Table 4 Examples of general design issues identified

Unclear scale instructions

Many (13 of 17) participants thought the scale instructions were unclear regarding the time of being faced with these barriers and how to answer if they had, at some point, sought help after their traumatic experience.

“Like what time are we talking about? And what if I did seek help at some point, should I still answer the scale?”

The specific time frame of asking about the last 12 months was added. Clearly stating that if people felt that they needed help during this specific time period but did not seek it, they are asked to answer the scale, even though they had sought or received help in the past.

Response options are forgotten

Several (6 of 17) participants forgot what the response options stood for while answering the scale.

“Halfway through, I forgot what the answer possibilities stood for, you should maybe have them visible at each item, so people do not have to scroll up and down.”

Description of the response options was made to appear more frequently on the scale.

Double-barreled items

Items with the conjunctions “or” and “and” were thought to be confusing and hard to answer by a few participants (3 of 17).

“I do not like these statements with “or” in them, you know asking about two things … it is a little confusing to answer. Also, if I have experienced only the other, how do you know which one I meant?”

None at this point, since fully addressing the issue would require significant modification to the scale.

Repetition

Some participants (5 of 17) thought that the scale included repetitive items.

“I just answered this … I know you are probably going to be looking at if I answered these questions in the same manner, but that is just really annoying.”

No need to adjust, as the BHS-TR is a multidimensional measure, and repetition in this context (and for that purpose) is consistent with good study design.