Table 6 Examples of cultural issues identified

Connotations and cultural idioms

In the item “I was afraid I couldn’t clearly express my needs,” the word “needs” was considered by many participants (11 of 17) to be strange in this context. They thought Icelanders would instead use sayings like “how I felt” or “what was wrong.”

“What do you mean by my needs? You know, I know what it literally means, but I would never sit down with my doctor or psychologist and say I need this and that.”

Despite good suggestions from participants, those changes would have altered the literal meaning of the item. The wording was nevertheless changed from “my needs” to “what I needed.”

Different healthcare system

All (17 of 17) participants commented on the item, “My health coverage wouldn’t cover the type of treatment I needed.” Some thought the item was not appropriate in the Icelandic context, while others thought it was relevant regarding some mental health services.

“This sounds very American, we don’t say our or my health insurance, everybody is insured … the system here is so different, and it covers a lot of care. Although not all mental healthcare is government-subsidized, so that affects trauma survivors in Iceland.”

The adapted version of the item became “The available health insurance wouldn’t cover the type of treatment I needed.”

Historically homogeneous nation

Some (8 of 17) participants wondered if the following item, “I felt that my culture, ethnic background or specific situation would not be understood,” should be on the Icelandic version of the scale. However, they often stated that if immigrants were to answer the scale, then this item might be relevant.

“Is this appropriate in Iceland? I don’t think that culture or ethnic background is a problem for most Icelanders … then again, we are becoming more diverse … still, I feel like there is a lot in your background besides ethnicity that you can be scared of people not understanding, so you don’t seek help.”

The item was adapted to the Icelandic context by changing it to “I felt that my culture, background or specific situation would not be understood.”

Historically homogeneous nation

In the item “I felt that there would be prejudice, racism, or discrimination against me,” several (9 of 17) participants focused only on the word “racism” and thought that prejudice or discrimination had to be related to their race.

“This focus on race is not very Icelandic, so yeah, I would answer that this did not affect me because you know of course I thought there would be prejudice, but not about my race or you know racism.”

The adapted version of the item became “I felt that there would be prejudice or discrimination against me,” which could include racism, among other things.