2.4. Measures

The BHS-TR asks about barriers to seeking help for trauma recovery in the past year. The instrument’s directions are: “Think about your experiences and feelings that are a result of gender-based violence. In the last 12 months, how much of the feelings or attitudes listed below influenced your decisions not to seek help?” Respondents answer on a 4-point Likert scale anchored at 1 (“Did not influence me”) to 4 (“Strongly influenced me”), with a higher total score indicating more help-seeking barriers [26]. The English BHS-TR consists of seven subscales that can be grouped along two indices. The “Structural Index” includes subscales that represent perceived structural barriers, including the “Unavailable/Not Helpful”, “Financial Concerns”, “Discrimination” and “External Constraints” subscales. The “Internal Index” includes subscales that represent perceived internal barriers and is comprised of the “Shame”, “Frozen/Confused” and “Problem Management Beliefs” subscales. The entire scale was psychometrically sound in a sample of American GBV survivors [34]. The initial CI testing of the Icelandic BHS-TR provided evidence of content validity [35], but further psychometric testing was needed which was a primary aim of this study.

The eight-item version of the Patient Health Questionnaire (PHQ-8) [46] is a valid diagnostic tool that measures depressive symptoms in the general population. It consists of eight of the nine criteria on which the DSM-IV diagnosis of depression is based, omitting the last item on PHQ-9 about suicidal or self-injurious thoughts, making it suitable for more general survey use. Respondents are asked to assess the frequency of symptoms in the past two weeks on a 4-point response scale from 0 (“Not at all”) to 3 (“Nearly every day”), resulting in a total score range from 0 to 24. A clinical cut-off score of ≥10 has been recommended to indicate probable depression [46,47]. The Icelandic version of the measure (or the PHQ-9) has been shown to have sound psychometric properties [48]. Cronbach’s alpha in our sample was 0.87.

The PTSD Checklist for DSM-5 (PCL-5) [49] is a widely used and validated measure that assesses the presence and severity of PTSD symptoms. The measure consists of 20 items that correspond with the DSM-5 criteria, and it can be used to screen for probable PTSD. Respondents are asked to rate how bothered they have been by the symptoms in the past month on a 5-point response scale from 0 (“Not at all”) to 4 (“Extremely”), resulting in a total score range from 0 to 80. A clinical cut-off score of ≥31 has been recommended to indicate probable PTSD [49,50,51]. Validation studies on the Icelandic version of the PCL-5 have not been published, but the measure is used in research and clinical work in Iceland. It has been shown to have good internal consistency [52]. Cronbach’s alpha in our sample was 0.96.

Beliefs Toward Mental Illness Scale (BTMI) [53] is a mental illness stigma measure that consists of 21 items assessing negative stereotypical views of psychological disorders, including subscales for dangerousness, social dysfunction, incurability, and embarrassment. The scale was designed to measure differences in such views and to predict treatment-seeking behavior among different cultural groups. Participants rate their level of agreement with the belief statements on a 6-point Likert scale ranging from 0 (“Completely disagree”) to 5 (“Completely agree”). Higher scores reflect more stigma towards mental illness. The BTMI has been demonstrated to be reliable and valid across cultures [53,54,55], but validation studies on the Icelandic version have not been published. Cronbach’s alpha for the full scale in our sample was 0.89, with the alpha values for the subscales ranging from 0.71 to 0.81.

The shortened version of the Orientation to Life Questionnaire (SOC-13) [56] is a widely used measure that assesses sense of coherence, a concept at the heart of the salutogenic model of health and argued to be an important determinant of successful coping with stressful life situations [57,58,59]. SOC-13 consists of 13 items about how people view their life, measuring the three main components of sense of coherence: comprehensibility, manageability, and meaningfulness. Participants rate their level of agreement or disagreement on a 7-point semantic differential scale, with two anchoring responses adjusted to each item. The total score range is from 13 to 91, and a higher score indicates a stronger sense of coherence. The measure has been found to be reliable and valid in multiple studies conducted in numerous countries [60,61], but validation studies on the Icelandic version of the SOC-13 have not been published. The original full 29-item version in Icelandic has been shown to have good internal consistency reliability [62], and Cronbach’s alpha for SOC-13 in our sample was 0.85.