Cognitive behavioral therapy (CBT) [1,2] is an effective treatment for depression and anxiety recommended by the National Institute for Health and Care Excellence (NICE). It is based on the assumption that most behavioral and emotional reactions are learnt and focuses on the interrelated components of emotions, behaviors, and thoughts [3]. A key advantage of CBT is that it adapts to computerization [4], with Internet-based cognitive behavioral therapy (ICBT) programs tailored to the needs of the individual. There are a range of ICBT programs adapted for different health issues, psychological disorders, and lifestyle choices such as substance misuse [5-8], insomnia [9,10], mild to moderate depression [11,12], pathological gambling [13], and perfectionist-related issues [14]. This feasibility study explores the acceptability and usability of an ICBT program that has been designed for people experiencing mental health problems due to difficult financial circumstances.

In the midst of a recession and with the continuing move by the UK government to implement austerity measures, vulnerable members of society are suffering the consequences of an economic contraction [15]. One of the adverse outcomes of the recession is the so-called “credit crunch” whereby individuals are struggling to cope with debt and the consequences of this on mental health and well-being [16-19]. Individuals in financial distress (especially those experiencing unemployment and impoverishment) manifest a range of illnesses including depression, anxiety, and alcohol use disorders [20,21], with greater austerity measures increasing the severity of such mental health issues [22,23]. Indeed, a survey by Rethink [24] revealed that almost 9 out of 10 of those in debt felt that their financial difficulties had made their mental health problems worse.

A further negative consequence of the imposed austerity measures is the continuing erosion of access to mental health services [24,25]. Financial institutions, such as the Citizens Advice Bureau, are not able to support those experiencing financial difficulties and associated mental health problems [26]. Due to limited access to appropriate support and intervention, individuals may therefore be less able to resolve their financial problems or access help, and subsequently, may find themselves sinking deeper into debt.

In light of the detrimental effects that debt may have on well-being, and the lack of evidence-based services that offer both financial and emotional advice, government and financial institutions now recognize that considerable work needs to be done to address this gap in services [27,28]. However, although the optimal treatment for debt and mental health is still being sought, there is good reason to assume that ICBT can be adapted to the specific issues associated with the burden of debt. ICBT may be appealing in that it may reduce concerns an individual has about stigma associated with seeking face-to-face help for debt and mental health issues [29]. Indeed, most of those who experience financial difficulty also experience feelings of shame, self-disgust, and secretiveness [30]. This means that individuals in debt can suffer in silence when confidential services that assure anonymity are lacking [31].

Therefore, this study was conducted to assess the usability and acceptability of a novel ICBT treatment program, Ostrich Community (OC), which is designed to help individuals with their financial difficulties while supporting them to overcome any associated mental health problems. The program aims to promote development of positive behaviors, increase financial knowledge, and improve self-efficacy with regards to financial management. The study adopted a mixed-methods approach as recommended by the Medical Research Council (MRC) guidance around the development and evaluation of complex, multicomponent psychosocial interventions [32,33]. This MRC guidance recommends that before examining clinical effectiveness of complex interventions via approaches such as randomized controlled trials (RCTs), feasibility and piloting work should be conducted in order to ascertain initial acceptability and usability of any novel intervention. This may be particularly important when developing digital interventions that can be perceived as “disruptive” to the status quo within an existing health or social care system [34,35].

In line with the MRC guidance, it was important to conduct a feasibility study to explore acceptability and usability in a group of participants experiencing only moderate financial difficulties, before examining effectiveness in the target population, that is, service users accessing support for financial and mental health difficulties. This approach is important to gain insights into improvements that could be made to the program before evaluating it more formally with a group who may have more complex needs [36]. Small-scale feasibility studies can also reveal insights into acceptability of novel treatment approaches, which can be used to facilitate engagement during formal piloting and effectiveness studies [37-40].

This was a mixed-methods feasibility study, incorporating semistructured qualitative interviews and quantitative satisfaction measures, alongside psychometric measures of stress and well-being. These measures were taken to explore acceptability and usability of the OC program.

The OC ICBT program provides practical advice about management of finances and psychological well-being and clinically validated evidence-based psychosocial intervention strategies that are grounded in the theoretical underpinnings of the CBT model [3]. Each module provides psychoeducation, cognitive-behavioral worksheets or strategies, and money management stories and quotes to help increase motivation. The program moves beyond information-giving and is the very first intervention program that is evidence-based and tailored to address issues surrounding financial and associated psychological distress.

The program comprises a 2-min introductory video, followed by 8 Web-based sessions at weekly intervals. Each session lasts approximately 30 min, with approximately 30 additional min per week spent practicing away from the computer (eg, keeping problem diaries, thought records, and completing behavioral experiments) in order to encourage the user to practice the skills taught throughout the program. The program contains information delivered by video and audio to enhance engagement and accessibility. See Table 1 for more detail of the content of individual modules and topics covered by the program.

The OC program is best suited to users who are experiencing mild to moderate stress or depression and anxiety symptoms, and who need information and guidance about money management. Participants with more serious mental health symptoms and debt issues are introduced to content on the home page and there is a toolbox that provides information on more intensive mental health and debt advice services that are more appropriate to their needs.

The sample consisted of 17 students from the University of Salford, who were not in significant financial distress, but were coping with the demands of a further education course of study, alongside the low income and financial difficulties many students experience. This group was selected as it was considered important to explore acceptability and usability of the program in a group without significant financial and emotional difficulties, before testing individuals with more complex needs that are facing real financial and emotional difficulties. All participants were studying full-time and some were also working to supplement their income. Table 2 provides demographic information on the sample.

Participants who consented to take part subscribed to the program by activating a Web-based account, providing an email address, and creating a password. They received a welcome message together with login details via email. Of the 17 consenting participants, 15 activated an account.

Participants worked through the modules sequentially, with a new module released each week for 8 weeks together with an email reminder. Following completion of all modules, participants were invited to take part in a semistructured interview exploring acceptability and usability of the program (7 took part). Before module 1 and after module 8, participants completed two standardized psychometric assessments, measuring stress and well-being (with a total of 13 participants providing these data). The flowchart depicted in Figure 3 demonstrates the sequence of events during the study, from initial recruitment to completion of qualitative interviews, and shows attrition rates at each stage.

Three separate methods were used to examine (1) acceptability and usability of the program, (2) participant satisfaction, and (3) stress and well-being outcomes.

Three themes were identified relating to (1) enhancing engagement with the OC program, (2) acceptability of program content, and (3) the programs’ potential to benefit the target population.

All 13 participants completed the usability questionnaire after each module and the CSQ-8 [42] at the end of the program. Data from the usability questionnaire (Table 3) demonstrated mean experience across the 8 sessions was favorable, with participants rating the usefulness of each topic and the benefits of each session as high. Following each session participants felt less stressed compared with how they felt at the beginning, with none reporting distress from any of the sessions.

From the CSQ-8 data (Table 4), 92% (12/13) of participants rated the quality as good or excellent. All participants received the service they wanted, and 92% (12/13) reported that the program met most or all of their needs and that they were satisfied with the amount of help provided. All would recommend the program to a friend in need of financial help and 92% (12/13) said that they would come back to the program if they needed help in the future. When asked how satisfied they were with the program overall, 69% (9/13) were “very satisfied” and 30% (4/13) were “mostly satisfied.”

Participants reported higher levels of anxiety before the program (median 24) than at the end (median 16) and this difference was significant, Z (13)=−2.006, P<.05 There was also a significant difference in stress scores before and after (median scores of 32 and 26 respectively) with participants reporting lower levels of stress at the end of the program, Z (13)=−2.814, P<.01. There was no difference between levels of depression at the end of the program (median 22) compared with the beginning (median 26), Z (13)=−0.393, P=.69.

Scores on the WEMWBS were lower at the beginning of the program (median 45.00) compared with the end (median 51). Participants reported a significant increase in well-being from pre- to postprogram, Z (13)=−2.275, P<.05.

The continuing government austerity measures, coupled with a bleaker outlook on jobs, have resulted in more people experiencing debt [15]. This often takes a toll on a person’s health and psychological well-being [16] and is exacerbated by a shortage of services available to assist people experiencing financial hardship and associated mental health difficulties. Financial and other governmental institutions have limited resources to assist people in this situation and the waiting list of people needing help is expanding [45].

The OC program is an innovative ICBT program that aims to support individuals who are having financial difficulties that are affecting their emotional well-being. The focus of the program is to relieve psychological stress, anxiety, and depression while teaching positive financial behaviors and resilience. This initial feasibility study was conducted to explore acceptability and usability of the program.

Many participants said that they appreciated taking part in the study because it helped them to learn how to budget effectively and how to be prepared in terms of dealing with sudden financial changes. One of the benefits of this program is therefore that individuals can use it as a preventative tool regardless of their financial circumstances and in the absence of significant levels of debt [2,46]. Indeed, participants noted that the CBT principles in the program could be beneficial for anyone, even for those without any significant financial or psychological difficulties. In addition, after completing the program, participants reported a significant reduction in anxiety and stress, and improvements in well-being.

Participants found the program to be helpful and easy to use and there was high satisfaction with the financial information and emotional help provided. These findings support the high satisfaction with ICBT when addressing gambling [13], insomnia [10], mild-to-moderate depression [11], and drug and alcohol use [6,8]. Participants liked the interactive and multimedia, digital format of the program, reporting that they found it to be user-friendly, and the information easy to understand. Some observed that although the program allows for people to work independently, it may be too much for some who may benefit from “computer-assisted therapy” (CAT) rather than “self-help therapy.”

CAT integrates therapeutic content delivered by an ICBT program with a human practitioner who may provide screening, supervision, and other support to the user [477], whereas self-help programs do not use practitioner monitoring or involvement [48]. Evidence suggests that people with higher levels of motivation, such as students, have improved outcomes from participation in this latter type of program. Students are generally driven by a desire to achieve [49] and are encouraged to be self-motivated autonomous learners [50]. This is a drawback with this sample as participants may have been more motivated than those in the general population suffering with debt problems. This is supported by the relatively low dropout rate compared with other studies of ICBT programs, some of which report high attrition rates [51]. In addition, as the students who participated in this study were not necessarily in debt, and instead were coping with a relatively low income that is common among students, the sample is not representative of the target user groups.

A “blended” approach to facilitation of ICBT programs has been demonstrated to be helpful for those individuals experiencing mental health difficulties [52]. Therefore, further work will explore delivery of the program not as self-help, but as CAT. By delivering the program as CAT with practitioner support, this may lessen the attrition rate in the target population, and may provide vital additional therapeutic support for individuals experiencing significant financial hardship and mental health difficulties [51].

This study intended to explore initial feasibility and acceptability of the OC program with a small cohort of participants experiencing some financial difficulties. This was to gain insights into improvements that could be made to the program before evaluating it with a population of service users with more complex needs. Multiple digital health studies take this approach, including studies of mental health intervention programs [53] and alcohol misuse programs [36]. The sample size was limited, yet when examining feasibility of novel digital interventions such as the OC program, small-scale studies can reveal important insights regarding acceptability and clinical content. This can facilitate optimal engagement during formal piloting and effectiveness studies [37-40]. Future work will include a larger pilot study with the target population, that is, service users accessing support for their financial and mental health difficulties.

The aims of this feasibility study were to assess the acceptability and usability of a novel ICBT program for people experiencing poor mental health due to financial difficulties. A total of 15 participants worked through the program over a period of 8 weeks, and they reported satisfaction with the program and noted that it was easy to use. They also suggested that it made them consider their financial situation and gave them skills they could use beyond the immediate focus of finances. There was also a significant improvement in well-being, anxiety, and stress on completion of the program.

Some participants reported that it was difficult to work through the modules individually and so future work will explore the addition of support from a practitioner and potentially a moderated peer support forum. These implementation approaches may help to increase impact [51], increase engagement, and support completion. The sample was also limited to participants not in serious financial difficulties. Therefore, further research will include a larger sample of participants who come from the intended targeted population for the OC program; individuals experiencing significant financial difficulties and associated mental health difficulties.