Understanding and Measuring Help-Seeking Barriers among Intimate Partner Violence Survivors: Mixed-Methods Validation Study of the Icelandic Barriers to Help-Seeking for Trauma (BHS-TR) Scale

Abstract

Intimate partner violence (IPV) against women is a global human rights violation of vast proportions and a severe public health problem. Despite high rates of adverse outcomes related to IPV, help-seeking and service utilization among survivors is low. This exploratory sequential mixed-methods study using a combined etic–emic approach describes the validation of the Icelandic Barriers to Help-Seeking for Trauma (BHS-TR) scale. The qualitative phase involved developing new items based on the experiences of 17 Icelandic IPV survivors, identifying barriers including beliefs that help-seeking is a sign of weakness, and the desire to safeguard oneself from re-traumatization. The quantitative phase examined the psychometrics of the BHS-TR in a sample of 137 IPV survivors in Iceland. Results supported an eight-factor structure (Financial Concerns; Unavailable/Not Helpful; External Constraints; Inconvenience; Weakness/Vulnerability; Problem Management Beliefs; Frozen/Confused; and Shame), which when grouped comprised two indices of Structural and Internal Barriers. The scale’s internal consistency was high (α = 0.87), and the results provided evidence of convergent, discriminant, and known-group validity. This study adds to the growing literature supporting the advantages of applying mixed methods for instrument development and validation, and its results highlight the significance of giving rise to the voices of survivors. The BHS-TR is the first trauma-specific and survivor-centered measure of help-seeking barriers available in Iceland. It can be used to provide valuable information that may guide the development of evidence-based interventions to break down barriers and help survivors find ways to trauma recovery.

Using Mixed Methods Integration to Evaluate the Structure of Help-Seeking Barriers Scale: A Survivor-Centered Approach

“…The data were collected between February and October 2020, and our sample included 137 IPV survivors in Iceland. A detailed description of the procedures has been previously reported [ 65 ].…”

“…Initially, the scale included 41 items, and a list of the 15 dropped items can be found in Supplementary Table S2 . The 26-item BHS-TR was found to have sound psychometric properties in our previous work [ 65 ]. There were no missing data for the BHS-TR, and the Cronbach’s α in this study was 0.87.…”

“…The BHS-TR was translated and cross-culturally adapted into the Icelandic language and context [ 64 ] and initially validated in a mixed-methods study among IPV survivors in Iceland [ 65 ], creating the first Icelandic trauma-specific measure that assesses help-seeking barriers. An essential part of this work was qualitatively evaluating the scale through cognitive interviewing, resulting in the development of new barrier items based on the survivors’ lived experiences.…”

“…Using these findings, we utilized building to adapt the BHS-TR scale and then carried out a psychometric evaluation of the whole instrument with the additional items. Both Qual and Quan phases provided evidence that the Icelandic BHS-TR is relevant, reliable, and valid [ 64 , 65 ]. Nevertheless, there was a noticeable mismatch between the Qual and Quan findings regarding several items on the scale.…”

“…Primarily, items that were significant barriers to help-seeking in the survivors’ narratives were problematic in the exploratory factor analysis technique, mainly due to cross-loadings with different factors. According to the factor analysis procedure, these cross-loaded items would be dropped and hereafter referred to as the dropped items [ 65 ]. This mismatch between the participants’ narratives and the factor analysis results points to a legitimation issue, demonstrating the need for further systematic assessment of the coherence of barriers to help-seeking Qual and Quan findings.…”