Abstract:
For more than 2 decades, mental health literacy has been a topic of interest among behavioral health researchers. Despite the older adult population’s significant growth, there is little information about how best to increase their mental health literacy. This article will provide a brief overview of the historical and current underpinnings of mental health literacy, methods by which mental health literacy is gauged, and examples of effective strategies to improve older adults’ mental health literacy. Also, it will recommend ways to identify and advance effective strategies to build elders’ mental health literacy.
Key Words:
mental health literacy, positive mental health literacy, eMental health literacy, education entertainment, serious games
First introduced more than 25 years ago, the term mental health literacy refers to “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” (Sampaio et al., 2022). Mental health literacy comprises multiple elements, including: “The ability to recognize specific disorders or different types of psychological distress; knowledge and beliefs about risk factors and causes; knowledge and beliefs about self-help interventions; knowledge and beliefs about professional help available; attitudes which facilitate recognition and appropriate help-seeking; and knowledge of how to seek mental health information” (Jorm, 2000).
But in recent years, an additional element of mental health literacy has been proposed, defined as, “understanding how to obtain and maintain good mental health” (Sampaio, et al., 2022). As in the original definition of mental health literacy, this newer idea includes multiple components: “Competence in problem-solving and self-actualization; personal satisfaction; autonomy; relatedness and interpersonal relationship skills; self-control; and a prosocial attitude” (Carvalho et al., 2022).
Several tools have been developed to assess mental health literacy, including the Mental Health Literacy Questionnaire (MHLq), which has been used with younger adolescents and young adults (Dias et al., 2018), as well as an adapted, shorter form of the MHLq used with adults (MHLq-SVa; Campos et al., 2022). These instruments focus on the elements of the original definition of mental health literacy, which concentrates on identifying signs of mental illness and beliefs about treatment and help-seeking. An additional instrument, the Mental Health Literacy Scale (MHLS), was developed to assess positive mental health literacy, and can be used with adults (O’Connor & Casey, 2015).
Mental Health Literacy and Older Adults
It is widely recognized that older adults represent an increasing percentage of the total population, a trend that is anticipated to continue for at least another decade. Data from the 2020 Census indicates that from 2010 to 2020, the U.S. population ages 65 or older grew 5 times faster than the total population across the 100 years between 1920 and 2020, reaching 16.8% of the total U.S. population. In other words, 1 in 6 people in the United States fall within this age group. Much of this growth is the result of the aging of the Baby Boomers (those born between 1946 and 1964), who began turning age 65 in 2011 (U.S. Census Bureau, 2023).
But despite the tremendous growth in this population and the continued research interest in mental health literacy, there has been very little investigation into the mental health literacy of older adults, as most of the literature is focused on adolescents (Sampaio et al., 2022).
‘There has been very little investigation into the mental health literacy of older adults.’
What, then, do we know about the mental literacy of older adults, and what does that knowledge imply about effective practices to increase it?
Existing literature indicates that the mental health literacy of older and younger adults differs in terms of their respective abilities to identify symptoms of mental disorders and their beliefs in the efficacy of treatment. In one study, researchers found that younger adults were better able to recognize the symptoms of depression than were older adults, and younger adults endorsed the value of informal supports over formal treatment, while older adults indicated they saw less value overall in any form of support (Farrer et al., 2008).
Also, older adults are less likely than younger populations to seek formal mental health services. Barriers to help-seeking associated with lower mental health literacy include, but are not limited to, concerns about stigma and negative feelings about mental health services (Elshaikh et al., 2023). Lower mental health literacy is also found among older adults with lower levels of educational attainment, a lack of prior contact with mental health professionals, and a lack of perceived need for treatment services for emotional distress (Elshaikh et al., 2023).
Approaches to mental health literacy intervention are not necessarily universally applicable and must consider language, culture, and other determinants that may influence older adults’ willingness to seek out mental health supports. At present, there is a dearth of widely available interventions that have been demonstrated to be effective in multiple languages or across multiple cultures. There also is a relative lack of mental health literacy interventions that have been demonstrated to be effective with speakers of certain languages other than English, or for older adults from specific cultural groups and/or ethnicities.
Interventions
Several strategies and interventions have been developed to improve mental health literacy in varied populations. While the majority do not explicitly focus on older adults, there are older adult–specific interventions that can be promulgated. Also, intervention approaches that have demonstrated success among younger adults may hold promise if adapted for an older audience. Examples of interventions focused on, or adaptable for, older adults include, but are not limited to: integration of mental health assessment and treatment into healthcare programs, increasing older adults’ ability to access and understand online information about mental health, using “education-entertainment” strategies, and developing “serious games” focused on increasing mental health literacy.
Integration of Physical and Mental Health Care
Older adults, who often manage multiple medical comorbidities, are frequent users of primary and specialty care. Primary care offers an entrée into mental health care that might otherwise be avoided (Lopez et al., 2018). While many older adults have lower levels of mental health literacy and, as a result, may shun contact with specialized mental health services, most older adults regularly encounter healthcare personnel and may be more willing to discuss mental health challenges with them, particularly if mental health education is given in a familiar setting.
‘Community health workers can be trained to provide supportive mental health services.’
One successful example of this approach is the House Calls and Behavioral Health Integration project, a collaboration between medical providers, aging services, and social services in New Jersey. In this approach, older adults in senior housing were provided mental health education, depression screening, and connections to services such as case management and/or supportive counseling. This enabled older adults to receive mental health information in an environment where they were comfortable and increased the acceptability of receiving mental health services and supports (Perweiler et al., 2019).
There also is evidence that community health workers can be trained to provide supportive mental health services. Increased use of community health workers may be particularly valuable in providing mental health information in a culturally appropriate way to older adults who otherwise might not seek evaluation and treatment (Weaver & Lapidos, 2018).
Improving eMental Health Literacy
As information and mental health supports are increasingly delivered online, the concept of eMental Health has arisen. This is understood as, “the degree to which individuals obtain, process, and understand basic mental health information online to inform mental health-related decisions” (Root & Caskie, 2023).
A systematic review published in 2016 indicates that online mental health information delivered via the Internet can increase mental health literacy efficaciously. The most promising Internet-based interventions included those that involved active user engagement through providing a structured program or other interactive and experiential approaches, contained population-specific information and approaches, and provided evidence-based information (Brijnath et al., 2016).
A Pew Research Center report noted that while the “digital divide” is closing among older adults, a significant gap remains between the oldest and the youngest users of the Internet (Faviero, 2022). Contributing factors to this divide include a lack of access to computers or smartphones, lack of access to broadband (particularly in rural areas), and lack of familiarity with how to use search engines to find accurate information.
Game-based learning is one approach that can be effective at increasing older adults’ mental health literacy.
More must be done to increase older adults’ ability to connect online, including boosting the availability of broadband and providing cost-effective technology and instruction on its use. Many older adults also would benefit from being trained on general Internet use and Internet-based technologies, particularly if the training content is provided in the languages older adults speak and the training is delivered by linguistically and culturally competent instructors.
Education Entertainment
Health information that is purely informational or educational is rarely effective in helping to change behaviors. Education-entertainment, or edu-tainment (EE), is described as, “The placement of educational messages in entertainment contexts,” and has been shown to be effective in “influencing knowledge, attitudes and behavior toward health-related issues” (Asbeek Brusse & Fransen, 2017), including increasing mental health literacy.
This approach is particularly adaptable to be culturally relevant among different populations (Cabassa et al., 2015). For example, a 2021 study of an EE video intervention in the form of a telenovela increased the mental health literacy of Latina adults when compared to traditional print approaches (Gonzalez & Benuto, 2022).
Serious Games
Game-based learning is another approach that can be effective at increasing older adults’ mental health literacy. Games that foster problem-solving and skill-building are known as “serious games,” and are most frequently developed in video game formats. One example of a serious game designed to increase the health and mental health literacy of older adults is Age-tastic! developed by the New York City Department for the Aging. Age-tastic! is a health and wellness–focused board game that can be implemented with facilitation across an 8-week period. A pilot study conducted to evaluate the efficacy of this intervention demonstrated statistically significant increases in older adults’ mental health literacy about depression and help-seeking (Berman et al., 2020).
Conclusion: What Can We Do?
To support older adults’ mental health literacy and increase their potential for accessing treatment, it will be critical to invest in the following strategies:
- Further research to determine what interventions are most effective with older adults;
- Ensure that intervention approaches are delivered using methods with which older adults are most likely to engage;
- Identify whether intervention strategies need to be segmented for different cohorts of older adults (i.e., the youngest Baby Boomers versus the oldest);
- Develop and promulgate approaches that are relevant and effective across cultures and among different groups of older adults;
- Promote the continued integration of physical and mental health care, which, while already in the works, is still not consistently available to older adults;
- Integrate interventions into the services where older adults are most likely to seek any information or services outside of healthcare (i.e., aging services programs, community centers, older adult residential programs, etc.); and,
- Advance the use of culturally appropriate technological approaches to mental health education.
As is often said, knowledge is power. Empowering older adults to seek and accept mental health services and supports when they need them will require multiple strategies. Mental health literacy, or knowledge about mental health and mental illness, is not an exclusive driver of help-seeking behavior in any population, including older adults. However, increased awareness of mental health and symptoms of mental illness, among other related topics, can help lay the foundation for future connections to clinical treatment and other services and supports.
The behavioral health sector continually seeks to innovate clinical interventions and improve methods of service delivery. The same effort must be made to encourage the development of mental health literacy among the fastest growing segment of the population.
Lisa Furst, LMSW, MPH, is chief program officer of Vibrant Emotional Health and has more than 20 years’ experience in the mental health service sector. She also serves as the director of the Geriatric Mental Health Alliance of New York and is an author and contributor to several books and publications on mental health. Kimberly Williams, MSW, is president and CEO of Vibrant Emotional Health, a New York City nonprofit reaching more than 3.6 million people each year to help them achieve emotional well-being. She also serves on several advisory committees and boards including the New York State Interagency Geriatric Mental Health and Chemical Dependence Planning Council, the New York State Health Foundation Community Advisory Committee, Mental Health News Education Inc., United Community Schools, and the National Coalition on Mental Health and Aging, for whom she is immediate past chair.
Photo credit: Shutterstock/Perfect Wave
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