Mental health first aid for Indigenous Australians: using Delphi consensus studies to develop guidelines for culturally appropriate responses to mental health problems

The importance of culture

Research investigating the impact of culture on mental health has found that it is profound, multidimensional and complex [13]. Investigations of mental health care use have shown that ethnic minority groups are under-represented in psychiatric services, both within Australia and across other nations with developed health systems [14, 15]. This trend occurs despite the prevalence of mental disorders in minority groups being either equal to, or greater than, those of the majority group. Research has also shown that the under-representation of minority groups in mental health care is not simply explained by inequalities in socioeconomic status across groups [15]. In fact, for cultural minorities other barriers, such as poor mental health literacy and culturally insensitive health services, play a much greater role in impeding use of services [16, 17]. In recent years, many countries including the USA, Australia and Aotearoa/New Zealand have recognised the important role that culture plays in the identification, treatment and prevention of mental illness, and in response, have implemented standards of cultural competency in service delivery and specialised cultural adaptations of health education programs [18, 19].

Indigenous Australians

In Australia, the diverse groups of Aboriginal and Torres Strait Islander peoples, who constitute 2.3% of the population [20] exemplify the trend of poor mental health service use in the context of mental illness prevalence that is either equal to, or greater than, that of non-Indigenous Australians. Although prevalence estimates for mental illnesses in the Indigenous population are not well researched or documented (the two National Health and Wellbeing Surveys both elected not to collect specific information on the prevalence of mental disorders within the Australian Indigenous population [1, 21]) there are some indirect measures which suggest that the mental health of Indigenous Australians is poor, recognition of mental illness within Aboriginal communities is low, and the prevalence of common mental illnesses such as depression and anxiety is high [22–30]. A recent health survey of Indigenous Australians reported that Aboriginal and Torres Strait Islander peoples are twice as likely as non-Indigenous Australians to report high or very high levels of psychological distress [31]. Furthermore, rates of suicide for the Indigenous population in Australia are estimated to be up to six times higher than rates for the non-Indigenous population [32].

While many programs aimed at improving mental health and reducing suicide in Indigenous Australians have been implemented in Aboriginal communities (e.g. Advanced Suicide Intervention Skills Training [33]), none have used an integrated approach to mental illnesses and associated crisis situations in a way that encourages early intervention and increased mental health literacy. The success of the MHFA course in increasing help-seeking behaviours, and the desperate need to provide Indigenous Australians with culturally appropriate training and education for improving mental health [34], led the Office of Aboriginal and Torres Strait Islander Health, a branch of the Australian Federal Government's Department of Health and Ageing, to fund the development of a cultural adaptation of the MHFA training program, specifically for Aboriginal and Torres Strait Islander Australians [35]. In 2007, an Aboriginal and Torres Strait Islander Mental Health First Aid training program (AMHFA) began teaching Australian Indigenous people a culturally adapted 14-hour course within Indigenous communities. The AMHFA course differs from the general MHFA course in recognising the historical, cultural and political forces that have affected Aboriginal mental health [35]. For instance, the course discusses how Australian Aboriginal people have endured centuries of racism, dispossession, violence, trauma and loss. The forced removal of communities from their land, the systematic denial of culture and language, the suppression of political and human rights, and the forced removal of children, have all contributed to an environment of poor mental health compounded by ongoing social and economic disadvantage [34]. In addition, the program acknowledges that Aboriginal people understand mental health within a unique cultural framework that is not necessarily complementary to the biopsychosocial model of western medicine [28, 34]. Furthermore, it recognises that this cultural divergence can at times complicate the use of mental health services because Aboriginal people are either unable to find services that provide culturally sensitive treatment approaches, or fear accessing mental health services because historically these services have failed to provide care which incorporates and respects an individual's cultural world-view [28].

The need for culturally specific mental health first aid guidelines

Although the existing Aboriginal Mental Health First Aid training program was developed through extensive consultation with Aboriginal people, it became apparent that the content of training would be improved by the development of best practice guidelines. In parallel to those developed for English-speaking [8–11] and Asian [6] countries, this research aimed to develop culturally appropriate guidelines for providing first aid to an Australian Aboriginal or Torres Strait Islander person who is experiencing a mental health crisis or developing a mental illness. By engaging Indigenous experts who work in the field of mental health, the research focused on the importance of culture and Indigenous experiences of mental illness.

The Delphi Method

Originally developed for technological forecasting, the Delphi technique has been used extensively within the last decade in health and social research, to enhance decision-making processes [7]. The Delphi method provides expert consensus on what constitutes best practice in scenarios that cannot be feasibly or ethically subject to a randomised controlled trial. The process involves questionnaires being sent out to a group of experts, who do not have to attend group meetings and can respond anonymously. Traditionally, the Delphi method has involved a number of iterations before consensus is achieved. Feedback is given at each stage in order to help experts assess their opinions against those of the group.

A sixth guideline about the importance of understanding and respecting Aboriginal culture while providing mental health first aid, entitled Cultural Considerations and Communication Techniques (hereafter referred to as Cultural Considerations) was also developed to accompany the series.

3. Data collection and analysis

Once panel members had been recruited, they were sent an electronic link to an online questionnaire, hosted by http://SurveyMonkey.com. Participants who were unable to complete the survey online were sent paper copies via mail. Allowing participants to choose between the two methods of delivery ensured that experts who had limited access to the internet were still able to participate in this research. Participants responded by rating how important the first aid action statements were to the development of a set of guidelines on providing culturally appropriate mental health first aid to an Aboriginal person. The questionnaire involved a five point scale including the following options:Essential, Important, Don't know/depends, Unimportant and Should not be included. In Round 1, panel members were also invited to make comments on any ambiguity or wording of the statements presented, and to suggest any new ones that had not yet been considered.

Once all participants had lodged their ratings, statements were placed into one of three categories.

• If between 90-100% of panel members rated a statement as either Essential or Important, the statement was endorsed as a guideline.

• If between 80-89% of panel members rated a statement as either Essential or Important, then the statement was entered into a second questionnaire to be re-rated.

• If neither of the above conditions were met, then the statement was excluded from the guidelines.

The protocol of using the Essential and Important ratings for categorisation was designed to allow selection of only those statements that were clear and broadly applicable for inclusion in the guidelines. Statements that were either unimportant to the provision of first aid, or dependent upon a situation or individual circumstance, were excluded because they did not constitute general principles that could instruct members of the public in how to provide first aid to an Aboriginal person.

Comments that were submitted by panel members were also analysed for any content that had not yet been addressed. To ensure comprehensibility and consistency, any additional ideas gleaned from these comments were written into first aid action statements and presented to the working group. Any statement that was judged by the group to be an original idea was included as a new statement in the second round questionnaire.

Once categorisation was complete, panel members were sent a report, which outlined the results of the questionnaire. The report consisted of a list of statements that had been endorsed, a list of statements that had been rejected, and a list of statements that were to be re-rated in the next questionnaire round. The statements to be re-rated were displayed with the group percentages for each possible rating, and also with the panel member's individual rating, so that panel members could compare their response to that of the group. Presentation of the report in this way allowed the panel members to decide whether to maintain or modify their ratings in the second round questionnaire.

The same criteria for endorsing, excluding and re-rating statements were applied to the data collected in Round 2, with one exception. If a statement was re-rated in the second round and again failed to achieve a consensus of between 90 and 100 percent across the panel, it was then excluded. Only those statements that had been entered as new statements in Round 2, and afterward fell into the Re-rate category, were entered into a third round questionnaire. Figure 1 outlines how the Delphi method proceeded through three rounds of consultation with expert panel members in order to achieve consensus.

Feedback from panel members

To the authors' knowledge, this research is only the second time the Delphi method has been used to develop expert consensus among Aboriginal people in Australia [39]. To assess the panel members' satisfaction with the research method, participants were invited to complete an online feedback survey at the end of the six Delphi studies. Respondents were encouraged to comment on the appropriateness of the contact methods, research methods, language and concepts used throughout the studies. They were also asked how culturally appropriate and useful they thought the developed guidelines would be to Aboriginal people in the future.

The feedback survey contained 48 statements that described the research experience (e.g. I thought the use of email and internet was a good medium for data collection). Participants were asked to respond by selecting where their opinion fell on a 5-point scale of agreement; Strongly Agree, Agree, Neither Agree nor Disagree, Disagree, and Strongly Disagree.

Expert panel members

Participants were recruited from across Australia including: the Australian Capital Territory (n = 2), New South Wales (n = 11), the Northern Territory (n = 1), Queensland (n = 7), South Australia (n = 1), Victoria (n = 4) and Western Australia (n = 2). Tasmania was the only state without representation on the panel. Having a geographical spread of panel members was thought to be important for the representation of different experiences and attitudes of Aboriginal communities across Australia. It is therefore important to note that no participants identified as Torres Strait Islander. According to the 2006 Australian Census, 90% of the Australians who identified as Indigenous were of Aboriginal origin only, 6% were of Torres Strait Islander origin only and 4% were of both Aboriginal and Torres Strait Islander origin [20]. Given that Torres Strait Islander people constitute such a small percentage of the Indigenous population, it is not surprising we found it difficult to recruit a representative from this community.

Participants were employed in a range of different services across the mental health field, including: private psychology clinics, Aboriginal medical services, government health services, universities, cultural resource and counseling services, prisons, social services, and drug and alcohol services.

The panel was very experienced, with more than half having between 6-10 years experience in the mental health field (5 years or less = 12.5%, 6-10 years = 62.5%, 11-15 years = 12.5%, 16-20 years = 12.5%). In addition, approximately one quarter of panel members had obtained a post-graduate degree (Certificate level = 11.6%, Diploma = 11.76%, Bachelor Degree = 47.06%, Bachelor degree with honours = 5.88% Graduate Diploma = 5.88%, Masters degree 17.65%, PhD = 0.00%).

Endorsed statements

Rejected statements

Some statements were strongly rejected by the panel, with a majority of participants rating a statement as either Unimportant or Should not be included (see Additional File 2, Table S7, for a list of strongly rejected statements). Across the 6 Delphi studies 36 items were rejected with strong consensus (50% or more of panel members rated an item as either Unimportant or Should not be included). The majority of strongly rejected items came from the suicide and deliberate self-injury surveys, while the psychosis, cultural considerations and trauma and loss surveys received no strong rejections.

Other statements were rejected because there was disagreement within the panel. For instance, some statements failed to be endorsed because, even after a second rating, the statement just failed to achieve 90% consensus.

Panel member feedback

Statements regarding the appropriateness of the Delphi research method also received a high level of agreement, with 83.3% of participants responding with either Strongly Agree or Agree to the statements I believe the Delphi process can be of benefit to Aboriginal people and I would recommend the Delphi method for other research projects for Aboriginal people.

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 statement Suggest 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; and Most 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 see Depression: First Aid Guidelines) [31], 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 [40] 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, the beyondblue: 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 from beyondblue. 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.