Aust. J.
Rural Health (2008) 16, 313–318
Original Article
Improving mental health capacity in rural communities:
Mental health first aid delivery in drought-affected rural
New South Wales
Gina-Maree Sartore,1 Brian Kelly,1 Helen J. Stain,1 Jeffrey Fuller,2 Lyn Fragar3 and
Anne Tonna1
1
Centre for Rural and Remote Mental Health, The University of Newcastle, Orange, 2Northern Rivers
University Department of Rural Health, University of Sydney and Southern Cross University, Lismore,
3
Australian Centre for Agricultural Health and Safety, Moree, New South Wales, Australia
Abstract
Objective: To assess the effectiveness of mental health
first aid (MHFA) training in drought-affected rural and
remote Australia, as part of a strategy to improve capac-
ity among farming communities to provide early inter-
vention for mental health problems.
Methods: Data were obtained from 99 participants
recruited across 12 New South Wales towns, before and
after delivery of MHFA seminars emphasising the role of
front-line workers from agricultural-related services.
Surveys assessed knowledge of, confidence in dealing
with, and attitude towards people experiencing mental
illness, along with the impact of training on response to
mental health problems among target population of
farmers and farming families.
Results: Rural support workers and community volun-
teers attended MHFA seminars because of perceived
mental health needs in the workplace. A majority of
responses reflect a concern with giving appropriate
advice and support well outside narrow job definitions.
Participants’ ability to identify high prevalence disor-
ders and endorse evidence-based interventions for both
high and low prevalence disorders increased following
MHFA training, as did their confidence in their ability to
provide appropriate help.
Conclusions: MHFA training can form an effective part
of a strategy to improve systems of care and pathways to
early intervention in rural communities by using local
networks to provide mental health support.
KEY WORDS: drought, mental health first aid,
network, rural.
Correspondence: Dr Gina-Marce Sartore, Centre for Rural
and Remote Mental Health, C/-Bloomfield Hospital, Forest
Road, Orange, New South Wales 2800, Australia. Email:
gina.sartore@newcastle.edu.au
Accepted for publication 15 March 2008.
© 2008 The Authors
Journal Compilation © 2008 National Rural Health Alliance Inc.
Introduction
This paper reports data from one arm of a strategy
aimed at improving local awareness of mental health
issues and facilitating access to formal and informal
mental health services. A more detailed account of the
development and implementation of this strategy is
reported in Fuller et al.1 Farming is associated with a
unique set of stressors,2 including unpredictable envi-
ronmental conditions and financial or business pres-
sures. A characteristic of rural locations of particular
salience in recent times is the prolonged drought that, at
the time of writing, affects large areas of Australia’s
agricultural land. Although this drought is causing
concern in both rural and urban communities, it is in
rural communities reliant on the agricultural industry
that the greatest social and economic impact is felt.
Many rural communities suffer isolation, economic
disadvantage and limited services. Even when services
do exist, rural residents can be reluctant to use them
and this can have health consequences. For instance,
an elevated rate of suicide among male farmers and
farm workers has been reported,3 and Caldwell et al.4
point out that young men in non-metropolitan areas
(the population with one of the greatest risks of
suicide) tend not to seek mental health care when
needed.
Services that do have close contact with farmers
include rural support workers such as rural financial
counsellors, Department of Primary Industry staff and
stock and station agents. These workers are often in a
position of trust with their local communities and have
on-farm contact with farmers at times of considerable
stress.5 Such workers can be the first point of contact
with farmers and farm families in distress, and are well
placed to link farmers with health services for mental
health advice and support.6 A national survey of rural
financial counsellors7 identified a need to develop skills
doi: 10.1111/j.1440-1584.2008.01005.x
314
What is already known on this subject:
• Rural communities based on agriculture are
experiencing drought-related distress.
• Access to health services is limited in many
rural communities.
• Mental Health First Aid (MHFA) training
can be a useful tool to support communities
through increasing recognition of mental dis-
orders, decreasing stigma, and improving
knowledge of effective treatments in commu-
nity participants.
to respond to distress among farmers and develop
improved networks with relevant mental health-related
services.
Mental health first aid (MHFA) training is a 12-hour
seminar delivered by trained presenters, which provides
participants with evidence-based resources to provide
help and appropriate referrals to people experiencing a
mental health crisis (such as an episode of acute psycho-
sis) or an ongoing mental health problem (such as
depression). The underlying rationale of MHFA training
is that people with mental health problems can be
assisted by those in their social network, but that
network members often lack the confidence and skills to
provide basic help and appropriate advice.8
MHFA training has demonstrated efficacy in a ran-
domised controlled trial (RCT) when delivered by
trained facilitators to members of the public in a large
population in New South Wales (NSW). The study
found improved recognition of disorders, decreased
stigma and increased confidence in providing help to
others, and an increase in the help provided. MHFA
training provides a tool to build confidence and literacy
regarding common mental health problems (e.g. depres-
sion, anxiety and substance use).9 The targeted delivery
of MHFA to farming communities is a priority action
identified within the NSW Farmers Association Blue-
print for Improving the Mental Health of People in
Farming.10 This interagency-based plan identifies a set of
actions based on existing evidence regarding mental
health promotion, prevention and early intervention
specifically tailored to factors relevant to rural farming
communities. Reduction in stigma of mental health
problems is a critical step in encouraging help-seeking,
alongside building confidence and knowledge about
mental health problems and available local services
among front-line agencies who have close contact with
farmers and their families. These aims are reflected in
key actions within this blueprint. MHFA has been
G.-M. SARTORE ET AL.
What this study adds:
• Rural support workers, who are trusted by
and have close contact with farming commu-
nities, undertook MHFA training which was
enhanced with introductions to local Area
Mental Health Service representatives.
• Following MHFA training, rural support
workers reported increased confidence and
knowledge in dealing with mental health
needs in the community.
• MHFA training, when conducted in conjunc-
tion with Health and other agencies, could be
a valuable tool for improving professional
networks and access to early intervention in
rural communities.
identified in this plan as the appropriate tool with estab-
lished effectiveness to address these goals.
Aim
This paper reports preliminary results of a strategy to
improve the capacity of agricultural and related services
working closely with farmers to identify and respond to
mental health concerns.
The MHFA training delivered in this study was linked
to improving knowledge of local health services and
pathways to care. This occurred in collaboration with
rural mental health services and community organisa-
tions to ensure an effective local response to identified
mental health problems that best uses available
resources. The aim of the strategy was to explore the
perceived needs of those attending MHFA training and
evaluate the impact of MHFA training on participant
skill and confidence in dealing with mental health prob-
lems in their community.
Method
Location
In 2005–2006 MHFA seminars were conducted in 11
towns in rural and remote NSW. The locations were
chosen in consultation with the rural Area Mental
Health Services in NSW and NSW Department of
Primary Industry staff. In each location training was
targeted at workers in agriculture-related roles who
provide front-line financial, farm management and
related assistance to farmers. Local contacts within each
Area Health Service (or local cluster) identified potential
participants from within each community’s service
© 2008 The Authors
Journal Compilation © 2008 National Rural Health Alliance Inc.
MENTAL HEALTH FIRST AID IN DROUGHT-AFFECTED RURAL NEW SOUTH WALES
sector. MHFA trainers delivering the seminars reported
here were accredited with the seminar developers.11
The survey
Participants completed surveys immediately before and
6–8 weeks following each MHFA seminar. The pre- and
post-seminar surveys were adapted from those reported
in Kitchener and Jorm12 following consultation with the
authors. The post-survey was sent to participants earlier
than in previous evaluations in order to gain partici-
pants’ impressions of the course and its relevance to
their work in the light of the development of strategies
for fostering local rural service networks that was pro-
ceeding simultaneously.
The questions of interest from the survey to be
reported here are: the perceived mental health needs of
the community and reasons for attending MHFA train-
ing; beliefs about treatment and degree of concordance
of those beliefs with those of health professionals;
degree of contact with people with a mental disorder in
professional capacity and confidence in those transac-
tions; and changes to attitudes towards people with a
mental disorder.
Statistical analyses
Data were analysed on a per-protocol basis. While
intention-to-treat analysis is the preferred method for
RCTs,13 the study reported here is an effectiveness trial
in a real-world context, and hence no control group has
been employed. An intention-to-treat analysis was
therefore unnecessary.
In determining concordance and social stigma scores,
the procedure outlined in Kitchener and Jorm,12 was
used. For depression, concordance was scored out of 6,
according to the number of evidence-based interven-
tions endorsed as helpful; for schizophrenia concor-
dance was scored out of 5. Each concordance score was
then converted to a percentage before further analysis.
Stigmatising attitudes were determined by measuring
willingness to participate in five possible social
scenarios.
Results
Participants
All seminar participants (n = 99) consented to their
survey feedback being used in publications arising from
the seminars (Table 1). Participants were drawn from a
wide range of rural community organisations (Table 2).
Reasons for attending seminar
The most common reason cited for attending the
seminar concerned mental health needs in the workplace
© 2008 The Authors
Journal Compilation © 2008 National Rural Health Alliance Inc.
315
TABLE 1: Gender and age group of mental health first aid
participants
n Valid percentage
Gender
Female 63 63.6
Male 27 27.3
Not specified 9 –
Age (years)
18–39 38 38.4
40–59 37 37.4
60+ 19 19.2
Not specified 5 –
(73/99). Many respondents cited problems specific to
rural workplaces – not surprising perhaps given that all
respondents worked in such locations; however, this was
over and above narrow work–education considerations,
and many respondents acknowledged a broad duty to
their communities outside their workplaces. Four
themes were identified. These are listed below with
appropriate illustration in order of decreasing fre-
quency. The number of illustrations of each theme
reflects the overall proportion of responses made relat-
ing to it.
Appropriate intervention given expectation
of need
This was the most commonly made type of response
(58%). A majority of responses reflect a concern with
giving appropriate advice and support well outside
narrow job definitions. For example:
• To gain knowledge of where to get help if someone
rings or comes to the office distressed or just looking
for areas of help – be it financial, mental, etc. I would
like to know what to do and where to refer them to.
• I deal with farmers who have financial problems.
This causes stress and associated problems and I
need to learn more about mental health to be able to
assist further.
• Through my work I’ve often been in situation where
clients have off-loaded their feelings to me. At times
they have talked of suicide and I have felt very inad-
equate to assist them. Trying to refer an Aussie bloke
farmer to a counsellor can be insulting to some.
Professional skill development
This theme is closely related to the previous one, but
appears to conform more closely with a traditional pro-
fessional development attitude (16% of responses).
Examples of such responses are:
316 G.-M. SARTORE ET AL.

TABLE 2: Organisations and occupations of mental health TABLE 3: Correct recognition of the disorder presented in
first aid participants the vignette (%)

n Valid (%) Type of vignette Pre course Post course P-value†

Organisations Depression (n = 67) 82.1 94.0 0.008

Social or welfare agency 26 26.3 Schizophrenia (n = 70) 55.7 67.1 0.077
Rural Lands Protection Board 15 15.2
Department of Primary Industry 13 13.1 †McNemar exact test.
Local business 7 7.1
Rural financial counselling service 7 7.1
National Association for Loss and Grieving 5 5.1 Enhance rural community
Shire Council 4 4.0
Finally, a series of responses emphasised the use of
Academic institution 4 4.0
MHFA training in everyday life outside the workplace
Department of Ageing, Disability and 3 3.0
as a community/social obligation (11% of responses).
Community
• To be able to give and offer more to the rural com-
NSW Ambulance Service 2 2.0
munity. To recognise underlying issues – take a holis-
NSW Farmers Association 2 2.0
tic approach.
NSW Police 1 1.0
Landcare 1 1.0
School/TAFE 1 1.0 Recognition of disorder in vignettes
Not stated 8 –
Table 3 shows the percentage of participants correctly
Occupations
recognising the disorders presented in the vignettes. Par-
Administration/management 26 29.5
ticipants were significantly better able to identify depres-
Community coordinator 10 11.4
sion as the probable mental disorder depicted in the
Community volunteer 10 11.4
vignette following MHFA training. An improvement
Ranger 8 9.1
was also seen in the recognition of schizophrenia,
Pastoral care 6 6.8
although this change was not significant.
Rural financial counsellor 5 9.1
Veterinarian/veterinary intern 5 5.7
Agronomist/advisor 4 4.5 Concordance of beliefs about treatment
Drought support worker 4 4.5 with those of health professionals
Customer service 3 3.4
The results of the paired-sample t-tests can be seen in
Shire councillor 2 2.3
Table 4. There was an improvement in the degree of
Police officer 1 1.1
concordance with the beliefs of health professionals.
Teacher 1 1.1
Not stated 11 –
Social distance measures
There was a significant (P < 0.05) reduction in
expressed stigma about both depression (measured
• To enhance my professional skills while communi-
social distance reduced from 9.87 (SD = 2.66) to 8.03
cating with families in crisis
(SD = 3.65)) and schizophrenia (measured social
• To complement my position as a drought support
distance reduced from 12.75 (SD = 3.61) to 9.91
worker.
(SD = 3.18)). The range of possible social distance
scores was 5–20.
General knowledge and awareness without
clear expectation of need Experience and confidence in helping
Some participants enrolled in MHFA out of a wish When the response categories ‘moderately confident’
for greater knowledge and understanding (15% of and ‘extremely confident’ were collapsed, participants
responses). were significantly more confident in their ability to
• I thought it would be interesting – am always willing provide appropriate help or referrals after participating
and prepared to learn new things. in MHFA training (P < 0.05; 60% pre versus 89% post
• I think many people need someone to talk to at course, McNemar exact test). The same number of par-
special times. ticipants felt that they were having contact with people

© 2008 The Authors

Journal Compilation © 2008 National Rural Health Alliance Inc.
MENTAL HEALTH FIRST AID IN DROUGHT-AFFECTED RURAL NEW SOUTH WALES
TABLE 4: Degree of concordance with the beliefs of health professionals
Pre course
Beliefs about treatment mean (SD)
Depression (n = 60) 74.72 (23.06)
Schizophrenia (n = 61) 80.65 (18.98)
†Paired t-test.
with a mental health problem (over a 6-month period)
before the course as after it (P = 0.202, McNemar–
Bowker test), and estimates of the number of people
seen were not significantly different (P = 0.975, paired-
sample t-test). When the response categories ‘not at all/a
little’ versus ‘some/a lot’ were collapsed, there was no
significant difference in participants’ perceptions of how
much help they gave following such a contact (P =
0.629, McNemar exact test pre and post training).
Discussion
The findings relating to improvements in identification
of depression and increasingly concordant views on
treatment and decreased stigma for both disorders were
not surprising given the previously demonstrated effi-
cacy of MHFA training. Of importance for delivery of
mental health support to isolated rural communities was
the improvement in confidence and perceived ability to
provide help.
One focus of this project was to increase the mental
health capacity of rural communities. We used the
MHFA training as a targeted intervention to build effec-
tive responses from agricultural workers to farmers and
their families, in recognition of the opportunity for early
intervention and improving access to services. The
observed improvements of recognition are small in mag-
nitude (although statistically significant) and start from
a high base rate. Concurrent public awareness cam-
paigns directly aimed at farming communities could
well have improved recognition of depression. Interest-
ingly, though, schizophrenia is also fairly well recogn-
ised though no similar public awareness campaign had
been conducted.
Participants reported similar rates of contact with
people with mental health concerns both before and
after the MHFA seminars, but felt more confident in
their ability to help after training. By increasing support
to front-line agricultural workers, improving mental
health literacy, knowledge of local services and personal
links with local service providers, these front-line
workers will be able to provide an effective first contact
for people with mental health issues. Additionally, the
distress of the workers themselves should decrease as
© 2008 The Authors
Journal Compilation © 2008 National Rural Health Alliance Inc.
317
Post course P-value†
88.05 (24.17) 0.000
87.86 (16.84) 0.015
they feel increasingly confident both in their ability to
provide appropriate advice to people suffering distress
and in their knowledge of local services. The failure to
demonstrate a significant change in the level of help that
participants believe they had provided, despite their
increased confidence, is of interest. The small sample
size could have limited the capacity of this investigation
to detect a statistically significant difference. In addition,
it is possible that while confidence in approaching
someone with a mental health problem improves, it
takes further time and experience of providing help for
the workers to be confident that the actions taken were
helpful. Furthermore, the lack of significant difference
could reflect barriers experienced in gaining access to
services when needed, leading to less confidence that
what is needed can actually be provided, especially as
knowledge of treatment need increases. This finding
requires further investigation in a larger and longer-term
follow-up study, which is currently under way.
A possible shortcoming of this study is the lack of a
control group. The efficacy of MHFA training in rural
and urban populations is already well demonstrated in
RCTs. However, research to commence in early 2007
will investigate a community-wide network-building
strategy, of which MHFA training will form an impor-
tant component, comparing intervention and control
communities in rural NSW.
Conclusions
An innovation of the later MHFA seminars reported
here was to have a local mental health worker (and in
some cases, local mental health consumer) conduct a
discussion session with participants. The effect of this
introduction and subsequent improvement in profes-
sional networks would make a suitable subject for
future investigation. A rural support worker’s confi-
dence in their own ability to identify problems and
knowledge of appropriate sources of support in the
community is an important factor in the success of their
work. For this reason the strategy has linked MHFA
training to the development of local mental health
service networks in order to increase linkage and col-
laboration between health and agricultural service
318
sectors in local communities. This project is incorpo-
rated within the NSW Farmers Association Mental
Health Network. The network and its blueprint set out
a series of actions linked to evidence within a National
Action Plan for Prevention, Promotion and Early Inter-
vention in Mental Health.10
MHFA training was of prime importance for the
service development project as part of a strategy for
improving networks between rural professionals. It is
recommended that MHFA training form part of a
routine strategy leading to improved systems of care and
pathways to early intervention in rural communities.
Acknowledgements
These MHFA workshops were funded by grants from
NSW Health through the Centre for Rural and Remote
Mental Health (CRRMH) and this evaluation was
funded by Australian Rotary Health Research Fund.
The authors thank the participants of MHFA seminars
who agreed to complete surveys and have them included
in this research, and for their valuable comments about
the running of the seminars. The authors also thank Ms
Fleur Hourihan and Ms Georgia Pollard for assistance
with data entry and analysis.
References
1 Fuller J, Kelly B, Sartore G et al. Using social network
analysis to describe local service links for farmers’ mental
health. Australian Journal of Rural Health 2007; 15:
99–106.
2 Department of Transport and Regional Services. Drought
Impacts Beyond the Farm Gate: Two Regional Case
Studies. Canberra, ACT: Commonwealth of Australia,
2005.
3 Page AN, Fragar LJ. Suicide in Australian farming, 1988,
1997. Australian and New Zealand Journal of Psychiatry
2002; 36: 81–85.
4 Caldwell TM, Jorm AF, Dear KB. Suicide and mental
health in rural, remote and metropolitan areas in Austra-
lia. Medical Journal of Australia 2004; 18 (Suppl 7):
S10–S14.
G.-M. SARTORE ET AL.
5 Sartore G, Hoolahan B, Tonna A, Kelly B, Stain H.
Wisdom from the drought: recommendations from a con-
sultative conference. Australian Journal of Rural Health
2005; 13: 315–320.
6 Fuller J, Edwards J, Martinez L, Edwards B, Reid K.
Collaboration and local networks for rural and remote
primary mental healthcare in South Australia. Health and
Social Care in the Community 2004; 12: 75–84.
7 Fuller J, Broadbent J. Mental health referral role of rural
financial counsellors. Australian Journal of Rural Health
2006; 14: 79–85.
8 Jorm AF, Kitchener BA, Mugford SK. Experiences in
applying skills learned in a Mental Health First Aid train-
ing course: a qualitative study of participants’ stories.
BMC Psychiatry 2005; 5 (43). Available from URL:
http://www.biomedcentral.com/content/5/1/43
9 Jorm AF, Kitchener BA, O’Kearney R, Dear K. Mental
health first aid training of the public in a rural area: a
cluster randomised trial. BMC Psychiatry 2004; 4 (33).
Available from URL: http://www.biomedcentral.com/
1471-244X/4/33
10 Fragar L, Kelly B, Peters M, Henderson A, Tonna A.
Partnerships to promote mental health of NSW farmers –
the New South Wales Farmers Blueprint for Mental
Health. Australian Journal of Rural Health (in
press).
11 Kitchener BA, Jorm AF. Mental health first aid training
for the public: evaluation of effects on knowledge, atti-
tudes and helping behaviour. BMC Psychiatry 2002;
2 (10). Available from URL: http://www.
biomedcentral.com/content/pdf/1471-244X-2-10.pdf
12 Kitchener BA, Jorm AF. Mental health first aid training in
a workplace setting: a randomized controlled trial. BMC
Psychiatry 2004; 4 (23). Available from URL: http://
www.biomedcentral.com/content/pdf/1471-244X-4-
23.pdf
13 Moher D, Schulz KF, Altman DG. The CONSORT state-
ment: revised recommendations for improving the
quality of reports of parallel group randomized trials.
BMC Medical Research Methodology 2001; 1 (2). Avail-
able from URL: http://www.biomedcentral.com/content/
pdf/1471-2288-1-2.pdf
© 2008 The Authors
Journal Compilation © 2008 National Rural Health Alliance Inc.