The Harvard Trauma Questionnaire: Validating a Cross-Cultural Instrument for Measuring Torture, Trauma, and Posttraumatic Stress Disorder in Indochinese Refugees
Abstract
There are no valid and reliable cross-cultural instruments capable of measuring torture, trauma, and trauma-related symptoms associated with the DSM-III-R diagnosis of posttraumatic stress disorder (PTSD). Generating such standardized instruments for patients from non-Western cultures involves particular methodological challenges. This study describes the development and validation of three Indochinese versions of the Harvard Trauma Questionnaire (HTQ), a simple and reliable screening instrument that is well received by refugee patients and bicultural staff. It identifies for the first time trauma symptoms related to the Indochinese refugee experience that are associated with PTSD criteria. The HTQ's cultural sensitivity may make it useful for assessing other highly traumatized non-Western populations.
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Functional impairment assessment was based on qualitative data from the study villages.
“Functional impairment was based on the degree of difficulty in performing important tasks of daily living that were identified on the basis of qualitative data from the study villages, with the use of methods described elsewhere.16,26”
From Controlled trial of psychotherapy for Congolese survivors of sexual violence (2013) · cites this paper as [16]
The Harvard Trauma Questionnaire is a validated cross-cultural screening instrument designed to assess torture, trauma exposure, and trauma-related symptoms in refugees.
“The Harvard Trauma Questionnaire is a validated cross-cultural screening instrument designed to assess torture, trauma exposure, and trauma-related symptoms in refugees.”
From Identifying resilience-promoting factors for refugee survivors of torture (2022) · cites this paper as Mollica et al., 1992
The HTQ has high test-retest reliability (α = .89) and internal consistency (α = .90).
“The HTQ has been reported to have high test-retest reliability ( α = .89) internal consistency ( α = .90; Mollica et al., 1992)”
From Identifying resilience-promoting factors for refugee survivors of torture (2022) · cites this paper as Mollica et al., 1992
The primary outcome measure was self-reported PTSD symptoms assessed using part IV of the Harvard Trauma Questionnaire (HTQ), which has been developed primarily for trauma-affected refugees and validated in several languages and settings.
“The primary outcome measure was self-reported PTSD symptoms assessed using part IV of the Harvard Trauma Questionnaire (HTQ), which has been developed primarily for trauma-affected refugees and validated in several languages and settings [26, 27].”
From Treatment of trauma-affected refugees with venlafaxine versus sertraline combined with psychotherapy - a randomised study (2016) · cites this paper as [26]
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“The PTSD scale of the HTQ-R (Mollica, et al, 1992 ) was derived from the Diagnostic and Statistical Manual (DSM-IV) criteria using the stipulated three sub-domains: re-experiencing traumatic events; avoidance and numbing and psychological arousal.”
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“Both instruments are considered valid and reliable instruments for measuring levels of psychological symptoms associated with war-related torture and trauma in culturally diverse communities (Mollica et al., 1992; Mollica, Wyshak, de Marneffe, Khuon, & Lavelle, 1987).”
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“For primary outcomes, if data from several commonly used rating scales were available, we used the following: for PTSD - HTQ, PCL-C, CAPS, and CAPS-CA; for anxiety - HAD-A for adults (Zigmond 1983) and SCARED-5 for children and adolescents (Birmaher 1997); for depression - HDRS (Hamilton 1960); and for somatic symptom…”
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“ified from the Harvard Trauma Questionnaire [ 11 ].”
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“To measure improvement in PTSD symptoms the Child PTSD Symptom Scale, 19 the 8item Impact of Events Scale, 20 the Harvard Trauma Questionnaire, 21 and the University of California Los Angeles PostTraumatic Stress Disorder Reaction Index 22 were used by study investigators.”
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“The HTQ [24] was used in a Danish, Icelandic or Faroese edition.”
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“The HTQ also provides an index of PTSD symptoms validated against semistructured clinical interviews and the SCID (HTQ; Mollica et al., 1992; Silove et al., 2007).”
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“Twelve items that comprised the PTSD/CPTSD item set were selected from two standardised measures, the Trauma Symptom Checklist (TSC; Briere & Runtz, 1989) and the Harvard Trauma Questionnaire Part IV (HTQ: Mollica et al., 1992).”
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Alemi, Q., James, S., Cruz, R., Zepeda, V., & Racadio, M. (2014) · Journal of Immigrant and Minority Health · doi:10.1007/s10903-013-9861-1 · Cited by 170 · see citing works
“Harvard Trauma Questionnaire/HTQ [102]) and those adapted for use in refugee research (e.”
MethodDebating war-trauma and post-traumatic stress disorder (PTSD) in an interdisciplinary arena
Kienzler, H. (2008) · Social Science & Medicine · doi:10.1016/j.socscimed.2008.03.030 · Cited by 171 · see citing works
“That is, protocols and scales based on the symptom lists such as the DSM and ICD have been translated into local languages, thus permitting investigators to distinguish traumatic suffering from seemingly similar kinds of psychological distress (Mollica et al., 1992).”
BackgroundInfluentialHajak, V. L., Sardana, S. M., Verdeli, H., & Grimm, S. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.643704 · Cited by 172 · see citing works
“(50) assessed symptoms of PTSD through combining the Post-traumatic Diagnostic Scale [PDS; (72)], which measures the 10 ICD-10 (International Statistical Classification of Diseases and Related Health Problems) criteria of PTSD, with the 25 items of the Harvard TraumaQuestionnaire [HTQ; (73)] and found a rate of 41.”
MethodDissociative disorders in DSM-5
Spiegel, D., Loewenstein, R. J., Lewis-Fernández, R., Sar, V., Simeon, D., Vermetten, E., Cardeña, E., & Dell, P. F. (2011) · Depression and Anxiety · doi:10.1002/da.20923 · Cited by 162 · see citing works
Onyut, L. P., Neuner, F., Ertl, V., Schauer, E., Odenwald, M. G., & Elbert, T. R. (2009) · Conflict and Health · doi:10.1186/1752-1505-3-6 · Cited by 165 · see citing works
“rightly validated the Havard Trauma Questionnaire among the Indochinese before using it for measurements within the same questionnaire [23].”
Victimization and PTSD in a Danish National Youth Probability Sample
Elklit, A. (2002) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/00004583-200202000-00011 · Cited by 181 · see citing works
“PSYCHIATRY, 41 :2 , FEBRUARY 2002 177 no HTQ reliability and validity data for adolescents or Danish subjects.”
MethodInfluentialMerz, J., Schwarzer, G., & Gerger, H. (2019) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2019.0951 · Cited by 170 · see citing works
Moral injury, mental health and behavioural health outcomes: A systematic review of the literature
Hall, N. A., Everson, A. T., Billingsley, M. R., & Miller, M. B. (2021) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2607 · Cited by 175 · see citing works
Acarturk, C., Konuk, E., Cetinkaya, M., Senay, I., Sijbrandij, M., Gulen, B., & Cuijpers, P. (2016) · Psychological Medicine · doi:10.1017/s0033291716001070 · Cited by 165 · see citing works
“Refugees, in addition to displacement from their homes, have been exposed to many horrifying traumatic events such as threat of death, torture, or serious injury and the injury, death, disappearance of family members, rape, lack of food and water, or lack of shelter (Mollica et al. 1992).”
BackgroundRates and impact of trauma and current stressors among Darfuri refugees in Eastern Chad.
Rasmussen, A., Nguyen, L., Wilkinson, J., Vundla, S., Raghavan, S. S., Miller, K. E., & Keller, A. S. (2010) · American Journal of Orthopsychiatry · doi:10.1111/j.1939-0025.2010.01026.x · Cited by 164 · see citing works
“…camps and host countries alike clearly supports the positive association between PTEs and psychological distress (Fox & Tang, 2000; Holtz, 1998; Jaranson, Butcher, Halcon, et al., 2000; Keller, Lhewa, Rosenfeld, et al., 2006; Mollica et al., 1992; Shrestha, Sharma, Van Ommeren, et al., 1998).”
Cardozo, B. L., Kaiser, R., Gotway, C. A., & Agani, F. (2003) · Journal of Traumatic Stress · doi:10.1023/a:1024413918346 · Cited by 161 · see citing works
“We used the same three screening tools as in the 1999 survey to assess mental health and social functioning: the General Health Questionnaire-28 (GHQ-28; Goldberg & Hillier, 1979), the Medical Outcomes Study 20 (MOS-20; Ware, Snow, Kosinski, & Gandek, 1997) and the Harvard Trauma Questionnaire (HTQ; Mollica, Casspi-Ya…”
MethodCardozo, B. L., Talley, L., Burton, A., & Crawford, C. (2004) · Social Science & Medicine · doi:10.1016/j.socscimed.2003.09.024 · Cited by 158 · see citing works
“Whether the PTSD symptoms score is lower than expected because the concept of PTSD is not known or used in the local culture is not clear, but does not seem likely because survey respondents easily recognized all 16 key PTSD ARTICLE IN PRESS B. Lopes Cardozo et al. / Social Science & Medicine 58 (2004) 2637–2644 2641…”
MethodInfluentialKumar, M. S., Murhekar, M. V., Hutin, Y. J., Subramanian, T., Ramachandran, V., & Gupte, M. D. (2006) · American Journal of Public Health · doi:10.2105/ajph.2005.071167 · Cited by 159 · see citing works
Compounding of Premigration Trauma and Postmigration Stress in Asylum Seekers
Sinnerbrink, I. B., Silove, D. M., Field, A., et al. (1997) · The Journal of Psychology · doi:10.1080/00223989709603533 · Cited by 157 · see citing works
Hsu, E., Davies, C. A., & Hansen, D. J. (2004) · Clinical Psychology Review · doi:10.1016/j.cpr.2003.10.003 · Cited by 156 · see citing works
“Additionally, the Harvard Trauma Questionnaire has been culturally validated as appropriate for evaluation of PTSD symptoms in Cambodian, Laotian, and Vietnamese refugees (Mollica et al., 1992).”
MethodHusain, F. S., Anderson, M., Cardozo, B. L., Becknell, K., Blanton, C., Araki, D., & Vithana, E. K. (2011) · JAMA · doi:10.1001/jama.2011.1052 · Cited by 154 · see citing works
The mental health of unaccompanied refugee minors on arrival in the host country
Vervliet, M., Demott, M. A. M., Jakobsen, M., Broekaert, E., Heir, T., & Derluyn, I. (2014) · Scandinavian Journal of Psychology · doi:10.1111/sjop.12094 · Cited by 152 · see citing works
“The HTQ has been validated for use with refugee populations in several studies (Mollica et al., 1992; Fawzi, Murphy, Pham, Lin, Poole & Mollica, 1997; Silove, Manicavasagar, Mollica et al., 2007).”
Jakobsen, M., Demott, M. A. M., Wentzel‐Larsen, T., & Heir, T. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-015157 · Cited by 153 · see citing works
Impact of the Russian Invasion on Mental Health of Adolescents in Ukraine
Osokina, O., Silwal, S., Bohdanova, T., Hodes, M., Sourander, A., & Skokauskas, N. (2022) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2022.07.845 · Cited by 153 · see citing works
Hooberman, J., Rosenfeld, B., Rasmussen, A., & Keller, A. (2010) · American Journal of Orthopsychiatry · doi:10.1111/j.1939-0025.2010.01060.x · Cited by 151 · see citing works
“Severity of PTSD symptoms was measured using the Harvard Trauma Questionnaire (HTQ), a 16-item self-report measure (Mollica et al., 1992).”
BackgroundMethodDas‐Munshi, J., Lund, C., Mathews, C., Clark, C., Rothon, C., & Stansfeld, S. A. (2016) · PLoS ONE · doi:10.1371/journal.pone.0154478 · Cited by 149 · see citing works
“Validated instruments assessed mental disorders; these included: Harvard Trauma Questionnaire (PTSD); Short Moods and Feelings Questionnaire (depression); Zung self- rated anxiety scale (anxiety).”
MethodInfluentialPersecution Experiences and Mental Health of LGBT Asylum Seekers
Hopkinson, R. A., Keatley, E. S., Glaeser, E., Erickson‐Schroth, L., Fattal, O., & Sullivan, M. N. (2016) · Journal of Homosexuality · doi:10.1080/00918369.2016.1253392 · Cited by 149 · see citing works
“The Harvard Trauma Questionnaire (HTQ) is a self-report instrument that assesses PTSD symptoms (Mollica et al., 1992).”
BackgroundMethodCoping and chronic psychosocial consequences of female genital mutilation in the Netherlands
Vloeberghs, E., van der Kwaak, A., Knipscheer, J. W., & van den Muijsenbergh, M. E. T. C. (2012) · Ethnicity and Health · doi:10.1080/13557858.2013.771148 · Cited by 147 · see citing works
“The survey consisted of four questionnaires including: the Harvard Trauma Questionnaire (HTQ-30; Mollica et al. 1992), a 30-item transculturally validated screening instrument for post-traumatic stress disorder (PTSD) symptomatology (Cronbach’s a 0.96 in the current sample); the Hopkins Symptom…”
BackgroundMethodInfluentialWilker, S., Pfeiffer, A., Kolassa, S., Koslowski, D., Elbert, T. R., & Kolassa, I. (2015) · European Journal of Psychotraumatology · doi:10.3402/ejpt.v6.28306 · Cited by 146 · see citing works
“93 over intervals of 1 4 weeks (Carlson et al., 2011; Goodman, Corcoran, Turner, Yuan, & Green, 1998; Gray, Litz, Hsu, & Lombardo, 2004; Hollifield et al., 2006; Mollica et al., 1992).”
InfluentialPsychological reactions in Icelandic earthquake survivors
Bödvarsdóttir, Í., & Elklit, A. (2004) · Scandinavian Journal of Psychology · doi:10.1111/j.1467-9450.2004.00373.x · Cited by 141 · see citing works
“In this study, the reliability co - efficients were very good and consistent with other studies (Mollica et al. , 1992; Elklit, 2000).”
ResultKun, P., Chen, X., Han, S., Gong, X., Chen, M., Zhang, W., & Yao, L. (2009) · Public Health · doi:10.1016/j.puhe.2009.09.017 · Cited by 142 · see citing works
Slewa‐Younan, S., Mond, J., Bussion, E., Mohammad, Y., Guajardo, M. G. U., Smith, M. M., Milosevic, D., Lujic, S., & Jorm, A. F. (2014) · BMC Psychiatry · doi:10.1186/s12888-014-0320-x · Cited by 140 · see citing works
“The Harvard Trauma Questionnaire (HTQ) [22] is a widely used, cross-cultural self-report checklist assessing the occurrence and frequency of various types of traumatic events as well as PTSD symptomatology.”
BackgroundMethodInfluential
- Authors
- MOLLICA, R. F., CASPI-YAVIN, Y., BOLLINI, P., TRUONG, T., TOR, S., & LAVELLE, J.
- Affiliations
- Harvard University (US)
- St. Elizabeth's Medical Center (US)
- ORCID
- MOLLICA, RICHARD F.
- Venue
- The Journal of Nervous and Mental Disease
- Published
- 1992-02
- Volume
- 180
- Issue
- 2
- Pages
- 111-116
- ISSN
- 0022-3018 (ISSN-L)
- OpenAlex
- W4292855834
- Cited by
- 1,489
- References
- 0
- Citations by year
- 2026: 56 · 2025: 92 · 2024: 66 · 2023: 92 · 2022: 100 · 2021: 98 · 2020: 103 · 2019: 73 · 2018: 90 · 2017: 86 · 2016: 71 · 2015: 59 · 2014: 63 · 2013: 50 · 2012: 54
- FWCI
- 6.74
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Nervous and Mental Disease (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
- Social Sciences › Psychology › Clinical Psychology › Migration, Health and Trauma
- Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
- Keywords
- Harvard Trauma Questionnaire, post-traumatic stress disorder, torture, trauma symptoms, Indochinese refugees, cross-cultural assessment, screening tool, cultural sensitivity, instrument validation, refugee mental health
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