1 Introduction

Youth mental illness is a global public health concern, with around one in five experiencing a mental illness such as behavioural disorders, anxiety and depression [1]. Mental illness accounts for almost half of the overall burden of disease in those aged 10–24 years [2], and is one of the leading causes of mortality in youth through suicide [3]. Over time, the number of youths experiencing mental illness has increased. The National Study of Mental Health and Wellbeing in Australia, conducted between 2020 and 2022 [4], found that 38.8% of youth aged 16 to 24 years experienced mental illness in the previous 12 months, a rise from 26% in 2007. There are many minority groups among youth vulnerable to mental illness, including those homeless, those of Aboriginal or Torres Strait Islander identity, those who identify as lesbian, gay, bisexual, transgender, queer or intersex, and those who abuse substances [5]. The complex interplay of personal, social and environmental factors associated with residing in non-metropolitan areas can also increase the risk of developing mental illness, as well as suicidality and completed suicide [6, 7].

Access to timely mental healthcare can support youth health and well-being, and promote longer-term social, educational and economic productivity into adulthood [8]. However, research suggests that up to half of youth in need of mental healthcare do not seek help [9, 10]. This can be attributed to previous negative experiences with mental health services [11], the social stigma associated with mental illness [5, 11, 12], a preference for self-reliance [5, 12] and lack of awareness of available services [5, 11]. These issues are compounded for non-metropolitan youth, where mental health services are often piecemeal, lack coordination and are poorly integrated [12]. In part, this is contributed to by a shortage of mental healthcare professionals such as psychologists [13], or a lack of youth mental health services in their local community [12, 14]. Physical attendance at a mental health service may therefore require a long travel time and incur a substantial cost for non-metropolitan youth, which many report as prohibitive [11, 12, 14]. Efforts to address these barriers have centred around the use of telehealth, which can help improve accessibility to services [15]. However, not all youth perceive telehealth as a suitable modality that meets their needs [12, 15].

To encourage more youth to access available mental healthcare services, we need to better understand what youth want and value in terms of service design and delivery [16]. One way of exploring what youth perceive as important regarding mental health service access is through a choice-based conjoint analysis (CBC) [17]. Although CBCs have previously been used across a broad range of health services research [18], few studies have used this technique to specifically explore mental health service preferences [19]. The aim of this study was therefore to conduct a CBC to elucidate the preferences of youth residing in Tasmania, Australia, toward mental health service access. The results from this study are expected to inform youth mental healthcare providers both locally and elsewhere on ways in which services may be configured to accommodate the preferences of non-metropolitan youth and help improve regional, rural and remote mental health service access.

2 Materials and Methods

3 Results

4 Discussion

To our knowledge, no study has used a choice-based conjoint analysis (CBC) to examine the relative importance of service-related factors non-metropolitan youth may consider when choosing to access mental health services. In this study of young people residing in Tasmania, a largely non-metropolitan island, service provider was the most important of the seven attributes presented, with the highest preference within this attribute for psychologists. These findings contradict other Australian studies which have identified a greater preference for mental health support amongst rural youth from school counsellors and general practitioners [12, 14, 39]. However, differences may reflect different population ages, with some studies sampling school-aged youth only [39]. This study included a lower proportion of youth aged 18 years or under who were likely to be at high school or secondary college where access to school-based mental health professionals (e.g., social workers and nurses) would be promoted [12]. This suggests that youth preferences for certain types of mental health support may be influenced by age and context.

Cost was the second most important factor for Tasmanian youth when considering mental health service access, with youth preferring free services versus incurring out-of-pocket costs. This finding validates the literature describing cost as a key hindrance in mental healthcare access [14] and reinforces the importance of providing locally accessible free mental health service options to limit access barriers [12]. While not all available mental health services offered in non-metropolitan areas incur out-of-pocket costs, youth can be unaware of this [40]. Therefore, marketing of available services also appears important, especially given that financial ramifications appear more important to financially dependent younger people and those unemployed.

Consistent with the literature, wait time was important for Tasmanian youth when considering mental health service access [40], with youth indicating a preference for either immediate services or a wait of up to 1 week compared to waiting periods of 2 to 4 weeks. Long waiting periods have been shown to result in youth foregoing services [41], failing to attend scheduled appointments [14] and seeking alternative service providers or social supports to address mental health concerns [12]. This can be a challenge in non-metropolitan areas which struggle to attract and retain suitably qualified professionals [42]. Interestingly, this study found that wait time was of higher importance to youth in paid work, most likely due to the fact that they may be in a stronger financial position to afford a range of service options. Youth with access to a car or motorbike also placed higher importance on wait time, which may reflect their ability to travel to a service that had a shorter wait time more easily than those using public transport, walking or cycling.

In circumstances where barriers exist to mental healthcare, particularly in non-metropolitan areas, telehealth has been introduced to facilitate service provision [43]. Telehealth can provide many advantages to youth needing mental health support such as affording the user greater privacy [44], reducing the embarrassment associated with mental health service access [5], negating travel time and financial impacts [45] and offering greater convenience [46]. Despite this, our study found Tasmanian youth placed a higher preference for accessing mental health services in person. Interestingly, a preference for face-to-face attendance has been observed in other studies of both non-metropolitan [12, 14], and metropolitan Australian youth [47], suggesting a desire to physically connect with mental health professionals; possibly for reasons of safety, comfort and a greater sense of ‘being with’ another when discussing mental health concerns [48]. These results underscore the importance of establishing a physical presence that provides youth with the opportunity to connect with mental healthcare professionals; a model demonstrated by headspace an Australian mental health service where physical centres are accessible for youth in non-metropolitan locations across the country [49].

This study observed that the importance placed on service delivery methods was predicted by where youths lived; both their geographic rurality (MM) and their level of socio-economic disadvantage (SEIFA-IRSD). Tasmanian youth living in more densely populated regional areas (MM2) placed higher importance on face-to-face service delivery than those from rural areas (MM3-7). This trend echoes other surveys of non-metropolitan youth, highlighting differences in service preferences with increasing remoteness [14]. In regional (MM2) areas of Tasmania and elsewhere, greater availability of public transport, shorter travel distances and lower travel-related costs may make it easier for youth to attend a service in person. Given these factors become increasingly problematic with rurality, youth residing in more rural and remote (MM3-7) areas may be more familiar with telehealth service delivery for other health conditions and therefore be less opposed (or more resigned) to accessing mental health services through this modality [50]. However, this should not imply that youths living in more rural or remote (MM3-7) settings of Tasmania do not want face-to-face mental healthcare, with Klinner et al. (2023) emphasising that even those living long distances from mental health services would like to physically attend appointments [12]. The challenge is to identify opportunities to establish local services that can be well utilised and hence achieve sustainability in the smaller population centres of rural and remote areas.

A prior survey of non-metropolitan Australian youth found that around a quarter of respondents felt they did not have the time to access mental healthcare even if they wanted to [14]. However, when given choices between differing travel times in this study, Tasmanian youth did not demonstrate significant differences between choice levels. Tasmanian youth ranked their highest preference as 15 min travel time compared to all other levels, which included a shorter travel time of up to 5 min. This may be due to the nature of the topic under study (mental health) and the possible embarrassment, especially for younger people, who may have deliberately selected to travel outside of their immediate residential area (< 5 min travel) to protect their privacy [5, 12]. Further, it may be that Tasmanian youth knew that mental health services were not available in their local area and may have indicated the length of time they would need to travel to access the closest services.

Study status was the only demographic characteristic found to be significantly associated with the importance placed on travel time; a likely corollary of the time-poor nature of students. Positively, Tasmanian youth appeared equally willing to access mental health services regardless of whether they were extremely concerned, very concerned or concerned about their mental health, suggesting that they are likely to be proactive and seek early intervention before concerns and symptoms escalate. This study also found no difference in preferences for service access based on the level of mental health concern between males and females. This finding differs from that reported in the literature, where it is suggested that females are more likely to be concerned about mental health and seek services compared to males [14].

The literature suggests that lack of transportation is a barrier to accessing mental health services for non-metropolitan youth, especially in circumstances of low car ownership and limited public transport infrastructure [14]. However, this study found that of all seven attributes, transport mode was ranked lowest in importance for Tasmanian youth. This suggests that respondents felt that they could travel to a mental health service if needed. Most respondents indicated their primary means of transport was a private car or motorbike. Travel was, therefore, a little easier than if they had to rely on public transport. Also, most respondents were recruited from regional (MM2) areas of the state with larger populations and hence better public transport infrastructure to allow travel to and from services.

There are several limitations to this study. The study was limited to one State of Australia, Tasmanian youth self-selected to participate in the survey, which means those who responded were motivated due to familiarity or interest in mental health. Second, this study did not account for mental health status; therefore, it is not known how much their choices were influenced by lived experience of mental illness. Third, recruitment using social media inherently favoured youth with access to social media platforms; although the potential effect of this bias may be low given the widespread use of Facebook amongst youth [51]. Fourth, the survey had many random responses. This may have been due to the online administration of the survey, which likely increased the distractibility of responding youths [52]. Finally, this study recorded low participation of males and youth from rural (MM3-7) areas, which reduces the generalisability of results to the broader Tasmanian population. Further research is required to understand any gender-related differences in choice for mental health service access considering their vulnerability to undiagnosed mental health conditions [53].

5 Conclusions

Non-metropolitan youth residing in Tasmania placed higher importance on the type of service provider, cost, wait time and service delivery method when considering mental health service access. Tasmanian youth preferred to access a mental health service delivered by a psychologist, in person, for no cost and with the shortest wait time. While these findings provide empirical data to assist in the design of youth mental health services in Tasmania and other non-metropolitan settings, further research is required to ascertain whether the mental healthcare preferences of non-metropolitan youth change according to gender, geographical location, mental health status, level of mental health literacy or with a greater variety in available service providers and service delivery methods.

Author Contributions

Edwin Paul Mseke: conceptualisation; writing – original draft; review and editing; Methodology. Belinda Jessup: conceptualisation; writing – original draft; writing – review and editing; methodology and supervision. Tony Barnett: conceptualisation; writing – review and editing; methodology and supervision.

Ethics Statement

Ethical approval to conduct the study was provided by the University of Tasmania, Social Sciences Human Research Ethics Committee (H0020228).

Conflicts of Interest

The authors declare no conflicts of interest.