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Journal of Mental Health

ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: https://www.tandfonline.com/loi/ijmh20

Going global: do consumer preferences, attitudes, and barriers to using e-mental health services differ across countries?

Bonnie A. Clough, Mostafa Zarean, Ilse Ruane, Niño Jose Mateo, Turana A. Aliyeva & Leanne M. Casey

To cite this article: Bonnie A. Clough, Mostafa Zarean, Ilse Ruane, Niño Jose Mateo, Turana A. Aliyeva & Leanne M. Casey (2019) Going global: do consumer preferences, attitudes, and barriers to using e-mental health services differ across countries?, Journal of Mental Health, 28:1, 17-25, DOI: 10.1080/09638237.2017.1370639

To link to this article: https://doi.org/10.1080/09638237.2017.1370639

Published online: 31 Aug 2017.

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J Ment Health, 2019; 28(1): 17–25 � 2017 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/09638237.2017.1370639

ORIGINAL ARTICLE

Going global: do consumer preferences, attitudes, and barriers to using e-mental health services differ across countries?

Bonnie A. Clough1,2, Mostafa Zarean3, Ilse Ruane4, Niño Jose Mateo5, Turana A. Aliyeva6 and Leanne M. Casey2

1Institute for Resilient Regions, University of Southern Queensland, Toowoomba, QLD, Australia, 2School of Applied Psychology, Behavioural Basis of

Health, Menzies Health Institute Queensland, Griffith University, Mt Gravatt, QLD, Australia, 3Department of Psychology, Faculty of Education and

Psychology, University of Tabriz, Iran, 4Private Practice, Pretoria, South Africa, 5Counseling and Educational Psychology Department, College of

Education, De La Salle University, Manila, Philippines, and 6Department of Social and Pedagogical Psychology, Baku State University, Baku,

Azerbaijan

Abstract

Background: e-Mental health services have the capacity to overcome barriers to care and reduce the unmet need for psychological services, particularly in developing countries. However, it is unknown how acceptable e-mental health interventions may be to these populations. Aims: The purpose of the current study was to examine consumer attitudes and perceived barriers to e-mental health usage across four countries: Australia, Iran, the Philippines and South Africa. Methods: An online survey was completed by 524 adults living in these countries, assessing previous contact with e-mental health services, willingness to use e-mental health services, and perceived barriers and needs for accessing e-mental health services. Results: Although previous contact with e-mental health services was low, the majority of respondents in each sample reported a willingness to try e-mental health services if offered. Barriers toward e-mental health usage were higher among the developing countries than Australia. The most commonly endorsed barriers concerned needing information and assurances regarding the programmes. Conclusions: Across countries, participants indicated a willingness to use e-mental health programmes if offered. With appropriate research and careful implementation, e-mental health has the potential to be a valuable part of mental healthcare in developing countries.

Keywords

e-Mental health, attitudes, cross-cultural, Internet interventions, barriers to care

History

Received 6 March 2017 Revised 4 May 2017 Accepted 26 July 2017 Published online 30 August 2017

e-Mental health interventions are now widely available across

disorders, therapeutic approaches and patient populations

(Griffiths et al., 2007; Meurk et al., 2016). One of the most

compelling arguments for the dissemination of e-mental health

is that such interventions have the capacity to address high

levels of unmet need for mental health treatment by overcoming

consumer and system barriers to care (Casey et al., 2013, 2014;

Shoemaker & Hilty, 2016). These barriers to care include

geographical and service constraints, cost, and attitudinal

barriers such as stigma. However, there is increasing recogni-

tion that e-mental health services may also have their own

associated barriers, including consumer attitudes toward the

services. Indeed, the importance of further research to under-

stand community and policymaker perspectives, particularly

across characteristics such as ethnicity and socioeconomic

status, has been identified as crucial to enhancing the uptake and

integration of e-mental health into existing healthcare systems

(Meurk et al., 2016). However, it is not yet known the extent to

which these barriers may differ across countries.

Consumer attitudes and preferences

Two systematic reviews have identified a consistent finding

across studies, in that consumers report preferring and estimate

a greater likelihood of using face-to-face treatment compared

to e-mental health programmes (Gough et al., 2016; Meurk

et al., 2016). However, consumers are not necessarily averse to

using e-mental health services, with many reporting a willing-

ness to try services if it were offered to them (Klein & Cook,

2010; Meurk et al., 2016). Attitudes may also be improved by

providing consumers with information regarding the purpose,

format and efficacy of e-mental health interventions (Casey

et al., 2013; Casey & Clough, 2016; Ebert et al., 2015). These

are findings that may be of particular relevance to populations

experiencing high barriers to care such as stigma, low mental

health literacy, and limited access to services.

A global gap in the research

One of the major limitations of research in this field is the

relative homogeneity of populations studied. Gough et al.

Correspondence: Bonnie Clough, School of Applied Psychology, 58 Parklands Drive, Southport, Queensland 4215, Australia. Tel: +61 7 5678 8101. E-mail: [email protected]

This article has been republished with minor changes. These changes do not impact the academic content of the article.

(2016) found that of 18 studies examining consumer attitudes,

likelihood, and willingness to use e-mental health services,

12 were conducted using Australian samples and all were

conducted in countries considered to be ‘‘developed’’.

Although no standard criterion exists for defining ‘‘develop-

ing’’ or ‘‘developed’’ countries, characteristics such as life

expectancy, literacy and income are typically considered

(United Nations Statistics Division, 2017). Individuals in

developing countries who suffer mental illness are more likely

to experience significant barriers to care, with social barriers

often compounding the effect of limited health resources and

difficulties with dissemination (Becker & Kleinman, 2013).

According to the World Health Organisation (WHO), over

75% of individuals with severe mental illness living in

developing countries do not receive treatment (Demyttenaere

et al., 2004), with considerable individual and societal

barriers evident even when treatments are available (Becker

& Kleinman, 2013). Considering the capacity for e-mental

health to provide care to previously underserved populations

(Muñoz, 2010), an important direction for research is to

examine the acceptability and feasibility of these interven-

tions in these populations.

e-Mental health interventions hold considerable promise

for improving access and quality of mental healthcare in

developing countries (Mucic et al., 2016; Muñoz, 2010).

However, there is a lack of research examining whether such

interventions are feasible and acceptable to individuals living

in these societies, as well as the potential barriers to their

implementation. Greater understanding of these populations

is required for e-mental health interventions to reach their full

potential on a global scale.

The current study

The aim of the current study was to examine consumer

preferences, attitudes and perceived barriers toward e-mental

health services across four countries: Australia, Iran, the

Philippines and South Africa. The four countries included in

the present study were considered to be geographically and

culturally diverse, and represented both developed (Australia)

and developing (Iran, the Philippines and South Africa)

countries. e-Mental health is a rapidly changing field of

research and practice, with calls for research in this area to be

more rapid and responsive to the evolving technologies.

(Clough & Casey, 2015a,b; Riley et al., 2013). As such, the

samples selected for the current research were intended to

provide a rapid insight into potential differences in attitudes

and barriers across countries. Focusing solely on developing

countries may not provide a context for interpreting results,

and as such Australia was included in the present study as an

exemplar for comparisons to a developed nation. To the

authors’ knowledge, this is the first study to examine

consumer attitudes and barriers to e-mental health services

within these countries, so data were analysed in an explora-

tory fashion. However, based on previous research identifying

large treatment gaps and significant barriers to access and

delivery of mental health services in low and middle income

countries (Eaton et al., 2011), it was predicted that barriers

and requirements for using e-mental health services would be

highest among the developing countries.

Method

Participants

The survey was accessed by 853 participants. Inspection of

response files revealed 63 participants exited the survey

prior to giving consent and 224 exited the survey after

providing consent but prior to acknowledging submission of

their responses. These incomplete files were taken as

withdrawal of consent and were removed from analyses

(n¼ 287). Also excluded from analyses were participants

who indicated they did not reside in one of the four

countries of interest (n¼ 37) or who reported being younger

than 18 years of age (n¼ 5). Participants were therefore 524

adults aged between 18 and 80 years (M¼ 29.26,

SD¼ 11.28), with 163 from Australia, 126 from Iran, 125

from South Africa, and 110 from the Philippines. The

sample was predominantly female (74.40%), married or in a

relationship (54.20%), with an undergraduate university

education (33.40%), and were not mental health profes-

sionals (84.70%) but had studied a psychology or counsel-

ling course in the past (66.40%). Almost all of the

participants reported having regular access to the Internet

(99.00%); an unsurprising finding given the survey was

administered online. Descriptive statistics by country are

provided in Table 2.

Design

The study was conducted as a quasi-experimental between

groups that design, with participants self-identifying to one of

the four country groups (Australian, Filipino, Iranian or South

African). Dependent variables were a mixture of categorical

variables (e.g. previous contact with services) and continuous

variables (e.g. mental health literacy).

Measures

Demographic information

Data were collected pertaining to participant gender, age (in

years), country of residence, relationship status (two levels; in

a relationship/married or single), highest level of education

completed (five levels; primary school, secondary school,

trade/diploma/certificate, undergraduate degree, postgraduate

degree), status as a mental health professional (two levels; yes

or no), previous engagement in a psychology or counselling

education course (two levels; yes or no), and access to the

Internet whether by means of a computer, Smartphone, or

other device (two levels; yes or no).

Previous contact and service preferences

A number of questions were developed to measure partici-

pants’ previous contact and service preferences. A brief

definition of e-mental health was also provided to partici-

pants: ‘‘e-Mental Health refers to the delivery of mental

health services (treatment, information and support) via the

Internet or mobile phone. This can be through websites, web

applications, video conferencing, chat or email. Some of these

services, such as video conferencing or online counselling,

involve direct one on one contact with a mental health

professional. Other e-mental health services, such as web

18 B. A. Clough et al. J Ment Health, 2019; 28(1): 17–25

applications or information websites, involve less or no

contact with mental health professionals.’’

Previous contact with e-mental health services

Previous contact with e-mental health services was measured

using one original item requiring participants to indicate the

services they had received support or help from for

difficulties with emotions, nerves, or use of alcohol or

drugs. Four e-mental health options (information website,

online counselling, Internet-based programme with therapist

assistance, Internet-based programme without therapist assist-

ance) were provided based on those identified by Klein &

Cook (2010), with the addition of a fifth ‘‘None of the above’’

option. Participants were permitted to select multiple treat-

ment response options.

Service preferences for e-mental health

To measure treatment preferences with the inclusion of e-

mental health services, participants were required to indicate

their willingness to use each service. A list of possible

services was generated by combining the 10 identified service

options (e.g. psychologist, psychiatrist, religious or spiritual

advisor, etc.) from item SR17 of the World Mental Health

Survey Initiative version of the WHO Composite

International Diagnostic Interview (WMH-CIDI; Kessler &

Üstün, 2004) with the four e-mental health treatment options

identified by Klein & Cook (2010). Participants indicated

their willingness to receive help from each of the 14 treatment

services dichotomously (yes or no), if it were to be offered to

them at a time when they were experiencing difficulties with a

personal or emotional problem.

e-Mental health concerns and barriers

Two questions were used to measure participants’ concerns

toward and barriers to using e-mental health services. The

first question asked participants to indicate agreement on

seven-point scales ranging from 1 (strongly disagree) to 7

(strongly agree) for eight statements relating to concerns

toward e-mental health services (e.g. ‘‘I would need to

arrange access to a computer or the Internet’’). Seven items

for this question were drawn from Klein & Cook’s (2010)

study, with one additional item (‘‘I would be concerned that I

would be caught or overheard whilst using e-mental health

services such as online counselling’’) included by the authors

to allow for situations involving shared devices or spaces.

A second question assessed participants’ barriers to

accessing and engaging with the technology required for an

example online programme. The programme scenario given

to participants involved the completion of 1-hour online

sessions, available once per week. Participants were

instructed to select any equipment or help (five options, e.g.

‘‘a computer’’ or ‘‘power or electricity for the computer or

smartphone’’) they would need, that they currently did not

have, in order to access the programme. Responses were

dichotomous: yes or no as to whether the equipment or help

was needed by the individual.

First point of contact

Using the 11 service options from SR17 of the WMH-CIDI

(WMH-CIDI; Kessler & Üstün, 2004), participants were

asked to indicate ‘‘If you, or someone close to you, were

experiencing mental difficulties such as with emotions,

nerves, or use of alcohol or drugs, who would you be most

likely to get help from?’’. Participants were instructed to

select one response option.

Procedure

An online survey was conducted among Australian, Iranian,

Filipino and South African populations. Although individual

access to the Internet differs between these countries

(Table 1), this method of dissemination was deemed appro-

priate as the first users of e-mental health approaches within

these countries will likely be those individuals who have

regular access to the Internet through either personal or

shared devices. The countries represented diversity in devel-

opment and systems of population-level healthcare. A sum-

mary of country characteristics and healthcare systems is

contained in Table 1, as based on government and WHO

documents (Australian Government, 2012, 2015; World

Health Organisation, 2006, 2007a, 2007b), as well as data

from the World Bank (2016).

Table 1. Summary of country characteristics and healthcare systems.

Commonwealth of Australia Islamic Republic of Iran Republic of the Philippines Republic of South Africa

Region Asia-Pacific Middle East/Western Asia South-East Asia Africa Income status High Upper middle Lower middle Upper middle Internet users per

100 people 84.60 39.40 39.70 49.00

Healthcare system Tax-based Insurance-based Insurance-based Tax-based � Government funded

psychological and psy- chiatric care widely available

� E-mental health estab- lished as a part of gov- ernment strategy for stepped care

� Variety of insurance policies, all cover mental health but with limita- tions on length of hos- pital stay and services covered

� Better implementation of national mental health guidelines in rural rather than urban areas, according to WHO

� Insurance covers mental disorders but is limited to acute inpatient care

� No defined national mental health law

� Access to and provision of mental healthcare dependent on region, with budgets decentra- lised to the nine provinces

DOI: 10.1080/09638237.2017.1370639 EMH health attitudes across four countries 19

Ethical approval was granted from Australian and South

African human research ethics committees. Due to a lack of

country-specific processes, ethical approval was not obtained

within Iran or the Philippines. In these contexts, fellow

researchers within each country reviewed the study design

and procedures, with the international ethical approvals

deemed adequate. The survey was administered in English

for the Australian, Filipino, and South African samples, and in

Persian (Farsi) for the Iranian sample. As the measures used

in this study were not available in Persian, the Iranian author

(MZ) conducted translations of all items, instructions, and

participant information and consent forms. The translated

version of the questionnaire package was then compared to

the English version by two independent bilingual (native Farsi

speaking) researchers for review and agreement on meaning

and translation.

Advertisements and notices for the study were placed on

social media sites, as well as invitation emails sent to staff and

students of the associated universities and workplaces.

Snowball sampling was then used to recruit participants

within each country. Advertisements encouraged participants

to provide their opinions towards various forms of healthcare,

with greater detail provided in the online information and

consent materials accessed through the online survey. No

incentives were offered for participation.

Statistical analyses

Data were screened according to guidelines by Tabachnick

and Fidell (2013). Data were analysed using SPSS version 22

(IBM Corp, 2013). Normality was violated on a small number

of variables and as such transformations were performed.

Where transformations did not alter the interpretation of

results, untransformed data are reported.

Results

Equality of groups

Preliminary analyses were performed to determine whether

significant differences existed between the groups on the

demographic variables. The variable of highest level of

education achieved was recoded to combine the two

categories of primary and secondary high school, due to the

low number (n¼ 2) of participants in the primary school

category.

Significant differences between groups were found on the

variables of age, gender, relationship status, highest level of

education, status as a mental health professional, having

undertaken at least one course in psychology or counselling,

and having experienced a mental or emotional difficulty (to

the point of interference) in the past (all p� 0.002).

Significant effects were followed up with main effects

comparisons or column proportion (z tests) analyses (as

appropriate) utilising Bonferroni corrections. Results of these

follow-up tests are displayed in Table 2.

Previous contact with e-mental health services

Previous contact was examined for e-mental health services.

Due to the number of comparisons conducted, alpha for the

initial chi-square tests was set at .01. Significant differences in

sample proportions were found for previous use of an online

website for support (�2 (3, N¼ 524)¼ 24.209, p50.001,

V¼ 0.215), online counselling (�2 (3, N¼ 524)¼ 12.657,

p¼ 0.005, V¼ 0.155), and for having no contact with online

services for mental health support (�2 (3, N¼ 524)¼ 26.970,

p50.001, V¼ 0.227). No differences in sample proportions

were found for previous contact with online programmes

without therapist assistance (p40.01). Due to the majority of

cell counts being less than 5, a chi-square analysis was not

performed for the online programme with therapist assistance

category. For the significant chi-square tests, follow-up

column proportion tests were conducted utilising Bonferroni

corrections (Table 3). Australians and South Africans

reported the highest use of online websites for information

and support, with less than a third of the Filipino sample

reporting such contact. Use of online counselling was highest

in the Australian and Iranian samples. Low levels of contact

with online programmes, particularly those with therapist

assistance, were observed across samples. The Filipino

Table 2. Participant characteristics by country sample.

Australia (n¼ 163) Iran (n¼ 126) The Philippines (n¼ 110) South Africa (n¼ 125)

Gender Female 126 (77.3%)a,b 87 (69.0%)b 71 (64.5%)b 106 (84.8%)a

Male 37 (22.7%) 39 (31.0%) 39 (64.5%) 19 (15.2%) Age 33.90 (13.80)a 34.57 (8.55)a 24.83 (7.78)b 21.76 (5.47)b

Relationship status In a relationship/married 104 (63.8%)a 71 (56.3%)a 36 (32.7%)b 73 (58.4%)a

Single 59 (36.2%) 55 (43.7%) 74 (67.3%) 52 (41.6%) Level of education

Primary school 1 (0.6%) 0 (0%) 1 (0.9%) 0 (0%) Secondary school 36 (22.1%)a 0 (0%)c 23 (20.9%)a 82 (65.6%)b

Trade/diploma/certificate 36 (22.1%)a 8 (6.3%)b 13 (11.8%)a,b 13 (10.4%)a,b

Undergraduate 51 (31.3%)a 42 (33.3%)a 60 (54.5%)c 22 (17.6%)b

Postgraduate 39 (23.9%)a 76 (60.3%)c 13 (11.8%)a,b 8 (6.4%)b

Participant as mental health Professional 12 (7.40%)a 38 (30.20%)b 19 (17.30%)a,b 11 (8.8%)a

Counselling/psychology education 62 (38.00%)a 83 (65.90%)c 85 (77.30%)c 118 (94.40%)b

Previous mental health difficulties 148 (90.80%)a 118 (93.70%)a 80 (72.70%)b 105 (84.00%)a,b

Access to Internet 162 (99.40%)a 125 (99.20%)a 109 (99.10%)a 123 (98.40%)a

For age standard deviations are shown in parentheses. Each subscript letter denotes a subset of the four country samples whose column proportions (or means) do not differ significantly from each at the .05 level (with Bonferroni correction).

20 B. A. Clough et al. J Ment Health, 2019; 28(1): 17–25

sample had the highest proportion of participants who

reported no previous contact with online services for mental

health support, followed by the Iranian and South African

samples, with the lowest proportion in the Australian sample.

Service preferences for e-mental health

Willingness to use services

Significant differences across country samples (utilising alpha

of .01) were observed in the proportion of participants

endorsing willingness to receive support from all listed

treatment options (13), except psychologist, counsellor,

Internet-based programme with therapist assistance, and

Internet-based programme without therapist assistance (all

�2 (3, N¼ 524)412.916, all p50.01, all V4.157). No

significant differences were observed in the proportion of

participants within each country sample endorsing willing-

ness to receive support from a psychologist (p40.05), with

high levels of endorsement observed across samples. Chi-

squared analyses were followed up with column proportions

tests (with a Bonferroni correction) and are summarised in

Table 3.

In general, participants were most willing to receive

mental health support from psychologists and counsellors.

Willingness to receive support from doctors, nurses or

religious leaders was low in the Iranian sample. Also of

note was that in the Iranian sample there was a high

willingness to use e-mental health services if offered, with

four of the top six endorsed services within this sample being

e-mental health services. Willingness to use e-mental health

services was generally higher within the Australian and

Iranian samples than within the Filipino or South African

samples. With the exception of the Iranian sample, participant

ratings of willingness to use services were generally higher

for the more traditional services [e.g. psychologists,

psychiatrists, counsellors and General Practitioners (GPs)]

than for e-mental health services. However, over half of the

respondents in each sample still indicated a willingness to

receive support by means of information websites, online

counselling, or Internet-based programmes with therapist

assistance. Endorsement of Internet-based programmes with-

out therapist assistance was lower than those with therapist

assistance for all country samples. However, a majority of

participants within the Australian and Iranian samples still

indicated a willingness to use these services.

e-Mental health concerns and barriers

A series of one-way Analyses of Covariance (ANCOVAs)

were conducted to examine cross-country differences in mean

endorsement of concerns regarding the use of e-mental health

services (Table 4), with the demographic variables related to

both country sample and endorsement of concerns (gender,

level of education, having previously experienced a mental or

emotional difficulty) entered as covariates. Significant main

effects of country sample were found for needing to arrange

access to a computer or the Internet (F (3, 517)¼ 84.497,

p50.001, gp 2¼ .329), needing to know more about e-mental

health services (F (3, 517)¼ 4.957, p¼ 0.002, gp 2¼ .028),

needing assurances that personal information was secure and

confidential (F (3, 517)¼ 4.691, p¼ 0.003, gp 2¼ .027), and

concerns about being caught or overheard whilst using e-

mental health services (F (3, 517)¼ 2.949, p¼ 0.032,

gp 2¼ .017). The results of the main effects comparisons are

summarised in Table 4.

The security and confidentiality of personal information

was consistently rated as the highest concern across country

samples, with needing to know more information about e-

mental health services also rating highly across the four

countries. The Iranian sample was more likely to endorse

Table 3. Previous contact and willingness to use e-mental health services across country samples.

Australia Iran The Philippines South Africa

Previous contact (e-mental health services) Information website *100 (61.3%)a *52 (41.3%)b *36 (32.7%)b *61 (48.8%)a,b

Online counselling 9 (5.5%)a,b 12 (9.5%)a 0 (0.0%)b 4 (3.2%)a,b

Online programme with therapist assistance 3 (1.8%) 2 (1.6%) 1 (0.9%) 6 (4.8%) Online programme without therapist assistance 11 (6.7%)a 5 (4.0%)a 5 (4.5%)a 7 (5.6%)a

None of the above *61 (37.4%)a *68 (54.0%)b,c *76 (69.1%)c *62 (49.6%)a,b

Willingness to receive help if offered Psychiatrist 127 (77.9%) a,b 82 (65.1%) a *92 (83.6%) b *100 (80.0%)b

GP or family doctor *151 (92.6%) a 42 (33.3%) c *81 (73.6%) b *93 (74.4%)b

Other medical doctor 80 (49.1%) a 32 (25.4%) b 62 (56.4%) a 52 (41.6%)a

Psychologist *153 (93.9%)a *110 (87.3%)a *102 (92.7%)a *119 (95.2%)a

Social worker 108 (66.3%)a 52 (41.3%)b 59 (53.6%)a,b *86 (68.8%)a

Counsellor *141 (86.5%)a *103 (81.7%)a *104 (94.5%)a *105 (84.0%)a

Other mental health professional *132 (81.0%)a 41 (32.5%)c 65 (59.1%)b 79 (32.2%)b

Nurse or health professional 94 (57.7%)a 35 (27.8%)b 58 (52.7%)a 71 (56.8%)a

Religious or spiritual advisor 49 (30.1%)a 31 (24.6%)a *82 (74.5%)b 79 (63.2%)b

Any other healer (herbalist, chiropractor etc.) 80 (49.1%)a 24 (19.0%)b 30 (27.3%)b 38 (30.4%)b

Information website *140 (85.9%)a *103 (81.7%)a,b 75 (68.2%)b *86 (68.8%)b

Online counselling 108 (66.3%)a,b *99 (78.6%)a 71 (64.5%)a,b 72 (57.6%)b

Internet programme with therapist assistance 110 (67.5%)a *93 (73.8%)a 62 (56.4%)a 74 (59.2%)a

Internet programme without therapist assistance 94 (57.7%)a 73 (57.9%)a 46 (41.8%)a 56 (44.8%)a

GP: General Practitioners. Each subscript letter denotes a subset of the four country samples whose column proportions do not differ significantly from each at the .05 level (with

Bonferroni correction). *Indicates the service is one of the most commonly endorsed service types, within the question group, for the country sample.

DOI: 10.1080/09638237.2017.1370639 EMH health attitudes across four countries 21

needing access to a computer or the Internet than the other

three samples, with the Filipino sample being the least likely

to endorse this concern. There was a trend for the Iranian

sample to endorse greater concerns over being caught or

overheard whilst using e-mental health services, although this

effect only approached significance (p¼ 0.058) when the

Bonferroni correction was applied. A mean value for

concerns/barriers was calculated across items (with item

one reverse scored) for each participant, with a significant

main effect for country sample found (F (3, 517)¼ 14.763,

p50.001, gp 2¼ .079). Overall, the Iranian sample reported

significantly greater concerns/barriers towards using e-mental

health services than the other three countries (p’s50.05).

Chi-squared analyses (with alpha for initial tests set at .01)

were conducted to explore participant responses to equipment

and requirements needed, that they do not currently have, in

order to access e-mental health services. Significant differ-

ences across country samples were observed for all items (all

�2 (3, N¼ 524)414.233, p50.01, V4.165). Significant

effects were followed up with column proportion tests using

a Bonferroni correction, as summarised in Table 4.

Across all samples, the majority of participants reported

having all equipment required to access e-mental health

programmes, although the proportion of Australian partici-

pants was significantly greater than the proportion of Filipino

and Iranian. In general, the highest proportion of participants

with unmet needs for accessing e-mental health programmes

was in the Iranian and Filipino samples. The most commonly

endorsed need across all samples was someone to explain how

to use equipment or sites, which was followed by access to the

Internet and smartphone or computer devices. Endorsement

of these barriers was generally lower in the Australian sample

than in the other three samples.

First point of contact

Participants indicated the type of service they would be most

likely to use for formal support with mental or emotional

difficulties (Table 5). A significant difference (with alpha set

at .01) was found in the distribution of service preference

across samples (�2 (30, N¼ 524)¼ 193.668, p50.001,

V¼.351), which was followed up with column proportion

Table 4. e-Mental health concerns and barriers by country sample.

Australia Iran The Philippines South Africa

e-Mental health concerns/barriers 1. I would not hesitate to use an e-mental health 4.15 (.14)a 4.50 (.18)a 4.09 (.18)a 4.02 (.19)a

2. I would need to arrange access to computer/ Internet 1.69 (.14)a *5.14 (.18)b 3.37 (.17)c 1.91 (.18)a

3. I would need to know more about e-mental health *5.18 (.13)a *5.82 (.17)b *5.11 (.16)a *5.57 (.17)a,b

4. I would only access online information not treatment 4.13 (.14)a 4.57 (.18)a 4.21 (.18)a *4.26 (.18)a

5. I would want assistance of online therapist in a programme *4.20 (.14)a 4.64 (.18)a 4.17 (.18)a 4.03 (.18)a

6. Need assurance personal information secure *6.25 (.11)a,b *6.28 (.15)a,b *5.82 (.14)a *6.56 (.15)b

7. Concerned about being caught/overheard 3.82 (.17)a 4.51 (.21)a *4.27 (.20)a 3.76 (.21)a

8. I would not use e-mental health services 2.93 (.15)a 3.10 (.19)a 2.89 (.18)a 2.93 (.19)a

Mean number of concerns/barriers endorsed 4.01 (.06)a 4.70 (.08)b 4.22 (.08)a 4.13 (.08)a

Requirements/participant needs to access e-mental health 1. Computer 4 (2.5%)a 13 (10.3%)b 17 (15.5%)b 13 (10.4%)b

2. Smartphone *12 (7.4%)a *31 (24.6%)b 14 (12.7%)a,b 8 (6.4%)a

3. Power or electricity for the computer/smartphone 1 (0.6%)a 8 (6.3%)b 14 (12.7%)b 6 (4.0%)a,b

4. Access to the Internet 6 (3.7%)a 18 (14.3%)b *23 (20.9%)b *20 (16.0%)b

5. Someone to explain to me how to use the equipment *15 (9.2%)a *22 (17.5%)a,b *29 (26.4%)b *20 (16.0%)a,b

6. None of the above – I have access to everything needed *132 (81.0%)a *74 (58.7%)b *63 (57.3%)b *88 (70.4%)a,b

Note. Each subscript letter denotes a subset of the four country samples whose means or column proportions do not differ significantly from each at the .05 level (with Bonferroni correction). Mean number of barriers/concerns endorsed is adjusted according to the covariates of gender, level of education, and having previously experienced a mental or emotional difficulty, with standard error of the mean displayed in parentheses.

*Indicates barrier/requirement is one of the most commonly endorsed, within the question group, for the country sample.

Table 5. First point of formal contact for mental health concerns.

Australia Iran The Philippines South Africa

Service Preference Psychiatrist 8 (4.9%)a *24 (19.0%)b 12 (10.9%)a,b 9 (6.4%)a

GP or family doctor *59 (36.2%)a 2 (1.6%)b 4 (3.6%)b *11 (8.8%)b

Other medical doctor 0 (0%)a 2 (1.6%)a 1 (0.9%)a 2 (1.6%)a

Psychologist *53 (32.5%)a *42 (33.3%)a *32 (29.1%)a *72 (57.6%)b

Social worker 0 (0%)a 1 (0.8%) a 0 (0.0%)a 3 (2.4%)a

Counsellor *33 (20.2%)a *30 (23.8%)a *37 (33.6%)a 8 (6.4%)b

Other mental health professional 2 (1.2%)a 3 (2.4%)a 0 (0%)a 3 (2.4%)a

Nurse or health professional 0 (0%)a 0 (0%)a 1 (0.9%)a 2 (1.6%)a

Religious or spiritual advisor 3 (1.8%)a 5 (4.0%)a,b *19 (17.3%)c *12 (9.6%)b,c

Any other healer (herbalist, chiropractor, etc.) 2 (1.2%)a 2 (2.4%)a 0 (0%)a 1 (0.8%)a

None of the above 3 (1.8%)a 14 (11.1%)b 4 (3.6%)a,b 3 (2.4%)a

Note. Each subscript letter denotes a subset of the four country samples whose column proportions do not differ significantly from each at the .05 level (with Bonferroni correction).

*Indicates the service is one of the most commonly endorsed service types, within the question group, for the country sample.

22 B. A. Clough et al. J Ment Health, 2019; 28(1): 17–25

analyses utilising a Bonferroni correction. Significant differ-

ences in proportions across samples were found for 6 of the 11

services, as displayed in Table 5. Australians indicated they

would be most likely to access mental health support from

their GP or family doctor, Iranians and South Africans were

most likely to access support from a psychologist, and

Filipinos from a counsellor. Other notable differences were

observed for participants endorsing a religious or spiritual

leader as being their most likely contact (highest proportion in

the Filipino sample) and participants who reported they would

likely not have contact with any of the services if they were

experiencing mental health difficulties (highest proportion in

the Iranian sample).

Discussion

The aim of the current study was to examine consumer

preferences, attitudes and perceived barriers toward e-mental

health services in a sample of developed and developing

countries. Although e-mental health may have considerable

potential to overcome barriers to care in developing countries,

to the authors’ knowledge no previous research has examined

whether attitudes and barriers towards e-mental health

services differ between developed and developing countries.

The present study examined these factors across Australia,

Iran, the Philippines, and South Africa, as an investigation

among exemplars of geographically and culturally diverse

countries and healthcare systems.

As representations of developed and developing countries,

previous use of e-mental health services was low, particularly

among the developing countries. In general, the Australian

sample had more previous contact with e-mental health

services than the other three samples. Highest rates of contact

with e-mental health services across samples were for

information websites, although still less than half of the

Iranian, Filipino and South African samples endorsed this

usage. Nearly 70% of the Filipino sample reported no contact

with any form of e-mental health services.

Yet even when previous use has been low in country, this

does not mean that e-mental health may have poor uptake if it

is made available. To the contrary, our results indicate that

given the opportunity, the majority of participants in each

sample were willing to use some form of e-mental health

services, with the highest endorsements observed for infor-

mation websites, online counselling, and online programmes

with therapist assistance. Lower rates of endorsement were

observed for programmes without therapist assistance, which

is consistent with previous studies in the field (Gough et al.,

2016). Interestingly, the highest rates of participant willing-

ness to try e-mental health services was typically observed in

the Iranian sample, who also reported the highest number of

barriers and concerns toward these services. As such, in

designing interventions to be used in countries such as these,

it seems clearly important for researchers, technologists, and

clinicians to consider the practical and technical assistance

that individuals will need to utilise these services. For

example, awareness of issues around cybersecurity is

increasing in developed countries, but in those developing

countries where there may be a stronger history of broader

security issues, individuals may be more immediately inclined

to have concerns and require assurances of data safety. In

sum, participants may be willing to use these services if they

were to be provided with the practical assistance or

assurances required to access e-mental health services.

The most common concerns/barriers reported across

samples were needing assurance about the safety of personal

data, wanting the assistance of an online therapist, and

needing more information about e-mental health services.

Self-reported participant needs for using e-mental health

services (such as Internet, a computer, etc.) were highest in

the Filipino and Iranian samples, with barriers and participant

needs lowest in the Australian sample. Overall, the data

suggest that the majority of individuals in developing

countries are willing to use e-mental health services for

support and information. However, these participants also

experience a number of barriers to programme use, both

structural (e.g. Internet access) and perceived (e.g. wanting

more information about services or support in using

equipment).

These results provide direction for key areas to target in

implementing e-mental health in these countries. That is, not

only will it be of importance to ensure adequate access and

technical support to potential users (e.g. through shared or

publically accessible computers in health clinics), but also

that healthcare providers will need to play an important role in

educating potential users on e-mental health approaches, to

overcome attitudinal barriers and concerns.

Significant differences were found across countries for first

point of contact for seeking formal mental health assistance.

In delivering e-mental health interventions in these countries,

it will likely be beneficial to include these stakeholders in

referral and dissemination processes. Access to mental health

treatments may be improved by those individuals acting in

first contact roles assisting in creating referral pathways for

individuals to access e-mental health services as appropriate.

Furthermore, within each country, these stakeholders may be

a key resource in assisting policymakers and healthcare

providers in overcoming the attitudinal and knowledge

barriers previously discussed, such as by providing individ-

uals with information regarding available services or what an

e-mental health programme involves.

The results of the current study should be interpreted with

reference to a number of limitations. First, this study only

examined four countries, however, the study has provided

evidence as to the existence of attitudinal differences across

countries and the importance of understanding these factors.

Second, the structure and validity of the translated question-

naires were not examined and should be considered for future

research.

The demographic differences observed across samples

would also indicate that the participants may not have been

representative of the general populations within each country,

such as by the overrepresentation of higher levels of education

in the Iranian sample. The samples were also predominantly

female, which is consistent with previous research in this field

(Gough et al., 2016) and psychological research more gener-

ally, but does however limit interpretation of results.

Furthermore, as the survey was conducted online, only the

opinions of those participants with Internet access in the

developing countries were able to be studied, thus

DOI: 10.1080/09638237.2017.1370639 EMH health attitudes across four countries 23

biasing results. However, these limitations should be con-

sidered within the context of the possible uses of e-mental

health services within these countries. In the initial stages of e-

mental health development in these countries, the most likely

users of these programmes will be individuals with Internet

access and capacity (education or otherwise) to engage in these

programmes. As such, the samples studied in the present

research were not conceptualized as representative of general

populations, however, they may be representative of potential

e-mental health users in these countries. Furthermore, the

mental health professionals represented in the samples may

serve an important role in championing the uptake and

dissemination of e-mental health services within these

countries. Lastly, information regarding the current mental

health status of individuals was not collected. Future research

may be needed to examine whether current need impacts upon

attitudes or preferences to these services.

e-Mental health programmes may have the potential to

overcome barriers toward mental health service use in

developing countries, particularly with reference to service

availability and stigma (Mucic et al., 2016). However, limited

research has been conducted to establish the extent to which

attitudes and barriers of potential users of e-mental health

services may differ across countries. The current study

suggests that there are differences between countries which

will need to be understood in order to effectively introduce e-

mental health. Importantly, our study indicates people in

countries where there is currently have low use of e-mental

health are at least willing to try these services should they be

offered. Furthermore, this research provides direction as to the

key areas and barriers that will need to be targeted for these

services to reach their potential within these countries. In

disseminating these services, it will be important to involve

key stakeholders from existing mental health services. For

example, existing service preferences can be used to dissem-

inate information and referral pathways regarding e-mental

health services. The use of e-mental health services may

increase individual access to efficacious support programmes,

and thereby allow the mental health services that are available

within these countries to have maximum reach in serving

vulnerable populations.

The present study demonstrates that there are important

differences between countries in knowledge and barriers to e-

mental health services, which to date has been an under-

researched area. Future research should aim to understand the

relationships between consumer attitudes in the developing

countries and factors such as perceived stigma, mental health

literacy and knowledge, and barriers to care. The current study

would suggest that with appropriate research and careful

implementation, e-mental health has the strong potential to

form a valuable part of mental healthcare in these countries.

Declaration of interest

None to declare.

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