Despite these adverse outcomes related to IPV, previous research has shown that help-seeking among survivors is low. Some never seek help, and those who do mainly choose informal sources of help, usually from their family or friends and are less likely to seek formal help, such as from shelters, healthcare services, or the police [22,23,24,25]. The IPV help-seeking literature is primarily focused on escaping the violence and attending to the immediate harm caused. While these often first steps are critical, there is a need for an increased focus on survivors’ pathways for trauma recovery [32,33,34]. Help-seeking after IPV is a complex journey involving a series of meaning-making judgments and socially engaged and culturally informed actions [35,36,37], and the road to recovery is often challenging [38,39].

Findings of low help-seeking rates are consistent with other studies reporting that IPV survivors are faced with a wide range of barriers on sociocultural, structural, interpersonal, and individual levels, e.g., normalization of violence, access challenges, fearing consequences of disclosure, and self-blame [30,40,41,42]. Moreover, studies have indicated that survivors with depression, PTSD, and low SOC face even more significant barriers to help-seeking, such as symptom burden, fearing mental illness stigmatization, and a weak sense of manageability and meaning, making it more challenging to take action [21,36,43,44].

One of the earliest examples of using multiple research methods for validation dates to the 1950s, with Campbell and Fiske’s [48] framework giving rise to methodological triangulation and arguing that the convergence of findings derived from more than one method would strengthen the evidence of validity. However, as innovative and valuable their framework has been, it is first and foremost quantitative (Quan). To date, in the instrument development literature, construct validation is often conceived as mainly a Quan endeavor [45,49,50,51,52]. When qualitative (Qual) data are used, it is usually only granted a supplementary role to Quan data, and often the methods are utilized in isolation rather than fully integrated [50,52,53]. Still, there is a growing literature on mixed methods validation. A few frameworks have been developed that place equal value on Quan and Qual methods, focusing on validity and trustworthiness, and emphasizing the integration or “mixing” of findings from both databases to inform validation evidence for a measure [49,51,52,54].

The term legitimation [46] has been recommended to refer to validity and quality in mixed methods studies, as it considers both Quan and Qual research paradigms [47,57]. The “fit” of data integration refers to the coherence of Quan and Qual findings [55]. Such assessment is likely to lead to four possible outcomes: Confirmation is when the findings are consistent with each other, supporting drawing the same conclusion from each. Complementarity is when the findings tell different but nonconflicting stories (reflecting different sides of the same coin). Expansion is when the findings diverge to a certain degree but, when combined, can expand insights. Discordance is when the findings are inconsistent, contradictory, or disagree with each other [55,56].

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 (n = 17), resulting in the development of new barrier items based on the survivors’ lived experiences. These new items represented barriers related to viewing help-seeking as a sign of weakness and the desire to safeguard oneself from re-traumatization. Using these findings, building was utilized to adapt the BHS-TR scale, and then a psychometric evaluation of the whole instrument with the additional items was carried out (n = 137). 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, mainly due to cross-loadings with different factors, indicating the removal of these items [65]. This mismatch between the participants’ narratives and the factor analysis results pointed to a legitimation issue, demonstrating the need for further systematic assessment of the coherence of barriers to help-seeking Qual and Quan findings.

The joint displays linking the Qual and Quan findings are shown in Table 1 (Structural Barriers) and Table 2 (Internal Barriers), revealing evidence of complementarity, expansion, and discordance. To illuminate the lived experiences of the barriers, exemplar quotations from the survivors were chosen and reported in the Qual columns. The items referred to (using their numbers) in the Quan columns can be found in Supplementary Tables S1 and S2.

Table 1. Joint display of the coherence of findings for structural barriers to help-seeking

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Table 2. Joint display of the coherence of findings for internal barriers to help-seeking

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Most of the Qual and Quan findings were congruent, reinforced one another, were deemed complementary, and strengthened the overall trustworthiness and validity evidence of the BHS-TR. Divergent (expansion and discordance) findings were critically evaluated in an iterative spiraling process [49,70] that illuminated core issues and guided potential refinements; that can help the scale better capture the significant hindrances faced and the immense amount of effort survivors often take to seek help.

This entry is adapted from 10.3390/ijerph19074297