INTRODUCTION
Close to 1 million U.S. military spouses may experience unique stressors related to a partner’s military service.
1 These stressors include prolonged separations during deployment or training, worry about their partner’s health and well-being during deployments, and frequent relocation that can uproot them from communities and employment.
2,3 Recent research showed most spouses cope well with the stressors of being married to someone in the military.
4 However, research also documented higher prevalence of mental health issues in female spouses when compared to non-military-affiliated women in the United States.
5Supporting military spouses in receiving mental health care is important not only for their health but also for the health of military families and retaining service members.
6,7 Previous research explored logistical and psychological barriers military spouses experience when accessing mental health treatment.
8,9 While this work focused on perceived barriers to treatment, it did not examine treatment use.
9 Furthermore, prior work did not control for a variety of socio-demographic variables, including spousal employment or prior military history. Understanding how different barriers can impact mental health care engagement, while accounting for socio-demographic characteristics, will offer a more nuanced understanding of mental health care use for a diversity of military spouses.
This study builds on prior work that examined barriers to mental health care in service members by exploring the impact of a variety of perceived barriers on actual care use in a sample of army spouses experiencing mental health symptoms. Overall, this article seeks to understand what types of barriers to care army spouses experience and whether certain barriers affect mental health care use for those with at least mild mental health symptoms, while controlling for several socio-demographic variables.
Practical barriers to mental health care
Previous military research identified two main barriers to care: practical barriers and perceived stigma.
8–11 Practical barriers to mental health care include organizational barriers, such as lack of availability of appointment times or long wait times to get an appointment, as well as personal barriers, such as not having time to go to an appointment.
9 Considering that all active duty military spouses are afforded the same health care benefits, one might expect there would be minimal practical barriers to mental health care treatment.
12 However, even in this context, there can be obstacles to seeking treatment, including differing resources at each military installation. For example, larger installations tend to have more resources, including hospitals.
13,14 Previous research highlighted several potential practical barriers to mental health care, including difficulty attending daytime appointments, availability of counsellors trained to meet the needs of military families, lack of transportation, and lack of knowledge about where to find services.
8,9,11 One of the most common practical barriers is the inability to leave work or household responsibilities to attend a daytime appointment.
9,11 Several contextual factors may account for these findings, including increased child care and household responsibilities during deployment or training separations.
15,16 These results indicate that, even in a context with equal health care benefits, practical barriers can still be substantial.
Perceived stigma and mental health care
Perceived stigma about mental health care is broadly defined as a thought or fear of a perception that prevents an individual from seeking or receiving care.
9 Perceived stigma is a documented problem for both spouses and service members seeking care.
8,16,17 Spouses report concerns seeking mental health treatment will adversely affect others’ opinions of, and confidence in, them,
8,17 which carries significant consequences in the military context where personnel and their families are expected to be mission ready.
9,16 Further, spouses express concerns that seeking treatment can limit their partners’ opportunities for promotion, advancement, and security clearances, and can lead to separation or removal.
16 Lewy and colleagues
11 compared psychological barriers among military wives, including perceived stigma, with a national sample of non-military-affiliated women and found military wives to have significantly more psychological barriers to mental health treatment than the national sample. Collectively, the minimal research documenting military spouses’ perceived stigma about mental health treatment indicates a need for further research on how these perceptions impact engagement in mental health services.
Socio-demographic factors and barriers to mental health care
Schvey and colleagues
9 examined perceived barriers to mental health care in a large sample of nearly 10,000 U.S. military spouses and found significant differences in reported barriers to care across gender, race, military service experience, and level of behavioral health symptoms. For example, racial and ethnic minority spouses were less likely to report logistical barriers and internalized mental health stigma than non-Hispanic white respondents. Spouses who previously served, or were currently serving in the military, were significantly more likely to report negative beliefs about mental health care, as well as to perceive negative consequences of seeking care.
9 This highlights the importance of understanding spouses’ history with the military, as that can impact perceptions of mental health treatment.
9,15However, this large-scale study did not assess the relationship between barriers to care and actual treatment engagement and did not account for important socio-demographic factors that could impact perceived barriers. For example, employment is an important socio-demographic variable that could impact health care use, as it may increase demands on a spouse’s time, potentially restricting the ability to access services.
18,19 Another socio-demographic factor that could impact perceived barriers is whether or not a spouse has children. Children can add logistical barriers, such as child-care planning, to appointment attendance. Child care is a known stressor for military spouses.
20–22 This study will consider socio-demographic factors that can impact mental health care engagement. It tested the following hypothesis: there will be an inverse relationship between reported barriers to care and treatment engagement among army spouses, after controlling for socio-demographic variables.
RESULTS
Most spouses indicated they were not currently in mental health treatment (87%). Since this was a sub-sample of army spouses that met clinical thresholds for either mild depression, anxiety, or PTSD, it meant most army spouses in this sample had at least mild mental health symptoms (see
Table 1).
Principal component factor analysis of the barriers to care scale revealed four sub-scales: 1) perceived stigma (Cronbach’s α = 0.92), 2) practical barriers (Cronbach’s α = 0.73), 3) self-management (Cronbach’s α = 0.81), and 4) attitudes toward care (Cronbach’s α = 0.60). Perceived stigma had eight items, practical barriers had two items, self-management had six items, and attitudes having adequate transportation, thinking getting mental health treatment should be a last resort, not trusting mental health professionals, and thinking they knew how to help themselves, did not load above a 0.4 on any sub-scale and were removed.
39 The sub-scales found are similar to those used among active service members
28 (
Table 2). Pairwise correlation analyses revealed the majority of correlations were weak (0 <= |r| < 0.3), with three indicating a moderate relationship (0.3 ≤ |r| < 0.7) and none demonstrating a strong relationship |r| >= 7
37 (
Table 3). Therefore, no analytic adjustments were required for regression analyses.
Multivariable logistic regression was run on the sub-sample of 146 spouses to examine the relationship between socio-demographic characteristics and the four barriers to care sub-scales and the odds of participating in mental health services among army spouses who experienced at least mild mental health symptoms. This model was significant (likelihood ratio χ
2: 36.11;
p < 0.001; Pseudo R2 = 0.34) and results are displayed in
Table 4. Four independent variables were significantly related to mental health services use: 1) employed full- or part-time (OR = 0.13, 95% CI, 0.02–0.82), 2) has at least one child (OR = 0.09, 95% CI, 0.01–0.61), 3) psychological barriers to care (OR = 0.82, 95% CI, 0.72–0.95), and 4) practical barriers (OR = 2.06, 95% CI, 1.36–3.14). Race, spouse rank, education achieved, age, military history, and the other barrier sub-scales of self-management and positive attitude were not significantly associated with treatment use.
DISCUSSION
This study assessed how barriers to mental health treatment affected mental health care use in a sample of army spouses experiencing mental health symptoms. This study builds on previous research that explored health care engagement in this population by including a variety of socio-demographic factors, such as race/ethnicity, spousal rank, employment status, age, education level, parenthood, and personal history with the military.
The military spouse barriers-to-care questionnaire revealed four different types of barriers that could affect care use: 1) perceived stigma, 2) practical barriers, 3) self-management, and 4) attitudes toward care. Perceived stigma and practical barriers were reported in prior literature as important factors to consider when assessing military spouse mental health treatment engagement.
8,9,11 The barriers to care questionnaire is optimal for use with spouses because it has been adapted to address unique barriers to mental health care for military spouses. Items were adapted to capture stigma in the military population (e.g., “it would harm my spouse’s career,” and “my spouse would disapprove of me receiving help”). With mental health stigma being relatively higher in the military than the general population, this is an important construct to assess in the military spouse population. This study adds that there may be additional barriers, such as beliefs people should be capable of managing mental health themselves (self-management), as well as how they view the utility and benefits of mental health care in general (attitudes toward care). While this preliminary study did not find these additional sets of barriers to be significantly related to treatment engagement for army spouses, future research should consider how other barriers could impact mental health use for military spouses.
The authors hypothesized more reported barriers to care would be associated with lower odds of being in care; this hypothesis was partially supported. Controlling for a variety of socio-demographic variables, spouses who reported more perceived stigma toward mental health treatment were significantly less likely to receive mental health services. These findings are similar to those found among soldiers, in that mental health stigma is cited as a main barrier to seeking care.
40,41 These findings are concerning when prior research suggests military wives are more likely than their civilian peers to report psychological barriers like perceived stigma.
11 This finding emphasizes the importance of continued efforts to decrease mental health stigma in the military for spouses through building a culture of support for psychological health.
42However, considering these, and other findings, efforts to reduce stigma may not go far enough to address this obstacle to service engagement. Another strategy to reduce perceived stigma to mental health services could be to describe these services using terms that are not as stigmatizing for this population. For example, the family-based resiliency intervention Families OverComing Under Stress (FOCUS) is used across the globe on various naval and Marine bases to provide preventative mental health support for military families.
43–45 While the FOCUS program is an adaptation of several family-based treatments to support the mental well-being and functioning of families, FOCUS markets itself as a resiliency-building intervention to support the mission readiness of military families, in acknowledgement of the potential stigma that surrounds family therapy in this population.
43 However, no formal studies have been conducted to determine whether this rebranding has led to greater mental health care engagement over other programs that use more traditional health service terms.
The authors found army spouses who experienced at least mild mental health symptoms and practical barriers to care were more likely to be in treatment. While this was unexpected, a similar relationship was observed in a study of treatment-seeking, previously deployed soldiers, in which organizational barriers were positively associated with use of civilian mental health care.
28 These findings could be due to the nature of cross-sectional data, reflecting that those in care are more likely to be aware of barriers like scheduling appointments and taking time away from other responsibilities. Future research assessing barriers to care should be conducted longitudinally to better assess the temporality of this relationship.
Army spouses employed full- or part-time or with at least one child were less likely to engage in mental health treatment. Other research on mental health treatment engagement for mothers showed employment was significantly related to less attendance in treatment.
46 Studies in the medical community showed mothers provided with free child care were better able to adhere to scheduled medical appointments.
47 This study builds on this literature by showing that army spouses experiencing at least mild mental health symptoms, and having other responsibilities such as taking care of a child or working, may need extra support in treatment. Future research should qualitatively explore specific supports for army spouses who attempt to engage in mental health treatment.
Limitations
These findings should be considered in light of several limitations. This study was a secondary analysis of data collected 10 years ago. However, the data were collected at a potentially stressful time for spouses, as 2012 was a time of high operational tempo. Additionally, as this study was cross-sectional, directionality between associated variables cannot be definitively determined and ability to track change over time is not possible. However, these data are useful because they offer an opportunity to consider factors associated with mental health treatment use at a time of particularly elevated military-related stressors. The sample used for this analysis was small and limited in its racial/ethnic and rank diversity; however, this sample is representative of the military spouse community as it is primarily white, associated with junior-ranking service members, and female.
1 Non-probability sampling with a 23% response rate from eligible spouses could introduce non-response bias and potentially limits generalizability. Several decisions were made to preserve power, such as collapsing race/ethnicity and employment status demographic categories. Therefore, comparisons across these sub-groups were not possible. The dichotomization of race/ethnicity fails to account for the various groups incorporated into non-white and that they may not have the same experiences with mental health treatment use. Additionally, information on spouse age was collected as a categorical variable; thus, it could not be treated as a continuous variable. Because of the small sample size, age was dichotomized to preserve power.
Finally, while previous experiences with mental health care can be relevant for current and future treatment seeking, analyses did not include a measure of past mental health treatment or intention to seek treatment because the data set did not contain this information. Additionally, the authors did not assess what participants may have meant by mental health treatment, such as having a conversation with their primary care doctors who then wrote them a prescription or going to talk therapy. Future research should tease out different versions of mental health services with a more nuanced set of outcomes.
Conclusion
Future research should also assess perceived barriers to care after the COVID-19 pandemic, as telehealth services have increased access and proven to be effective at treating mental illness (see Rauschenberg et al. for meta-analysis).
48 Access to telehealth services may increase use in the military spouse population, as this mode of service delivery may minimize some practical and perceived stigma barriers. For example, a military spouse does not have to worry about being seen in, or near, the treatment office if they are able to receive services at home.
49 Additionally, considering stigma toward mental health care among this population, future research should explore military spouse treatment preferences and current health care engagement. These findings suggest a need for solutions to promote enduring and trusting relationships with military providers, and telehealth could be a promising solution.