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Psychometric validation of the Moral Injury Outcome Scale in a Danish military population
Cirkeline Hovgaard1, Maria Louison Vang2,3, Maria Haahr Nielsen1,4
1Department of Military Psychology, Danish Veteran Centre, Copenhagen, Denmark.
Background:
Moral injury (MI) refers to the enduring psychological, relational, and existential impact of exposure to potentially morally injurious events (PMIEs). The Moral Injury Outcome Scale (MIOS) was developed to assess these outcomes and has demonstrated good psychometric properties. However, evidence for the MIOS is limited outside English-speaking contexts, and the MIOS has not previously been examined in a European military population, highlighting the need for cross-cultural validation studies.
Objective:
This study provides the first psychometric evaluation of the Danish MIOS in a clinical sample of treatment-seeking veterans, examining its internal structure, construct validity, and incremental validity beyond ICD-11 PTSD and CPTSD symptoms.
Method:
Formerly deployed Danish veterans reporting exposure to a PMIE completed the MIOS (N = 212) as part of the routine assessment battery at the Danish Veteran Centre. Competing latent structures were tested using confirmatory factor analysis. Convergent and discriminant validity were evaluated via correlations with ICD-11 PTSD, Disturbances in Self-Organization (DSO), and depression. Incremental validity was examined using hierarchical regression predicting functional impairment.
Results:
The expected two-factor structure - shame-related and trust-violation-related outcomes - demonstrated good model fit. MIOS subscales showed modest correlations with PTSD symptom clusters and stronger correlations with DSO domains, particularly negative self-concept and disturbances in relationships. MIOS scores were associated with additional variance in functional impairment beyond PTSD, DSO, and depression symptoms.
Conclusion:
This study provides the first evidence for the psychometric validity of the MIOS in a European veteran population. Findings support the cross-cultural robustness of the two-factor structure and underscore the MIOS as a promising brief, distinct, and clinically useful screening tool for MI outcomes in military settings.
