The Healing after Gender-Based Violence Scale (GBV-Heal): An Instrument to Measure Recovery Progress in Women-Identifying Survivors

Abstract

Current literature has primarily equated gender-based violence recovery with an improvement of physical or mental health symptoms, causing a gap in our understanding of the impact of interventions beyond the amelioration of adverse symptomology. The purpose of this research was to create an instrument to holistically measure gender-based violence recovery based on survivor healing goals. Ethnographic interviews were conducted in women-identifying gender-based violence survivors (ages 18–76) to determine healing domains and develop items using survivor language (n = 56). Focus groups with academic and community experts (n = 12) and cognitive interviews with gender-based violence survivors (n = 12) were conducted to ensure content and face validity, as well as to evaluate acceptability. This yielded a 31-item instrument to measure healing progress on a 5-point Likert scale. The Healing after Gender-based Violence Scale has the potential to highlight survivor strength and growth while more accurately measuring their recovery process based on survivor goals and desires.

Keywords

healing recovery violence against women domestic violence sexual assault instrument development Midwest United States

Introduction

Throughout the world, it is estimated that one in three women will experience some form of gender-based violence (GBV) throughout her lifetime, threatening her quality of life and overall wellbeing as she navigates healing and recovery after these experiences (Heise et al., 2002; Walsh et al., 2015). The physical and emotional distress caused by GBV (i.e., intimate partner violence, sexual violence, harassment, stalking) can impact survivors long after their perpetrator is out of their life. For example, adverse social and psychological effects related to intimate partner violence, sexual assault, and child abuse have been well documented in the scientific literature (e.g., posttraumatic stress disorder symptoms, substance use, suicidality, depression, eating disorders, and anxiety). In addition, the injuries, fear, and stress associated with GBV have also been linked to physical health problems such as chronic pain syndromes, gastrointestinal disorders, somatic complaints, fibromyalgia, and gynecological disorders (see Heise et al., 2002 for review).

Impact of Gender-Based Violence beyond Symptom Burden

Beyond physical and mental health symptoms, GBV can affect survivors on many personal, social, and spiritual levels, impacting their ability to connect to themselves, others, and the world around them (Sinko & Saint Arnault, 2019). For example, many survivors struggle to rebuild their identities and self-concepts after these experiences, as they seek to find meaning (Barnes, 2013, Duma et al., 2007; Flasch et al., 2017; Taylor, 2004). Other survivors experience difficulties embracing their freedom or feeling the power to direct their own lives, as they attempt to regain feelings of self-efficacy, competence, and confidence (Flasch et al., 2017). The impact of violence goes well beyond impacting selfhood. Survivors also can struggle to rebuild trust in themselves and those around them, making it difficult for them to build and maintain new relationships (Lewis et al., 2015; Ranjbar & Speer, 2013; Sinko & Saint Arnault, 2019). Negative feelings and worldviews can also perpetuate challenges for survivors, as they seek to rebuild a positive outlook and recognize their potential (Crann & Barata, 2016; Heywood et al., 2019; Matheson et al., 2015). Despite these difficulties and challenges, healing after GBV is possible. Current quantitative instruments to measure and document this process holistically, however, has been limited. Therefore, the purpose of this study is to create a survivor-centered GBV healing measure using survivor voices that can be used to evaluate healing progress and goals.

Healing after Gender-Based Violence

According to Allen and Wozniak (2010), recovering from abuse is “a social, spiritual, cultural, and psychological process” (p. 37). From the perspectives of survivors, healing is non-linear (Sinko et al., 2020b), requires active recovery engagement (Barnes, 2013; Duma et al., 2007; Thompson, 2000), and consists of integrating one’s trauma into their selfhood as they move toward their future goals (Sinko & Saint Arnault, 2019; Sinko et al., 2019, 2020a). Drawing from these concepts, healing after GBV is defined in the present study as a social, spiritual, cultural, and psychological process in which one actively strives to find wellbeing, integrate their GBV experience into their identity, and move toward a future where their trauma does not limit their ability to connect with others and pursue their goals and aspirations. This definition is used as an overarching concept to articulate measurable goals identified through the analysis described below. Quantitative studies to date have been limited in their measurement of healing in this way, typically equating it with a lack of mental or physical health symptom burden, without recognizing the many other areas in which survivors seek to make progress (see Ahrens et al., 2010; Lindhorst & Beadnell, 2011 for examples). While symptom management is a critical element of recovery, as noted in the studies cited above, survivors often see recovery as much more than the alleviation of symptom burden. Thus, healing must be evaluated holistically using survivor-relevant concepts to give a more accurate understanding of this process in relation to other variables.

Current Outcome Measures Being Used To Measure Recovery after GBV

There has been some progress looking at positive growth in survivors of GBV. However, these outcome measures have been created to measure recovery from trauma generally, rather than trying to capture specific nuances of healing that GBV survivors want and need (see Table 1 for a description of these measures). One way recovery has been discussed in the literature is using the concept of resilience. Resilience is conceptualized as an individual’s ability to bounce back after adverse life events (Bonanno, 2004) or “the ability of individuals facing adversity to utilize resources within psychological, social, and cultural domains that sustain their wellbeing and promote adaptive outcomes” (Schaefer et al., 2018, p. 18). Resilience has been measured in many ways in the scientific literature to date and has been applied to individuals who experienced many different types of adversity. Despite this, resilience, as it is measured, focuses more on protective traits individuals possess (e.g., personal competence, social competence, family coherence, social support, personal Structure; Friborg et al., 2003) rather than their perceived progress from baseline. The concept of resilience itself may also be problematic to survivors of GBV, as it fails to recognize structural and systemic issues that perpetuate violence and can label survivors who are still struggling with their trauma symptoms as “non-resilient,” rather than recognizing the non-linearity of the healing journey.

Table 1.

Instruments Used to Measure GBV Recovery.

Measure	Authors	Objective	Pop. of interest	Items	Subscales
Posttraumatic growth inventory (PTG)	Tedeschi and Calhoun (1996)	To measure perceived benefits to self, to interpersonal relationships, and philosophy on life after a traumatic event	Persons experiencing a variety of traumatic events (e.g., heart attack, combat, etc.)	21	1. Relating to others
					2. New possibilities
					3. Personal strength
					4. Spiritual enhancement
					5. Appreciation
Connor-Davidson resilience scale (CD-RISC)	Connor and Davidson (2003)	To quantify resilience and to assess treatment response	Persons experiencing generalized anxiety disorder (GAD), depression, and posttraumatic stress disorder (PTSD)	25	1. Personal competence
					2. Acceptance of change and secure relationships
					3.Trust/Tolerance/Stress strengthening effects
					4. Control
					5. Spiritual influences
Resilience scale for adults (RSA)	Friborg, Hjemdal, Rosenvinge, and Martinussen (2003)	To measure the presence of protective resources that promote adult resilience	Persons overcoming difficult life conditions	37	1. Personal competence
					2. Social competence
					3. Family coherence
					4. Social support
					5. Personal structure
Trauma symptom checklist for children (TSCC)	Briere (1996)	To assess the effects of childhood trauma through the child’s self-report of trauma symptoms	Children (aged 8–16) experiencing complex trauma	54	1. Anxiety
					2. Depression
					3. Posttraumatic stress
					4. Dissociation
					5. Anger
					6. Sexual concerns
Coping strategy indicator (CSI)	Amirkhan (1990)	To measure coping responses to a specific stressful event	Persons having experienced a stressful event (e.g., physical disability, partner violence, etc.)	33	1. Problem-solving
					2. Seeking social support
					3. Avoidance
Brief resilience coping scale (BRCS)	Sinclair and Wallston (2004)	To measure resilience as it pertains to coping with stress	Persons suffering from rheumatoid arthritis (R.A.) and related stress	4	N/A
Posttraumatic stress disorder checklist for DSM-5 (PCL-5)	Blevins et al. (2015)	To diagnose posttraumatic stress disorder (PTSD).	Persons having experienced very stressful life events	20	1. Re-experiencing
					2. Avoidance
					3. Negative alterations in cognition/ mood
					4. Anhedonia
					5. Dysphoric arousal
					6. Anxious arousal

Another growing body of literature highlights the idea of posttraumatic growth. Posttraumatic growth is a concept that highlights the positive changes and individual experiences as a result of their survival of a highly stressful event (Tedeschi & Calhoun, 1996). The literature on posttraumatic growth has encompassed a wide variety of traumatic experiences (e.g., natural disasters, community violence, medical trauma), highlighting the importance of three general domains: changes in the perception of the self, changes in the experience of relationships with others, and changes in one’s general philosophy of life (Tedeschi & Calhoun, 1996). The posttraumatic growth literature postulates that positive posttraumatic changes occur through the process of making meaning out of traumatic events, enabling individuals to overcome psychological burdens and distress (Tedeschi & Calhoun, 2004). Despite progress looking at growth in trauma survivors using this instrument, there are important nuances to recovery that are related to the type of trauma experienced, and these may warrant more specific measurements to better track outcomes. For example, a study conducted by Shakespeare-Finch and Armstrong in 2010 revealed that sexual assault survivors had significantly higher PTSD levels and more significant difficulties relating to others and appreciating life when compared to survivors of motor vehicle accidents and those in bereavement. The authors concluded that the direct threat to personal physical integrity and the fact that sexual assault is a trauma that is intentionally perpetrated by another person might add another dimension to one’s trauma experience (Shakespeare-Finch & Armstrong, 2010). This study reveals that the posttraumatic growth instrument may not capture some nuances of healing after sexual assault and other forms of GBV. This missing data was confirmed through subsequent qualitative studies conducted by the first and senior author, used as a foundation for this analysis (see Sinko & Saint Arnault, 2019; Sinko et al., 2019, 2020b).

It is also important to note that the wording of the posttraumatic growth instrument may be problematic for the population of GBV survivors. Specifically, the stem of the questions on the posttraumatic growth instrument state each improved outcome “as a result of [the survivor’s] crisis.” This stem may feel objectionable to GBV survivors because it implies that one experiences such positive changes as a result of their crisis, rather than as a result of personal efforts toward healing and recovery (Tedeschi & Calhoun, 1996). Attributing positive changes merely due to experiencing trauma itself may feel disempowering to GBV survivors. Moreover, this attribution may be difficult for them to relate to because it does not give justice to the work and effort survivors have put into their healing journeys. This impact of this wording is even more critical because of the trauma-informed practice guidelines, as well as the emphasis on empowerment that many survivors have in their healing, in which they try to feel strong and capable throughout their recovery experiences (Sinko & Saint Arnault, 2019; Sinko et al., 2019). We suggest that a more relevant recovery outcome measure is needed for survivors of GBV.

The Present Study

This manuscript documents the first step in a larger sequential multiple method study design aimed to create and psychometrically test a holistic healing instrument that captures recovery progress in survivors of GBV. Specific aims of this portion of the study include: (1) create a measure to capture healing progress using the narratives of GBV survivors, and (2) evaluate the content validity, face validity, and acceptability of this instrument incorporating feedback from both experts and survivors themselves. By involving survivors and supporters of survivors in all aspects of the process, we aimed to synthesize key elements and shared goals as one navigates their healing journey. While we recognize that survivors may differ in their healing goals and desires, we believe the development of this measure can create an important starting point for evaluation and discussion of healing goals and progress with GBV survivors.

Methods

Design

As mentioned above, this manuscript reports the qualitative results of a larger sequential multiple methods study aimed to develop and psychometrically test a healing after GBV measure in the United States (Benson & Clark, 1982). Thematic analysis on GBV survivor narratives documented overarching healing domains, with codes being used to generate items using survivor language. The domains identified for this measure were verified by a qualitative metasynthesis, prior to further testing content and face validity with academic and service provider focus groups. Finally, cognitive interviews with survivors were conducted to gain survivor feedback on the measure and to gauge acceptability of its use to document healing progress.

Psychometric testing of this measure can be found here (Sinko et al., under review). Additional testing is currently underway in partnership with an international GBV consortium consisting of 11 countries to evaluate this measure’s transferability and relevance in populations outside of the United States (Thomas & Magilvy, 2011). This study was deemed exempt by the University of Michigan Institutional Review Board.

Item Development and Validation

The items for this instrument were derived from narratives gathered from four studies conducted by the first author and senior author. In these studies, women survivors of GBV (N = 56) from the United States were asked about their healing goals and aspirations using photographic and narrative methods (Sinko & Saint Arnault, 2019; Sinko et al., 2019, 2020a, 2020b). In this pooled sample, 42 participants were white, 8 were African American or Black, and 6 were Asian. Thirty-one women were age 18 to 30, 5 women were age 31 to 40, 9 women were age 41 to 50, and 11 women were over the age of 50. The highest education achieved varied in the sample, but most of the participants had graduated high school (n = 52) and been exposed to higher education at least at some point in their life (n = 41), though not all had graduated with a degree (n = 22). Women experienced a variety of GBV events including sexual assault, sexual harassment, intimate partner violence, childhood abuse, or a combination of multiple forms of GBV.

Transcripts from these studies were pooled together and were analyzed as one large dataset, to articulate common survivor healing goals across studies. Thematic analysis was used to identify healing goals and overarching domains (Strauss & Corbin, 1998). Healing goals were defined broadly as any outcome survivors mentioned wanting to work toward in their recovery or any deficit survivors noticed that they wanted to work toward improving. Close readings of the transcripts contributed to a preliminary sense of the interviews, and a preliminary codelist was developed. This codelist was defined and then applied to the full dataset of interviews. Main themes were identified via codes created through abstracting to main categories, allowing “systematic comparison” and “conceptualizing” (Strauss & Corbin, 1998). These main themes served as the healing domains mentioned below (N = 7). Codes under each domain that were mentioned by more than five survivors were created into items using participant-derived wording (N = 67).

Reconciliation meetings were held within the team to subsequently synthesize and condense items to minimize participant burden without losing core content, creating a final measure of 28 items. ATLAS.ti qualitative software was used for data management and analysis (Muhr, 2006). An audit trail using personal, theoretical, and analytic memos was maintained, with coding concepts being discussed at length in research team meetings for verification of accuracy and to ensure dependability of our findings (Thomas & Magilvy, 2011). A qualitative metasynthesis of literature to date describing healing after GBV was conducted independently using meta-ethnographic techniques (Noblit & Hare, 1998) to validate the domains discovered prior to additional content validity testing in the community (see Sinko & Hughesdon, in press for details of this metasynthesis).

Expert Focus Groups to Evaluate Face Validity and Content Validity

We conducted two focus groups with experts in GBV survivor recovery to evaluate face validity, whether the instrument appears to be measuring the concept of interest, and content validity, whether instrument content adequately covers the domain of interest (Fitzpatrick et al., 1998). These experts were asked to provide their perspectives in these areas and provide suggestions to refine the items of our instrument before we engaged survivors in cognitive interviews. The first focus group was with nursing and public health academics with GBV expertise (n = 4) along with undergraduate students whose research focused on recovery after GBV (n = 2) (academic focus group). These individuals were chosen due to their active participation in a GBV lab focused on help-seeking and recovery. The second focus group was with GBV survivor advocates and program directors with service delivery experience in rape crisis and domestic violence (n = 8) (advocate focus group). Both focus groups had one facilitator, were 1 hour in duration, and consisted of open-ended questions with a subsequent discussion surrounding item wording, instrument structure, and content. The academic focus group consisted of GBV researchers who were at various stages in their training (one full professor, one assistant professor, two masters students, two undergraduate students). The advocate group consisted of individuals with experience in GBV service delivery (four advocates with masters in social work (MSW), one PhD and one MSW violence services director, two GBV prevention education specialists with MSWs). Edits from the first academic focus group were applied before receiving edits from the advocate group. This edited instrument was used during cognitive interviews with survivors.

Cognitive Interviews for Additional Content Validation and Acceptability

We conducted cognitive interviews with women who self-identified as having experienced GBV to provide further evidence of content validity (Drennan, 2003) as well as to gather survivor perspectives of the acceptability of using this instrument to document healing progress. Cognitive interviewing is an interviewing tool that has been used in previous studies to pretest instruments and determine item and conceptual clarity (Drennan, 2003). We framed our cognitive interviews as “think-alouds,” asking survivors to complete the measure while speaking their thoughts aloud, as research study staff took notes on their paper copy (Collins, 2003). After completing the measure while thinking out loud, raters were asked some general probing questions to stimulate further discussion about acceptability (i.e., general impressions of acceptability, usefulness, clarity, emotional experience, suggestions for improvement to more holistically meet the needs of the population).

Cognitive interviewing participants were recruited via a university health system research portal, connecting patients of a local academic medical center to research opportunities as well as through community GBV service agency listservs in Southeastern Michigan in the United States (N = 12). Participants were eligible if they self-identified as a woman survivor of gender-based violence and were able to meet study staff for the in-person interview. Interested participants were given two research days where they could sign up for anonymous cognitive interviewing slots. Due to a desire for anonymity, these interviews were not recorded and demographic and other identifying information was not collected. While this was done to make evaluation as low barrier as possible, this is a limitation that should be noted. Survivors were compensated with a $10 gift card for their time and were given a GBV resource list following the think-aloud session. Once the cognitive interview process no longer elicited new feedback, the researchers pooled the notes and made further revisions.

Two interviewers conducted the cognitive interviews. Both interviewers had training in trauma-informed interviewing and de-escalation strategies to mitigate and feel prepared to appropriately respond to emotions triggered by the discussion. Interviews were also conducted within a local GBV service agency in case participants needed any additional professional follow-up. While these safeguards were in place, no significant de-escalation or professional referrals were needed during the duration of this study. Handwritten notes were taken by study staff during this discussion and a written list of participant feedback and comments was generated after each interview, with appropriate edits to the measure made accordingly at the conclusion of each research day.

Results

Original Items

Through our synthesis, we identified seven main healing domains: (1) reconstructing identity, (2) reconnecting with the self, (3) regaining power and control, (4) cultivating worthiness, (5) relating to others, (6) rebuilding hope and a positive worldview, (7) finding peace. We will describe each domain below and will provide examples of quotations that generated our items (see Table 2 for definitions and additional quotations). These themes were compared with the results gathered from an independent qualitative metasynthesis conducted by the first author along with a researcher outside of the research team to minimize bias. Core themes found in that analysis included: (1) trauma processing and reexamination, (2) managing negative states, (3) rebuilding the self, (4) connecting with others, and (5) regaining hope and power (Sinko & Hughesdon, in press). These themes were found to be similar to the domains discovered through our analysis, with no glaring contradictions, improving confidence to our findings before further testing content validity in the community.

Table 2.

Domain Table for GBV-Heal Items.

Domain	Definition	Exemplar quotes	Items created
Reconstructing identity	Learning who one is after trauma by acknowledging one’s strength, practicing self-acceptance, and rebuilding one’s path.	“So that was the biggest thing .So probably just really focus on trying to figure out what strength is, where there is good, and what things still hold value to you”	1. I feel comfortable with my path and who I am becoming.
		“Healing is a process. It is finding ways to integrate what I have been through with who I am, both despite it and because of it. It’s not about trying to get rid of the pieces of me that have been shaped by it, because that’s never going to happen. . . It’s about trying to accept parts of myself and work through what has happened”	2. I feel like I know who I am and what makes me, me.
			3. I feel able to accept the parts of myself that I do not like.
			4. I feel able to acknowledge and build on the parts of myself that I do like.
			5. I feel that I have inner strength.
Reconnecting with the self	Feeling able to trust one’s decision-making and connect to one’s body, mind, and emotions.	“Yeah, I probably don’t spend enough time thinking about being present in my body, as much as I think about pushing it in some way; whether it be mental, physical, or emotionally capacity”	6. I feel connected to my mind and body
			7. I trust my ability to keep myself safe.
		“So, still being able to experience joy and experience pride and triumph and all of that without trying to push away from the other side of things”	8. I feel able to experience joy and other positive emotions.
			9. I allow myself to process and feel my negative emotions.
Regaining power and control	Feeling as though one is capable of managing their own decisions, symptoms, and recovery process.	“I am in a better mindset than I was before, because I am recognizing the signs [of distress]. I accept them, and I am taking the steps to try to circumvent the effects, and just advocating for myself”	10. I feel like I am in the driver’s seat of my recovery process.
			11. I feel able to cope with my post-trauma symptoms without having them control or overwhelm me.
		“So, you know, it was just a good productive time in my life, where I really felt like I had a lot of autonomy and flexibility to kind of explore what I was doing, while working and feeling like I was being a contributing member of society”	12. I feel like I am able to function within and contribute to society.
Cultivating worthiness	Fostering positive beliefs about one’s value through self-reflection, engaging in activities, and interacting with people who empower individuals to feel capable and deserving of respect and healing.	“Yeah, and I have been really working on it. . .I have been trying to really put my energy where it is helpful to me. . .pursue what makes me feel good about myself, which is my art. . .I feel like after all of this, I feel good about myself, and I feel proud of where I am”	13. I feel worthy of love and respect.
			14. I feel able to love myself.
			15. I feel that others acknowledge my worth and treat me the way I should be treated.
		“Part of my art is about normalizing the body and accepting it . . .I feel like I become more comfortable with myself. . .feeling like the things that I’ve been taught are flaws in myself don’t need to actually be thought of as flaws, they’re just parts of bodies that are normal and natural”	16. I engage in activities that make me feel like my life is worth living.
Relating to others	Feeling able to build and maintain relationships through building trust and feeling as though one can be vulnerable with others in order to connect with them on an authentic level.	“Don’t be like me and withdraw completely. . .but don’t pretend to be someone else either”	17. I trust those close to me to act in my best interest.
		“Like the trust that I lost or like the things that I think about myself that I wouldn’t have before I was, um, assaulted. Um, and then building new truths about like what is my relationship to men or my friends or my family, and like what is my relationship to what happened? What is my relationship to myself?”	18. I feel capable of being in an intimate relationship should I so choose.
			19. I feel heard and understood by trusted others in my life.
			20. I feel able to connect with trusted others on an authentic level.
			21. I feel able to contribute to a larger conversation about issues that are important to me.
Rebuilding hope and a positive world view	Feeling safe and optimistic about one’s future while finding and acknowledging the positives within one’s life and the world around them.	“So I have a picture in my minds eye of a house it’s a 2 story house, its yellow, it has a drive up to it, there’s well maintained gardens on one side and this side runs into the forest and somewhere in the future that is”	22. I feel hope that healing is possible in time.
			23. I trust that the world is a safe place.
		“I haven’t like felt really hopeful or successful recently. . .so, this moment was me feeling like hopeful for this job that I was about to go and talk about. Um, and I guess like noticing that hopefulness. . .”	24. I feel that my future is bright.
Finding peace	Feeling able to be present within one’s life through feelings of lightness, calm, and peace	“I would say we have learned what serenity, quietness, calmness, peace is because we’ve had it now for 11 months. It’s absolutely fantastic, you can hear the birds in the morning….”	25. I am able to feel peaceful when I am alone.
Finding peace		“So, I went to Niagara Falls for the first time. . .I just felt really at peace there. . . I’d like to experience more moments like that, having more of those calm moments where like you feel at peace. You don’t feel the pressure of the world. It’s a time to like be introspective and just experience things”	26. I feel able to be emotionally present in my everyday life.

Reconstructing identity

The concepts of regaining identity and purpose, finding strength, and self-acceptance contributed to our understanding of our first domain—reconstructing identity—and led to the creation of five items. For example, the quotation “I have inner strength. . .I learned it. . .I could’ve given up, but I’ll never give up” led to the creation of the item “I feel that I have inner strength.”

Reconnecting with the self

Concepts of restoring feelings of competency, rebuilding self-trust, reclaiming one’s body, and allowing oneself to feel and process emotions contributed to our understanding of our second domain—reconnecting with the self—which led to the creation of four items. For example, one participant said “I think I am still scared. . .of not knowing whom to trust, and about being worried that I am going to choose somebody that is wrong and I am not going to know until it is too late.” This participant went on to describe how regaining self-connection and trust in herself was a goal for her. She shared, “I have been really working on it, you know. I see my therapist twice week. . .I think I am starting to get to the point where I am considering starting to kind of try to get back out there a bit.” This healing goal, though not fully actualized by this survivor yet, led to the creation of “I trust my ability to keep myself safe.”

Regaining power and control

Themes of managing symptoms, navigating darker moments, and engaging in active recovery contributed to our understanding of our third domain—regaining power and control—which led to the creation of three items. For example, the quotation “I stopped believing in me, so I took the backseat of the car. . . when I decided enough was enough I climbed back, I changed the roles around and. . .got into the driver’s seat” led to the creation of the item “I feel like I am in the driver’s seat of my recovery process.”

Cultivating worthiness

Themes of sense of belonging, living a purposeful life, self-love, and finding fulfillment contributed to our understanding of our fourth domain—cultivating worthiness—which led to the creation of four items. For example, the quotation “healing means finding a life worth living. I think I need to find what I enjoy and am passionate about” led to the creation of the item “I engage in activities that make me feel like my life is worth living.”

Relating to others

Themes of regaining trust, connecting with others, having authentic interactions, building and maintaining relationships, finding your voice, and feeling heard and understood contributed to our understanding of our fifth domain—relating to others—which led to the creation of five items. For example, the quotation “I remember hearing boys talking about [a rape in the news] . . .just staying really stupid things. In my heart, I knew it was wrong. . .but I [didn’t] say anything. I didn’t feel articulate enough” led to the creation of the item “I feel able to contribute to a larger conversation about issues that are important to me.”

Rebuilding hope and a positive worldview

Themes of releasing negativity, finding hope, belief in a brighter future, and feelings of safety contributed to our understanding of our sixth domain—rebuilding hope and a positive worldview—which led to the creation of three items. For example, the quotation “be open to the idea that maybe something will help someday, and to look for things that might” led to the creation of the item “I feel hope that healing is possible in time.”

Finding peace

Themes of feelings of freedom and serenity contributed to our understanding of our last domain—finding peace—which led to the creation of two items based on our synthesized first-order constructs. For example, the quotation “[I] just enjoy the silence and the peace by myself. . .getting to think and just to reflect on how I [am] feeling” led to the creation of the item “I am able to feel peaceful when I am alone.”

The Healing after Gender-based Violence Scale (GBV-heal)

This synthesis led to the creation of two similar 27-item instruments. The first instrument was designed to evaluate the items based on one’s perception of their lowest point. The second instrument was designed to evaluate the items based on the participant’s current feelings. Each item in both scales was evaluated on a five-point Likert scale anchored at 0 for “not at all” and 4 for “to a great extent.” The scales were constructed in this way in an attempt to measure the healing process cross-sectionally, using one’s lowest point as a baseline to understand trauma impact and one’s current feelings to demonstrate progress to date. These instruments were then brought to focus groups of GBV academics and advocate experts for further refinement.

Academic and Service Provider Focus Groups

The six person academic focus group provided important feedback on the structure of the instruments themselves, suggesting condensing the two instruments into one measure evaluating each item from one’s lowest point and current feelings back to back (as opposed to filling out the lowest point instrument first before the current feelings instrument). They also suggested adding wording to the beginning of the measure to frame the scope and impact of GBV. Overall, the academic focus group verified content and face validity, but did note the missingness of the concept “reaching out for help” leading to the creation of the item “I feel able to reach out to others if I am struggling or need help.” These changes were made and were then evaluated by the advocacy focus group.

The eight members of the advocate focus group read the measure silently while taking notes in the margins before engaging in group discussion. Revisions suggested included changing the wording of items derived directly from survivor quotes to more standardized language to be more applicable to all survivors (i.e., changing “I feel like I am in the driver’s seat of my recovery process” to “I feel empowered to take charge of my recovery process”). Advocates also challenged the notion that the item “I trust that the world is a safe place” may not be necessarily valid for all survivors and preferred us to rephrase and say, “I feel able to recognize and acknowledge the good in the world.” They also suggested we change “I feel my future is bright” to “I can see new possibilities for my future” for similar reasons. The advocate group also requested the addition of two items they felt were missing from the measure: (1) “I feel able to recognize and act on my own discomfort” and (2) “I feel able to forgive myself for my post-trauma behaviors that bring me guilt and shame.” These edits were made, and the revised instrument was then evaluated by survivors using cognitive interviews.

Cognitive Interviews

Overall, survivors described feeling impressed with the measure saying things like “each statement connected with me. . .nothing was irrelevant” (Participant GR16), and “this reminded me about how far I have come, although some things are not perfect” (Participant NE05). Participants also shared that they thought the measure was acceptable because it didn’t feel “triggering” (Participant BE265; Participant R07; Participant LA10). Survivors suggested three additional items to improve relevance. First, four survivors suggested adding questions surrounding self-blame and responding to oneself with kindness. These comments led to the addition of the items “I feel as though I am not to blame for my experiences” and “I am able to be kind to myself” (Participant NE05; Participant BE265). Another suggestion was adding an item about “not feeling alone” to the end of our survey to ensure the person ended on a positive note to improve the acceptability of this measure (Participant BE265). This comment led to the creation of the item “I feel as though I am not alone in my experiences,” which is now the final question in our scale.

While no significant content suggestions were made to existing items, suggestions on item wording and removal were voiced to reduce redundancy (n = 7). Some survivors also noticed some double-barreled questions that caused some response confusion which was not mentioned by our previous focus groups. For example, the question “I feel able to acknowledge and build on the parts of myself that I do like” was changed to “I feel able to acknowledge the parts of myself that I do like.” Similarly, participants struggled with the question “I feel connected to my mind and body,” as they said the mind and body are different, and thus could not be asked together in a single question. Upon further discussion, however, it appeared that rather than breaking this question into two, survivors were satisfied by the coverage of this question by other items in the scale, causing us to end up removing this item entirely. Additionally, the item “I feel able to be emotionally present in my everyday life” was confusing to some survivors and due to redundancy with items pertaining to experiencing positive and negative emotions, this item was also dropped. After adding participant suggestions, our final version included 31-items (evaluating the difference between one’s lowest point after their GBV experience and current feelings) that will be used for psychometric testing and item reduction. See Appendix 1 for full scale prior to psychometric testing.

Discussion

Our study, based on narrative interviews with 56 women survivors of GBV, yielded a 31-item self-report measure called the “Healing after Gender-based Violence” scale (GBV-Heal). The evaluation of this measure by academics, GBV survivor advocates, and survivors themselves, helped ensure high content and face validity, while also demonstrating its acceptability as a progress measure. These beginning study phases found that the measure was considered useful, relevant, and helpful for survivors to examine their healing goals, providing a strong rationale for the next study phase of psychometric testing. Because it was derived from survivors themselves, it captures vital processes they believe are important. Further, psychometric testing can now be used to reduce the number of items, discover subscales, evaluate test-retest reliability, and determine convergent and divergent validity with other relevant measures in the field.

While the domains revealed in the qualitative portion of this development have some overlap with other measures in the literature, our initial synthesis, subsequent focus groups, and cognitive interviews revealed essential nuances related to GBV trauma recovery that warrant specific quantitative attention and evaluation. For example, the literature in posttraumatic growth focuses on important subconcepts of relating to others, new possibilities, personal strength, spiritual change, and appreciation of life (Tedeschi & Calhoun, 1996). While some of our synthesized themes overlapped with these concepts (particularly with relating to others, personal strength, and new possibilities), our synthesis revealed that posttraumatic growth does not cover all the healing domains survivors deemed important. Our analysis found that survivors also had healing processes and goals related to the examination of self-concepts, including reconstructing identity and reconnecting with the self. These self-concepts are a highly documented area of GBV survivor healing in the scientific literature to date (e.g., Duma et al., 2007; Flasch et al., 2017; Taylor, 2004). Similarly, while resilience measures one’s ability to bounce back from adversity, it does not capture how one might bounce back (e.g., Connor & Davidson, 2003). Therefore, while there are similarities, our measure expands toward a broader notion of healing and the goals survivors seek to reach along the way. Interpersonal traumas, particularly GBV, may require additional or different healing considerations because their experience of violence was an intentional violation of bodily autonomy perpetrated by another person (Shakespeare-Finch & Armstrong, 2010). Additionally, measures such as posttraumatic growth are restricted in that they do not get a sense of the impact of one’s trauma in their measurement, limiting their ability to evaluate progress from baseline in cross-sectional studies.

Nurses are well-positioned to advocate for the holistic healing needs of survivors of GBV and to use GBV-Heal to measure recovery progress for survivors within our healthcare system and communities. GBV has historically been a nurse championed public health issue, with nurses not only spearheading the 1970’s grassroots feminist effort calling for reform in healthcare to address domestic violence, but also leading healthcare’s effort to provide better, more tailored care to sexual assault survivors (“Confronting Violence,” 2015; Draucker, 2002; Holloway, 1993; O’Brien, 1996). As nurses, it is important to ensure we are appropriately evaluating the interventions we are delivering, and by relying on the medical model alone to understand recovery after violent experiences, important elements of our patients lived experience are being missed. Future research will understand how nurses can best integrate this assessment and subsequent progress evaluation into current clinical and community infrastructure, to ensure we are empowering survivors to actively engage in their healing journey, a critical element to regaining health and wellness after these experiences (Sinko & Hughesdon, in press).

The GBV-Heal can have many practice and research implications. This instrument is the first of its kind to evaluate GBV healing progress using concepts based on survivor healing experiences. A measure of this type may allow nurses and other healthcare providers to evaluate healing progression based on GBV survivor-derived healing goals rather than depression, anxiety, and PTSD metrics alone. Using this process approach can also help nurses evaluate the nuances of trauma healing in this population and better track client progress toward areas the survivor deems important. This approach may also empower survivors by helping them identify their areas of strength and accomplishment, while also identifying areas they want to focus on as they move through their recovery journey.

GBV-Heal provides a change score based on differences in items, allowing researchers to cross-sectionally evaluate survivor perspectives about where they are in their healing journey based on how they felt at their lowest point. This change score can allow measurement of an additional piece of the trauma recovery puzzle. We can also use the change score to understand variable correlations with the domains that have been consistently identified by survivors for the past 25 years (Sinko & Hughesdon, in press). Additionally, our psychometric testing in the next phase of this study will reveal whether the “current feelings” portion of this measure alone can be used as a baseline in studies that have multiple time points. This will allow scores to be evaluated overtime, promoting more holistic intervention evaluation of trauma recovery initiatives.

It is important to note that healing does not occur in a vacuum. While this measure was intended to serve as a way to better understand cross-sectional correlations with healing as well as a tool to more holistically evaluate GBV recovery interventions, caution should be used when interpreting these results without context. The role of culture, social standing, and social context are important things to consider when evaluating one’s recovery process. Thus, future research should aim to use this measure to better understand culturally-relevant mechanisms, barriers, and facilitators of these healing goals. Safety and security has also been found to be an essential foundation before one works toward recovery (Sinko & Hughesdon, in press) and tracking one’s progress toward these goals may not be appropriate if one is currently in an active abuse or crisis situation.

The creation of GBV-Heal has some important limitations to note. Items were created based on American survivor stated goals, and future testing will be needed to evaluate its relevance with other cultures who experience GBV. In addition, the lack of demographic information collected is a significant limitation of this work and next steps include evaluating the transferability of this scale in cultures internationally (n = 11) as well as in Indigenous or other marginalized populations who may have different or more culturally-nuanced healing needs. Additionally, our cognitive interviewing participants and expert panel members were volunteers with varying levels of education residing in the Midwest United States. This could have contributed to gaps in understanding of how clients of different areas of the world or country would conceptualize healing. Finally, this measure was created based on the feedback of woman-identifying survivors. Additional research is needed to understand healing experiences, processes, and goals for male-identifying, non-binary, and gender-nonconforming individuals. Despite these limitations, the GBV-Heal shows great promise to move the quantitative literature forward to better describe variable relationships with the often nebulous concept of survivor healing. Because this measure was derived from the voices of survivors, it has the potential to allow for more survivor-centered research, intervention, and practice approaches. By creating a more holistic measure for recovery after GBV experiences, we can better understand how to foster and promote healing in this population. This will encourage providers and survivors to view their healing in a holistic way, acknowledging small victories as they actively work toward recovery and wellness.

Footnotes

Appendix 1

Table A1.

GBV-Heal Items Prior to Psychometric Testing.

		Not at All	A little bit	Somewhat	To a considerable degree	To a great extent
1. I feel comfortable with my path and who I am becoming.	At my lowest point
1. I feel comfortable with my path and who I am becoming.	My current feelings
2. I feel like I know who I am and what makes me, me.	At my lowest point
2. I feel like I know who I am and what makes me, me.	My current feelings
3. I feel able to accept the parts of myself that I do not like.	At my lowest point
	My current feelings
4. I feel able to acknowledge the parts of myself that I do like.	At my lowest point
	My current feelings
5. I feel that I have inner strength.	At my lowest point
5. I feel that I have inner strength.	My current feelings
6. I trust my ability to keep myself safe.	At my lowest point
6. I trust my ability to keep myself safe.	My current feelings
7. I feel able to experience positive emotions.	At my lowest point
7. I feel able to experience positive emotions.	My current feelings
8. I feel able to accept my negative emotions.	At my lowest point
8. I feel able to accept my negative emotions.	My current feelings
9. I feel empowered to take charge of my recovery process.	At my lowest point
9. I feel empowered to take charge of my recovery process.	My current feelings
10. I feel able to cope with my posttrauma symptoms without having them overwhelm me.	At my lowest point
	My current feelings
11. I feel able to contribute to society.	At my lowest point
11. I feel able to contribute to society.	My current feelings
12. I feel able to reach out to others if I am struggling or need help.	At my lowest point
	My current feelings
13. I feel worthy of respect.	At my lowest point
13. I feel worthy of respect.	My current feelings
14. I feel able to love myself.	At my lowest point
14. I feel able to love myself.	My current feelings
15. I feel that those around me acknowledge my worth and treat me the way I should be treated.	At my lowest point
	My current feelings
16. I engage in activities that make me feel like my life is worth living.	At my lowest point
	My current feelings
17. I trust those close to me to act in my best interest.	At my lowest point
17. I trust those close to me to act in my best interest.	My current feelings
18. I feel capable of being in an intimate relationship should I so choose.	At my lowest point
	My current feelings
19. I feel heard and understood by trusted others in my life.	At my lowest point
	My current feelings
20. I feel able to connect with trusted others on an authentic level.	At my lowest point
	My current feelings
21. I feel able to contribute to a larger conversation about issues that are important to me.	At my lowest point
	My current feelings
22. I feel hope that healing is possible in time.	At my lowest point
22. I feel hope that healing is possible in time.	My current feelings
23. I feel able to recognize the good in the world.	At my lowest point
23. I feel able to recognize the good in the world.	My current feelings
24. I can see new possibilities for my future.	At my lowest point
24. I can see new possibilities for my future.	My current feelings
25. I am able to be kind to myself.	At my lowest point
25. I am able to be kind to myself.	My current feelings
26. I am able to feel peaceful when I am alone.	At my lowest point
26. I am able to feel peaceful when I am alone.	My current feelings
27. I feel able to communicate my needs to others	At my lowest point
27. I feel able to communicate my needs to others	My current feelings
29. I feel able to recognize and act on my own discomfort.	At my lowest point
29. I feel able to recognize and act on my own discomfort.	My current feelings
30. I feel able to forgive myself for my past posttrauma behaviors that bring me guilt and shame.	At my lowest point
	My current feelings
31. I feel as though I am not to blame for my experiences	At my lowest point
31. I feel as though I am not to blame for my experiences	My current feelings
32. I feel as though I am not alone in my experiences	At my lowest point
32. I feel as though I am not alone in my experiences	My current feelings

Note. Gender-based violence (GBV) can encompass such acts as intimate partner violence, sexual violence, sexual harassment, child abuse, forced sex work, genital cutting, and stalking. GBV can have great impacts on our physical, social, mental, and emotional health. Below are statements that depict experiences and feelings people have. Please indicate for each statement below the degree to which this characterizes how you felt at your lowest point after your GBV experience as well as what best describes your current feelings now.

Acknowledgements

We would like to acknowledge the Sexual Assault Prevention and Awareness Center at University of Michigan for their partnership and substantive feedback to this instrument development project along with Andreea Taran for her help with data collection for this project.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We would like to thank the National Clinician Scholars Program for their funding of this project via allocated research funds to the first author.

ORCID iDs

Laura Sinko

Denise Saint Arnault

Author Biographies

Laura Sinko, PhD, RN, CCTS-I, is a postdoctoral fellow in the National Clinician Scholars Program at Perelman School of Medicine at The University of Pennsylvania in Philadelphia, Pennsylvania, USA.

Chris Schaitkin MPH is a graduate from University of Michigan’s School of Public Health in Ann Arbor, Michigan USA

Denise Saint Arnault PhD, RN, FAAN, is a professor at University of Michigan School of Nursing in Ann Arbor, Michigan USA

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