Understanding and measuring barriers to help-seeking after trauma : Survivor-centered mixed methods validation study

Abstract

Aim: The overarching aim of this thesis was to create the first Icelandic traumaspecific and survivor-centered help-seeking barriers instrument. More specifically, to cross-culturally adapt, validate, and legitimate the Barriers to Help-Seeking for Trauma Scale (BHS-TR) among intimate partner violence (IPV) survivors in Iceland. Methods: A combined etic–emic strategy using mixed methods was employed, involving forward–backward translation, expert committee review, cognitive interviews with 17 IPV survivors (study I), psychometric examination in a sample of 137 IPV survivors (study II), and legitimation strategy of integration (study III). Data were analyzed using qualitative content analysis, statistical analysis, and joint display analysis. Results: The translation and adaptation process of study I led to an Icelandic version, which appears to be semantically and conceptually equivalent to the original BHS-TR; additionally, the findings provided evidence of the relevance and content-related validity. Still, the Icelandic survivors mentioned a few but significant barriers missing from the scale. The new BHS-TR items developed in study II based on the participants’ lived experiences represented barriers related to viewing help-seeking as a sign of weakness and safeguarding efforts. The psychometric evaluation of the scale supported an eight-factor structure which, when grouped, comprised two indices of Structural and Internal Barriers. Further, the scale’s internal consistency was high (α = 0.87), and the results provided evidence of convergent, discriminant, and known-groups validity. The integration of the qualitative and quantitative data in study III revealed mainly complementarity findings, strengthening the BHS-TR’s overall legitimation evidence. Divergent findings involved items that were significant help-seeking barriers in the survivors’ narratives, whereas factor analysis indicated their removal. These items were critically evaluated in a spiraling process that supported the barriers’ influence, illuminated core issues, and guided potential refinements. Conclusions: The overall findings indicate that the Icelandic BHS-TR is a culturally sensitive, trustworthy, and valid instrument but deserves continuing attention for refinements. This thesis contributes to the growing literature supporting the advantages of applying mixed methods for instrument development and cross-cultural adaptation. The BHS-TR can be used to provide valuable information that may guide the development of evidencebased interventions to break down barriers and help survivors find their way to trauma recovery.