The goal of this study is to investigate why potential clients do not choose the insurance-paid option (non-anonymous) even though this option would provide them with immediate treatment. Tactus wants to know which reasons are of significant importance to these potential clients. With this knowledge Tactus would be in a position to tailor its website and/or the information it provides about treatment options in such a way as to encourage a greater percentage of those potential clients to choose the non-anonymous option.
This is important to Tactus because with increased enrollment in the non-anonymous option, it would have the financial resources necessary to provide treatment to more clients, and it would not lose as many potential clients due to the long wait involved the anonymous option choice. These benefits would be multiplied as online treatment becomes more popular, and a greater number of individuals with alcohol addiction seek assistance.
This research would also benefit the target group of potential clients because they would receive more accurate information about their option choices, and improved incentives for choosing the non-anonymous option. Their attitude and satisfaction would also hopefully improve since they would be able to start treatment without delay.
In order to reach the main goal, to find out the most important reasons for future participants to choose against signing up for the non-anonymous option, an answer has to be given to the research question “How can future participants be stimulated to sign-up for the non-anonymous treatment option (insurance paid)?”Background for this research questions and specifications into sub questions can be found in chapter 2.
The research project is described and explained in order to advise the organization Tactus in their improvements regarding the presentation of and recruitment for the non-anonymous treatment variant. Therefore the research thesis began with describing theoretical and practical background aspects, leading into the research questions (chapter 1). Furthermore the research thesis contains an extended theoretical framework which describes theories and approaches concerning online therapy, the role of anonymity and barriers and benefits of online treatment (chapter 2). A model that guides the research project is constructed and explained in that chapter as well; however it forms the transition to the next chapter, methods, which take the model as a base. The chapter methods (chapter 3) informs about the research process, including respondents, construction of the instrument, preliminary and main research and analysis methods. The results from that are shown (chapter 4) and discussed (chapter 5) and lead to specific recommendations for Tactus (chapter 6).
Alcoholism – prevalence and consequences
The National Institute on public health (RIVM, 2003) noted in 2003 that nearly 7.8 % of all adults (18-64 years) in the Netherlands have alcohol abuse and –addiction problems. Overall, the National Institute for Public Health and the Environment data (RIVM) shows that rates of alcohol abuse and dependence in 2005 were substantially higher in men than women (alcohol abuse: 7,3% men, 1,8% women and alcohol addiction: 6,2% by men and 1,1% by women). In 2004 almost 1.800 people died because of alcohol misuse or as result of the serious consequences of long-term alcohol abuse.
The majority of individuals with alcohol use disorders do not enter treatment. The gap between need and actual treatment received for mental disorders is universally large and with 78.1% the widest for alcohol abuse and dependence (Postel, de Jong, & de Haan, 2008). Patients often withhold information because of shame or fear of stigmatization, with the result that many people with mental health problems will never seek or engage in treatment. Reasons for not receiving treatment are access barriers, delay in treatment, stigma associated with treatment, patients not having time, and not knowing where to go for services. Furthermore, people often only seek help at a late stage of abuse, usually after 10 years or more. During this time, the dysfunctional alcohol use has damaged several areas of life including health, work, finances and relationship (Jordan & Oei, 1989).
Long-term alcohol abuse results in a number of negative long-term effects. These manifest themselves as health related problems such as liver disease, cancer, pancreatitis, heart disease and stroke (Latt & Saunders, 2002).
Long term misuse of alcohol can also cause a wide range of mental health effects. Psychiatric disorders are common in alcoholics, especially anxiety and depression disorders with as many as 25% of alcoholics presenting with severe psychiatric disturbances (Cowley, 1992).
The social problems arising from alcoholism can be massive and are caused in part due to the serious pathological changes induced in the brain from prolonged alcohol misuse and partly because of the intoxicating effects of alcohol (Latt & Saunders, 2002).
Substance use disorder is one of the most common mental health problems in the Western world (Hall, Tesson, & Henderson, 1999) with a significant level of unmet treatment needs (Mojtabai, Olfson, & Mechanic, 2002). In the Netherlands, only 10% of the problem drinkers ever get professional help. Research data has shown that higher percentages of women, higher educated people, working people and elderly people are harder to reach for face-to-face care (Postel, de Haan, & de Jong, 2008; Van Laar et al., 2006). Online clients tend to be younger, more educated, and more likely to have never visited a psychiatric clinic (Bai et al., 2001). Therefore, there exists a great need to understand the people’s reasons for not signing up for the non-anonymous treatment.
On-line counselling, “e-therapy” is when a professional counsellor or psychotherapist communicates with a patient over the Internet, to give emotional support, mental health advice or some other professional service (Matthews, 2006). This type of therapy aims to provide treatment through real time or asynchronous correspondence between a human therapist and a client, without face to face contact (King & Moreggi, 1998).
The Internet combines attributes of mass communication (e.g. broad reach) with attributes of interpersonal communication (e.g. interactivity, rapid individual feedback). This combination of qualities simplifies the access to therapeutic interventions. These don’t involve all the usual treatment requirements and make the internet an effective means of implementing behavioural health interventions on a far larger scale than previously possible (Postel, de Haan, & de Jong, 2008; Cassell, Jackson, & Cheuvront, 1998).
The percentage of people with an internet connection in the Netherlands rose enormously over the past years. According to the “Statistics Netherlands” (2008), 91% of the population in the Netherlands had internet access at home. Fogel and colleagues (2002) found out that half of all internet users already looked for health related information on the internet. Psychotherapy and counselling services are now available on-line, expanding rapidly. This relatively new and successful growing opportunity to seek and receive help via the internet is especially interesting for people who wish to remain anonymous, because they won’t seek out traditional services (NCI & RWJF, 2001).
Internet-based intervention is attractive to a large population whose alcohol use may be problematic but who have not sought, or are unwilling to seek, traditional treatment (Barak, 1999)
There are a number of ways in which computers and the internet may be used to deliver interventions for mental health disorders. These include stand-alone computers with internet access to find mental health-related information; pre-programmed, interactive software packages available via the internet; or psychotherapy delivered via the internet with live therapist involvement (real time or messaging). The focus of this paper will be on the therapy via secure web messaging.
Clearly, this type of psychological counselling has limits and benefits that are different from traditional therapy. On the one hand it is an easy and valid way to supervise counsellors, because the therapy material is always available and it is a simple way to verbally communicate between therapy partners (Ybarra & Eaton, 2005; Zabinski et al., 2003). It holds the possibility of making the intensity of interaction flexible which can be helpful with regard to the individuality of therapy progress (Barak et al., 2008). It makes it easy to access for people in need for therapy who refrain from using conventional psychological services for a number of reasons (Barak et al., 2008).In contrast to many other psychological treatment programmes you can participate 24 hours a day in the online-therapy, 7 days a week . This makes it easier for clients to integrate the therapist into his or her everyday life instead of waiting for the weekly or annual meeting; the patient can email issues while he or she is actively processing thoughts and feelings (Childress, 2000).
According to Barak et al. (2008), the anonymity plays an important role in the treatment of alcoholism. Anonymity is usually assumed to reduce social desirability and lead to more “honest” answers. The term social desirability means the behaviour of clients of giving social desirable responses rather than truthful responses. This finding is consistent with findings about mental health interventions in general. A research of Ybarra and Eaton (2005) shows that the majority of participants like the anonymity of the internet-based therapy and appear to benefit in terms of relief of psychological symptoms.
Matheson and Zanna (1990) present evidence to suggest that, during computer-mediated communication (CMC), people experience increased private self-awareness (which could explain greater self-disclosure) while simultaneously experiencing reduced public self-awareness. This would suggest that, although self-presentation concerns are reduced (via lower public self-awareness), self-regulation and focus on internal states and standards may be enhanced (via higher private self-awareness) (Joinson, 1999). The anonymity of the online-therapy makes it possible for people who wish to remain anonymous to receive help with their abuse problem through reducing stigma and sense of shame (Winzelberg, 1997; White & Dorman, 2001; Hsiung, 2001; Finn, 1999).
Another advantage of online-treatment is the online disinhibition effect, which leads to being more relaxed and unconcerned about expressing personal thoughts, feelings and fears so that people talk more honestly about those things without having to care about what other people might think (Barak et al., 2008).
On the other hand, there are also some negative aspects of online-treatment. The absence of regular face-to-face interaction and the missing nonverbal cues can lead to misunderstandings. It also disallows the flow of communication from body language, voice fluctuation and less productive projection may then be more likely in this nonverbal email therapy environment (Barak, 2008; Childress, 2000).
Obtaining informed consent is also critical because e-mail correspondence is not considered to be confidential and private as the possibility of tapping electronic messages is relatively easy (e.g. third party reads the email) (Barak et al., 2008).
Although these negative aspects may point out some barriers to conducting effective counselling via e-mail, it seems that the actual impact of negative factors is relatively small (Barak et al., 2008).
It has been a repeated and robust finding that people tend to reveal more personal and/or embarrassing information with a computer-administered interview than when interacting with another person face-to-face (Joinson, 1998).
One approach to The “Pathways Disclosure Model” (PDM) predicts the attitude of people regarding treatment and states that people are more willing to participate in a treatment if they don’t need to publish any personal details. The PDM is an approach that articulated the advantages of receiving assistance through the Internet. It implies that online asynchronous treatment hold particular promise for those who experience personal problems where stigma is involved. By availing themselves of online forms of help, individuals essentially control all of the levers of personal disclosure and are, therefore, more likely to “test drive” help-oriented interventions or participate “anonymously” (Cooper, 2004). The role of perceived anonymity is an important one. Prentice-Dunn and Rogers (1982) suggest that deindividuation is caused by two factors – a reduction in accountability cues (e.g. leading to a reduced concern about others’ reactions) and a reduction in private self-awareness – which lead to decreased self-regulation and use of internal standards (Joinson, 1998). Anonymity is usually assumed to reduce social desirability and leads to more “honest” answers.
The question arising from these facts is: what are the reasons for people wanting to remain anonymous when it comes to choosing between the anonymous or insurance paid variant for participating in an online treatment. There is a gap in literature concerning this question and therefore this study tries to investigate the underlying factors contributing to this issue.
Responsibility for using the Theory of Reasoned Action
Numerous studies about the relationship between attitude and behaviour have shown that attitudes of people often are not consistent with their behaviour (Wicker, 1969). This incongruence stimulated researchers to develop models of the influence of attitudes by making all kinds of decisions. One of the most popular models in this area is the “Theory of Reasoned Action” (TRA) (Fishbein & Ajzen, 1975).
Figure 2.1 Theory of Reasoned Action based on Fishbein and Ajzen (1975)
The “Theory of Reasoned Action” is a model that has its origins in the field of social psychology and holds promise as a conceptual model for understanding help seeking behaviour (Halgin, Weaver, Edell, & Spencer, 1987). It was developed by Fishbein and Ajzen in 1975 and defines the links between beliefs, attitudes, norms, intentions, and behaviours of individuals. It is based upon the assumption that people’s actions are decided through a series of rational judgments (Aijzen & Fishbein, 1980). The model states that a person’s behaviour is determined by its behavioural intention to perform it. The intention is itself determined by the person’s attitudes and his subjective norms toward the behaviour.
According to TRA, the attitude of a person towards a particular behaviour (i.e., the positive and negative feelings about the behaviour) is determined by his outcome beliefs of this behaviour, and multiplied by his evaluation of these consequences. Generally speaking, a person who believes that performing a particular behaviour will mostly lead to positive outcomes will hold more favourable attitude than a person who believes that performing this particular behaviour will lead to mostly negative outcomes. Beliefs are defined by the person’s subjective probability that performing a particular behaviour will produce specific results. This model therefore suggests that external stimuli influence attitudes by modifying the structure of the person’s beliefs. Indeed, consistent with this perspective, studies have shown that the best predictor of help-seeking intent is the person’s attitude toward seeking professional help (Bayer & Peay, 1997; Halgin et al., 1987). Most behaviour is dependent on non-motivational factors as availability of required resources and opportunities (for example: time, money, skills, encouragement of others etc.).
Whether or not a person participates or intents to participate in any behaviour is influenced strongly ba people around them. These people may include friends, family or co-workers. Subjective Norm is a person’s perception of what others believe that the individual should do or not. A belief that friends and family sentence the behaviour of undergoing a treatment against alcohol abuse might lead to not participating in that treatment or doing this in an anonymous way.
One of the strengths of the TRA is that it allows comparing the relative influence of each variable isolated. This has implications for persuasive communication programs. If Attitude is substantially more influential than Subjective Norms in prediction of Intention then all communication efforts should be aimed toward gaining the awareness of the harmful consequences of not remaining untreated with an alcohol abuse problem.
For this study a new model was derived to examine the important variables relevant to decision making in favour of the non-anonymous option of the online treatment. These additional variables were added during the literature research while investigating all the variables which might play a role in this context. The additional variables are: Perceived Severity, Motivation to change, Barriers, Information Status, Intention, Solution Suggestions. The definitions of these constructs can be seen in table 2.1 below. The overall goal of this research was to directly examine the role that different variables play in people’s intention to choose against the non-anonymous option.
More specifically, our objective was to assess the relationships among the different factors that influence the Intention to sign up for the non-anonymous variant. We hypothesized that intention to sign up for the non-anonymous variant would be influenced by the participant’s self-perceived severity, self-efficacy, motivation to change, subjective norm, information status, influence of solution suggestions and demographic variables. Further, we hypothesized that outcome beliefs and barriers to treatment would predict the intention to sign up for the anonymous variant.
Because of the fully guaranteed anonymity in this research project it was impossible to link the intention of participants to their actual behaviour. Therefore the behaviour is not included. The intention to choose for the non-anonymous treatment is the target variable to which the correlations and influences must be investigated.
Table 2.1 shows the constructs used for the derived integrative model with references to the literature on which the variables are based on. The full model can be seen in Figure 2.2 in the hypotheses section.
Table 2.1 Constructs and variables in the research model
Based namely on
Jordon & Oai
Situational and psychological features that give purpose and direction to behavior (alcohol use)