Theory‐based behaviour change intervention to promote mental health help‐seeking among older adults in Australia: Initial dissemination and acceptability

Rates of help‐seeking for mental health problems among older adults are low and initiatives to increase help‐seeking in older populations are limited. To our knowledge, no interventions have aimed to promote help‐seeking among older adults by tapping internal motivations to seek help. In this paper, we describe the development of a theory‐based intervention designed to promote mental health help‐seeking among older adults in Australia, using an internal motivation paradigm.


| INTRODUCTION
Rates of help-seeking for mental health problems among older populations are consistently low. 1,2Not seeking help, or delaying help-seeking, can lead to severe mental health disorders, increase the burden of disease and hinder healthy ageing. 3,4It is important that older adults engage mental health supports early, to protect their health and facilitate timely access to treatment.
Nevertheless, initiatives to increase help-seeking in older populations are limited.A 2018 systematic review identified 98 studies that reported on interventions to promote help-seeking, only three of which specifically targeted older adults. 5The three studies used a systems-level, collaborative care approach to increase help-seeking.Collaborative care approaches involve integrating systems of care to improve communication between health professionals and enhance patient outcomes. 6Collaborative care requires financial support and multi-agency partnerships, which can be difficult to sustain, particularly in lowresourced settings such as mental health services. 7They also only reach people who are already accessing services, which is problematic for help-seeking interventions, as those who are likely to be most in need of intervention will not be reached by such approaches.Individual-level approaches that target older adults' underlying attitudes and beliefs towards help-seeking may be a more feasible way to promote help-seeking.Indeed, such approaches have been shown to be effective in younger populations and people with mental health problems. 8,9e developed a behaviour change intervention, tapping older adults' internal motivations to seek help, to promote help-seeking for mental health problems among older adults in Australia.In this report, we describe the development and acceptability of the intervention and its potential application.

| Study design
A consultative process with nine key stakeholders was used to design and develop the intervention.We drew on the UK Medical Research Council guidance for developing and evaluating complex interventions to inform our approach. 10

| Ethics
Ethics approval was granted by the Edith Cowan University Human Research Ethics Committee, approval number 14248-Adams.All participants provided written informed consent.

| Participants
Stakeholders were recruited using purposive sampling in Perth, Western Australia.The Western Australian Mental Health Research Alliance, university directories, google searches, word-of-mouth and the Consumer and Community Involvement Program were the avenues of recruitment.Stakeholders comprised five main groups: primary health-care providers; mental health professionals; health-care executives; representatives from community organisations and consumers.

| Data collection and procedure
Semi-structured interviews were conducted individually with each stakeholder, in person (n = 5), via Zoom (n = 2) or via telephone (n = 2), to investigate stakeholders' views and recommendations regarding the design and implementation of the intervention.The interviews lasted between 30 and 60 minutes and were focussed on the following topics: • Factors that influence older adults' help-seeking behaviour.• The most appropriate theoretical framework to inform the intervention.• The best methods to present the intervention in terms of layout, format and delivery.• Ways to make the intervention as effective as possible.

| Data synthesis
Handwritten notes were taken during the interviews by the first author and transferred into Microsoft Word postinterview.Major themes were identified based on the topics above:

Practice Impact
Help-seeking for mental health problems is important to improve health outcomes.This study describes the development and acceptability of a theory-based brochure, co-designed with stakeholders, to promote older adults' willingness to seek mental health help.Preliminary data indicate that the intervention is an acceptable method for promoting help-seeking among older adults in Australia.
• Theoretical relevance: the TPB was seen as a suitable theory to inform the intervention.Attitudes, subjective norms and perceived behavioural control were targeted in the intervention as planned.• Burdening others: the belief that seeking help burdens loved ones was seen to influence help-seeking.A sentence addressing this barrier was included in the intervention.• Where to get reliable help: not knowing which sources of information to trust was seen to influence helpseeking.A list of organisations that provide information and support was included in the intervention.• Size of the intervention materials: delivering the intervention in a familiar format that could easily be carried was seen as desirable.The intervention content was delivered as a trifold brochure.• Well-being versus mental health: the term well-being was seen as less confronting than mental health.The title of the intervention was changed to 'well-being'.
An initial draft of the intervention was designed based on stakeholders' feedback and sent to stakeholders via email for review to identify problems and solutions prior to implementation.Changes were made to the wording of the intervention messages based on stakeholder feedback.

| Intervention: help-seeking brochure
The intervention was informed by our past research and consisted of a theory-based brochure couched in the Theory of Planned Behaviour (TPB), designed to promote help-seeking for mental health problems from a general practitioner (GP). 11,12Past research has shown that older adults prefer to seek mental health help from a GP, and in Australia, GPs are the gatekeepers for further referrals. 13,14he TPB is a widely applied theory used to predict and change health-related behaviours, including helpseeking. 15,16Our previous work demonstrated that the TPB is acceptable for conceptualising mental health help-seeking in older adults with chronic diseases in Australia. 12The present intervention included behaviour change messages targeting the three main components of the TPB: attitudes, subjective norms and perceived behavioural control, as well as barriers to help-seeking and mental health literacy.Guidance from previous research and stakeholders was used to inform the behaviour change messages. 17

| Attitudes
Messages to promote favourable attitudes towards helpseeking aim to convey that help-seeking is a good and useful thing to do.

| Subjective norms
Messages to promote favourable subjective norms aim to increase perceived social support and reduce mental health-related stigma.

| Perceived behavioural control
Messages to promote perceived behavioural control aim to strengthen self-efficacy and reinforce personal choice in help-seeking.

| Barriers to seeking help
Messages to address barriers to help-seeking aim to target key barriers identified in our past research such as low perceived need for help and those recommended by stakeholders.

| Mental health literacy
Information was also included to increase mental health literacy, as suggested by stakeholders.Messages included details on how and where to seek help and what treatment options are available.
Images from each page of the intervention, colour coded to reflect the components described above, are presented in Figure 1.

| Pilot test
Participants ≥65 years living in metropolitan Perth were recruited through community centres, social groups and snowballing procedures to provide feedback on the acceptability of the intervention.Participants were excluded if they (i) had been diagnosed with dementia or Alzheimer's disease and/or (ii) were not fluent in English.Participants completed a questionnaire online in the Qualtrics survey platform 18 that encompassed 10 items measuring the clarity, relevance, appropriateness and appeal of the intervention.Items were rated on 5-point Likert-type scales from 'strongly disagree' to 'strongly agree'.Higher scores indicated greater acceptability.Counts and percentages were calculated to determine the acceptability of the intervention.Results are presented in Table 1.
Five participants (26%) reported current mental health concerns and three (16%) reported speaking with a doctor about their mental health in the past 12 months.More than 74% of the sample responded with 'agree' or 'strongly agree' to the 10 items, indicating support for the acceptability of the intervention.Notably, 84% of participants reported that they would recommend the intervention to older adults who are experiencing mental health challenges.

| DISCUSSION
This report described the development and acceptability of a theory-based intervention aimed at promoting mental health help-seeking among older adults in Australia.To our knowledge, this intervention is the first to target older adults' internal motivations to seek help.Tapping internal motivation is likely to be more effective than previous system-level approaches, which only reach older people who are already accessing health services and address external motivations that are more vulnerable to resistance. 19he help-seeking intervention was co-designed with key stakeholders, consistent with best practice guidelines. 10esults demonstrated that the help-seeking brochure may be an acceptable method for targeting mental health helpseeking; participants responded most frequently with 'agree/strongly agree' to the acceptability criteria, indicating that the intervention is relevant, clear, appropriate and appealing.Importantly, no participants disagreed with the clarity and appropriateness of the intervention, and only one participant deemed the intervention not relevant.
A limitation was the use of an online survey to collect data, which may have led to the exclusion of participants without internet access or with poor digital literacy.Digital literacy is important to older adults' psychosocial well-being and has been found to increase knowledge of and access to health information. 20A further limitation was the sample size, which restricts confidence in the generalisability of the conclusions.
A strength was the co-design of the intervention with key stakeholders, which may have improved the acceptability of the intervention. 10The use of theory to inform intervention design and development also added to the rigour of this research.

| CONCLUSIONS
The intervention shows promise as an acceptable method for promoting help-seeking for mental health problems among older adults.A pilot randomised controlled trial has been conducted to determine the feasibility and preliminary effectiveness of the intervention in changing intentions to seek help and help-seeking behaviour (paper forthcoming).If successful, the intervention could be used as part of larger mental health campaigns to increase older adults' engagement with mental health support when experiencing psychological challenges.