By engaging Aboriginal people who are experts in the field of mental health, this research aimed to develop culturally appropriate guidelines for providing mental health first aid to an Australian Aboriginal or Torres Strait Islander person. Despite diverse backgrounds, the expert panel was able to reach consensus on a range of first aid techniques, from offering a cup of tea or coffee to a person who has experienced trauma, through to talking about the sensitive issue of suicide.
Across the different Delphi topics, statements were rejected and endorsed at different rates. For instance, the psychosis study proposed a total of 187 first aider action statements, of which 81% were endorsed and 19% were rejected. In contrast, the deliberate self-injury study proposed a total of 114 statements, of which 27% were endorsed and 73% were rejected. While it might be expected that the Delphi studies containing the most cultural information may have had the highest rates of endorsement (e.g. trauma and loss or cultural considerations), in fact the pattern of endorsement mirrored that of other international Delphi studies, which have found differences in the strength of established expert consensus [8–11]. That is, because of wide-ranging and effective research into first episode psychosis, there is a strong consensus on how emerging psychosis should be managed. Conversely, due to a dearth in controlled trials and treatment studies, there is little expert consensus on how deliberate self-injury should be treated in a clinical context, let alone managed in the community.
Although each Delphi study addressed a different mental health issue, there were two themes that appeared in each survey and subsequent guidelines. The first theme was about how the person providing first aid needed to understand and assess symptoms of mental illness within the cultural context of the person they were helping. The second was the essential role that family and community play in promoting and protecting the health and wellbeing of individuals with mental health problems.
Understanding symptoms of mental illness within a cultural context
A particular concern of culturally appropriate mental health first aid is to check, or to understand, the cultural norms of the community, before assuming that an Indigenous person is displaying symptoms of mental illness. All of the Delphi study surveys included statements about symptom recognition in the context of culture. For instance, the depression study included the statement -The first aider should take into consideration the spiritual and/or cultural context of the person's behaviours. The psychosis study included the statement -The first aider should be aware of what constitutes culturally appropriate behaviours so that they don't misinterpret such behaviours as symptoms of psychosis (e.g. in some communities, limited eye contact is expected behaviour). The suicidal thoughts and behaviours study included the statement -The first aider should learn about the behaviours that are considered warning signs for suicide in the person's community. And the deliberate self-injury study included the statement -The first aider should be aware that pathological self-injury, such as cutting and burning, is fundamentally different to ritualistic, culturally accepted Aboriginal ceremonial or grieving practice.
Each of these statements were endorsed by panel members and incorporated into the guideline documents. That each of the developed guidelines contain information about the need for the person providing first aid to be mindful of cultural norms, before assuming that someone is experiencing a mental health problem, suggests that this is a cornerstone of culturally appropriate first aid. Importantly, from the feedback provided by panel members during the Delphi studies, this principle was not only seen as important for non-Indigenous people providing first aid to Indigenous people, it was also seen as crucial for any Indigenous person who was assisting outside their own community.
While panel members endorsed this idea of culturally appropriate first aid, they did so with a caveat. Panel members comments suggested that individuals providing first aid need not get so immersed in the need for cultural awareness that they lose sight of the physical and emotional needs of the person they are assisting; as one panel member's comments suggest: "Whilst having attested to the importance of these cultural awareness items, they sum to a maxim that it's crucial to take time to become familiar with local beliefs and norms, [yet] it is actually counter-productive to think one has to be an anthropologist - across the minutiae of all Australian Indigenous cultures...". This idea was also especially apparent in the study on trauma and loss. In the Round 1 and 2 surveys, panel members were presented statements about seeking culturally appropriate professional help. Allowing an Aboriginal person to seek out a professional who is trained or experienced in treating Aboriginal people and their experiences of trauma, was seen as particularly important in facilitating recovery. As the Delphi progressed, however, it became apparent that any rigid statements about the need for culturally appropriate professional help were not going to be endorsed, because they alone precluded the right of the person receiving care to seek help that is close to their home and community, and which suits their individual needs. The Trauma and Loss guidelines therefore not only include the statementSuggest that the person see a professional who is trained or has experience in working with Aboriginal people and their experiences of trauma and loss, it also contains the additional caveats: It is important to note that counselling suitable for Aboriginal people may be quite difficult to find or gain access to, as there is a shortage of appropriately trained Aboriginal psychologists and counsellors. If this is the case, you can engage other options; andMost importantly, encourage the person to find someone who will help them tell their story and who the person can trust and feel comfortable talking to. So while this research supports the importance of providing culturally appropriate first aid, it also asserts that when assisting an Indigenous person with a mental health problem, it is equally important to meet their individual needs, regardless of their cultural identity.
The role of family and community
The statements endorsed by the panel and the feedback comments submitted in the first round of each study revealed that, to provide culturally appropriate first aid, the person assisting should facilitate additional support for the person in their care, by encouraging positive relationships with family and community members, while upholding the person's right to confidentiality. For example, the Psychosis guideline contains the statement -Encourage the person to take a support person, such as a family member, to their appointment. If you wish to help the person contact their family, be aware that you must ask the person if its okay for you to talk to family. The Cultural Considerations guideline contains the statement -Try to get the person's family involved in supporting them until they get better, but in doing so, you must uphold the person's right to confidentiality. The Trauma and Loss guideline contains the statement -Whether or not the person seeks professional help, you should encourage them to identify sources of support. These may include community members, support groups and men's or women's groups.
While facilitating support for a person experiencing a mental health problem is recommended as a first aid action in the guidelines produced by previous Delphi studies for English-speaking countries (for instance seeDepression: First Aid Guidelines) , the focus of previous guidelines has been on developing a supportive relationship between the person providing the first aid and the person receiving care. The Delphi studies conducted in this research, reveal that it is important to establish an additional support person, who can act as a mentor or carer.
This additional first aid strategy appears to have arisen for a number of important reasons. For example, many Aboriginal people live in regional or remote communities with limited access to mental health care. Establishing a positive and trusting relationship with another person is a way to establish additional psychological support that may otherwise be unavailable. This is demonstrated by the Cultural Considerations guidelines, which state: Establishing a network of support for an Aboriginal person is a very important step in helping them resolve their mental health crisis, especially if access to professional support or mental health services is limited. Another reason for including the facilitation of additional support is to protect against further psychological distress by enhancing the person's social and emotional wellbeing. This is exemplified in the statement: Discuss with the person what their interests and activities are and encourage participation in any group activities that will help them to develop feelings of purpose, belonging and achievement, which also appears in the Cultural Considerations guidelines.
Acceptance of research outcomes and plans for dissemination
The feedback from panel members demonstrated that support for the Delphi method and the guidelines it produced was very strong (see Additional File 2 Table S4). However, for the developed guidelines to be successful, they need to have a direct impact on the Indigenous communities within Australia. The culturally specific 14-hour course developed by the Aboriginal Mental Health First Aid program is one avenue to achieve this impact.
Since its inception in 2007, the AMHFA course has been presented to over 1,936 Australians. When the teaching materials are revised to reflect the consensus on first aid techniques developed by these Delphi studies, the information in these guidelines will reach a significant number of Indigenous Australians. Furthermore, the detailed material presented in the guidelines will be organised under the MHFA ALGEE action plan  and will have associated teaching activities such as role plays and DVD clips. A pictorial flip-chart is also planned. The dissemination of the guideline information in this way reduces the need for English literacy and thus makes the first aid information more accessible to Indigenous people who may only use English as a second (third or fourth) language.
In addition to the AMHFA course, thebeyondblue: the national depression initiative has developed a national dissemination program whereby copies of the guidelines will be sent free of charge to health, education and community resource centres across Australia, who engage Indigenous clients. Furthermore, the guidelines will be made available to order free frombeyondblue. Given that a number of important stake-holders in Aboriginal mental health were involved in the guideline research as expert panel members, and that the feedback survey demonstrated these stake-holders approve of the research outcome and are willing to recommend the guidelines to others, the authors believe the national dissemination project will be successful in presenting the guidelines to a large number of people who care for Indigenous Australians with mental health problems.
One limitation of the current research is the lack of pertinent information for members of the community who wish to provide mental health first aid to young Indigenous Australians. Given that, in 2001, 39% of Indigenous people were under 15 years of age, compared with 20% of non-Indigenous people, providing first aid resources for young Aboriginal and Torres Strait Islander Australians is an important task for AMHFA. It was however, a considered decision of the research team to develop guidelines focused on adults. Now that the validity and acceptability of the research method and outcomes have been established, it is hoped that future Delphi studies will be able to develop best practice guidelines for providing assistance to young Indigenous people developing a mental illness or experiencing a mental health crisis.
Despite provisional support from the experts involved in the guideline production, and a highly structured dissemination plan, only further evaluation of first aid outcome will elucidate whether or not the information developed by this research is effective in decreasing the barriers to mental health care faced by many ethnic minority groups in Australia, such as poor mental health literacy, and ultimately increasing the use of health services by Indigenous people.