General Information: *Note: The Dari and Arabic translation of the items were tested. These are English translations of the original German source items.*
Question Text: To what extent did you experience the following troubles during the last four weeks?
[In welchem Ausmaß traten bei Ihnen während der letzten vier Wochen die folgenden Beschwerden auf?]
Answer Categories
Not at all [Überhaupt nicht]

Little [Wenig]

Moderate [Moderat]

Quite [Ziemlich]

Extreme [Extrem]

Not specified [Keine Angabe]
- Findings for Answer Categories
- Recommendations for Answer Categories

Findings/Recommendations for Multi-Item Scale:
- Findings for Multi-Item Scale
- Recommendations for Multi-Item Scale
Findings for Multi-Item Scale: Introductory question text) What do the test persons understand by the word "troubles"?

In the run-up to the pretest, concern was expressed on the part of the translators that the translation of the word for "troubles," especially in the Dari translation, might be misleading. However, none of the test persons spontaneously commented on the question text, showed signs of confusion, or were bothered by it. After completing the battery of questions, the test persons were asked what they understood by the word "troubles". Two test persons stated that troubles were what was listed in the individual items (SY03, SY06), and two others defined troubles solely in terms of examples given in the matrix (IR05, DA06). Four test persons defined troubles as reactions to negative events that happen to you from the outside (IR01, IR02), that can surprise you (SY01), or that can affect your everyday life (DA01). One test person explained that troubles include everything that lead to the fact that one is not free of troubles and thus cannot feel lightheartedness (DA03).

Four test persons stated that troubles included physical as well as psychological or emotional aspects (SY02, IR05, DA03, DA06) or concerned general well-being (DA05). The physical aspects mentioned included troubles of illness in general (SY02), (head) pain (SY04, IR05, DA06), and physical exhaustion (SY05). Regarding the psychological aspects of "troubles," sadness (SY03, IR05), being sad (DA06) or having to cry quickly (IR05), loneliness (DA02), depression (IR05), depressed (SY03), or pressure (SY02) were mentioned.

The test person who had received the uncorrected Arabic-language questionnaire without the question text (IR03) had answered the items without any visible problems, and the missing question text only became apparent when asked about it.

In summary, the question text was well understood by all test persons and no differences were found by language or country of origin.

Other findings

One test person initially had problems understanding the matrix format of the question (DA06). She initially answered only the introduction and stated how much she had suffered from troubles in the last four weeks. This led to a spontaneous exchange between the test person and the interpreter, who pointed out to the test person that she should only answer the individual statements.
Recommendations for Multi-Item Scale: Introduction: We recommend formulating the introductory question text as a sentence. In addition, the introduction should not be presented as part of the matrix, but as a detached heading. The temporal frame of reference should be visually emphasized, for example by underlining:
“Please indicate the extent to which you experienced the following troubles during the last four weeks.”
[„Bitte geben Sie an, in welchem Ausmaß bei Ihnen während der letzten vier Wochen die folgenden Beschwerden aufgetreten sind.“]
All Items: We recommend formulating the items in a uniform manner as far as possible. For the German version, we therefore recommend formulating the items uniformly in the first person and as complete sentences.
Since the response scale refers to the extent of the respective trouble, we recommend not to additionally include the frequency of the respective trouble (e.g., "most of the time" in item 2) in the item text.
In this population, it cannot be assumed that respondents know how to proceed if they do not suffer from the aforementioned troubles, i.e. that they should still answer the question, as this only becomes clear from the answer options. We therefore recommend that a corresponding instruction be added:
“If you have not suffered from the above trouble, please tick “not at all””
[„Sollten Sie nicht unter der genannten Beschwerde gelitten haben, kreuzen Sie bitte „überhaupt nicht“ an.“] Response format: No changes recommended.

Cognitive Techniques: Comprehension Probing, Category Selection Probing, Specific Probing, Emergent Probing

Items

Item Text	Item Tested
Feeling unhappy, sad or depressed most of the time (2) [Sich die meiste Zeit unglücklich, traurig oder deprimiert fühlen (2)] Tested Item and Recommendations Findings Topic and Construct Item Text: Feeling unhappy, sad or depressed most of the time (2) [Sich die meiste Zeit unglücklich, traurig oder deprimiert fühlen (2)] Recommendations: We recommend splitting the item into two items, one asking about "unhappy or sad" and the other asking about "depressed" or "down": “I felt unhappy or sad.” [„Ich fühlte mich unglücklich oder traurig.“] “I felt depressed/down.” [„Ich fühlte mich deprimiert/niedergeschlagen.“] Findings: What do the test persons understand by feeling "unhappy, sad, or depressed"? While all of the Iraqi test persons stated that they felt "moderately" or even "quite" unhappy, sad or depressed, the Syrian test persons stated that this was "not at all," "not very much" or "moderately. The test persons from Afghanistan used the entire range of answers, with "little" being the most frequently selected answer category and thus more similar to the Syrian test persons. Another difference between the test persons from Iraq on the one hand and from Syria and Afghanistan on the other hand was that only test persons from Syria and Afghanistan (SY01, SY02, SY04, DA05, DA06) made a clear distinction between "unhappy/sad" on the one hand and "depressed" on the other. Sadness was described as something caused by an external event (SY01), such as losing one's house or home due to war (SY01, SY02) or losing an important person (SY03, SY04). Sadness is a negative feeling when one does not feel joy (DA05), but a rather short-term feeling (DA06). Depressiveness, on the other hand, is a stronger negative feeling than sadness (DA05), which is more equivalent to depression (DA06), and especially more persistent than sadness (SY02, DA06). Moreover, depressiveness is not caused by external events, but one carries it within oneself (SY01). One test person explained that sadness is felt when one loses someone, whereas depressiveness is felt when one basically has no one (SY04). For a test person from Afghanistan, the item even contained a double stimulus. She herself was often sad, but not at all depressed, and therefore did not know how to answer (DA06, answer: not specified). None of the test persons from Iraq explicitly made this distinction between sadness/unhappiness and depressed, and all used all three terms synonymously in their explanations. Despite these differences, the test persons from all three countries named similar triggers and also effects of the feelings, so that the item as a whole was understood in the same way across all three countries of origin. States in which one feels "unhappy, sad or depressed" were often described in connection with the social environment. Some test persons were concerned with the loss of family members (SY03, SY04), while others were concerned with the state of being alone (SY04, IR01) and loneliness (SY02, DA02). One test person mentioned the distance to the family, which was in the country of origin (IR06). Not being able to integrate in Germany (currently due to the Corona pandemic; SY06) and general uncertainty about the future (IR02, IR04) were also mentioned as reasons. The effects mentioned included feelings of restlessness (DA02), but also the need to withdraw into oneself (DA05). Question Topic: Public health/ Health impairments Construct: Health-Screener	Yes
Feeling restless, unable to sit still (8) [Sich ruhelos fühlen, nicht stillsitzen können (8)] Tested Item and Recommendations Findings Topic and Construct Item Text: Feeling restless, unable to sit still (8) [Sich ruhelos fühlen, nicht stillsitzen können (8)] Recommendations: In order to standardize the item formulations, we recommend the following wording: “I felt restless, could not sit still.” [„Ich fühlte mich ruhelos, konnte nicht stillsitzen.“] Findings: How do the test persons understand "not being able to sit still"? Across both languages and all three countries of origin, the test persons showed a good and very homogeneous understanding of the item. The only exception was a test person from Syria (SY05), who did not understand the first part of the item, "feeling restless". Moreover, she could only imagine physical causes for "not being able to sit still". This test person showed comprehension problems several times during the interview. All other test persons understood the item in the intended sense, that inner restlessness could be expressed physically, so that one could no longer sit still. There were hardly any differences between the countries of origin with regard to the triggers and effects of this feeling. The test persons described the emotional state mainly as restlessness (SY02, SY05, DA02, DA03), excitement (DA01) or nervousness (SY03, IR04, IR05). The Arabic-speaking test persons from Syria and Iraq saw the reasons for restlessness or "not being able to sit still" more in psychological aspects, such as grief (SY06) or internal pressure (IR01, IR02). The test persons from Afghanistan also described aspects related to work, such as unemployment (DA02) or unsuccessful applications (DA03), as well as family problems (DA02) and living conditions (DA04, DA05). Only one test person stated that feelings of restlessness, at least in her case, were mainly due to personal predisposition (SY02). Question Topic: Public health/ Health impairments Construct: Health-Screener	Yes
Cry easily (9) [Leicht weinen zu müssen(9)] Tested Item and Recommendations Findings Topic and Construct Item Text: Cry easily (9) [Leicht weinen zu müssen(9)] Recommendations: We recommend formulating the item in such a way that it is clear that it is not a general disposition to cry, but a deviation from the general condition: “I cried quickly, even without a special occasion.” [„Ich weinte schnell, auch ohne besonderen Anlass.“] Findings: Is the question about having to "cry easily" perceived as uncomfortable? When translating the item into Arabic and Dari, the translators expressed fears that the translation could be interpreted as "tearful" or even "pretending to cry" and that the question could make the test persons uncomfortable. The cognitive interviews contained evidence that the Arabic-speaking test persons in particular found the item uncomfortable or at least wanted to make sure when answering that they did not portray themselves as tearful. These instances are explained below. Two test persons left the item unanswered (SY05, IR05). Both spontaneously stated that they did not understand the question. SY05 wanted to know whether it was about herself or about other people in general. Although she was supposed to answer in general, she answered that she did not know such situations. When asked if she could imagine why someone else might indicate that they cry easily, she replied that it probably has to do with that person's psyche. The test person seemed to want to avoid any discussion of crying. IR05 explained that she would have to cry quickly if something bothered her that involved a friend or family member, but most of all it was because some people would cry quickly as a matter of principle. She chose to leave the question unanswered. Two other test persons who answered the question with "not at all" also spontaneously indicated comprehension problems (SY01, SY03). For example, one test person remarked that she did not understand the question and asked what was supposed to make her cry (SY03). Pictures and videos showing her home under fire would naturally make her cry, but otherwise this did not happen. Finally, a fourth person made sure whether it was tears of joy or sadness (SY01). She decided herself that it was about tears from sadness. Furthermore, one test person stated that showing tears was a sign of weakness (SY02, answer: little). The remaining seven Arabic-speaking and all Dari-speaking test persons did not seem to find the question unpleasant. The Arabic-speaking test persons focused more on their personality and predisposition to cry in their answers. For example, four Arabic-speaking persons stated that they described themselves as very emotional and empathetic and would therefore cry more easily (SY04, SY06, IR01, IR03). Occasions for this were when they saw other people crying (SY04), when they noticed that others were unwell because they could not manage their daily tasks (IR01), during films or series (SY04, SY06) or also to express their emotional state (IR03). Another test person said that it was basically very difficult for her to cry, especially in front of other people (IR02). The test persons from Afghanistan, on the other hand, included more concrete situations in their explanations that made them cry easily. Two test persons explained that this was triggered primarily by memories and news from their homeland (DA02, DA03, DA05) or interpersonal conflicts (DA03, DA05). Across both languages, only one test person (DA02) explicitly referred to the period of the last four weeks in her answer. In summary, the item was perceived as unpleasant by several test persons; moreover, several test persons understood the item to be about their general disposition to cry. If the health screener is to record whether the respondents have had to cry quickly more often than usual in the last four weeks, this should be emphasized in the item wording. Question Topic: Public health/ Health impairments Construct: Health-Screener	Yes
Reliving a trauma (emotional injury) from the past; behaving or feeling as if it were happening again now (10) [Ein Trauma (seelische Verletzung) aus der Vergangenheit wieder zu erleben; mich zu verhalten oder zu fühlen, als würde es jetzt wieder passieren (10)] Tested Item and Recommendations Findings Topic and Construct Item Text: Reliving a trauma (emotional injury) from the past; behaving or feeling as if it were happening again now (10) [Ein Trauma (seelische Verletzung) aus der Vergangenheit wieder zu erleben; mich zu verhalten oder zu fühlen, als würde es jetzt wieder passieren (10)] Recommendations: For better comprehensibility and in accordance with the goal of standardization, we recommend formulating the item in the first person and shortening the text: “I was reliving a trauma (emotional injury) from the past, i.e., it felt like it was happening now.” [„Ich erlebte ein Trauma (seelische Verletzung) aus der Vergangenheit wieder, d. h, es fühlte sich an, als würde es jetzt passieren.“] Findings: What do the test persons understand by the term "trauma"? The word trauma only caused problems for one test person from Afghanistan, who knew the word but in the sense of a physical trauma from the medical field (DA03). This test person spontaneously asked how the word was to be understood, because she noticed that the explanation as "mental injury" in brackets behind it contrasted with her understanding of the term. All other test persons were able to define the term without any problems. Trauma exists when events from the past have a negative influence on the future (SY01) or when one is psychologically impaired by the past (DA05, DA06). Negative sensations are considered a trauma if one cannot escape them, but one's thoughts revolve around them again and again (SY02). Traumas are events that cannot be explained (IR02). The test persons named a wide variety of events that could trigger trauma. The most frequently mentioned were experiences from home that had led to flight (SY03, SY05, IR03, IR04, IR06, DA02, DA03), or the flight itself (SY02, DA02, DA03). In Syria, the events described included the shelling of civilians by the air force and the sight of the dead, as well as the unaccounted for whereabouts of relatives (SY03, SY05). The test persons from Iraq told that they had witnessed murders and acts of IS and Al-Qaeda and that terrorists had come to their place of residence and kidnapped young people who had never returned (IR03, IR06). In addition to the flight-related aspects, the loss of important people (e.g., parents or own children) was named as the most frequent trigger of trauma, especially by test persons from Syria (SY02, SY03, SY04, SY05, SY06, IR01). Two test persons mentioned occupational events as possible triggers of trauma (SY01, DA03), such as a dismissal or the frustration of not finding a job in Germany. In addition, the family situation in marriage, betrayal or cheating up to separation (SY01, IR01, IR04) could trigger trauma. Lastly, the reason for trauma could also lie in childhood (DA04). How do the test persons arrive at their answers? Five test persons stated that they suffered "quite" or "extremely" from reliving traumas from the past. The explanations of three of these test persons indicated that they suffered from a re-experiencing of past situations that clearly went beyond a mere recollection. One test person from Iraq had experienced terrorists coming to her hometown in Iraq and kidnapping young people who never returned. She said she had to think about that when she went to sleep. These memories still caused her such anxiety that she feared it might happen to her as well (response: extreme). Another test person stated that memories from home "buzzed around" in her head as if they were happening now (IR03, response: extreme). The third test person stated that her memories even preoccupied her more since she was in Germany (IR04, response: quite). For the other two test persons, it remained unclear whether they were reliving traumatic events as if they were happening now, or whether they "merely" had to think about these events often and intensely. One of these test persons spontaneously asked how it was to be understood that something occurred to one "as if it were happening again now" (SY05). She understood it as grief or sorrow and thought of the unresolved whereabouts of relatives and the death of a parent, which bothered her a lot. The second test person had thought of the separation of her own family, which had thrown her into a deep crisis (IR05). In both cases, the test persons suffered from traumatic events that strongly influenced their current lives. On the other side of the response scale, four test persons stated that they relive traumas from the past "a little". Two of them stated that they had suffered more from recurring traumas in the past. One test person had been repeatedly traumatized in the course of her life and had always relived these situations internally until about a year ago. In recent months, she had been able to work on this with the help of a psychiatrist, which is why she gave "little" as her answer (IR02). Another test person stated that in the meantime she no longer had to think only of negative events in and in a sad mood about her homeland but could enjoy beautiful memories again (SY06). Six test persons stated that they did not relive traumas "at all," two of whom stated that they had experienced traumatic events in their homeland; however, they would not take such events with them so easily (SY01) or had come to terms with them in the meantime (SY02). The other test persons stated that they had not experienced any traumas (DA01, DA04, DA05, DA06). What time periods do test persons think of when answering the question? To answer the item, test persons had to consider two time spans: First, Item 10 vaguely asked about a trauma "from the past"; in addition, test persons were asked to indicate whether they had relived such a trauma "in the past four weeks". Regarding the phrase "from the past," seven test persons stated that they would refer exclusively to the time in their home country and their flight (SY03, SY06, IR03, IR04, IR06, DA01, DA02), while six test persons stated that the question referred to their entire life, from birth to yesterday (SY01, SY02, SY04, IR02, DA03, DA06). Two test persons from Iraq related the question exclusively to their immediate past in Germany and mentioned a period of no more than two years (IR01, IR05). One test person was also of the opinion that it was primarily about childhood (DA04). Regardless of the different time spans, the test persons included all potentially traumatizing events from their lives. Several test persons also stated that they were less likely to relive trauma in the meantime, indicating that they related the question to their current situation in the last four weeks. There were no differences regarding the time periods mentioned by language or country of origin. Question Topic: Public health/ Health impairments Construct: Health-Screener	Yes
Feeling emotionally numb (for example, feeling sad but not being able to cry, not being able to feel loving feelings) (12) [Mich emotional taub gefühlt (zum Beispiel traurig fühlen, aber nicht weinen können, keine liebevollen Gefühle empfinden können) (12)] Tested Item and Recommendations Findings Topic and Construct Item Text: Feeling emotionally numb (for example, feeling sad but not being able to cry, not being able to feel loving feelings) (12) [Mich emotional taub gefühlt (zum Beispiel traurig fühlen, aber nicht weinen können, keine liebevollen Gefühle empfinden können) (12)] Recommendations: We recommend formulating the item in the first person to make the explanation of "emotionally numb" easier to understand: “I felt emotionally numb (for example, I felt sad but couldn't cry, or had a hard time feeling loving emotions).” [„Ich fühlte mich emotional taub (zum Beispiel fühlte ich mich traurig, konnte aber nicht weinen, oder fiel es mir schwer, liebevolle Gefühle zu empfinden).“] Findings: What do the test persons mean by feeling "emotionally numb"? Two test persons from Afghanistan did not receive this item because it had been accidentally replaced by another item in the Dari translation. The interpreter read the item to be tested orally to the other four test persons and asked the test persons to answer using the answer scale. All Arabic-speaking test persons received the item. Two Arabic-speaking test persons spontaneously expressed problems understanding the question (SY05, IR05). One of them asked about the meaning of "numb" in this context (SY05) but seemed to understand the explanation in the brackets behind it. The other found feeling sad but not being able to cry contradictory (IR05). This test person made no statement because of the perceived contradiction. One Dari-speaking test person commented that she did not find the question easy to understand but was able to answer the item without further difficulty (DA05). A total of seven test persons stated that they felt "quite" or "moderately" emotionally numb. Most of the explanations showed that they had correctly understood the feeling described in the item text. For example, one test person explained that she currently felt rather emotionally cold because of bad events she had experienced (IR01, response: moderate). Another stated that although she was very emotional, especially when witnessing the suffering of others, she was unable to cry (IR06, response: quite). One test person from Syria stated that showing one's emotions openly is a sign of weakness and that even one's partner should not know when one is crying inside (SY02, response: moderate). Another test person from Syria explained that she consciously tried not to deal emotionally with events from the past, but to ignore them (SY05, response: moderate). Meanwhile, in the case of one test person from Afghanistan, it remained unclear whether she was refer-ring to internal numbness. She stated that she had been in very severe pain but had not been able to cry (DA06, response: moderate). She seemed to be referring to an injury to her leg from the previous month. Likewise, seven test persons stated that they did not feel emotionally numb "at all". These test persons either stated that they considered themselves to be an emotional person who could weep easily (SY04, SY06), or commented rather succinctly that they did not feel as described in the item. Question Topic: Public health/ Health impairments Construct: Health-Screener	Yes