Aging & Mental Health

ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage: www.tandfonline.com/journals/camh20

Rural and urban older adults’ perceptions of

mental health services accessibility

Bob G. Knight & Sonya Winterbotham

To cite this article: Bob G. Knight & Sonya Winterbotham (2020) Rural and urban older adults’
perceptions of mental health services accessibility, Aging & Mental Health, 24:6, 978-984, DOI:
10.1080/13607863.2019.1576159

To link to this article: https://doi.org/10.1080/13607863.2019.1576159

Published online: 14 Feb 2019.

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AGING & MENTAL HEALTH
2020, VOL. 24, NO. 6, 978–984
https://doi.org/10.1080/13607863.2019.1576159

Rural and urban older adults’ perceptions of mental health services

accessibility
Bob G. Knighta and Sonya Winterbothama
a
School of Psychology and Counselling, University of Southern Queensland, Toowoomba, Australia; 2School of Psychology (Honorary),
University of Queensland, Brisbane, Australia

ABSTRACT ARTICLE HISTORY

Objectives: Older adults have been recognised as a group with poor access to mental health serv- Received 4 December 2018
ices, particularly those in rural areas. Using a decision framework of recognizing psychological Accepted 23 January 2019
problems, deciding to seek help, and choice of help, this study investigated older adults’ access to
KEYWORDS
mental health services using a mixed methods design.
Rural older adults; mental
Methods: Ninety-four older adults from remote, regional and urban Australia returned surveys and health services;
twenty-one of them participated in focus groups and in-depth interviews. Participants were asked accessibility; stigma
to identify psychological problems, the decision to seek help including perceived barriers to acces-
sibility of mental health services, and the choice of help including their understanding of mental
health disciplines and their views of service use.
Results: When regional differences appeared, inner regional older adults reported more access
problems than either urban or outer regional participants. Although older adults have a good
understanding of mental health disciplines and accurately identified depression and substance
abuse, they had difficulty recognizing anxiety and were uncertain as to when symptom severity
should indicate that one should seek help. Though stigma was largely dismissed as a thing of the
past, self-sufficiency was implicated as a psychological barrier to accessibility.
Conclusion: Older adults may have difficulty in recognizing anxiety and milder levels of mental
health concerns. This may be further complicated by a high value of self-sufficiency. These barriers
need to be considered by all professionals working with older adults, in particular GP’s who were
identified as expert health advisors.

Access to mental health services is an issue for rural popula-
tions internationally. Both physical and mental health profes-
sionals are concentrated in cities. The accessibility of mental
health services for rural older adults is an understudied area.
Available research suggests that aside from limited availabil-
ity of mental health services locally, the psychosocial barriers
are similar to those of urban older adults, but potentially
more severe (e.g., Brenes, Danbauer, Lyles, Hogan, & Miller
(2015); Stewart, Jameson, & Curtin, 2015).
It has frequently been hypothesized that older adults are
more likely to see psychological treatment as stigmatized.
However, quantitative research studies have suggested that
older adults view psychological treatments in positive terms
at least equal to younger adults (Hanson & Scogin, 2008;
Rokke & Scogin, 1995; Woodward & Pachana, 2009). Pepin,
Segal and Coolidge (2009) found that stigma was not an
important barrier to service for older adults and that per-
ceived fear of psychotherapy was higher in younger adults.
If not stigma, what other barriers might there be to the
use of psychological treatments? Knight (2004), drawing
upon the Americans View Their Mental Health surveys
(Gurin, Veroff, & Feld, 1960; Veroff, Kulka, & Douvan, 1981)
described a three part decision structure that determines
whether people seek mental health services: Is the problem
psychological? Do I seek help for it? What type of help do
I seek?
Identifying problem as psychological
Gurin et al. (1960) noted that older adults were less likely
to identify problems as psychological, but those who did
were equally likely as younger adults to seek help. Later
studies including Veroff et al. (1981) and Currin, Hayslip,
Schneider, and Kooken (1998) suggested this was a cohort
effect with later born cohorts more likely to identify psy-
chological problems. However, much of the community
education focus in aging and mental health has been on
dementia and depression until quite recently and so
whether the identification of other psychological problems
such as anxiety and alcohol abuse has become easier
is unknown.
The role of referral sources is also a potential issue.
In the decision framework, referral sources can play a
key role in identifying psychological problems. Robb
et al. (2003) found that although older adults were
more likely than younger ones to identify their GP as
primary source of mental health care referrals, they were
about half as likely to agree that the GP met their men-
tal health needs. Gum et al. (2006) found that collabora-
tive care between GPs and mental health providers
increased access to counselling services dramatically.
Sirey and Trevino (2017) noted a key role for primary
medical care in connecting older adults to mental health

CONTACT Bob G. Knight bob.knight@usq.edu.au

ß 2019 Informa UK Limited, trading as Taylor & Francis Group

services and also suggested partnership with the aging
care network.
Deciding to seek help
An important influence on deciding to seek help is the
availability and accessibility of such help. Internal barriers
such as stigma and other negative attitudes about mental
health services can play a role in the decision to seek psy-
chological help once a problem is identified. External bar-
riers such as physical and financial service accessibility can
also be key decisional factors. This may be particularly rele-
vant in Australia where geographical remoteness has com-
monly been associated with poorer access to health
services. The Australian Bureau of Statistics classifies
remoteness areas into five classes (urban, inner regional,
outer regional, remote, & very remote) based on a combin-
ation of population level and distance to more populous
areas (ABS, 2016). The population of Australia is largely
concentrated in the capital cities of the states, with the
rest of the country considered to be regional or rural. The
Australian Bureau of Statistics (2016) reported outer
regional and remote communities are more likely to experi-
ence barriers to health care and difficulties accessing
a doctor.
There is some evidence that older adults may have a
higher threshold for perceiving need for psychological
help. Robb, Haley, Becker, Polivka, and Chwa (2003) found
that older adults were equally likely to seek help for severe
disorders, but less likely than younger adults to seek help
for milder disorders. In a large nationally representative
sample in Australia, Forbes, Crome, Sunderland, and
Wuthrich (2017) found that older adults were the least
likely age group to report a need for mental health care,
but those perceiving a need were most likely to have
needs met. Thus, there is reason to think one barrier is rec-
ognizing need for psychological treatment.
Type of help to seek
Once the decision to seek help is reached, the decision on
what type of help to seek is made. People may decide to
seek help from a mental health professional, from their GP,
from religious sources et cetera. As noted earlier, the
sparse literature on this point shows older adults are as
likely as younger adults to seek psychotherapy. Gum et al.
(2006) reported that older adults in primary care preferred
counselling to medication. Evidence for rural older adults
is lacking.
The current study
Thus, quantitative findings on underutilization of mental
health services by older adults have been inconclusive but
appear to contradict earlier thinking about stigma as a key
factor. Evidence exists for issues in identifying psycho-
logical problems as needing help and in accessibility, how-
ever, little is known about the influences on older adults
seeking psychological help. In the current study, we
obtained quantitative survey data and qualitative inter-
view/focus group data from older adults from rural and
urban areas asking about their knowledge of and attitudes
AGING & MENTAL HEALTH 979
toward mental health services. As Tashakkori and Teddlie
(2003) note, a potential strength of the mixed methods
approach is the opportunity to go beyond the answers to
structured questionnaires and discover what older adults
themselves think that researchers and service providers
may not have inquired about.
This research took place in Australia which has coverage
for mental health services under universal national health
insurance (called Medicare). General practitioner physicians
are the main gatekeepers and refer patients to psycholo-
gists and other mental health professionals for services
reimbursed in part or in whole by Medicare. The coverage
is determined in practice by the psychologist provider who
can opt not to have lower income clients pay the gap
between Medicare payment and the typical fee. There are
also services available in the public hospital and clinics sys-
tem, but these are largely taken up by persons with more
severe mental health problems and tend to have lengthy
wait lists.
The current study was designed to explore older adults’
responses concerning mental health services within the
decision making structure of identifying problems as psy-
chological, deciding to seek help, and choosing what type
of help to seek. The recruitment of participants was tar-
geted toward regional/rural areas with recruitment of
urban dwellers as a comparison group.
Method
This study used a concurrent mixed method design to
explore the research questions (University Human Research
Ethics Committee approval number H117REA059).
Quantitative data were gathered via an online (or print)
questionnaire drawing on a combination of rating scales
and vignettes describing an older woman with psycho-
logical symptoms. As Creswell and Plano Clark (2017) point
out, such a questionnaire may not provide researchers with
a full account of the phenomena, by further conducting
qualitative interviews with a selection of this same cohort a
comparison of results provided insight, either via corrobor-
ation of quantitative findings or through the discovery of
contradictions in the data.
The quantitative survey study
Methods
Participants
Participants were recruited from a variety of senior citizen
organizations (e.g., University of the Third Age) and both
senior focused and general newspaper announcements.
Surveys could be completed anonymously, however at
the end of the questionnaire, participants were invited to
provide an expression of interest in the interview phase.
This meant providing name and contact details with the
completed survey; this information was then stored separ-
ate to the survey data.
Survey measures
Mental health vignettes. Respondents were randomly pre-
sented with one of three vignettes of an older woman with
psychological symptoms. Upon reading the vignettes
980 B. G. KNIGHT AND S. WINTERBOTHAM

Table 1. Summary of multiple regression analysis for correlates of intentions to see a mental health professional.
Step 1 Step 2 Step 3
Variable
B SE B b B SE B b B SE B b
Age
0.04 0.07
0.07
0.04 0.07
0.06
0.05 0.06
0.07
Gender
0.21 0.87
0.03 0.04 0.87 0.01
0.17 0.78
0.02
Education
0.00 0.30
0.00 0.01 0.29 0.00
0.21 0.27
0.08
Health 0.25 0.24 0.12 0.36 0.24 0.17 0.16 0.22 0.08
Inner regional
2.13 0.91
.28
1.69 0.83
0.22
Outer regional
0.41 1.32
0.04
1.38 1.20
0.12
Attitude barriers
.18 .04
.47
p < .05 p<.01.

respondents were asked to identify the disorder (e.g., what,
if anything, do you think is wrong with the person
described in the vignette?) and from a list of 10 help-seek-
ing options, rate the five best ways the person could be
helped. These vignettes followed the formatting used by
Reavley and Jorm (2011) in the National Mental Health
Literacy Survey. Vignettes were written to satisfy the diag-
nostic criteria for (a) major depression, (b) anxiety, or (c)
alcohol use disorder. Consistency in word length was main-
tained across all versions. The vignettes were used to
determine participants’ ability to correctly identify the men-
tal health problems presented. The researchers separately
coded responses as correct, other mental health disorder
identified, or no disorder identified. Cohen’s j = .76 for
inter-coder agreement.
BMHSS-R brief questionnaire. The Barriers to Mental
Health Services Scale-Revised (BMHSS-R) is a 44-item self-
report questionnaire designed to measure 10 barriers to
individuals seeking out mental health services (Pepin et al.,
2015). In considering overall survey length, we developed a
brief version (25 items) of the BMHSS-R, maintaining all 10
subscales with two to four items per subscale. Two psy-
chologists independently reviewed each subscale, items
deemed similar to other items or irrelevant to the sample
were removed.
Because this shortened version had two to four items
per each of the 10 subscales and the subscales were highly
correlated, we combined these brief subscales into three
domains: external barriers (GP referral, transportation and
payment) a = .80; internal barriers (considering depression
normal, unable to find help, unwilling to seek help, and
limited knowledge about psychotherapy) a = .78; and
stigma (ageism, stigma about psychotherapy, concerns
about whether it works) a = .88. These domains were used
for mean level comparisons among groups. Because they
were too highly correlated with one another to use in
regression equations, we used the total score in the regres-
sion analysis, a = .92
Attitudes to mental health and intent to see a mental
health professional. Three items from an APA nationwide
US study (see Farberman, 1997, as cited in Robb et al.,
2003) were included in this survey. These were two general
attitude and perception questions (e.g., “Do you feel you
personally have adequate access to mental health care?”),
and a question about likelihood of seeking help from a
mental health professional for a variety of psychological
disorders. Participants responded by rating a four point
scale from “very likely” to “not at all likely” for each prob-
lem type. Responses were reverse coded then summed
across depression, suicidal feelings, drugs/alcohol, divorce/
marital problems, death in family, and stress, so that higher
scores meant more likely to seek help (a = .84).
Results
Participants
94 participants aged 60–87 returned surveys (mean age =
70.45, sd = 6.17). 69% were female, 98% identified as
White or of European heritage, 87% were retired. The
median level of education was trade/vocational training.
30.9% lived in urban areas; 55.4% inner regional areas, and
13.1% in outer regional or remote areas.
Global sense of access to mental health care
All participants indicated that access to mental health care
was very important (82.6% to 90.9%) or somewhat import-
ant. There was no significant difference by geographic
remoteness, v2 (2) = 0.689, p = .708. When asked if they
had adequate access to mental health care, the differences
were significant with outer regional and remote people
reporting best access (81%) and inner regional the worst
(37%), urban dwellers were in the middle at 64%, v2 (4) =
9.793, p = .044.
Recognizing the problem as psychological
Participants were randomly assigned one of the three men-
tal health vignettes. The percentage of the sample correctly
identifying the diagnosis varied significantly across the
vignettes v2 (4) = 12.917, p = .012. 85.2% correctly recog-
nized depression. 69.0% recognized alcoholism, but only
42.9% identified anxiety, with 52.4% not seeing a mental
health problem in that vignette. There were no regional
differences in accuracy.
Deciding to seek help
We found no regional differences on intent to seek help
for a variety of psychological problems.
On the modified Barriers to Mental Health Services ques-
tionnaire, for regionality, there were no significant differen-
ces for stigma [F (2, 74) = 1.619, p = .205] or for external
barriers [F (2, 73) = 1.007, p = .370]. We did find a signifi-
cant difference for internal barriers [F (2, 73) = 5.789, p =
.005]. Outer regional respondents reported lower levels of
internal barriers than urban and inner regional respondents
who did not differ from one another.
We explored potential correlates of intention to see a
mental health professional using multiple regression. We
entered age, gender, education and health in Step 1, then

dummy coded remoteness (urban as the comparison
group) in Step 2, then the total score from the Barriers
questionnaire in Step 3. See Table 1 for details. The demo-
graphic variables as a group did not explain intent to seek
mental health help. Adding the regional variables took the
equation to borderline significance with being inner
regional making intent less likely as compared to urbanites.
Adding barriers explained additional variance. In the full
model being in an inner regional location and endorsing
more barriers made intent to see a mental health profes-
sional less likely.
What type of help to seek
The most common help seeking responses across all
vignettes were general practitioner, psychologist, help from
family member, seek information from a local health cen-
ter. We included psychiatrist in further analyses because it
is a mental health discipline even though selected by few
respondents. Regional location was significant for psycholo-
gist/counsellor only [F (2, 60) = 6.121, p = .004], with outer
regional people seeing them as being less helpful than
inner regional people with urban dwellers in the middle
and not different from the other two groups. Post hoc
exploratory analysis by specific diagnosis showed that this
difference was largely due to responses to the alcohol
abuse vignette, F (2,32) = 6.607, p = .004, one significant
result of 12 ANOVAs. Outer regional respondents rated the
helpfulness of psychologist/counsellor for alcohol abuse
significantly lower than both of the other regional groups.
All of the above data were analysed for gender differen-
ces. Across all measures no significant gender differen-
ces found.
The qualitative interviews
Method
Participants
Semi-structured interviews or focus groups were conducted
with survey participants who volunteered for the interview
phase and were contactable. Qualitative data collection
ceased when it was deemed that the data had reached sat-
uration point. Interviews and focus groups collected further
impressions from those living in geographically diverse
areas of Australia.
Procedure
Where enough participants were available in a given loca-
tion, focus group participation was sought, however due to
the nature of the topic all participants were offered the
option of individual interview. Focus groups and interviews
were conducted either (a) in person (n ¼ 11); (b) over the
phone (n ¼ 9); or (c) via video link (n ¼ 1). One focus group
of four participants was recorded, with three participants
attending in person, and a fourth (Virginia) participating via
Zoom video technology. Two interviews consisted of two
participants, one of these interviews consisted of two par-
ticipants from a similar region, the other of spouses.
Despite the variation in qualitative data collection methods,
there were no discernible differences in participant
responses that could be attributed to collection methods
AGING & MENTAL HEALTH 981
(i.e., focus group responses contained the same depth and
breadth as individual interviews). As is accepted practice all
participants were encouraged to provide a response to
each question, with focus group and dual participant inter-
view data exceeding that of individual interviews,
of course.
An interview schedule guided discussion around partici-
pants’ knowledge, attitudes, and beliefs regarding mental
health and mental health services. Interviews and focus
groups lasted between 30 minutes and 80 minutes
(M ¼ 52 minutes), were audio recorded and transcribed by
the second author. To protect participant anonymity, the
second author assigned a pseudonym to each participant.
Analysis
Transcripts were entered into the qualitative data analysis
software program NVivo Version 11 (QRS International,
2015) with analysis procedures guided by Braun and Clarke
(2006). Analysis was approached deductively, with coding
and theme development at the semantic-level. Each author
read, and re-read the interview and focus group transcripts.
Authors completed a preliminary list of ideas coding each
transcript independently. Coded data were then compared
across all transcripts with collation allowing for initial inde-
pendent interpretation of possible patterns. Periodic com-
munication between authors allowed for a review of
coding process, discussion of broader patterns of meaning,
and conceptual consistency. Themes were discarded if it
was deemed by both authors that these were not repre-
sentative of the data set (patterns revealed in less than
50% of participants) or if interrater agreement could not
be reached.
Findings
Participants
Twenty-one participants between 62 and 80 were inter-
viewed for the study. 62% were female. Sixteen were from
inner regional towns, three from urban areas and two from
outer regional or remote areas. Thirteen indicated they had
direct experience with mental health services as a client. A
further four indicated indirect experience, through career
(e.g., mental health nurse), family, or friends.
Recognizing the problem as psychological
Participants talked about a blurring between what was
‘natural’ or ‘normal’ ageing versus a mental health issue.
This blurring could in itself lead to a reluctance to seek
help. Harry (Outer Regional) suggested that it was possible
older adults might simply dismiss issues concluding ‘oh
yeah it’s natural to feel that way’. Brian (Inner Regional),
suggested that differentiating between a genuine problem
and age-related decline was difficult as individuals
attempted to identify whether it was in a ‘normal range’ or
‘abnormal range’.
In Australia, access to Medicare funding for mental
health services is through the GP and the majority of the
respondents recognized the GP role both as a gatekeeper
in this sense and as a first stop for seeking help. Those
with direct experience reported their mental health
982 B. G. KNIGHT AND S. WINTERBOTHAM
problem was identified by their GP rather than themselves.
Jean (inner regional) recognised her GP as a trusted expert
of symptoms, services, and appropriate specialists, there-
fore the GP’s advice was decisive:
I think too that’s where your, you know your relationship with
your GP, like mine is really good and we’ve been with Dr J for a
long time. And so if she kind of said, you know ’I think you’re
suffering depression I, let’s, we might try this’. I would be much
more inclined to do that.
Deciding to seek help
Attitudinal barriers
Respondents mostly felt that psychological problems
needed to be very severe before seeking help. Nicole, for
example believed that the media perpetuated a miscon-
ception that: “you’ve either got to be totally depressed, or
totally suicidal, or totally off your rocker, to go” (Nicole,
Inner Regional). This ‘misconception’ appeared to be
adopted by several participants who only viewed symp-
toms as problematic when they reached a certain stage of
severity. Brian described a situation where he had not
thought of mental health services until symptoms
were severe:
So I couldn’t speak, read or, or articulate anything. At that stage I
thought ‘oh this is pretty bad’. Well I don’t know I just rang up a
friend and asked for help. (Brian, Inner Regional)
Catherine (Remote) noted that even third parties may
not see the signs “until kind of things have got a bit dire”
further highlighting difficulties in initial recognition that
mental health services may be required.
Stigma. A majority of respondents mentioned stigma as a
thing of the past, feeling it decreased markedly over their
lifetimes. Participants viewed mental health as something
that was talked about more openly today. They saw this as
a positive step in reducing stigma:” Because we’re not
scared that someone’s going to point at us in the street, as
people in the past might have been. I think it’s much better.”
(Catherine, Remote). There was also acknowledgment that
national organisations with a focus on mental health had
increased public awareness and assisted in the growing
acceptance of mental health issues.
Interestingly, Della (Inner Regional), who at the time of
data collection was visiting a psychologist for help, openly
discussed with friends and neighbours her experiences
with mental health services. In contrast, Grace, who was
also receiving psychological support for depression, felt
less comfortable opening up to friends:-
I’m still in that place of not telling people that I suffer depression
… I don’t tell them because I tend to feel that that’s, they look
at you differently. They did that in the past with me I guess, and,
and I’ve still got that attitude and that’s possibly why I feel,
there’s still a stigma. (Grace, Inner Regional)
Self-sufficiency. More respondents endorsed self-suffi-
ciency as a barrier: that a value of handling one’s emo-
tional and personal problems on one’s own was more of
an issue. In discussing self-sufficiency, most participants
separated themselves from other older adults, suggesting
that they themselves would take a more proactive
approach (i.e., discuss it with their GP) whilst ‘others’ would
attempt to handle the issue themselves. Vince (Inner
Regional) however was one participant who identified his
own reaction as similar to that of ‘others’:- “I probably just
wouldn’t do anything about it. Just grit me teeth sort of
thing”. Catherine (Remote) described this attitude as per-
taining to “the old school type men who think you know the
way you solve problems is go out and work hard. And then if
that all, else fails, … the poor things shoot themselves”.
Several participants noted that this was the attitude
they were brought up with, and that there was little time,
recognition, or empathy afforded to mental health issues in
the past. For example Monica reflected on losing her family
when she was a child, she recounted being told to “Stop
your crying, stop your whinging … stop snivelling” (Monica,
Inner Regional).
External barriers
One potential reason for older adults not accessing mental
health services is inaccessibility for practical reasons. Upon
being asked what might prevent an older adult from
accessing mental health services, two main factors dis-
cussed were distance and costs. However, responses con-
cerning these factors as barriers were mixed.
Distance. It is interesting to note that issues surrounding
distance were discussed by participants living in each of
the five remoteness classes, from urban areas to very
remote. However, several participants indicated that dis-
tance would not be an issue for themselves or that if they
needed the service they would be willing to travel the dis-
tance. Grace, a 74 year old inner regional participant, sug-
gested that even a four or five hour one-way journey
would not deter her “if it meant I was getting something
that I needed from it”. For Grace, and other participants,
the value placed on the service overcame distance as a
potential barrier.
Of interest, one of the firmest assertions of distance as a
barrier came from a respondent in the outer suburbs of
the urban area rather than from those in more remote
regional areas.
Because we’re looked upon as a pimple on the butt of Brisbane
… services are very poor. So, anybody who needs assistance
with, with mental problems, there’s not a lot of services based in
[location] … You’ve got to go to Brisbane. (Joseph, Urban)
Costs. Responses about cost were also mixed; more than
half mentioned cost, but they were roughly evenly split
between suggesting it was a barrier and saying it was not.
Those viewing services as cost prohibitive were from inner
or outer regional centres and considered this on several
grounds with references made to health insurance, SES,
and a national health system unable to cope with the
demands of mental health needs.
For Harry, who had no direct experience with mental
health services, the imagined costs associated with services
were viewed as ‘expensive’:-if you didn’t, didn’t have private
health insurance. I don’t know whether it would all come
under Medicare or not, so it could possibly get expensive
yeah. (Harry, Outer Regional)

As would be expected, several participants who had dir-
ect experience with mental health services indicated that
they were aware of government funded plans for mental
health which had, for them, eliminated any cost-related
barriers. However, Joseph suggested that systemic failings
of these services had the potential to increase the cost bur-
den due to the immediate need for assistance:
I mean to go on a waiting list to see a psychiatrist for a mental
health thing, to me is a bit of an oxymoron, it’s just not going to
work. So then you say well I’ll … go and see someone privately.
Maybe you can afford six sessions … . Then you’ve got to stop,
and that’s probably the worst thing you can do. (Joseph,
Inner Regional)
Deciding what type of help to seek
Most respondents knew the mental health disciplines and
could accurately detail differences among psychiatrists, psy-
chologists, and counsellors.
You know a counsellor … doesn’t have to be as highly qualified
as a psychologist … there’s all sorts of people that can be
counsellors and you can have a friendly chat and they could very
well help you. … . A psychologist you’d expect to have some
academic qualifications and be a bit more able to analyse what,
what you are talking about … And I suppose a psychiatrist I’ve
kind of always thought of as being a bit more of a super
psychologist. … More qualifications and perhaps … getting into
more into physiology and stuff … (Vince, Inner Regional)
Despite past and/or current experience with mental
health services, responses related to knowledge of services
specifically available within the participant’s local commu-
nity area were more mixed. Those with little knowledge
tended to identify mental health services available through
the local public hospital, though these services were seen
as addressing severe symptoms: “I always have thought
that that’s, like if you’re really, like got schizophrenia or some
extreme sort of presentation of mental health”.(Monica,
inner regional)
Those with direct experience with services in the area
tended to use this as a benchmark. Grace’s use of local
services for example meant that she was aware of available
options and used her own experiences to rate the quality
of services:
I understand from my own experiences … that they have a very
good mental health progr-, help in this town. I go to a
psychologist. I went to him through the doctor … So, in my eyes
I think it’s a very good service here. (Grace, Inner Regional).
General discussion
Contrary to expectations, we found that inner regional
older adults had the worst perceived access to mental
health services. We would speculate that this is due to dif-
fering viewpoints with outer regional older adults being
accustomed to low levels of service across many domains
whereas inner regional people may compare their access
to urban levels. Within the framework of the decision
stages model, these results suggest that older adults have
difficulty identifying symptoms of anxiety as a psycho-
logical disorder needing help. In interviewees’ own words,
there was uncertainty distinguishing psychological prob-
lems from normal aging changes and a reliance on GPs to
AGING & MENTAL HEALTH 983
identify psychological disorders. This finding aligns with
existing literature which indicates that older adults are less
likely to define an issue in their lives as a mental health
problem (Forbes et al., 2017; Robb et al., 2003).
Deciding to seek help from a mental health professional
depended mainly on attitudinal barriers in the quantitative
analysis. With attitudinal barriers held constant, inner
regional people were less likely than urbanites to seek help
from a mental health professional. Interviewees expressed
a perception that problems needed to be severe to con-
sider mental health help. They perceived stigma to be a
thing of the past, while seeing values around self-suffi-
ciency as more of a barrier.
Values around self-sufficiency could be quite influential
in that older adults might recognize a problem as psycho-
logical, but feel that they should work it out on their own.
To our knowledge, this is a shift in perspective on why
older adults might not seek psychological treatment for
problems. It also would appear to be a motivation that
could be mistaken for stigma. In effect, mental health pro-
fessionals might see the avoidance of their offered help as
reflecting bias against psychological services, but it may
well reflect a broader ethic of self-sufficiency. In fact, hav-
ing learned this distinction from our participants, some dis-
cussions of stigma in previous literature include this sense
of self-sufficiency in measures of stigma (e.g., Pepin et al.,
2015; Stewart et al., 2015). Recognizing the value of self-
sufficiency and encouraging older adults to see seeking
help for psychological problems as part of self-care and
maintaining independence may well be better strategy
than combatting stigma.
External barriers got mixed results in the interviews.
Distance and cost were seen as potential issues but
regional people saw traveling the distance as worth it if
help were needed. Perceptions of cost seem to depend on
knowledge of costs and financial supports. In terms of
deciding what type of help to seek, for the group as a
whole, psychologists rated quite highly along with GPs,
family members, and local health centers as sources of
help for the woman in the vignette.
Taken together, these findings suggest that efforts to
increase the accessibility of mental health services for older
adults should focus on educating older adults about how
to recognize common psychological problems, especially
anxiety and to use a lower threshold for recognizing that
help is needed. As noted in the literature, GPs are import-
ant for identifying psychological problems and referring
older patients to mental health services (Robb et al., 2003;
Sirey & Trevino, 2017). Several respondents noted their GP
identified the problems rather than themselves.
Limitations
This research was carried out in Australia where the role of
the GP in access to mental health services is codified into
Australian national health care (called Medicare) in that
psychological services require a GP referral to be covered
under Medicare. Thus, the role of the GP could be lessened
in other nations, although the GP connection is also
described as highly important in the US which has a pay-
ment system that does not require their referral (Sirey &
Trevino, 2017).
984 B. G. KNIGHT AND S. WINTERBOTHAM
Australia also has extensive public education programs
regarding mental health issues. These programs could be
responsible in some part for the perception of our
respondents that mental health stigma has decreased. That
decrease could be less characteristic of nations without
such programs, although as noted in the Introduction,
stigma has not been found to be a problem in US studies.
Conclusion
Regional differences were less pronounced than expected
and we found inner regional respondents perceived lower
accessibility of mental health services than did outer
regional ones. This study adds to literature on accessibility
of mental health services for older adults by identifying
anxiety as an under-recognized psychological disorder, con-
firming findings that older adults have a higher threshold
for seeking help for psychological disorders, and shifting
the focus from mental health stigma to values around self-
sufficiency as a key attitudinal barrier to address in public
education efforts about mental health services for
older adults.
Disclosure statement
No potential conflict of interest was reported by the authors.
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