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Research Questions

  1. What items are most reliable and valid for capturing barriers and facilitators to mental health among military service members?
  2. How can these items be administered in an efficient way (e.g., through a short form)?
  3. Would changing the language of items from general mental health problems to specific mental health disorders influence the item properties?
  4. How can DoD best utilize these items?

Many service members report suffering from mental health conditions, such as depression, posttraumatic stress disorder, and problematic substance use. While the proportion of service members initiating treatment has increased in the past decade, fewer than half of the service members who indicate a need for mental health services actually receive care. Service members report a variety of barriers, both logistical (e.g., difficulty scheduling an appointment) and attitudinal (e.g., negative beliefs about treatment), to seeking mental health care.

This report summarizes the findings of a study to develop an item bank of barriers to mental health care for the Department of Defense (DoD); establish the reliability and preliminary validity of the item bank and a short form (i.e., a subset of items from the bank that can be used as a short survey); and identify options for how DoD can use the item bank to assess and monitor barriers to such care. During the course of the study, the authors also identified a series of facilitators of mental health care.

The analyses resulted in the creation of two item banks — a 54-item bank assessing barriers to mental health care and a six-item bank assessing facilitators of care — and a 15-item short form culled from the barriers bank. The contents of this report will be of particular interest to policymakers and health policy officials within DoD, as well as policymakers in other sectors who sponsor or manage efforts to reduce barriers to mental health and increase treatment seeking and appropriate treatment utilization.

Key Findings

Great potential for utilization

  • The barriers bank and facilitators bank have great potential for monitoring barriers and facilitators to care in a way that has not been done before.
  • Reliability analyses showed excellent model fit (RMSEA = 0.00) and high marginal reliability (MR = 0.98) for the 54-item barriers bank. Due to its limited number of items, the facilitators bank had a lower MR (0.76) and worse, but still acceptable, model fit (RMSEA = 0.13) relative to the barriers bank.
  • Preliminary validity analyses suggested that the barriers bank and short-form are valid ways to measure barriers to care.
  • The barriers bank correlated strongly with two existing barriers to care scales, suggesting convergent validity.
  • There were minor or no group differences in scores because of age, gender, race/ethnicity, education, service branch, or component, suggesting additional precision of measurement across populations over and above prior measures.
  • Bank scores from respondents exhibiting PTSD or depression symptoms and respondents diagnosed with a mental health disorder reflect greater barriers to care.

System design

  • The barriers bank and facilitators bank address several limitations of existing measures by broadly assessing barriers related to any type of mental health problem or professional care, and by covering various types of barriers related to the individual, social networks, treatment process, and social norms.
  • The item-bank approach allows for more flexible (i.e., can use different subsets of items to create various short forms) and adaptive (i.e., can be updated over time as new research emerges) monitoring of barriers and facilitators to care.

Recommendations

The authors identified four options for how DoD could use the item banks.

  • Option 1: Use the item banks to track trends in service members' perceived barriers and facilitators to mental health care. This option, if carried out repeatedly over time, could help to answer the following basic questions: What are the most prevalent barriers to care? How is the prevalence of barriers or facilitators to care changing over time?
  • Option 2: Assess how specific DoD interventions impact self-reported barriers to and facilitators of care.
  • Option 3: Assess which perceived barriers and facilitators predict help-seeking behaviors.
  • Option 4: Conduct pilot test(s) to help identify the best ways (including specific tests of Options 1–3) to deploy the item bank.

If data collection across the military is required, DoD could consider leveraging existing survey efforts by embedding bank items into an ongoing survey (e.g., the Health Related Behaviors Survey).

Using the item banks will require coordinated planning efforts, leadership support, and significant resources to implement surveys that yield meaningful and actionable results and regularly share findings from any data collected with key audiences.

To add items to the current item banks, DoD would need to (1) estimate the new item parameters, (2) establish whether the new item bank is unidimensional and does not include clusters of items that are highly correlated, (3) determine whether the new items function differentially for different subgroups (e.g., race/ethnicity, gender), and (4) determine whether the new bank has good reliability and validity.

Table of Contents

  • Chapter One

    Introduction and Purpose

  • Chapter Two

    Conceptual Model of Influences on a Service Member's Decision to Seek Mental Health Care

  • Chapter Three

    How Barriers to and Facilitators of Mental Health Care Have Been Measured

  • Chapter Four

    Factor Analyses, Item Analyses, and Preliminary Validity of RAND Barriers and Facilitators Banks

  • Chapter Five

    How DoD Can Use the RAND Barriers to and Facilitators of Mental Health Care Item Banks

  • Appendix A

    Methods Used to Identify Existing Measures and Develop a Conceptual Framework

  • Appendix B

    Methods Used to Narrow Down the Measures to a Manageable List for Field-Testing

  • Appendix C

    Methods Used to Field-Test the Preliminary Item Pool

  • Appendix D

    Methods Used to Analyze Field-Test Data to Create the Final Item Bank

  • Appendix E

    Methods Used to Develop Options for Utilizing the Item Banks

This research was sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.

This report is part of the RAND Corporation research report series. RAND reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND reports undergo rigorous peer review to ensure high standards for research quality and objectivity.

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