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
:1. Introduction
1.1. Intimate Partner Violence against Women
1.2. Barriers to Help-Seeking
1.3. Existing Measures
1.4. The Barriers to Help-Seeking for Trauma Scale
1.5. Study Aims
2. Materials and Methods
2.1. Study Design
2.2. Sampling and Data Collection
2.2.1. Qualitative Phase
2.2.2. Quantitative Phase
2.3. Ethical Considerations
2.4. Measures
2.4.1. The Barriers to Help-Seeking for Trauma (BHS-TR) Scale
2.4.2. Patient Health Questionnaire
2.4.3. Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5
2.4.4. Beliefs toward Mental Illness Scale
2.4.5. Orientation to Life Questionnaire
2.5. Data Analysis
2.5.1. Qualitative Phase
Item Generation
Pretesting the New Items
2.5.2. Quantitative Phase
Factor Structure and Dimensionality
Convergent and Discriminant Validity
Known-Groups Validity
Reliability
3. Results
3.1. Qualitative Phase
3.1.1. Reveals Weakness
3.1.2. Safeguard Yourself
3.1.3. Pretesting the New Items
3.2. Quantitative Phase
3.2.1. Participants’ Characteristics, Health Status, and Help-Seeking
3.2.2. Construct Validity
Factor Structure
Structural and Internal Barriers Indices
Convergent and Discriminant Validity
Known-Groups Validity
3.2.3. Reliability
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Characteristics | Qual Phase (n = 17) | Quan Phase (n = 137) |
---|---|---|
Age | ||
18–29 | 4 (23.5%) | 24 (17.5%) |
30–39 | 7 (41.2%) | 34 (24.8%) |
40–49 | 4 (23.5%) | 38 (27.7%) |
50–59 | 1 (5.9%) | 18 (13.1%) |
60+ | 1 (5.9%) | 6 (4.4%) |
Not stated | – | 17 (12.4%) |
Racial and ethnic background | ||
Caucasian | 17 (100%) | – |
Iceland-born | 16 (94.1%) | – |
Foreign-born | 1 (5.9%) | – |
Level of education | ||
High school or less | 3 (17.6%) | 11 (8.0%) |
Technical or junior college degree | 5 (29.4%) | 29 (21.2%) |
University degree | 9 (52.9%) | 82 (59.9%) |
Not stated | – | 15 (10.9%) |
Employment status (not mutually exclusive) | ||
Working | 12 (70.6%) | 88 (64.2%) |
Unemployed or looking for work | 2 (11.8%) | 7 (5.1%) |
Student | 5 (29.4%) | 26 (19.0%) |
Homemaker | 1 (5.9%) | 3 (2.2%) |
Unable to work due to sickness/disability | 3 (17.6%) | 20 (14.6%) |
Other | – | 24 (17.5%) |
Number of children | ||
None | 5 (29.4%) | 24 (17.5%) |
One or two | 9 (52.9%) | 59 (43.1%) |
Three or more | 3 (17.6%) | 46 (33.6%) |
Not stated | – | 8 (5.8%) |
Current medical diagnosis (mental and/or physical) | ||
No | 6 (35.3%) | 44 (32.1%) |
Yes | 11 (64.7%) | 93 (67.9%) |
History of receiving mental healthcare | ||
No | 8 (47.1%) | 24 (17.5%) |
Yes | 9 (52.9%) | 112 (81.8%) |
Not stated | – | 1 (0.7%) |
QCA Inductive Approach | Description of How Each Step Was Performed |
---|---|
Preparation phase | |
Selecting the unit of analysis | In accordance with the aim of the study, it was decided to analyze the parts of the interviews where the women spoke about help-seeking barriers they thought were missing from the scale. |
Making sense of the data and obtaining a whole | First, the transcribed material was read through several times without coding to become immersed in the data. |
Organizing phase | |
Open coding | The transcribed material was read through again, and this time paragraphs and phrases (meaning units) directly related to the phenomenon under study were highlighted, and headings written down in the margins. Next, the headings were collected onto coding sheets and categories freely generated. |
Grouping and categorization | The initial categories were compared and grouped based on similarities and differences into broader higher-order categories. |
Abstraction | Each category was defined and named according to its content. Sub-categories with similar meanings were then grouped to form categories, which were all classified under the main category. The analysis process was continued until new categories could no longer be formed. |
Reporting phase | |
Report on the process | Each step was thoroughly documented during the process, allowing tracking of all the decisions made. This article represents the final step, where the analysis and findings are reported. |
Barriers Reveals Weakness | Meaning Units | Proposed New Items |
---|---|---|
Strong women shouldn’t need help | “It was so strong within me the need to be tough and keep going, needing help felt like a sign of weakness” “I wanted to feel strong, show some strength, we are supposed to be so hardy and resilient…you know Vikings or whatever, and I guess that some part of me believed that strong women shouldn’t need help” | I thought that strong people should not need help |
Didn’t want to be seen as weak | “I didn’t want to be looked at as weak and then to have people treat me differently…you know, feel sorry for me” “I was scared of being seen as a weakling” | I was scared of being seen as weak |
Being vulnerable would weaken me | “It was like I would somehow become less…I don’t like being vulnerable, and vulnerability is to me at least a big part of seeking help” “I felt like, if I would open up…you know about my feelings or whatever that it would weaken me” | I felt like opening up to my feelings would weaken me |
Meant that I had failed | “It was like a defeat or something, like such a personal failure, and that’s why it took me such a long time to seek help, it wasn’t until I had nothing left” “To seek help would mean that I had ultimately lost, for him and what he did to be the reason I was so fucked up…and like still…I couldn’t bear it” | Getting help would mean that I had failed or had been defeated |
Barriers Safeguard Yourself | Meaning Units | Proposed New Items |
---|---|---|
In protective mode | “I wanted to protect myself, and I was in this mode that I just could not deal with it and needed to let myself be there…but you shouldn’t stay there for too long, you can get stuck” “I didn’t want to take the chance of regretting it. You know if I would seek help, and I wouldn’t be believed, or it wouldn’t be taken seriously, I was dealing with enough” | I did not seek help in an effort to protect or safeguard myself |
Fear of re-traumatization | “I had made my world trigger-free, so yeah, I was really isolated but it was easier that way, and I just didn’t see the point…to go there, talking about it would only hurt me even more” “I was afraid that it would be too difficult for me because then I had to think about it, talk about it, recall these painful memories, and there was no way that I could do that” | I was afraid that seeking help would be too emotionally difficult or hurt me even more |
Not ready to face it | “The desire to be whole was so strong, and if I had to get help, that would mean that I wasn’t whole anymore…of course, deep down, I knew I was broken, but I wasn’t ready to admit it” “Denial was a huge barrier for me, because you know, staying in denial doesn’t hurt as much…if you seek help, you need to face your experience” | Seeking help would require acknowledging things I did not want to face |
Dropped Items |
---|
From the original mental healthcare scale |
3. I was unsure about where to go for help or how to access help |
4. I thought help probably would not do any good |
9. I could not get time away from work or my family |
12. I was concerned that I would not be able to get help soon enough |
13. I was scared about being put into a hospital against my will |
20. I felt that my culture, background, or specific situation would not be understood |
21. Suitable professionals were not available to me |
22. The kind of help I needed was not available |
23. I felt that there would be prejudice or discrimination against me |
From the trauma-specific additions |
31. I was afraid I would explain what I needed, and no one would help me anyway |
32. I felt that I could not trust people to help me |
33. I felt no one could understand or help me |
From the cognitive interviews (emic) additions |
36. I was afraid that seeking help would be too emotionally difficult or hurt me even more |
37. I did not seek help in an effort to protect or safeguard myself |
38. I felt like opening up to my feelings would weaken me |
Factors Items (Communalities) | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 |
---|---|---|---|---|---|---|---|---|
Weakness/Vulnerability (Cumulative % of Variance: 26.47; Eigenvalue: 6.88) | ||||||||
40. I thought that strong people should not need help (0.84) | 0.93 | |||||||
39. Getting help would mean that I had failed or had been defeated (0.81) | 0.83 | |||||||
35. I was scared of being seen as weak (0.79) | 0.72 | 0.22 | ||||||
41. Seeking help would require acknowledging things I did not want to face (0.68) | 0.69 | 0.34 | ||||||
24. I thought my situation was too personal or wanted to keep it private (0.50) | 0.40 | 0.27 | 0.27 | |||||
Financial Concerns (Cumulative % of Variance: 37.96; Eigenvalue: 2.99) | ||||||||
2. I was concerned that the help I needed would be too expensive (0.80) | 0.87 | |||||||
19. The available health insurance would not cover the type of treatment I needed (0.78) | 0.85 | 0.28 | ||||||
18. I did not have adequate financial resources (0.81) | 0.82 | |||||||
Unavailable/Not Helpful (Cumulative % of Variance: 45.98; Eigenvalue: 2.07) | ||||||||
15. I was not satisfied with the available services (0.75) | 0.87 | |||||||
16. I felt that the help available would not provide the type of treatment or help that was best for the problem (0.72) | 0.85 | |||||||
17. I had sought help before, but it did not help (0.60) | 0.61 | 0.32 | −0.24 | |||||
External Constraints (Cumulative % of Variance: 53.06; Eigenvalue: 1.84) | ||||||||
14. I was worried that if others discovered my health problems or situation, I could lose my children, security, or housing (0.74) | 0.86 | |||||||
34. Others were preventing me from getting the help I needed (0.71) | 0.78 | |||||||
25. I was afraid of the consequences for myself, my children, or my family (0.71) | 0.72 | 0.32 | ||||||
Problem Management Beliefs (Cumulative % of Variance: 58.38; Eigenvalue: 1.38) | ||||||||
1. I thought the problem would probably get better by itself (0.59) | 0.77 | |||||||
11. I thought the situation was normal or was not severe (0.69) | 0.21 | 0.62 | −0.34 | |||||
10. I wanted to or thought I should solve the problems on my own (0.64) | 0.58 | 0.31 | ||||||
Frozen/Confused (Cumulative % of Variance: 63.54; Eigenvalue: 1.34) | ||||||||
29. I could not seem to clarify my feelings or know what I needed (0.83) | −0.91 | |||||||
30. I was afraid I could not clearly express what I needed (0.67) | 0.22 | −0.61 | ||||||
26. I was confused or unable to plan out all the details or steps (0.69) | 0.24 | −0.20 | −0.56 | 0.31 | ||||
27. I felt paralyzed or frozen and unable to get started (0.70) | 0.26 | 0.30 | −0.43 | 0.25 | ||||
Inconvenience (Cumulative % of Variance: 68.08; Eigenvalue: 1.18) | ||||||||
5. I had distance or transportation problems (0.78) | −0.83 | |||||||
8. I thought getting help would take too much time or was inconvenient (0.64) | 0.27 | 0.22 | −0.60 | |||||
Shame (Cumulative % of Variance: 72.14; Eigenvalue: 1.06) | ||||||||
6. I was concerned about what others might think (0.80) | 0.86 | |||||||
7. I was ashamed (0.72) | 0.79 | |||||||
28. I believed that people would judge me (0.75) | 0.75 |
BHS-TR | Depression | PTSD | ||||
---|---|---|---|---|---|---|
Indices and Subscales | No (n = 80) | Probable (n = 57) | p | No (n = 75) | Probable (n = 62) | p |
Structural Barriers | 20.4 (5.4) | 23.7 (7.7) | 0.00 | 20.5 (5.5) | 23.3 (7.5) | 0.01 |
Financial Concerns | 7.0 (3.2) | 7.3 (3.4) | – | 6.9 (3.3) | 7.4 (3.2) | – |
Unavailable/Not Helpful | 4.4 (2.0) | 5.5 (2.7) | 0.01 | 4.6 (2.2) | 5.1 (2.6) | – |
External Constraints | 5.2 (2.5) | 6.7 (3.2) | 0.00 | 5.2 (2.6) | 6.6 (3.1) | 0.00 |
Inconvenience | 3.8 (1.8) | 4.4 (1.9) | 0.05 | 3.7 (1.7) | 4.5 (2.0) | 0.02 |
Internal Barriers | 39.9 (10.5) | 43.8 (9.9) | 0.03 | 39.8 (10.9) | 43.6 (9.5) | 0.04 |
Weakness/Vulnerability | 12.6 (4.8) | 13.9 (4.7) | – | 12.6 (4.9) | 13.7 (4.7) | – |
Problem Management Beliefs | 8.7 (2.5) | 9.0 (2.4) | – | 8.6 (2.7) | 9.1 (2.1) | – |
Frozen/Confused | 10.5 (3.4) | 12.3 (3.0) | 0.00 | 10.7 (3.6) | 12.0 (3.2) | 0.03 |
Shame | 8.0 (2.9) | 8.6 (3.0) | – | 7.8 (3.0) | 8.8 (2.8) | 0.05 |
Total | 60.3 (13.2) | 67.5 (15.0) | 0.00 | 60.3 (13.7) | 66.9 (14.3) | 0.00 |
Indices and Subscales | Min. | Max. | M | SD | α |
---|---|---|---|---|---|
Structural Barriers | 11 | 44 | 21.8 | 6.6 | 0.75 |
Financial Concerns | 3 | 12 | 7.1 | 3.3 | 0.82 |
Unavailable/Not Helpful | 3 | 12 | 4.8 | 2.4 | 0.71 |
External Constraints | 3 | 12 | 5.8 | 2.9 | 0.77 |
Inconvenience | 2 | 8 | 4.0 | 1.8 | 0.52 |
Internal Barriers | 15 | 60 | 41.5 | 10.4 | 0.88 |
Weakness/Vulnerability | 5 | 20 | 13.1 | 4.8 | 0.86 |
Problem Management Beliefs | 3 | 12 | 8.8 | 2.5 | 0.62 |
Frozen/Confused | 4 | 16 | 11.2 | 3.3 | 0.79 |
Shame | 3 | 12 | 8.3 | 2.9 | 0.83 |
Total | 26 | 104 | 63.3 | 14.3 | 0.87 |
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Thorvaldsdottir, K.B.; Halldorsdottir, S.; Saint Arnault, D.M. 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. Int. J. Environ. Res. Public Health 2022, 19, 104. https://doi.org/10.3390/ijerph19010104
Thorvaldsdottir KB, Halldorsdottir S, Saint Arnault DM. 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. International Journal of Environmental Research and Public Health. 2022; 19(1):104. https://doi.org/10.3390/ijerph19010104
Chicago/Turabian StyleThorvaldsdottir, Karen Birna, Sigridur Halldorsdottir, and Denise M. Saint Arnault. 2022. "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" International Journal of Environmental Research and Public Health 19, no. 1: 104. https://doi.org/10.3390/ijerph19010104
APA StyleThorvaldsdottir, K. B., Halldorsdottir, S., & Saint Arnault, D. M. (2022). 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. International Journal of Environmental Research and Public Health, 19(1), 104. https://doi.org/10.3390/ijerph19010104