Aging & Mental Health
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Familiarity with and intentions to use Internetdelivered mental health treatments among older rural adults Tonelle Handley, David Perkins, Frances Kay-Lambkin, Terry Lewin & Brian Kelly To cite this article: Tonelle Handley, David Perkins, Frances Kay-Lambkin, Terry Lewin & Brian Kelly (2015) Familiarity with and intentions to use Internet-delivered mental health treatments among older rural adults, Aging & Mental Health, 19:11, 989-996, DOI: 10.1080/13607863.2014.981744 To link to this article: http://dx.doi.org/10.1080/13607863.2014.981744
Published online: 24 Nov 2014.
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Date: 11 November 2015, At: 01:06
Aging & Mental Health, 2015 Vol. 19, No. 11, 989 996, http://dx.doi.org/10.1080/13607863.2014.981744
Familiarity with and intentions to use Internet-delivered mental health treatments among older rural adults Tonelle Handleya,b*, David Perkinsc, Frances Kay-Lambkina, Terry Lewind and Brian Kellyd,1 a National Drug and Alcohol Research Centre, University of New South Wales, Waratah, Australia; bCentre for Rural and Remote Mental Health, University of Newcastle, Waratah, Australia; cCentre for Rural and Remote Mental Health, University of Newcastle, c/o Bloomfield Hospital, Orange, Australia; dCentre for Translational Neuroscience and Mental Health, University of Newcastle, Callaghan, Australia
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(Received 27 June 2014; accepted 16 October 2014) Objectives: Older adults are the fastest growing age group in Australia, necessitating an increase in appropriate mental health services in the coming years. While Internet-delivered mental health treatments have been established as acceptable and efficacious among younger samples, little research has explored whether they would be similarly useful in older populations. Methods: The participants were part of the Australian Rural Mental Health study, which explores mental health and wellbeing in residents of non-metropolitan New South Wales. A postal survey was used to assess knowledge of and intentions to use Internet-delivered mental health treatments. Demographics, mental health, and frequency of Internet use were also measured. Results: The survey was completed by 950 adults aged 50 93. The sample was largely unfamiliar with Internet mental health services, with 75% reporting that they had never heard of them and a further 20% not knowing any details of what they involved. Intentions to use these services were also low, at 13.5%; however, this increased with level of familiarity. Respondents with higher psychological distress, higher education, and more frequent Internet use were significantly more likely to consider using Internet treatments. Conclusions: Among older adults, overall awareness of Internet-delivered mental health treatments appears to be limited; however, higher familiarity contributes to higher intentions to use these treatments. Importantly, respondents with higher distress and greater computer literacy were more likely to consider mental health treatments delivered via the Internet. Future research exploring strategies to increase the promotion of these services to older samples may further improve their perceptions and use. Keywords: Internet treatment; mental health; rural; older adults
Introduction Older adults are the fastest growing age group in Australia, with the number of people aged over 75 expected to increase by four million between 2012 and 2060 (Australian Government Productivity Commission, 2013). Although evidence suggests that the prevalence of mental health problems decreases with age (Slade, Grove, & Burgess, 2011), the rising number of older adults in the coming years will necessitate an approximate doubling of the time that psychologists currently spend with older adults even if raw rates of mental health problems do not increase (Karel, Gatz, & Smyer, 2012). Older adults face numerous difficulties in their ability to obtain mental health assistance, with the use of psychological services decreasing with age (Byles, Dolja-Gore, Loxton, Parkinson, & Stewart Williams, 2011). Evidence suggests that structural barriers, such as the distance to and cost of services, concerns about transport, and the lack of mental health professionals with adequate experience working with older age groups, may contribute considerably to the low rates of mental health help-seeking in this age group
*Corresponding author. Email: [email protected] 1 The authors declare no competing interests. Ó 2014 Taylor & Francis
(Fitzpatrick, Powe, Cooper, Ives, & Robbins, 2004; Horton & Johnson, 2010; Murata et al., 2010). The availability of Internet-delivered mental health treatments has increased dramatically in recent years, particularly in Australia (Christensen & Petrie, 2013). The most prominent of these, including MoodGYM, MyCompass, and This Way Up, are primarily focused on highprevalence conditions such as affective and anxiety disorders, which affect approximately 6% and 14% of the Australian population each year, respectively (Slade, Johnston, Oakley, Andrews, & Whiteford, 2009). Such treatments predominantly use cognitive behaviour therapy techniques; however, a wider range of treatments are becoming available, including dialectical behaviour therapy. Online treatments have been shown to have high clinical efficacy, producing reductions in psychiatric symptoms comparable to those achieved by face-to-face therapies (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010). Such interventions may help overcome common barriers associated with mental health service use, through being highly accessible, not requiring clients to travel to
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sessions, not being subject to waiting periods, and often being free of charge. This is particularly advantageous for people who face challenges in accessing traditional mental health care, such as those residing in rural or remote areas (Griffiths & Christensen, 2007), and older adults. Online treatments also offer the benefit of anonymity, which may overcome common deterrents to help-seeking by appealing to individuals concerned about confidentiality and stigma. The long-term effectiveness of Internet-based mental health programmes at a population level is dependent on several factors. Maintaining progress in this area is reliant on integrating with constantly developing hardware technology, and investigating the broader utility, including acceptability of such interventions to people in greatest need (Christensen & Petrie, 2013). Public awareness and perception of Internet-delivered treatments is key to acceptability and utilisation (Handley et al., 2014; Jorm, 2009; Leach, Christensen, Griffiths, Jorm, & Mackinnon, 2007), and in relation to e-health it has been identified as important to consider not only technical development, but also the attitudes and state of mind of the target audience (Eysenbach, 2002). This is particularly relevant in rural areas, where perceived stigma and attitudinal barriers to mental health service use may be greater than in metropolitan centres (Judd et al., 2006; Wrigley, Jackson, Judd, & Komiti, 2005). Focusing solely on the creation of Internet interventions without addressing active dissemination may undermine the potential success of this important developing field, and it has been noted that a focus on consumers’ perspective of Internet-delivered treatments is lacking (Ekeland, Bowes, & Flottorp, 2010). We have recently published findings from a general rural community sample (The Australian Rural Mental Health Study; ARMHS) showing relatively low support for Internet-delivered mental interventions, with only 20% of respondents reporting that they would consider using these services (Handley et al., 2014). While this rate was considerably higher in some subgroups, such as people with a recent mental health problem, younger people, and males, a general hesitance about this method of treatment delivery was notable in the sample as a whole. As Internet access was reasonably high (ranging from 79% in inner regional areas to 60% in very remote areas), we concluded that our findings may be attributable to attitudinal barriers towards Internet treatments, rather than structural difficulties in accessing these services. The ARMHS sample is highly representative of older adults, with a mean age of 55 years at baseline (Kelly et al., 2010), and 59 years in the three-year follow-up data used for this analysis, which may also have influenced our findings. National data show that Internet use is the highest among younger populations (e.g. 97% of those aged 15 17 accessed the Internet at any time in the past 12 months), with a marked decrease among those aged 65 or over (46% accessed the Internet in the past 12 months; Australian Bureau of Statistics [ABS], 2014). Internetdelivered strategies are being used increasingly to engage younger people in mental health treatments (Rickwood, Deane, & Wilson, 2007), with positive findings related to their acceptability and perceived helpfulness (Burns,
Davenport, Durkin, Luscombe, & Hickie, 2010; Horgan & Sweeney, 2010; Oh, Jorm, & Wright, 2009). A recent study in Australia found that one-third of young people with a mental health problem had used the Internet as a source of information about their condition (Burns et al., 2010). However, very little information currently exists on how older age groups respond to the idea of Internet treatments, and whether this strategy may translate into a viable approach to address the mental health needs of this population. To build on our previous research about the feasibility of Internet-delivered treatments for older people in rural areas (Handley et al., 2014), a series of questions relating to awareness and perceptions of Internet-delivered mental health treatments were incorporated into the subsequent wave of ARMHS (wave 4, conducted in 2013). These questions addressed three key areas: (1) knowledge and awareness of Internet treatments; (2) beliefs about the accessibility and effectiveness of Internet treatments; and (3) intentions to use Internet treatments. The aim of this paper is to explore general community awareness of Internet-delivered mental health treatments among a rural sample, and to determine whether low knowledge of Internet treatments may contribute to the low intentions to use these services. While this research is largely exploratory, our previous findings led to the expectation that knowledge of and intentions to use Internet-delivered treatments would be low in this older sample. Although we did not anticipate that gender would be related to knowledge of these treatments, it was expected that males may be more willing to use them (based on our previous findings; Handley et al., 2014). In accordance with our previous research, we anticipated that higher psychological distress would increase the intentions to use Internet treatments, and we also predicted that those with higher distress would have a higher awareness of these treatments. It is anticipated that the results of this research may provide insight into the currently restricted use of Internet-delivered treatments in some samples, and inform strategies to increase uptake rates of programmes with demonstrated clinical efficacy among diverse population groups such as older rural adults.
Methods Participants The sample for the present analysis was obtained from the five-year follow-up (wave 4) of the ARMHS, conducted in 2013. This study targeted residents of rural and remote New South Wales (NSW); this area is made up of major regional centres and coastal cities, small towns and remote communities. Approximately one-quarter of NSW residents occupy rural or remote regions. Participants completed a self-report postal survey about mental health and wellbeing. The full methods for ARMHS have been reported in detail elsewhere (Kelly et al., 2010). There were no gender differences between those sampled and the census population data, although there was a statistically significant under-representation of those aged 18 47 (except for in very remote regions). As the present analysis is concerned with older adults, those aged under 50 were excluded.
Aging & Mental Health Measures
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Outcome variables To assess awareness and the use of Internet-delivered treatments, a set of novel questions were developed. Awareness of Internet-delivered mental health treatments was assessed by the question ‘how familiar are you with Internet-delivered therapies for the treatment of mental health problems (e.g. MoodGYM, mycompass, etc.)?’ with five response options: I have never heard of Internet-delivered mental health treatments. I have heard of Internet-delivered mental health treatments, but do not know any details about them. I have some understanding of what Internetdelivered mental health treatments involve. I have a good understanding of Internet-delivered mental health treatments. I have used an Internet-delivered mental health treatment in the past. Intentions to use Internet-delivered treatments were assessed by a single question: ‘would you consider using the computer or the Internet as a way of accessing treatment for your mental health?’ with an ‘yes/no’ response option. Explanatory variables Based on our previous model, age, gender, and psychological distress were included as explanatory variables in analyses. Age and gender were self-reported. Current psychological symptoms were assessed by the Kessler-10 (K10) psychological distress scale. The K10 assesses the frequency of psychological symptoms during the previous four weeks, and is commonly used as an indicator of general mental health and well-being both on an individual and population level. A cut-off of greater than 15 was used to indicate moderate or high distress, in alignment with the previous research (Slade et al., 2011). Negative beliefs about Internet mental health treatments were also included as explanatory variables, and were explored by a series of nine statements with a Likert scale response option. Participants were asked: ‘what barriers are there to you using the Internet to access information or treatment related to mental health and well-being?’ and rated their response on a four-point scale from ‘does not apply to me at all’ to ‘applies to me very much.’ Examples of these barriers include: ‘I worry that my information will not stay private on the Internet’ and ‘I am concerned about the credibility of the people who design the websites.’ Control variables Education, household income, and frequency of Internet use were included as covariates in the multivariate analyses. Education and income were self-reported by single items in the survey. Participants indicated the frequency of their use of the Internet on a five-point scales from ‘I don’t use the Internet’ through to ‘several times a day.’
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They also completed a series of questions about locations in which they would be willing to use an Internet-based treatment for their mental health (e.g. at home, at a friend’s home, in a library, or other public setting), and which services they would first seek help from if experiencing a mental health problem.
Statistical analysis Associations with awareness of Internet treatments were first explored by bivariate analyses, which included all explanatory and control variables. Bivariate analyses involved one-way ANOVA for continuous variables and chi-square tests for categorical variables (where cell counts were less than five, a Fisher’s exact test was used). As a means of dimension reduction, a factor analysis with oblique rotation was conducted on the negative beliefs about Internet treatments (allowing the resulting factors to be correlated with one another). The strength of endorsement of these negative beliefs was explored using descriptive statistics. The resultant factors were also included as covariates in the logistic regression. A logistic regression was conducted to determine the relationship between awareness of Internet-delivered treatments and intentions to use them. Intentions to use Internet-delivered treatments were the outcome variable, and all explanatory and control variables were included as covariates. Results were reported as adjusted odds ratios (OR) and 95% confidence intervals (95% CI).
Results Overall, 1165 participants completed the survey; of these 950 were aged 50 or over and were included in the analysis. Of these, 40.3% (n D 383) were male and the mean age was 65.5 years (§9.2 years). The majority of the sample was aged 50 64 years (n D 452; 47.6%) or 65 79 years (n D 413; 43.5%), with a lesser representation of those aged 80 years or over (n D 85; 8.9%). Of the 2003 baseline, ARMHS participants who would have been eligible for the present analysis (i.e. those aged 45 or over at baseline, and hence would have been aged 50 or over at five-year follow-up), 950 (47%) were retained at five-year follow-up. There was a slightly lower representation of males at follow-up (40.5%) than at baseline (45.1%; x2(1) D 4.3, p D .038), and those who were retained were younger than those who were not (60.6 § 9.3 vs. 62.0 § 10.5, F(1, 2002) D 10.0, p D .002). Married participants were more highly represented at follow-up compared to baseline (78.1% vs. 73.4%, x2(1) D 4.3, p D .016), as were those who were employed (60.9% vs. 47.6%, x2(2) D 4.3, p < .001). The majority of participants (n D 724; 76.2%) had a computer with Internet access in their home, with an additional 43 (4.5%) having access to a computer with the Internet at another location, and 9 (0.9%) having access to the Internet by mobile phone only. In total, 81.7% of the sample had access to the Internet in some form.
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Awareness of Internet-delivered mental health treatments In total, only five (0.5%) participants reported ever having used an Internet-delivered mental health treatment; therefore, this category was collapsed into the previous subgroup (i.e. ‘I have a good understanding of Internetdelivered mental health treatments’). Generally, awareness of Internet-delivered mental health treatments was low, both in the overall sample and among those with elevated psychological distress, as shown in Table 1. Three-quarters of participants (n D 699) reported that they had never heard of Internet-delivered treatments; cumulatively, 95% reported that they had either never heard of these treatments, or did not know any details about them. This did not differ significantly between the overall sample and the subgroup with elevated distress. An effect by age was observed, with older participants being significantly less likely to be familiar with Internet treatments. Similarly, familiarity increased with higher household income, and was also greater among participants who had completed high school compared with those who had not. There was no significant effect for gender, or for frequency of Internet use. Beliefs about Internet-delivered services The most commonly endorsed negative belief about Internet-delivered mental health services was ‘I don’t know
whether to trust the accuracy of the information provided,’ with two-thirds of the sample endorsing this statement (Table 2). This was followed by ‘I worry that my information will not stay private on the Internet’ and ‘I don’t think Internet treatment will work for mental health problems.’ General barriers, such as not liking computers/the Internet or not being able to afford Internet access, were less common. The factor analysis of negative beliefs about Internetdelivered mental health treatments is displayed in Table 2, and revealed two key factors: specific beliefs about the perceived credibility/effectiveness of Internet-delivered treatments (M D 12.8 § 3.5, range 1 20, Cronbach’s alpha D 0.84), and broader barriers to using the Internet in general (M D 7.6 § 2.7, range 1 16, Cronbach’s alpha D 0.77). These factors were moderately correlated (r D 0.47, p < .001). Specific negative beliefs about the credibility of Internet-delivered treatments decreased linearly as knowledge of Internet-delivered mental health treatments increased, being the highest in those who had never heard of Internet treatments (M D 13.2 § 3.5) and the lowest in those who reported a lot of knowledge about these treatment or had used one before (M D 9.0 § 2.5; F(3, 851) D 13.5, p < .001). Similarly, general barriers to the use of Internet treatments were rated the highest in those who were unfamiliar with them (M D 7.9 § 2.8) and decreased significantly with increasing knowledge, being the lowest in
Table 1. Awareness of Internet-delivered mental health treatments by participant characteristics,% (n). I have never heard of them
I have heard of them but do not know any details
I have some understanding
I have a good understanding, or I have used one before
Total sample
75.3 (699)
19.7 (183)
3.7 (34)
1.3 (12)
Age, mean (SD)
65.5 (9.2)
66.4 (8.9)
61.7 (7.9)
59.7 (7.3)
Gender Male Female
74.1 (278) 76.1 (421)
21.6 (81) 18.4 (102)
3.5 (13) 3.8 (21)
0.8 (3) 1.6 (9)
Education Did not complete high school Completed high school
82.7 (278) 70.6 (396)
16.1 (54) 22.1 (124)
1.2 (4) 5.2 (29)
0 2.1 (12)
Household income Less than $30,000 $30,000 $69,999 $70,000C
79.7 (216) 75.7 (274) 68.4 (175)
18.1 (49) 19.6 (71) 23.0 (59)
2.2 (6) 3.0 (11) 6.3 (16)
0 1.7 (6) 2.3 (6)
Psychological distress Low Moderate/high
76.1 (584) 71.4 (115)
19.3 (148) 21.7 (35)
3.4 (26) 5.0 (8)
1.2 (9) 1.9 (3)
Internet use frequency Once week or less Several times week Every day
75.5 (219) 71.0 (174) 72.3 (141)
20.0 (58) 22.0 (54) 20.0 (39)
2.8 (8) 4.9 (12) 6.7 (13)
1.7 (5) 2.0 (5) 1.0 (2)
Note: p < .05, p < .01
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Table 2. Factor analysis of barriers to Internet-delivered mental health treatments. Component Factor Specific negative beliefs
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General barriers
% agree/strongly agree
1
2
I worry that my information will not stay private on the Internet I don’t think an Internet program can help with mental health problems I don’t think Internet treatment will work for mental health problems I am concerned about the credibility of the people who design the websites I don’t know whether to trust the accuracy of the information provided
60.5 49.9
.58 .85
.23 .13
52.8
.83
.17
51.6
.80
.15
68.5
.85
.12
I cannot afford to access the Internet I don’t like using computers or the Internet for anything I don’t like using computers or the Internet for health problems I don’t have time to look on the Internet for treatment or information about mental health
10.4 21.7 46.4 25.1
.03 .11 .55 .34
.74 .85 .58 .69
4.33 48.06
1.45 16.16
Eigenvalues % of total variance
those who were most familiar with these treatments (M D 5.3 § 1.5; F(3, 863) D 9.2, p < .001). Intentions to use Internet-delivered mental health treatments In the overall sample, 13.5% (n D 128) of respondents reported that they would consider using an Internet treatment for their mental health. Intentions to use Internetbased treatments increased in accordance with the level of awareness of these services, as shown in Figure 1. This effect remained significant after controlling for age, gender, and current psychiatric symptoms (see logistic regression shown in Table 3). Compared to those who were not aware of Internet treatments, those who had either a minimal or moderate level of awareness were approximately twice as likely to consider using these services; this effect
increased to eightfold for those who indicated a good understanding (although the wide confidence intervals for this subgroup should be noted). Intentions to use Internet treatments were also significantly higher for respondents who had completed high school compared to those who had not, and for participants who used the Internet daily compared to those who used it once a week or less. Respondents with high psychological distress were approximately twice as likely to consider using Internet mental health treatments as those with low distress. Higher negative beliefs about Internet-delivered treatments were associated with significantly lower intentions to use them. The bivariate effect for age was no longer significant when frequency of Internet use was controlled for. In response to the question: ‘Which one of these services would you first go to get help for a mental health
Figure 1. Percentage of participants who would consider using Internet-delivered mental health treatments, by familiarity with Internet-delivered treatments.
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Table 3. Logistic regression model predicting intentions to use (yes/no) internet-delivered mental health treatments. OR (95% CI)
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Awareness of internet treatments I have never heard of them I have heard of them but do not know any details about them I have some understanding I have a good understanding, or I have used one before
1.00 2.37 (1.46 3.85) 2.04 (0.86 4.81) 11.34 (3.17 40.61)
Age
0.98 (0.95 1.01)
Gender Male Female
1.00 0.93 (0.60-1.45)
Psychological distress Low High
1.00 3.07 (1.81 5.21)
Education Did not complete high school Completed high school
1.00 2.32 (1.31 4.12)
Household income Less than $30,000 $30,000 $69,999 $70,000C
1.00 1.62 (0.69 2.32) 0.95 (0.49 1.87)
Internet use frequency Once week or less Several times week Every day
1.00 1.14 (0.66 1.96) 2.42 (1.41 4.17)
Note: p < .05, p < .01; OR D adjusted odds ratio.
problem?’, only 1.2% of the sample indicated that they would use an Internet service. Conversely, 85.4% indicated that they would consult a general practitioner. When asked about locations in which participants would consider accessing Internet-delivered mental health services, the majority of the sample indicated that they would use these services in their own home (74.6%). Support for other locations was considerably lower, with 6.9% reporting they would use these services at work, 7.5% at a friend’s home, 7.4% at a library, and 1.8% at an Internet cafe or other setting open to the public. Discussion The aim of this analysis was to explore knowledge of Internet-delivered mental health treatments among general rural community residents, and to investigate the relationship between knowledge of these treatments and intentions to use them. Our findings provide evidence that awareness of Internet-delivered mental health services among older rural residents is low, with the vast majority of respondents being unfamiliar of these services. Even among those with current psychiatric symptoms, around
90% indicated that they had either never heard of Internet mental health treatments, or knew no details about them. This suggests that potential need for mental health treatment does not correlate with knowledge about this treatment option in this age group. These findings are concerning in that they indicate that many of those who could receive the greatest benefits from this mode of treatment delivery (i.e. those with current mental health needs and residing in geographical areas that may not have appropriate services) do not have sufficient knowledge of Internet programmes to make use of them. Awareness of Internet-delivered therapies was considerably lower than previous community-based research exploring recognition of mental health services in Australia, which has been reported as between 62% and 70% for beyondblue: the national depression initiative (an independent organisation that raises public awareness of depression and anxiety, and provides resources for recovery, management, and resilience), and 39% for the youth-targeted headspace (a Government-established National Youth Mental Health Foundation providing mental and health well-being support, information, and services to young people) (Highet, Luscombe, Davenport, Burns, & Hickie, 2006; Jorm, 2009). This highlights the need for social marketing campaigns to raise familiarity with these services in older age groups; however, the relative absence of research examining the efficacy of Internet treatments for older populations presents a challenge to encouraging uptake. A more encouraging observation from this analysis was that greater knowledge of Internet-delivered mental health programmes was related to the increased intentions to use them, with this effect observed in both the subsample with elevated distress and in the overall sample. This effect remained significant after accounting for age, gender, and current psychiatric symptoms, which we have previously found to have a strong relationship with this outcome (Handley et al., 2014). This is similar to the previous research, which has reported that attitudes toward Internet treatments are more positive among people who have used them than people who have not (Gun, Titov, & Andrews, 2011). This may relate to the Theory of Planned Behaviour (Ajzen, 1991), which emphasises the important relationship among beliefs, attitudes, and behavioural intentions, with intentions being the strongest predictor of actual behaviour. In alignment with this theory, our findings point to knowledge as a significant correlate of selfreported behavioural intentions, suggesting that increasing knowledge and improving attitudes towards Internet treatments may influence an increase in intentions to use them. After controlling for knowledge of Internet-delivered mental health treatments, intentions to use these services were predicted by three factors: elevated psychological distress, higher education, and more frequent Internet use. These findings support the notion that Internet treatments may be more appealing to older individuals with higher mental health and computer literacy, and suggest that focusing promotion efforts towards people with these characteristics in particular may be effective. Public health campaigns promoting mental health services have
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Aging & Mental Health previously proven to raise community awareness (Jorm, Christensen, & Griffiths, 2006a; Jorm Christensen, & Griffiths, 2006b), which in turn has also been associated with increases in their perceived effectiveness (Yap, Reavley, & Jorm, 2012). However, evidence that public education campaigns lead to an increase in actual mental health service use (in addition to improvements in perceptions) is less consistent (Dumesnil & Verger, 2009). Future research to investigate the effects of specific promotion campaigns for Internet-delivered treatments targeted towards the specific populations identified in this study (i.e. more highly educated, frequent Internet users, etc.) would be useful. This promotion could incorporate strategies such as online advertising through social media sites (e.g. Facebook, Twitter) to ensure that those recruited have sufficient computer literacy and to take advantage of the avenues which social networking offer for advertising research trials. In addition, advertising through establishments such as Returned Service League clubs (RSLs) and community groups including local rotary clubs may be an efficient way to distribute information about Internet treatments to older audiences. Negative beliefs about Internet mental health services were common in the sample, and were associated with reduced odds of considering the use of Internet-delivered treatments. However, negative beliefs decreased in accordance with self-reported familiarity with these services. The main concerns reported related to privacy and credibility. Considering the low awareness of Internet treatments among respondents, these beliefs may be due to a lack of information or general misconceptions, rather than an informed opinion based on accurate information. In the first place, the vast majority of the sample reported that they would seek help for a mental health problem from a general practitioner. Hence, general practitioners (GPs) may play an increasingly important role as Internet-based mental health treatments continue to develop, not only to inform patients about the existence of these treatments but also to integrate these within their treatment (as an adjunct to face to face contact) and overcome concerns about aspects such as credibility and confidentiality. This is particularly relevant for older age groups, who are more likely than younger age groups to access GPs regularly (ABS, 2012). Older adults are more likely to experience chronic illness and multi-morbidity, and there is a high co-occurrence of physical and mental health conditions. Exploring avenues to promote Internet treatments to health practitioners who work with older adults may be an important step for future research, as this approach would enable health workers to educate older adults about this treatment option. This analysis is limited by a low response rate (in accordance with attrition throughout the five-year period of ARMHS). From the 2639 baseline participants, 1165 remained at wave 4, which may influence the generalisability of the current analysis. However, this is also among the first explorations of the feasibility of Internet-delivered mental health treatments among older adults, and importantly, has a focus on rural and remote residents, who may receive the greatest benefit from this treatment delivery
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method. Hence, our findings may have considerable implications for future research and resource development. Among older adults, awareness of Internet-delivered treatments for mental health problems appears low, and concerns about privacy and efficacy are common. Regardless, people experiencing mental health problems report that they would consider using these treatments, particularly if they already use the Internet for other purposes. Future research is necessary to explore whether greater promotion and targeting of these programmes may increase their acceptability and uptake among older audiences. Acknowledgements We wish to recognise the contribution of the ARMHS chief investigators: Professor David Lyle, Associate Professor Lyn Fragar, Professor John Beard, Professor Vaughan Carr, Professor Jeffrey Fuller, Associate Professor Helen Stain, Professor Prasuna Reddy, and Senior Project Co-ordinator Dr Clare Coleman. We wish to acknowledge the support of directors of Mental Health Services in the relevant Local Health Districts during the course of this phase of the study: Drs Russell Roberts, Richard Buss, and Dinesh Arya, and particularly acknowledge the research site coordinators in each site: Jan Sidford, John Ogle (Broken Hill), Trim Munro, Amy Strachan (Moree), Louise Holdsworth, Kath O’Driscoll (Lismore), Cheryl Bennett, Jannelle Bowler (Orange), along with Fleur Hourihan, Dr Gina Sartore and Denika Novello.
Funding The study was funded by the National Health and Medical Research Council [grant number 401241], [grant number 631061]; and also supported by a Research Capacity Building Grant to the Australian Rural Health Research Collaboration. Tonelle Handley is supported by a postdoctoral fellowship from Australian Rotary Health, which is acknowledged with gratitude.
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Australian and New Zealand Journal of Psychiatry, 40, 42 46. doi: 10.1080/j.1440-1614.2006.01739.x. Judd, F., Jackson, H., Komiti, A., Murray, G., Fraser, C., Grieve, A., & Gomez, R. (2006). Help-seeking by rural residents for mental health problems: The importance of agrarian values. Australian and New Zealand Journal of Psychiatry, 40, 769 776. doi: 10.1111/j.1440-1614.2006.01882.x. Karel, M.J., Gatz, M., & Smyer, M.A. (2012). Aging and mental health in the decade ahead: What psychologists need to know. American Psychologist, 67, 184 198. doi: 10.1037/ a0025393 Kelly, B.J., Stain, H.J., Coleman, C., Perkins, D., Fragar, L., Fuller, J., . . . Beard, J.R. (2010). Mental health and wellbeing within rural communities: The Australian Rural Mental Health Study. Australian Journal of Rural Health, 18, 16 24. doi: 10.1111/j.1440-1584.2009.01118.x Leach, L.S., Christensen, H., Griffiths, K.M., Jorm, A.F., & Mackinnon, A.J. (2007). Websites as a mode of delivering mental health information: Perceptions from the Australian public. Social Psychiatry and Psychiatric Epidemiology, 42, 167 172. doi: 10.1007/s00127-006-0138-z Murata, C., Yamada, T., Chen, C., Ojima, T., Hirai, H., & Kondo, K. (2010). Barriers to health care among the elderly in Japan. International Journal of Environmental Research and Public Health, 7, 1330 1341. doi:10.3390/ ijerph7041330 Oh, E., Jorm, A.F., & Wright, A. (2009). Perceived helpfulness of websites for mental health information: A national survey of young Australians. Social Psychiatry and Psychiatric Epidemiology, 44, 293 299. doi: 10.1007/ s00127-008-0443-9 Rickwood, D.J., Deane, F.P., & Wilson, C.J. (2007). When and how do young people seek professional help for mental health problems? Medical Journal of Australia, 178, S35 S39. Slade, T., Grove, R., & Burgess, P. (2011). Kessler psychological distress scale: Normative data from the 2007 Australian National Survey of Mental Health and Wellbeing. Australian and New Zealand Journal of Psychiatry, 45, 308 316. doi: 10.3109/00048674.2010.543653 Slade, T., Johnston, A., Oakley Browne, M.A., Andrews, G., & Whiteford H. (2009). 2007 National Survey of Mental Health and Well-being: Methods and key findings. Australian and New Zealand Journal of Psychiatry, 43, 594 605. doi:10.1080/00048670902970882 Wrigley, S., Jackson, H., Judd, F., & Komiti, A. (2005). Role of stigma and attitudes toward help-seeking from a general practitioner for mental health problems in a rural town. Australian and New Zealand Journal of Psychiatry, 39, 514 521. doi: 10.1111/j.1440-1614.2005.01612.x Yap, M.B., Reavley, N.J., & Jorm, A.F. (2012). Associations between awareness of Beyondblue and mental health literacy in Australian youth: Results from a national survey. Australian & New Zealand Journal of Psychiatry, 46, 541 552. doi: 10.1177/0004867411435288
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Familiarity with and intentions to use Internetdelivered mental health treatments among older rural adults Tonelle Handley, David Perkins, Frances Kay-Lambkin, Terry Lewin & Brian Kelly To cite this article: Tonelle Handley, David Perkins, Frances Kay-Lambkin, Terry Lewin & Brian Kelly (2015) Familiarity with and intentions to use Internet-delivered mental health treatments among older rural adults, Aging & Mental Health, 19:11, 989-996, DOI: 10.1080/13607863.2014.981744 To link to this article: http://dx.doi.org/10.1080/13607863.2014.981744
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Date: 11 November 2015, At: 01:06
Aging & Mental Health, 2015 Vol. 19, No. 11, 989 996, http://dx.doi.org/10.1080/13607863.2014.981744
Familiarity with and intentions to use Internet-delivered mental health treatments among older rural adults Tonelle Handleya,b*, David Perkinsc, Frances Kay-Lambkina, Terry Lewind and Brian Kellyd,1 a National Drug and Alcohol Research Centre, University of New South Wales, Waratah, Australia; bCentre for Rural and Remote Mental Health, University of Newcastle, Waratah, Australia; cCentre for Rural and Remote Mental Health, University of Newcastle, c/o Bloomfield Hospital, Orange, Australia; dCentre for Translational Neuroscience and Mental Health, University of Newcastle, Callaghan, Australia
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(Received 27 June 2014; accepted 16 October 2014) Objectives: Older adults are the fastest growing age group in Australia, necessitating an increase in appropriate mental health services in the coming years. While Internet-delivered mental health treatments have been established as acceptable and efficacious among younger samples, little research has explored whether they would be similarly useful in older populations. Methods: The participants were part of the Australian Rural Mental Health study, which explores mental health and wellbeing in residents of non-metropolitan New South Wales. A postal survey was used to assess knowledge of and intentions to use Internet-delivered mental health treatments. Demographics, mental health, and frequency of Internet use were also measured. Results: The survey was completed by 950 adults aged 50 93. The sample was largely unfamiliar with Internet mental health services, with 75% reporting that they had never heard of them and a further 20% not knowing any details of what they involved. Intentions to use these services were also low, at 13.5%; however, this increased with level of familiarity. Respondents with higher psychological distress, higher education, and more frequent Internet use were significantly more likely to consider using Internet treatments. Conclusions: Among older adults, overall awareness of Internet-delivered mental health treatments appears to be limited; however, higher familiarity contributes to higher intentions to use these treatments. Importantly, respondents with higher distress and greater computer literacy were more likely to consider mental health treatments delivered via the Internet. Future research exploring strategies to increase the promotion of these services to older samples may further improve their perceptions and use. Keywords: Internet treatment; mental health; rural; older adults
Introduction Older adults are the fastest growing age group in Australia, with the number of people aged over 75 expected to increase by four million between 2012 and 2060 (Australian Government Productivity Commission, 2013). Although evidence suggests that the prevalence of mental health problems decreases with age (Slade, Grove, & Burgess, 2011), the rising number of older adults in the coming years will necessitate an approximate doubling of the time that psychologists currently spend with older adults even if raw rates of mental health problems do not increase (Karel, Gatz, & Smyer, 2012). Older adults face numerous difficulties in their ability to obtain mental health assistance, with the use of psychological services decreasing with age (Byles, Dolja-Gore, Loxton, Parkinson, & Stewart Williams, 2011). Evidence suggests that structural barriers, such as the distance to and cost of services, concerns about transport, and the lack of mental health professionals with adequate experience working with older age groups, may contribute considerably to the low rates of mental health help-seeking in this age group
*Corresponding author. Email: [email protected] 1 The authors declare no competing interests. Ó 2014 Taylor & Francis
(Fitzpatrick, Powe, Cooper, Ives, & Robbins, 2004; Horton & Johnson, 2010; Murata et al., 2010). The availability of Internet-delivered mental health treatments has increased dramatically in recent years, particularly in Australia (Christensen & Petrie, 2013). The most prominent of these, including MoodGYM, MyCompass, and This Way Up, are primarily focused on highprevalence conditions such as affective and anxiety disorders, which affect approximately 6% and 14% of the Australian population each year, respectively (Slade, Johnston, Oakley, Andrews, & Whiteford, 2009). Such treatments predominantly use cognitive behaviour therapy techniques; however, a wider range of treatments are becoming available, including dialectical behaviour therapy. Online treatments have been shown to have high clinical efficacy, producing reductions in psychiatric symptoms comparable to those achieved by face-to-face therapies (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010). Such interventions may help overcome common barriers associated with mental health service use, through being highly accessible, not requiring clients to travel to
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sessions, not being subject to waiting periods, and often being free of charge. This is particularly advantageous for people who face challenges in accessing traditional mental health care, such as those residing in rural or remote areas (Griffiths & Christensen, 2007), and older adults. Online treatments also offer the benefit of anonymity, which may overcome common deterrents to help-seeking by appealing to individuals concerned about confidentiality and stigma. The long-term effectiveness of Internet-based mental health programmes at a population level is dependent on several factors. Maintaining progress in this area is reliant on integrating with constantly developing hardware technology, and investigating the broader utility, including acceptability of such interventions to people in greatest need (Christensen & Petrie, 2013). Public awareness and perception of Internet-delivered treatments is key to acceptability and utilisation (Handley et al., 2014; Jorm, 2009; Leach, Christensen, Griffiths, Jorm, & Mackinnon, 2007), and in relation to e-health it has been identified as important to consider not only technical development, but also the attitudes and state of mind of the target audience (Eysenbach, 2002). This is particularly relevant in rural areas, where perceived stigma and attitudinal barriers to mental health service use may be greater than in metropolitan centres (Judd et al., 2006; Wrigley, Jackson, Judd, & Komiti, 2005). Focusing solely on the creation of Internet interventions without addressing active dissemination may undermine the potential success of this important developing field, and it has been noted that a focus on consumers’ perspective of Internet-delivered treatments is lacking (Ekeland, Bowes, & Flottorp, 2010). We have recently published findings from a general rural community sample (The Australian Rural Mental Health Study; ARMHS) showing relatively low support for Internet-delivered mental interventions, with only 20% of respondents reporting that they would consider using these services (Handley et al., 2014). While this rate was considerably higher in some subgroups, such as people with a recent mental health problem, younger people, and males, a general hesitance about this method of treatment delivery was notable in the sample as a whole. As Internet access was reasonably high (ranging from 79% in inner regional areas to 60% in very remote areas), we concluded that our findings may be attributable to attitudinal barriers towards Internet treatments, rather than structural difficulties in accessing these services. The ARMHS sample is highly representative of older adults, with a mean age of 55 years at baseline (Kelly et al., 2010), and 59 years in the three-year follow-up data used for this analysis, which may also have influenced our findings. National data show that Internet use is the highest among younger populations (e.g. 97% of those aged 15 17 accessed the Internet at any time in the past 12 months), with a marked decrease among those aged 65 or over (46% accessed the Internet in the past 12 months; Australian Bureau of Statistics [ABS], 2014). Internetdelivered strategies are being used increasingly to engage younger people in mental health treatments (Rickwood, Deane, & Wilson, 2007), with positive findings related to their acceptability and perceived helpfulness (Burns,
Davenport, Durkin, Luscombe, & Hickie, 2010; Horgan & Sweeney, 2010; Oh, Jorm, & Wright, 2009). A recent study in Australia found that one-third of young people with a mental health problem had used the Internet as a source of information about their condition (Burns et al., 2010). However, very little information currently exists on how older age groups respond to the idea of Internet treatments, and whether this strategy may translate into a viable approach to address the mental health needs of this population. To build on our previous research about the feasibility of Internet-delivered treatments for older people in rural areas (Handley et al., 2014), a series of questions relating to awareness and perceptions of Internet-delivered mental health treatments were incorporated into the subsequent wave of ARMHS (wave 4, conducted in 2013). These questions addressed three key areas: (1) knowledge and awareness of Internet treatments; (2) beliefs about the accessibility and effectiveness of Internet treatments; and (3) intentions to use Internet treatments. The aim of this paper is to explore general community awareness of Internet-delivered mental health treatments among a rural sample, and to determine whether low knowledge of Internet treatments may contribute to the low intentions to use these services. While this research is largely exploratory, our previous findings led to the expectation that knowledge of and intentions to use Internet-delivered treatments would be low in this older sample. Although we did not anticipate that gender would be related to knowledge of these treatments, it was expected that males may be more willing to use them (based on our previous findings; Handley et al., 2014). In accordance with our previous research, we anticipated that higher psychological distress would increase the intentions to use Internet treatments, and we also predicted that those with higher distress would have a higher awareness of these treatments. It is anticipated that the results of this research may provide insight into the currently restricted use of Internet-delivered treatments in some samples, and inform strategies to increase uptake rates of programmes with demonstrated clinical efficacy among diverse population groups such as older rural adults.
Methods Participants The sample for the present analysis was obtained from the five-year follow-up (wave 4) of the ARMHS, conducted in 2013. This study targeted residents of rural and remote New South Wales (NSW); this area is made up of major regional centres and coastal cities, small towns and remote communities. Approximately one-quarter of NSW residents occupy rural or remote regions. Participants completed a self-report postal survey about mental health and wellbeing. The full methods for ARMHS have been reported in detail elsewhere (Kelly et al., 2010). There were no gender differences between those sampled and the census population data, although there was a statistically significant under-representation of those aged 18 47 (except for in very remote regions). As the present analysis is concerned with older adults, those aged under 50 were excluded.
Aging & Mental Health Measures
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Outcome variables To assess awareness and the use of Internet-delivered treatments, a set of novel questions were developed. Awareness of Internet-delivered mental health treatments was assessed by the question ‘how familiar are you with Internet-delivered therapies for the treatment of mental health problems (e.g. MoodGYM, mycompass, etc.)?’ with five response options: I have never heard of Internet-delivered mental health treatments. I have heard of Internet-delivered mental health treatments, but do not know any details about them. I have some understanding of what Internetdelivered mental health treatments involve. I have a good understanding of Internet-delivered mental health treatments. I have used an Internet-delivered mental health treatment in the past. Intentions to use Internet-delivered treatments were assessed by a single question: ‘would you consider using the computer or the Internet as a way of accessing treatment for your mental health?’ with an ‘yes/no’ response option. Explanatory variables Based on our previous model, age, gender, and psychological distress were included as explanatory variables in analyses. Age and gender were self-reported. Current psychological symptoms were assessed by the Kessler-10 (K10) psychological distress scale. The K10 assesses the frequency of psychological symptoms during the previous four weeks, and is commonly used as an indicator of general mental health and well-being both on an individual and population level. A cut-off of greater than 15 was used to indicate moderate or high distress, in alignment with the previous research (Slade et al., 2011). Negative beliefs about Internet mental health treatments were also included as explanatory variables, and were explored by a series of nine statements with a Likert scale response option. Participants were asked: ‘what barriers are there to you using the Internet to access information or treatment related to mental health and well-being?’ and rated their response on a four-point scale from ‘does not apply to me at all’ to ‘applies to me very much.’ Examples of these barriers include: ‘I worry that my information will not stay private on the Internet’ and ‘I am concerned about the credibility of the people who design the websites.’ Control variables Education, household income, and frequency of Internet use were included as covariates in the multivariate analyses. Education and income were self-reported by single items in the survey. Participants indicated the frequency of their use of the Internet on a five-point scales from ‘I don’t use the Internet’ through to ‘several times a day.’
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They also completed a series of questions about locations in which they would be willing to use an Internet-based treatment for their mental health (e.g. at home, at a friend’s home, in a library, or other public setting), and which services they would first seek help from if experiencing a mental health problem.
Statistical analysis Associations with awareness of Internet treatments were first explored by bivariate analyses, which included all explanatory and control variables. Bivariate analyses involved one-way ANOVA for continuous variables and chi-square tests for categorical variables (where cell counts were less than five, a Fisher’s exact test was used). As a means of dimension reduction, a factor analysis with oblique rotation was conducted on the negative beliefs about Internet treatments (allowing the resulting factors to be correlated with one another). The strength of endorsement of these negative beliefs was explored using descriptive statistics. The resultant factors were also included as covariates in the logistic regression. A logistic regression was conducted to determine the relationship between awareness of Internet-delivered treatments and intentions to use them. Intentions to use Internet-delivered treatments were the outcome variable, and all explanatory and control variables were included as covariates. Results were reported as adjusted odds ratios (OR) and 95% confidence intervals (95% CI).
Results Overall, 1165 participants completed the survey; of these 950 were aged 50 or over and were included in the analysis. Of these, 40.3% (n D 383) were male and the mean age was 65.5 years (§9.2 years). The majority of the sample was aged 50 64 years (n D 452; 47.6%) or 65 79 years (n D 413; 43.5%), with a lesser representation of those aged 80 years or over (n D 85; 8.9%). Of the 2003 baseline, ARMHS participants who would have been eligible for the present analysis (i.e. those aged 45 or over at baseline, and hence would have been aged 50 or over at five-year follow-up), 950 (47%) were retained at five-year follow-up. There was a slightly lower representation of males at follow-up (40.5%) than at baseline (45.1%; x2(1) D 4.3, p D .038), and those who were retained were younger than those who were not (60.6 § 9.3 vs. 62.0 § 10.5, F(1, 2002) D 10.0, p D .002). Married participants were more highly represented at follow-up compared to baseline (78.1% vs. 73.4%, x2(1) D 4.3, p D .016), as were those who were employed (60.9% vs. 47.6%, x2(2) D 4.3, p < .001). The majority of participants (n D 724; 76.2%) had a computer with Internet access in their home, with an additional 43 (4.5%) having access to a computer with the Internet at another location, and 9 (0.9%) having access to the Internet by mobile phone only. In total, 81.7% of the sample had access to the Internet in some form.
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Awareness of Internet-delivered mental health treatments In total, only five (0.5%) participants reported ever having used an Internet-delivered mental health treatment; therefore, this category was collapsed into the previous subgroup (i.e. ‘I have a good understanding of Internetdelivered mental health treatments’). Generally, awareness of Internet-delivered mental health treatments was low, both in the overall sample and among those with elevated psychological distress, as shown in Table 1. Three-quarters of participants (n D 699) reported that they had never heard of Internet-delivered treatments; cumulatively, 95% reported that they had either never heard of these treatments, or did not know any details about them. This did not differ significantly between the overall sample and the subgroup with elevated distress. An effect by age was observed, with older participants being significantly less likely to be familiar with Internet treatments. Similarly, familiarity increased with higher household income, and was also greater among participants who had completed high school compared with those who had not. There was no significant effect for gender, or for frequency of Internet use. Beliefs about Internet-delivered services The most commonly endorsed negative belief about Internet-delivered mental health services was ‘I don’t know
whether to trust the accuracy of the information provided,’ with two-thirds of the sample endorsing this statement (Table 2). This was followed by ‘I worry that my information will not stay private on the Internet’ and ‘I don’t think Internet treatment will work for mental health problems.’ General barriers, such as not liking computers/the Internet or not being able to afford Internet access, were less common. The factor analysis of negative beliefs about Internetdelivered mental health treatments is displayed in Table 2, and revealed two key factors: specific beliefs about the perceived credibility/effectiveness of Internet-delivered treatments (M D 12.8 § 3.5, range 1 20, Cronbach’s alpha D 0.84), and broader barriers to using the Internet in general (M D 7.6 § 2.7, range 1 16, Cronbach’s alpha D 0.77). These factors were moderately correlated (r D 0.47, p < .001). Specific negative beliefs about the credibility of Internet-delivered treatments decreased linearly as knowledge of Internet-delivered mental health treatments increased, being the highest in those who had never heard of Internet treatments (M D 13.2 § 3.5) and the lowest in those who reported a lot of knowledge about these treatment or had used one before (M D 9.0 § 2.5; F(3, 851) D 13.5, p < .001). Similarly, general barriers to the use of Internet treatments were rated the highest in those who were unfamiliar with them (M D 7.9 § 2.8) and decreased significantly with increasing knowledge, being the lowest in
Table 1. Awareness of Internet-delivered mental health treatments by participant characteristics,% (n). I have never heard of them
I have heard of them but do not know any details
I have some understanding
I have a good understanding, or I have used one before
Total sample
75.3 (699)
19.7 (183)
3.7 (34)
1.3 (12)
Age, mean (SD)
65.5 (9.2)
66.4 (8.9)
61.7 (7.9)
59.7 (7.3)
Gender Male Female
74.1 (278) 76.1 (421)
21.6 (81) 18.4 (102)
3.5 (13) 3.8 (21)
0.8 (3) 1.6 (9)
Education Did not complete high school Completed high school
82.7 (278) 70.6 (396)
16.1 (54) 22.1 (124)
1.2 (4) 5.2 (29)
0 2.1 (12)
Household income Less than $30,000 $30,000 $69,999 $70,000C
79.7 (216) 75.7 (274) 68.4 (175)
18.1 (49) 19.6 (71) 23.0 (59)
2.2 (6) 3.0 (11) 6.3 (16)
0 1.7 (6) 2.3 (6)
Psychological distress Low Moderate/high
76.1 (584) 71.4 (115)
19.3 (148) 21.7 (35)
3.4 (26) 5.0 (8)
1.2 (9) 1.9 (3)
Internet use frequency Once week or less Several times week Every day
75.5 (219) 71.0 (174) 72.3 (141)
20.0 (58) 22.0 (54) 20.0 (39)
2.8 (8) 4.9 (12) 6.7 (13)
1.7 (5) 2.0 (5) 1.0 (2)
Note: p < .05, p < .01
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Table 2. Factor analysis of barriers to Internet-delivered mental health treatments. Component Factor Specific negative beliefs
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General barriers
% agree/strongly agree
1
2
I worry that my information will not stay private on the Internet I don’t think an Internet program can help with mental health problems I don’t think Internet treatment will work for mental health problems I am concerned about the credibility of the people who design the websites I don’t know whether to trust the accuracy of the information provided
60.5 49.9
.58 .85
.23 .13
52.8
.83
.17
51.6
.80
.15
68.5
.85
.12
I cannot afford to access the Internet I don’t like using computers or the Internet for anything I don’t like using computers or the Internet for health problems I don’t have time to look on the Internet for treatment or information about mental health
10.4 21.7 46.4 25.1
.03 .11 .55 .34
.74 .85 .58 .69
4.33 48.06
1.45 16.16
Eigenvalues % of total variance
those who were most familiar with these treatments (M D 5.3 § 1.5; F(3, 863) D 9.2, p < .001). Intentions to use Internet-delivered mental health treatments In the overall sample, 13.5% (n D 128) of respondents reported that they would consider using an Internet treatment for their mental health. Intentions to use Internetbased treatments increased in accordance with the level of awareness of these services, as shown in Figure 1. This effect remained significant after controlling for age, gender, and current psychiatric symptoms (see logistic regression shown in Table 3). Compared to those who were not aware of Internet treatments, those who had either a minimal or moderate level of awareness were approximately twice as likely to consider using these services; this effect
increased to eightfold for those who indicated a good understanding (although the wide confidence intervals for this subgroup should be noted). Intentions to use Internet treatments were also significantly higher for respondents who had completed high school compared to those who had not, and for participants who used the Internet daily compared to those who used it once a week or less. Respondents with high psychological distress were approximately twice as likely to consider using Internet mental health treatments as those with low distress. Higher negative beliefs about Internet-delivered treatments were associated with significantly lower intentions to use them. The bivariate effect for age was no longer significant when frequency of Internet use was controlled for. In response to the question: ‘Which one of these services would you first go to get help for a mental health
Figure 1. Percentage of participants who would consider using Internet-delivered mental health treatments, by familiarity with Internet-delivered treatments.
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Table 3. Logistic regression model predicting intentions to use (yes/no) internet-delivered mental health treatments. OR (95% CI)
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Awareness of internet treatments I have never heard of them I have heard of them but do not know any details about them I have some understanding I have a good understanding, or I have used one before
1.00 2.37 (1.46 3.85) 2.04 (0.86 4.81) 11.34 (3.17 40.61)
Age
0.98 (0.95 1.01)
Gender Male Female
1.00 0.93 (0.60-1.45)
Psychological distress Low High
1.00 3.07 (1.81 5.21)
Education Did not complete high school Completed high school
1.00 2.32 (1.31 4.12)
Household income Less than $30,000 $30,000 $69,999 $70,000C
1.00 1.62 (0.69 2.32) 0.95 (0.49 1.87)
Internet use frequency Once week or less Several times week Every day
1.00 1.14 (0.66 1.96) 2.42 (1.41 4.17)
Note: p < .05, p < .01; OR D adjusted odds ratio.
problem?’, only 1.2% of the sample indicated that they would use an Internet service. Conversely, 85.4% indicated that they would consult a general practitioner. When asked about locations in which participants would consider accessing Internet-delivered mental health services, the majority of the sample indicated that they would use these services in their own home (74.6%). Support for other locations was considerably lower, with 6.9% reporting they would use these services at work, 7.5% at a friend’s home, 7.4% at a library, and 1.8% at an Internet cafe or other setting open to the public. Discussion The aim of this analysis was to explore knowledge of Internet-delivered mental health treatments among general rural community residents, and to investigate the relationship between knowledge of these treatments and intentions to use them. Our findings provide evidence that awareness of Internet-delivered mental health services among older rural residents is low, with the vast majority of respondents being unfamiliar of these services. Even among those with current psychiatric symptoms, around
90% indicated that they had either never heard of Internet mental health treatments, or knew no details about them. This suggests that potential need for mental health treatment does not correlate with knowledge about this treatment option in this age group. These findings are concerning in that they indicate that many of those who could receive the greatest benefits from this mode of treatment delivery (i.e. those with current mental health needs and residing in geographical areas that may not have appropriate services) do not have sufficient knowledge of Internet programmes to make use of them. Awareness of Internet-delivered therapies was considerably lower than previous community-based research exploring recognition of mental health services in Australia, which has been reported as between 62% and 70% for beyondblue: the national depression initiative (an independent organisation that raises public awareness of depression and anxiety, and provides resources for recovery, management, and resilience), and 39% for the youth-targeted headspace (a Government-established National Youth Mental Health Foundation providing mental and health well-being support, information, and services to young people) (Highet, Luscombe, Davenport, Burns, & Hickie, 2006; Jorm, 2009). This highlights the need for social marketing campaigns to raise familiarity with these services in older age groups; however, the relative absence of research examining the efficacy of Internet treatments for older populations presents a challenge to encouraging uptake. A more encouraging observation from this analysis was that greater knowledge of Internet-delivered mental health programmes was related to the increased intentions to use them, with this effect observed in both the subsample with elevated distress and in the overall sample. This effect remained significant after accounting for age, gender, and current psychiatric symptoms, which we have previously found to have a strong relationship with this outcome (Handley et al., 2014). This is similar to the previous research, which has reported that attitudes toward Internet treatments are more positive among people who have used them than people who have not (Gun, Titov, & Andrews, 2011). This may relate to the Theory of Planned Behaviour (Ajzen, 1991), which emphasises the important relationship among beliefs, attitudes, and behavioural intentions, with intentions being the strongest predictor of actual behaviour. In alignment with this theory, our findings point to knowledge as a significant correlate of selfreported behavioural intentions, suggesting that increasing knowledge and improving attitudes towards Internet treatments may influence an increase in intentions to use them. After controlling for knowledge of Internet-delivered mental health treatments, intentions to use these services were predicted by three factors: elevated psychological distress, higher education, and more frequent Internet use. These findings support the notion that Internet treatments may be more appealing to older individuals with higher mental health and computer literacy, and suggest that focusing promotion efforts towards people with these characteristics in particular may be effective. Public health campaigns promoting mental health services have
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Aging & Mental Health previously proven to raise community awareness (Jorm, Christensen, & Griffiths, 2006a; Jorm Christensen, & Griffiths, 2006b), which in turn has also been associated with increases in their perceived effectiveness (Yap, Reavley, & Jorm, 2012). However, evidence that public education campaigns lead to an increase in actual mental health service use (in addition to improvements in perceptions) is less consistent (Dumesnil & Verger, 2009). Future research to investigate the effects of specific promotion campaigns for Internet-delivered treatments targeted towards the specific populations identified in this study (i.e. more highly educated, frequent Internet users, etc.) would be useful. This promotion could incorporate strategies such as online advertising through social media sites (e.g. Facebook, Twitter) to ensure that those recruited have sufficient computer literacy and to take advantage of the avenues which social networking offer for advertising research trials. In addition, advertising through establishments such as Returned Service League clubs (RSLs) and community groups including local rotary clubs may be an efficient way to distribute information about Internet treatments to older audiences. Negative beliefs about Internet mental health services were common in the sample, and were associated with reduced odds of considering the use of Internet-delivered treatments. However, negative beliefs decreased in accordance with self-reported familiarity with these services. The main concerns reported related to privacy and credibility. Considering the low awareness of Internet treatments among respondents, these beliefs may be due to a lack of information or general misconceptions, rather than an informed opinion based on accurate information. In the first place, the vast majority of the sample reported that they would seek help for a mental health problem from a general practitioner. Hence, general practitioners (GPs) may play an increasingly important role as Internet-based mental health treatments continue to develop, not only to inform patients about the existence of these treatments but also to integrate these within their treatment (as an adjunct to face to face contact) and overcome concerns about aspects such as credibility and confidentiality. This is particularly relevant for older age groups, who are more likely than younger age groups to access GPs regularly (ABS, 2012). Older adults are more likely to experience chronic illness and multi-morbidity, and there is a high co-occurrence of physical and mental health conditions. Exploring avenues to promote Internet treatments to health practitioners who work with older adults may be an important step for future research, as this approach would enable health workers to educate older adults about this treatment option. This analysis is limited by a low response rate (in accordance with attrition throughout the five-year period of ARMHS). From the 2639 baseline participants, 1165 remained at wave 4, which may influence the generalisability of the current analysis. However, this is also among the first explorations of the feasibility of Internet-delivered mental health treatments among older adults, and importantly, has a focus on rural and remote residents, who may receive the greatest benefit from this treatment delivery
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method. Hence, our findings may have considerable implications for future research and resource development. Among older adults, awareness of Internet-delivered treatments for mental health problems appears low, and concerns about privacy and efficacy are common. Regardless, people experiencing mental health problems report that they would consider using these treatments, particularly if they already use the Internet for other purposes. Future research is necessary to explore whether greater promotion and targeting of these programmes may increase their acceptability and uptake among older audiences. Acknowledgements We wish to recognise the contribution of the ARMHS chief investigators: Professor David Lyle, Associate Professor Lyn Fragar, Professor John Beard, Professor Vaughan Carr, Professor Jeffrey Fuller, Associate Professor Helen Stain, Professor Prasuna Reddy, and Senior Project Co-ordinator Dr Clare Coleman. We wish to acknowledge the support of directors of Mental Health Services in the relevant Local Health Districts during the course of this phase of the study: Drs Russell Roberts, Richard Buss, and Dinesh Arya, and particularly acknowledge the research site coordinators in each site: Jan Sidford, John Ogle (Broken Hill), Trim Munro, Amy Strachan (Moree), Louise Holdsworth, Kath O’Driscoll (Lismore), Cheryl Bennett, Jannelle Bowler (Orange), along with Fleur Hourihan, Dr Gina Sartore and Denika Novello.
Funding The study was funded by the National Health and Medical Research Council [grant number 401241], [grant number 631061]; and also supported by a Research Capacity Building Grant to the Australian Rural Health Research Collaboration. Tonelle Handley is supported by a postdoctoral fellowship from Australian Rotary Health, which is acknowledged with gratitude.
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