETNAM TOUR OF EQUAL LENGTH, SELECT THE FIRST/SECOND TOUR. , NURSES, SELECT THE LONGEST TOUR OF DUTY BETWEEN 1965 - 1972 jjf TOURS OF DUTY WHILE A STUDENT AND GO TO NURSING SECTION. 7.(a) Where were you stationed? (COUNTRY, CITY, STATE, AND AREA) And, what unit were you~ attached to? ** 7.(b) For how long? (From when to when?) • I 7.(c) What was your rank during that time? 7.(d) What was your assignment and your primary military occupational specialty? 7.(e) FOR NURSES, ASK: What hospital were you assigned to? What type of ward did you work on? m 7.(*f) FOR SELECTED TOUR, ASK: May I please have the name and address of another woman who served with you on that tour of duty? (a) WHERE BRANCH (b) TIME (c) RANK TO (5) MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR (UNIT) TO (6) (UNIT) (*f) NAME STREET ADDRESS CITY STATE ZIP �(d) ASSIGNMENT/MOS (e) (NURSES) HOSPITAL, WARD �TOURS OF DUTY CONTINUED * NOTE: AT END OF THE SECTION, FOR NURSES WHO SERVED IN VIETNAM SELECT THE LONGEST VIETNAM TOUR OF DUTY. IF 1 VIETNAM TOUR OF EQUAL LENGTH, SELECT THE FIRST/SECOND TOUR . FOR ALL OTHER NURSES, SELECT THE LONGEST TOUR OF DUTY BETWEEN 1965 - 1972 ^ EXCLUDING ANY TOURS OF DUTY WHILE A STUDENT AND GO TO NURSING SECTION. 7.(a) Where were you stationed? (COUNTRY, CITY, STATE, AND AREA) attached to? 7.(b) For how long? And, what unit were yo\ * (From when to when?) m 7.(c) What was your rank during that time? 7.(d) What was your assignment and your primary military occupational specialty? - 7.(e) FOR NURSES, ASK: What hospital were you assigned to? What type of ward did you work on? m 7.(*f) FOR SELECTED TOUR, ASK: May I please have the name and address of another woman who served with you on that tour of duty? (a) BRANCH (c) RANK (b) TIME WHERE TO (7) MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR (UNIT) TO (8) (UNIT) (*f) NAME STREET ADDRESS CITY STATE ZIP �(d) ASSIGNMENT/MOS (e) (NURSES) HOSPITAL, WARD �TOURS OF DUTY CONTINUED * NOTE: AT END OF THE TOUR OF DUTY. FOR ALL OTHER EXCLUDING ANY SECTION, FOR NURSES WHO SERVED IN VIETNAM SELECT THE LONGEST VIETNJfi IF 1 VIETNAM TOUR OF EQUAL LENGTH, SELECT THE FIRST/SECOND TOUR. NURSES, SELECT THE LONGEST TOUR OF DUTY BETWEEN 1965 - 1972 = TOURS OF DUTY WHILE A STUDENT AND GO TO NURSING SECTION. M 7.(a) Where were you stationed? (COUNTRY, CITY, STATE, AND AREA) attached to? 7.(b) For how long? And, what unit were yo w' (From when to when?) __ 7.(c) What was your rank during that time? ** 7.(d) What was your assignment and your primary military occupational specialty? * 7.(e) FOR NURSES, ASK: What hospital were you assigned to? What type of ward did you work on? 7.(*f) FOR SELECTED TOUR, ASK: May I please have the name and address of another womanm who served with you on that tour of duty? (b) (c) TIME (a) WHERE BRANCH • TO (9) MONTH MONTH YEAR MONTH YEAR MONTH YEAR YEAR (UNIT) TO (0. 1) (UNIT) <*f) NAME STREET ADDRESS CITY m RANK STATE ZIP �(d) ASSIGNMENT/MOS (e) (NURSES) HOSPITAL, WARD �TOURS OF DUTY CONTINUED * NOTE: AT END OF THE SECTION, FOR NURSES WHO SERVED IN VIETNAM SELECT THE LONGEST VIETNAM TOUR OF DUTY. IF 1 VIETNAM TOUR OF EQUAL LENGTH, SELECT THE FIRST/SECOND TOUR__ FOR ALL OTHER NURSES, SELECT THE LONGEST TOUR OF DUTY BETWEEN 1965 - 1972 ^ EXCLUDING ANY TOURS OF DUTY WHILE A STUDENT AND GO TO NURSING SECTION. * 7. (a) Where were you stationed? (COUNTRY, CITY, STATE, AND AREA) And, what unit were ycn^ attached to? ** 7.(b) For how long? (From when to when?) __ 7.(c) What was your rank during that time? 7.(d) What was your assignment and your primary military occupational specialty? 7.(e) FOR NURSES, ASK: What hospital were you assigned to? What type of ward did you work on? m 7.(*f) FOR SELECTED TOUR, ASK: May I please have the name and address of another woman who served with you on that tour of duty? (a) BRANCH (c) RANK (b) TIME WHERE TO (11). MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR (UNIT) TO (12) (UNIT) (*f) NAME STREET ADDRESS CITY STATE ZIP �(d) ASSIGNMENT/MOS (e) (NURSES) HOSPITAL, WARD �The following questions deal with any problems or difficulties you may have experienced while in the Military or may be currently experiencing. * 8a. While in the Military, did you: l 8b. Do you currently: [IF NO LONGER IN THE MILITARY, ASK:) 8c. Between then and now did you: (8a) NO YES DK (a.) Have trouble dealing with bad memories about your experiences i n t h e Military? (b.) Have trouble sleeping due to nightmares o r b a d dreams? (c.) Have trouble getting along with others? (d.) (e.) (f.) (8b) NO YES DK 1 2 9 i 1 2 9 1 2 9 129 '_ (8c) ' NO YES DK 129 129 1 2 9 1 2 9 1 2 9 1 Have any trouble with: (8a. superiors) (8b. t h e law)? 129 129 1 Have trouble getting emotionally close t o others? 1 2 9 1 - 2 9 1 2 9 , Have trouble controlling your temper? 1 2 9 1 2 9 1 2 9 2 9 § • (g.) Have trouble tolerating frustration? 1 2 9 1 2 9 (h.) Have sexual problems? 1 2 9 1 2 9 (i.) Have trouble expressing your feelings t o those y o u care about? 129 1 2 1 2 9 129 129 (j.) Ever feel depressed a lot? 129 129 129 (k.) Ever feel nervous a lot? 129 129 129 (1.) Have trouble feeling and expressing emotions (numbness)? 1 2 9 1 2 9 1 2 9 Have trouble trusting other people? 1 2 9 1 2 9 1 2 9 Have trouble dealing with stressful experiences? 1 2 9 1 2 9 1 2 9 129 129 (m.) (n.) (o.) Have trouble concentrating? (p.) Ever feel your actions in t h e military were n o t worthwhile? 129 129 12 12 �COMBAT EXPOSURE 9. For each of the following questions, please tell me whether or not it applies to your military experience. [READ a - i] NO a. Did you serve in area designated as a war zone? 1 b. Did you fly in an aircraft over a combat zone? YES DK 2 9 1 c. Were you stationed in a combat zone? d. Did you receive incoming fire from enemy artillery, rockets, or mortars? 1 2 e. Did you receive bombing attacks? 1 2 f. Did you receive sniper or sapper fire? g. Did you receive full-scale enemy attack? 1 h. Did you receive war-related wounds? 1 i. Did you see Americans being killed or being wounded? •. 1 2 j . Were you a prisoner of war? 1 2 �NURSING SECTION These questions refer to your general nursing experience prior to entry into the military. 1. At what type of school did you receive your basic nursing education? 1. Community or Junior College 2. Hospital based school of nursing 3. College Program 4. OTHER 9. (SPECIFY): DK 2. At graduation did you feel professionally competent to be a registered nurse? 1. NO 2. YES 9. NOT SURE/DK 3. At graduation did you feel emotionally competent to be a registered nurse? 1. NO 2. YES 9. NOT SURE/DK 4. What was your highest nursing degree when you entered the military? 01. SJUDENT [ SKIP TO Q # 18 [ 02. A.D. 03. R.N. 04. B.S.N. 05. M.S.N. 06. OTHER (SPECIFY:) 99. NOT SURE/DK �5. Before you entered the military, how much nursing experience did you have? 1. < 6 months 2. > 6 months, but 5l 1 year 3. > 1 "£- 3 years 4. > 3 ^ 5 years 5. > 5 years 9. DK 6. Before you entered the military, had you been a charge nurse? 1. NO 2. YES 9. NOT SURE/DK 7. Before you entered the military, had you worked evenings (3 - 11 PM)? 1. NO 8 2. YES 9. NOT SURE/DK . :fore you entered the military, had you worked nights (11 PM / AM)? 1. NO 2. YES 9. NOT SURE/DK 9. Before you entered the military, had you worked in a: [READ a - b] [IF YES, ASK: During which years?] NO a. Tax supported hospital (City hospital)? b. Private hospital c. OTHER (SPECIFY): 1 YES 2 YEARS �I'd like to ask you some questions regarding your work experience at the facility you worked in just prior to your entry in the military. 10. What type of facility was this? Was it a: (READ a - e) CIRCLE ONE ONLY. (a) General hospital, (b) Psychiatric hospital, (c) Outpatient facility, or (d) Doctor's office (e) OTHER (SPECIFY): 11. Was there adequate nursing staff at this facility? 1. NO 12. 2. YES 9. NOT SURE/DK In general, how were you treated by the civilian physicians at this facility? Were you treated: 1. As a colleague 2. As a servant, or 3. As a sexual object 4. OTHER (SPECIFY): 9. DK 13. Were equipment and/or supplies at this facility adequate? 1. NO 2. YES 3. NOT SURE/DK �14. Before you entered the military, in what area did you work the most? 01. MEDICAL NURSING 02. SURGICAL NURSING 03. OBSTETRICAL NURSING 04. PEDIATRIC NURSING 05. OPERATING ROOM 06. EMERGENCY ROOM 07. PSYCHIATRIC NURSING 08. PRE-ANESTHESIA HOLDING AREA (PRE-OP) 09. RECOVERY ROOM (POST-OP) 10. OTHER (SPECIFY): 99. DK 15. Before you entered the military, how much experience did you have with critically ill patients? Would you say you had: 1. A great deal of experience 2. A moderate amount 3. A limited amount, or 4. None 9. DK 16. Before you entered the military, did you regard nursing as a personally fulfilling profession? 1. NO 2. YES 9. NOT SURE/DK 17. Before entering the military, was nursing emotionally satisfying? 1. NO 2. YES 9. NOT SURE/DK �*SELECT LONGEST VIETNAM/OTHER TOUR OF DUTY '65-'72 PER INSTRUCTIONS AND EXCLUDING ANY TOUR OF DUTY WHILE A STUDENT* I'd like to focus on just one of your tours of duty, namely the time when you were stationed in ; from to . Now, I'd like to ask you a set of questions about that particular assignment. 18. What was your nursing position during this assignment? [READ 01 - 06 AND CIRCLE ONE ONLY] OjL. Operating room nurse 02. Staff nurse, 03. Charge nurse, 04. Flight nurse, 05. Intensive care nurse, or a 06. Triage/Emergency room nurse 07. OTHER (SPECIFY): [GO TO QUESTION # 19] \' 18.1 Which of the following anesthetics were used in the O.R.: was; [READ a - d] NO YES DK a . Fluothane, 1 2 9 b . Halothane, 1 2 9 c . Ketamine, o r 1 2 d . Nitrous Oxide a n d Oxygen 1 18.2 Were instruments sterilized, using: . Gas, YES 1 b. Ethylene Oxide, or c 18.3 1 . Steam NO 2. YES 1 9. NOT SURE/DK 9 DK 2 2 Were supplies of sterile equipment adequate? 1. 2 [READ a - c] NO a 9 9 9 2 9 �ASK FOR ALL NURSES 19. During this assignment was the nursing staff adequate? 1. NO 2. YES 9. NOT SURE/DK 20. During this assignment were there adequate supplies? 1. NO 2. YES 9. NOT SURE/DK 21. At the beginning of your assignment did you feel professionally competent to carry out your military assignment? 1. NO 2. YES 9. NOT SURE/DK 22. At the end of your assignment did you feel professionally competent to carry out your military assignment? 1. NO 2. YES 9. NOT SURE/DK 23. At the beginning of your assignment did you feel emotionally competent to carry out your military assignment? 1. NO 2. YES 9. NOT SURE/DK 24. At the end of your assignment did you feel emotionally competent to carry out your military assignment? 1. NO 2. YES 9. NOT SURE/DK 25. In general, how were you treated by military physicians? 1. As a colleague 2. As a servant, or 3. As a sexual object 4. OTHER (SPECIFY): 9. NOT SURE/DK 26. Were you prepared emotionally for the types of injuries you would see as a military nurse? 1. NOT PREPARED 9. NOT SURE/DK 2. YES, PREPARED 3. DIDN'T SEE INJURIES �27. Were you prepared professionally for the types of injuries you saw in the military? 1. NOT PREPARED 9. 2. YES, PREPARED 3. DIDN'T SEE INJURIES NOT SURE/DK 28. While in the military did you feel the workload was more than you could handle? 1. 29. NO 2. YES 9. NOT SURE/DK Were the hospital units where you worked noisy? 1. NO 2. YES 9. NOT SURE/DK 30. Were you concerned about physical injury to yourself while on the job? 1. NO 2. YES 9. NOT SURE/DK 31. Were you concerned about physical injury to your patients while you were working in the hospital? 1. NO 2. YES 9. NOT SURE/DK 32. In general, did you experience communication problems with other nurses? 1. NO 2. YES 9. NOT SURE/DK 33. While on this assignment were you able to adequately meet the physical needs of the patients? 1. NO 2. YES 9. NOT SURE/DK 34. Do you remember many nursing tasks as unpleasant on this assignment? 1. NO 2. YES 9. NOT SURE/DK 35. On this assignment, did new staff need to be oriented frequently? 1. NO 2. YES 9. NOT SURE/DK �36. Were your expectations of what you would be doing as a military nurse on this assignment realistic? 1. NO 2. YES 9. NOT SURE/DK 37. How stressful was it for you to perform procedures that patients experienced as painful or embarrassing? Would you say: 1. Very stressful, 2. Moderately stressful, or 3. Only mildly stressful 9. NOT SURE/DK 38. How frequently did you need to operate specialized equipment with which you were unfamiliar? Would you say: 1. Often, 2. Sometimes, or 3. Never 9. NOT SURE/DK 39. Did you personally need to make rapid decisions: 1. Often, 2. Sometimes, or 3. Never 9. NOT SURE/DK 40. Was there adequate opportunity to share your experiences and feelings with other personnel? 1. 41. NO 2. YES 9. NOT SURE/DK Were there frequently large numbers of admissions at one time? 1. NO 2. YES 9. NOT SURE/DK 42. Were non-nursing tasks often required of you? 1. NO 2. YES 9. NOT SURE/DK �43. Were you frequently without a physician available during medical emergencies? 1. NO 2. YES 9. NOT SURE/DK 44. Were you frustrated by the inability to take scheduled breaks or days off. 1. NO 2. YES 9. NOT SURE/DK 45. Do you remember many patients dying while you were on this assignment? 1. NO 2. YES 9. NOT SURE/DK 46. Were you able to follow up on the condition of your patients after they left your care? YES 1. NO 2. 9. 46.1 Did you follow up on the condition of your patients? DK I 1. NO 2. YES 9. DK 47. Did you take care of patients who were not Americans? 1. NO 9. I DK 2. YES i 47.1 Who were they? 47.2 Did you have emotional problems in dealing with these patients? YES 1. NO 2. 9. DK V (What nationality were they?) 47.2a I What types of problems? �48. On this assignment was military nursing satisfying to you in that you had the feeling of having helped your patients? 1. NO 2. YES 9. NOT SURE/DK 49. Did you receive feedback from your patients on-the nursing .care that you had given them? 1. NO 2. YES 9. NOT SURE/DK These next few questions ask about your current nursing status. 50. Are you currently employed as a nurse? 2. YES 1. NO 9. DK I SKIP TO QUESTION 51 I i 50.a How many years after this assignment did you leave nursing? 01. 0 - 3 YEARS 02. > 3 £.5 YEARS 03. > 5 ; . 7 YEARS £ 04. > 7 £ 10 YEARS 05. > 10 YEARS 06. NOT CURRENTLY EMPLOYED AS A NURSE, BUT HASN'T LEFT NURSING 99. DK 51. What is the highest nursing degree you have earned up until now? 01. A.D. 02. R.N. 03. BACHELORS IN NURSING 04. MASTERS IN NURSING 05. DOCTOR OF NURSING SCIENCE/PH.D. IN NURSING 06. OTHER (SPECIFY): 99. DK �VETERANS SERVICES [INTERVIEWER CHECK: IF RESPONDENT IS CURRENTLY IN THE MILITARY SKIP TO QUESTION # 3] Now I would like to ask you some questions about some programs for veterans. 1. Have you had any contact at all with the Veterans Administration since you got out of the service? 1. NO 9. DK 2. YES I 1.1 What have you been in contact with them about as best as you can recall? (DO NOT READ LIST -- CIRCLE ALL THAT APPLY] 01. LIFE INSURANCE 02. EDUCATION BENEFITS 03. HOME LOAN 04. MEDICAL PROBLEMS/BENEFITS 05. DISABILITY COMPENSATION 06. EMPLOYMENT, JOB ASSISTANCE 07. DENTAL CARE 08. INFORMATION ABOUT BENEFITS 09. OTHER (SPECIFY): 2. Are you currently receiving service-connected-disability compensation from the Veterans Administration? 1. NO 1 9. 2. YES I 2.1 What is your current VA disability rating? DK PERCENT 2.2 In what year did you first receive this rating? 19 3. Do you currently belong to any Veterans organizations? 1. NO 2. YES .1. 8.1 Which ones: (1.) NAME STREET ADDRESS CITY STATE ZIP NAME STREET ADDRESS CITY STATE ZIP (2.) �4. To the best of your knowledge, are you currently eligible for any Veterans Administration programs? 1. NO 9. DK I SKIP TO NEXT SECTION 2. YES I 4.1 Which ones? [RECORD VERBATIM AND CIRCLE ALL THAT APPLY] 01. HOSPITAL CARE FOR VETERANS WITH SERVICE-CONNECTED DISABILITIES 02. HOSPITAL CARE FOR VETERANS WITH LOW INCOMES 03. HOSPITAL CARE IN VA FACILITIES FOR ALL VETERANS 65 AND OVER 04. MONEY TO HELP VETERANS COMPLETE THEIR EDUCATION UNDER THE G.I. BILL 05. VOCATIONAL REHABILITATION TRAINING FOR VETERANS WITH SERVICE-CONNECTED DISABILITIES 06. FINANCIAL COMPENSATION FOR VETERANS WITH SERVICE-CONNECTED DISABILITIES 07. PENSIONS FOR LOW-INCOME VETERANS 08. NURSING HOME CARE FOR VETERANS AGED 65 AND OVER 09. DENTAL CARE IN VA FACILITIES 10. LIFE INSURANCE 11. HOME LOAN GUARANTEES 12. VOCATIONAL COUNSELING 13. TREATMENT FOR VETERANS WITH DRINKING PROBLEMS 14. TREATMENT FOR VETERANS WITH DRUG PROBLEMS 15. READJUSTMENT COUNSELING 16. PSYCHOLOGICAL COUNSELING OTHER THAN READJUSTMENT COUNSELING ' 17. DOMICILIARY CARE IN VA FACILITIES ' 18. OUTPATIENT CARE AT VA FACILITIES | i i , ' i �OVERSEAS VOLUNTEER WORK This question deals with any volunteer overseas assignments you may have had apart from your work history which we've already discussed. Did you ever go overseas or to another country as a volunteer? through the Peace Corps, or with a religious group? 2. For example, YES (a.) With what organization? (b.) Where did you go? (c.) When were you there? (d.) From when to when? What type of volunteer work did you do? (e.) Why did you decide to join the ? (f.) Why did you go to this particular country? [PROBE: Any others?] (a) (b) ORGANIZATION (c) TIME WHERE (d) TYPE OF WORK TO MONTH YEAR (e) MONTH YEAR MONTH YEAR MONTH YEAR (f) TO MONTH YEAR (e) (f) TO MONTH (e) YEAR (f) �PERSONAL HISTORY AND DEMOGRAPHICS Now I have just a few general background questions. 1. What is your date of birth? MONTH DAY I need the month, then the day and year. YEAR 2. How many people live in your household (unit) including yourself? TOTAL # 1. LIVES ALONE 2. LIVES WITH OTHERS (IF ONE OTHER MENTIONED) Who is that? (IF MORE THAN ONE OTHER) Who are they in relation to you? PROBE AT END: Anyone else? [RECORD # IN EACH BOX] a. SPOUSE/PARTNER b. MOTHER &/OR M-IN-L c. FATHER &/OR F-IN-L d. DAUGHTERS (STEPDAUGHTERS) e. SONS (STEPSONS) f. SISTERS g. BROTHERS h. OTHER FEMALE/FEMALES i. OTHER MALE/MALES �Did your mother ever take DES (Diethylstylbesterol) while she was pregnant with you or during any other pregnancy before you were conceived? 1. NO 2. DK 2. YES 3.1 Was that with you or during another pregnancy before you were born? 1. WITH RESPONDENT 2. WITH ANOTHER PREGNANCY BEFORE RESPONDENT WAS BORN 9. DK V Were any of your female blood relatives ever diagnosed as having breast cancer? 1. NO I 9. DK 2. YES 4.1 Who was that: I don't need the name, just the relationship to you. [PROBE: Any other blood relatives? CIRCLE ALL THAT APPLY] 01. MOTHER 02. SISTER 03. MOTHER'S SISTER 04. FATHER'S SISTER 05. MATERNAL GRANDMOTHER 06. PATERNAL GRANDMOTHER �5. Have you ever been fearful of having children, or of having more children for any reason? 1. NO 2. YES 9. DK 5.1 (a) When was that, (during what years)? (b) And, why were you afraid? (a) 19 TO 19 (b) V 6. While you were growing up, did anyone in your family have a drinking problem? 1. NO I 9. DK 2. YES v 6.1 Could you please tell me what that person's relationship was to you? [PROBE: Anyone else? CIRCLE ALL THAT APPLY] 01. MOTHER 02. FATHER 03. SISTER 04. BROTHER 05. SON 06. DAUGHTER 07. HUSBAND OR PARTNER 08. STEP-PARENT/FOSTER PARENT 09. OTHER RELATIVE (IN-LAWS, AUNTS, UNCLES, COUSINS, NIECES, NEPHEWS, ETC.) 10. MYSELF �7. Have you ever lived on a farm or ranch? 2. YES V FOR EACH ASK: 1. NO 9. DK I (a) During what years did you live on a farm or ranch? (b) Was it a farm or a ranch? SKIP TO QUESTION # 8 (c) What was the street address, and the city, state and zip code? [PROBE: any others?] (a) DATES FARM 1 YEAR MONTH YEAR MONTH YEAR MONTH YEAR 1 MONTH YEAR 1 YEAR MONTH YEAR 2 YEAR MONTH 2 YEAR MONTH 2 YEAR MONTH 2 1 MONTH 2 1 TO MONTH (b) RANCH TO TO TO TO (c) STREET ADDRESS CITY, STATE, ZIP CODE �8. Did you ever live in an area that was subject to documented chemical or toxic exposures? (TIMES BEACH, MO, LOVE CANAL, NY) 1. NO 2. YES 9. DK [FOR EACH ASK:] I (a) When did you live there? (b) What was the street address and the city, state and zip code? SKIP TO QUESTION # 9 [PROBE: any others?] (b) (a) DATE S A STREET ADDRESS CITY, STATE, ZIP CODE TO MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR MONTH YEAR TO TO TO TO �9. Have you ever been exposed to any of the following substances in situations other than what we've already discussed [READ a - f] FOR EACH YES, ASK: (a) When were you exposed? (What were the dates?) (b) How were you exposed? (c) What was the street address and the city, state and zip code of the area? NO DK YES (a) DATES a. Asbestos b. Nuclear radiation c. Industrial chemicals d. Defoliants or herbicides e. Insecticides or pesticides 1 f. Degreasing chemicals 10. Have you ever used insect repellant on a weekly basis for a month or more? 1. NO 9. DK 2. YES 10.1 When was this? [PROBE FOR YEARS] �(b) HOW (c) STREET ADDRESS CITY, STATE, ZIP CODE �11. And, what state were you born in? [INTERVIEWER NOTE: IF R BORN OUTSIDE THE UNITED STATES, RECORD THE COUNTRY OF BIRTH.] STATE OR COUNTRY OF BIRTH 12. How would you describe your ethnic background? [CIRCLE ALL MENTIONED] 01. IRISH 11. SCOTTISH 02. ENGLISH 12. WELSH 03. FRENCH OR FRENCH CANADIAN 13. GERMAN, AUSTRIAN, SWISS 04. GREEK 14. SWEDISH, FINNISH, DANISH, NORWEGIAN 05. ITALIAN 15. NO PARTICULAR ETHNIC BACKGROUND 06. BLACK, AFRO-AMERICAN 16. OTHER (SPECIFY:) 07. JEWISH 08. HISPANIC, SPANISH 77. REFUSED 09. POLISH 99. NOT SURE/DK 10. RUSSIAN 13. What is your religious preference now? Are you: 01. Catholic, 02. Jewish, 03. Protestant, or 04. Something else? (SPECIFY): 05. NO RELIGION 14. What religion were you raised in? 01. CATHOLIC 02. JEWISH 03. PROTESTANT 04. SOMETHING ELSE 05. NO RELIGION (SPECIFY): ________ �15. Which of the following groups do you consider yourself to be a part of? 01. White, Non-Hispanic 02. Black, Non-Hispanic 03. White - Hispanic 04. Black - Hispanic, or 05. Asian or Pacific Islander 06. OTHER 99. DK 16. Which of the following groups represents the total income during the past 12 months for all members in your household added together. Think of all possible sources of income such as wages, salaries, social security, interest income and so forth. Is it: 01. Less than $5,000 02. $5,000 - $9,999 03. $10,000 - $19,999 04. $20,000 - $29,999 05. $30,000 - $39,999 06. $40,000 - $49,999 07. $50,000 - $79,999 08. $80,000 - $99,999 09. OVER $100,000 77. REFUSED 99. DK �INTERVIEWER CHECK: 1. NO WERE THERE ANY "CODE REDS"? 2. YES We would like to obtain copies of your medical records. We will mail you a release form in the near future. Please sign it and return it promptly. Thank you again. In order for us to re-contact you, should we need to do so, I'd like to get the name, address and phone number of someone who does not live in your household, but who is likely to know how to reach you. NAME LAST FIRST MI CITY STATE ZIP CODE STREET ADDRESS TELEPHONE NUMBER ( ) Thank you, this concludes our interview. If you have any comments regarding the interview in general or the questions I have asked please tell me and I will jot them down. �[PLEASE COMPLETE AFTER EACH INTERVIEW] INTERVIEWER'S NOTES 1. Please rate how comfortable Respondent was during interview. Not at all comfortable 1 Very comfortable 2 3 4 5 2. Please rate how cooperative Respondent was during interview. Not at all cooperative 1 Very cooperative 2 3 4 5 3. Did the Respondent have difficulty answering any of the questions? 1. NO 2. YES >Which ones? 4. Do you feel that the Respondent gave inaccurate or misleading information in any of the questions? 1. NO 2. YES >Which ones? 5. Were there any unusual circumstances at the time of the interview (e.g., R had difficulty hearing, concentrating, or there were frequent interruptions, etc.)? 1. NO 2. YES >Which ones? � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 068 Folder The folder containing the original item. 1849 Series The series number of the original item. Series III Subseries III Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource McKinlay, Sonja M. Description An account of the resource <strong>Corporate Author: </strong>New England Research Institute, Inc., Watertown, Massachusetts Title A name given to the resource Women's Vietnam Veterans Health Study Protocol Development, Questionnaire, Deliverable C Subject The topic of the resource Women Vietnam Veterans Health Study PTSD veteran psychological health VA ao_seriesIII Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alvin L. Young Collection on Agent Orange Description An account of the resource <p style="margin-top: -1em; line-height: 1.2em;">The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.</p> <p>For more about this collection, <a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a">view the Agent Orange Exhibit.</a></p> Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Box The box containing the original item. 072 Folder The folder containing the original item. 1912 Series The series number of the original item. Series III Subseries IV Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Creator An entity primarily responsible for making the resource Lindley, Forrest, Jr. Source A related resource from which the described resource is derived The Stars and Stripes - The National Tribune Date A point or period of time associated with an event in the lifecycle of the resource May 6 1982 Title A name given to the resource Australian Vets Visit States Subject The topic of the resource veteran health and hygiene veteran psychological health ao_seriesIII