Steering Straight: Adapting suicide risk safety planning as a prevention-focused self-management resource for the Australian farming community.

OBJECTIVE: This paper draws on the principles of suicide risk safety planning to co-design a farming community resource for preventing and managing risks to mental health. SETTING: This project was undertaken in the Great South Coast Region of Victoria, Australia. PARTICIPANTS: A working group (n = 6-8) from the Victorian farming community contributed to the iterative co-design and co-production of Steering Straight: My plan to keep on track. Twenty-four members of the farming community pilot tested Steering Straight. DESIGN: Co-design to develop, pilot and refine the resource with working group and target farming community. RESULTS: Steering Straight was viewed positively by the farming community as a tool that prompts prioritising well-being; encourages reflection, planning and concrete steps towards taking action; helps set and meet personal goals; is simple and practical; and identifies pathways to support. Most participants (94%) completed Steering Straight on their own, taking approximately 15-30 min to create their personalised plan. Questions most likely to be filled in related to recognising personal signs of deteriorating well-being and listing and planning enjoyable activities. A majority of participants (67%) kept a hard copy of their Steering Straight plan on hand to refer back to, while 78% expressed a preference for a digital version. CONCLUSION: The co-design and co-production process resulted in a tailored prevention-focused resource that was accepted and valued by the farming community.

Co-designing a peer-led model of delivering behavioural activation for people living with depression or low mood in Australian farming communities.

INTRODUCTION: Farmers face a range of factors that negatively influence their mental health and suicide risk, yet have limited access to appropriate support. Behavioural activation (BA) is an evidence-based therapy that can be effectively delivered by nonclinical workers. Working with members of farming communities to deliver BA to their peers has the potential to overcome many well-established barriers to mental health help-seeking and improve outcomes for this at-risk group. OBJECTIVE: This paper describes the findings of a co-design phase informing the development of a peer (farmer)-led approach for delivering BA for farmers living with depression or low mood. DESIGN: This qualitative study used a co-design approach involving members of the target community. Focus groups were transcribed and analysed using Thematic Analysis and the Framework approach. FINDINGS: Ten online focus groups with 22 participants were held over 3 months. Four overarching, interlinked themes were identified: (i) filling the gap in rural mental health support; (ii) alignment with the farming context-tailoring how, where and when we engage about mental health; (iii) the 'messenger' is as important as the message; and (iv) sustainability, governance and support. DISCUSSION: Findings suggest BA could be a contextually appropriate model of support for the farming community-given its practical and solution-focused approach-and could help improve access to support. Having peer workers deliver the intervention was viewed as appropriate. Ensuring governance structures are developed to support peers to deliver the intervention will be essential to facilitate effectiveness, safety and sustainability. CONCLUSION: Insights gained through co-design have been critical to the success of developing this new model of support for members of farming communities experiencing depression or low mood.

Rural suicide risk and physical ill health: A qualitative study of the Victorian Suicide Register, 2009-2015.

OBJECTIVE: To gain new insight into contextual factors shaping how physical ill health acts as a stressor in rural suicides-informing the development of appropriate targeted interventions. DESIGN: Retrospective cohort study. SETTING: Non-metropolitan Victoria, Australia. SAMPLE: 802 rural (non-metropolitan) suicide deaths between the years 2009 and 2015. MAIN OUTCOME MEASURE: Qualitative data from the Victorian Suicide Register relating to physical ill health of suicide decedents. RESULTS: Thematic analysis identified 4 themes: (a) 'living with physical ill health in a rural area' highlights both practical and cultural challenges associated with managing physical ill health within the context of life in a rural setting; (b) 'causes and experience of chronic pain' highlights rural risk factors for chronic pain, how pain was experienced and treatment managed; (c) 'when living an independent, contributing life is no longer possible' describes the debilitating physical and mental outcomes of chronic ill health and pain; and (d) 'the cumulative impact of physical ill health and other factors on suicide risk' highlights the complexity of risk factors-in combination with (or as a result of) physical ill health-that contribute to a suicide death. CONCLUSION: Identified themes suggest pathways to improve understanding and support for those experiencing physical ill health and associated suicide risk. These supports include contextually and culturally appropriate rural services to provide effective and necessary treatment, pain relief and mental health support; acknowledgement and response to a culture of alcohol misuse as an (ultimately ineffective) coping strategy; proactive psychosocial support mechanisms; and alternative approaches to support including consideration of innovative peer support models.

Suicide and Accidental Death for Australia's Farming Families: How Context Influences Individual Response.

This article presents qualitative data to explore the experience of farming family members faced with accidental or suicide death and understand how this is experienced within the farming context. Individual semistructured interviews were conducted with 25 members of Australian farming families bereaved by suicide or accidental death. Qualitative data was thematically analyzed. Three interconnected themes were identified: acceptance of risk, normalization of death, pragmatic behavior patterns and connection to place. Bereavement and reconstruction of meaning following suicide or accidental death for farming families is influenced by the cultural, social, geographical, and psychological contexts of farming families. This article challenges traditional conceptions of suicide and accidental death as necessarily experienced as "violent" or "traumatic," bereavement as experienced similarly across western cultures, and the reaction to suicide or accidental death as one that challenges people's understanding of their world and leaves them struggling to find a reason why the death occurred.

The ripple effect: a digital intervention to reduce suicide stigma among farming men.

BACKGROUND: Compared with the general population, Australian farmers-particularly men-have been identified as at greater risk of suicide. A complex range of factors are thought to contribute to this risk, including the experience of Stigma. stigma also impacts those who have attempted suicide, their carers, and those bereaved by suicide-manifesting as shame, guilt, social isolation, concealment of death, reduced help seeking and ongoing risk of suicide. This paper evaluates the effectiveness of an intervention, tailored for the farming context, designed to reduce stigma among farming men with a lived experience of suicide. METHODS: The digital intervention used an adult learning model providing opportunity to share insights, reflect, learn and apply new knowledge among people with shared farming interests, suicide experience and cultural context. A range of content-tailored to the gender, farming type and suicide experience of participants-included video stories, postcard messages, education and personal goal setting. Pre- and post- assessment of suicide stigma and literacy was complemented by qualitative data collection during the intervention and participant feedback surveys. RESULTS: The intervention was successful in reaching members of the target group from across Australia's rural communities-with diverse geographic locations and farming industries represented. One hundred and sixty-nine participants from the target group (farming males aged 30-64 years) were recruited. While the Stigma of Suicide Scale failed to identify a reduction in self- or perceived-stigma, qualitative data and participant feedback identified behavioural indicators of stigma reduction. Four subthemes-'growth', 'new realisations', 'hope' and 'encouragement'-highlighted attitudinal and behaviour change indicative of reduced stigma associated with mental health and suicide. Participants' baseline suicide literacy (Literacy of Suicide Scale) was high when compared with previous community samples and total literacy scores did not demonstrate significant improvement over time, although literacy about the link between suicide and alcoholism did significantly improve. CONCLUSIONS: These results highlight opportunities in groups with high suicide literacy for targeted stigma reduction and suicide prevention efforts for both the target group and other populations within Australia and internationally. Results also highlight the need to reassess how stigma change is understood and evaluated across a wider range of population groups. TRIAL REGISTRATION: This research project was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12616000289415) on 7th March, 2016.

Development and evaluation of e-mental health interventions to reduce stigmatization of suicidality - a study protocol.

BACKGROUND: Worldwide, approximately 800,000 persons die by suicide every year; with rates of suicide attempts estimated to be much higher. Suicidal persons often suffer from a mental disorder but stigma, lack of available and suitable support, and insufficient information on mental health limit help seeking. The use of internet-based applications can help individuals inform themselves about mental disorders, assess the extent of their own concerns, find local treatment options, and prepare for contact with health care professionals. This project aims to develop and evaluate e-mental health interventions to improve knowledge about suicidality and to reduce stigmatization of those affected. In developing these interventions, a representative telephone survey was conducted to detect knowledge gaps and stigmatizing attitudes in the general population. METHODS: First, a national representative telephone survey with N = 2000 participants in Germany was conducted. Second, e-mental health interventions are developed to address knowledge gaps and public stigma detected in the survey. These comprise an evidence-based health information package about suicidality, information on regional support services, a self-administered depression test-including suicidality-and an interactive online intervention including personal stories. The development is based on a trialogical exchange of experience between persons affected by suicidality, relatives of affected persons, and clinical experts. Australian researchers who developed an e-mental health intervention for individuals affected by rural suicide were invited to a workshop in order to contribute their knowledge and expertise. Third, the online intervention will be evaluated by a mixed methods design. DISCUSSION: From representative telephone survey data, content can be developed to address specific attitudes and knowledge via the e-mental health interventions. These interventions will be easily accessed and provide an opportunity to reach people who tend not to seek professional services, prefer to inform themselves in advance and/or wish to remain anonymous. Evaluation of the online intervention will provide information on any changes in participants' self-stigma and perceived-stigma of suicidality, and any increase in participants' knowledge on suicidality or self-efficacy expectations. TRIAL REGISTRATION: German Clinical Trial Register DRKS00015071 on August 6, 2018.

Online assessment of suicide stigma, literacy and effect in Australia's rural farming community.

BACKGROUND: In Australia, farming populations have been identified as having higher rates of suicide, in comparison to metropolitan, rural and regional communities. The reasons for this are unclear although stigma is considered a risk factor. This study was designed to understand the role of suicide stigma and suicide literacy and the relationship between these. METHODS: A mixed-methods online intervention was developed. This paper reports on baseline quantitative data (suicide stigma, suicide literacy and suicide effect) collected from male and female rural Australian participants (N = 536) with an experience of suicide. RESULTS: When compared with previous Australian community samples, our sample demonstrated higher levels of stigma and higher levels of suicide literacy. Males were more likely to have considered suicide than females. Females were more likely than males to report a devastating and ongoing effect of suicide bereavement, but less likely than a previous Australian community sample. CONCLUSION: Results of this study reiterate the need for improved understanding of the risk factors and experience of suicide within the context of life and work in rural Australian farming communities and how 'best practice' can be adapted to improve stigma reduction and suicide prevention efforts. TRIAL REGISTRATION: This research project was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) ( ACTRN12616000289415 ) on 7th March, 2016.

Research protocol for a digital intervention to reduce stigma among males with a personal experience of suicide in the Australian farming community.

BACKGROUND: Australian farming communities have up to twice the suicide rate of the general population. Men, particularly, demonstrate debilitating self- and perceived-stigma associated with an experience of suicide. The Ripple Effect is aimed to reduce suicide stigma within the social, cultural, geographical and psychological contexts in which it occurs. METHODS: A mixed-method design with multi-level evaluation will be effected following the development and delivery of a personalised website experience (combining shared stories, education, personal goal setting and links to resources) to farming men, aged 30-64 years, with an experience of suicide. Pre- and post-surveys will be used to assess changes in self- and perceived-stigma and suicide literacy. Online feedback from participants and semi-structured interviews during follow-up will be thematically analysed. DISCUSSION: This project will provide information about increasingly accessible, innovative approaches to reducing the debilitating health and wellbeing effects of suicide stigma on a population of Australia's farmers. TRIAL REGISTRATION: This research protocol was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN: ACTRN12616000289415 ) on 7th March, 2016.

Suicide and accidental death in Australia's rural farming communities: a review of the literature.

INTRODUCTION: Australia's farmers constitute a heterogeneous group within the rural population. This literature review incorporates four broad areas: an understanding of farming communities, families and individuals and the contexts in which they live and work; an exploration of the challenges to morbidity and mortality that these communities face; a description of the patterns of suicide and accidental death in farming communities; and an outline of what is missing from the current body of research. Recommendations will be made on how these gaps may be addressed. METHODS: In developing this comprehensive literature review, a snowballing and saturation approach was adopted. Initial search terms included suicid*, farm*, accident*, fatal*, death, sudden death, rural OR remote, Australia and NOT Australia. Databases searched included SCOPUS, PubMed, Proquest and SafetyLit; research from 1995 onwards was examined for relevance. Earlier seminal texts were also included. Reference lists of retrieved articles were searched and citations explored for further relevant research material. The primary focus was on Australian peer-reviewed research with supplementary grey literature. International material was used as examples. RESULTS: The literature variously describes farmers as members of both rural farming communities and farming families, and as individuals within an occupational classification. Within each of these classifications, there is evidence of the cumulative impact of a multiplicity of social, geographical and psychological factors relating to work, living and social arrangements that impact the health and wellbeing of Australia's farmers and their families, particularly accidental death and suicide. Research consistently demonstrates traumatic death to be at a greater rate than in the general Australian population, with reductions found more recently in some modes of farming-related accidental death. Patterns of accidental death and suicide are commonly linked to the changing shape of contemporary farming. Suicide rates are also frequently described in relation to lethality and accessibility of means. The limitations of suicide and accidental death data are considerable. CONCLUSION: While there is consistent reporting of heightened levels of risk for suicide and accidental death in farming communities the limitations of the research remain significant. There are substantial gaps in current knowledge, and the body of research to date lacks clarity, inclusiveness and contextual specificity. Absent from the literature is any investigation of the impact of these frequently preventable deaths on the families and communities in which they occur. Recommendations for future research are suggested.

Training and experience of nurses in responding to alcohol misuse in rural communities.

OBJECTIVE: Alcohol misuse by farmers continues to challenge rural nurses. This article reports on the experiences of Australian nurses participating in the Alcohol Intervention Training Program (AITP). DESIGN AND SAMPLE: Qualitative interviews of 15 rural and remote nurses. MEASURES: Semi-structured phone interviews were utilized to assess the response to and implementation of the AITP-an intervention designed to build nurses' knowledge, confidence and skills when responding to alcohol misuse. It comprises practical and theoretical components and was designed for rural and remote settings where nurses encounter alcohol misuse. RESULTS: Nurses found the training provided new-or built on existing-knowledge of alcohol misuse and offered practical hands-on "real life" skills. A range of workplace and personal situations where the content of the training was now being utilized were identified, and future use anticipated. Barriers to using the new knowledge and skills included both rural and generic issues. Constructive feedback to increasingly target the training to rural settings was recommended. CONCLUSIONS: The AITP is an effective training program. It can be further tailored to meet common needs of rural and remote nurses working with farmers who misuse alcohol, while recognizing diversity in rural practice.

The Alcohol Intervention Training Program (AITP): a response to alcohol misuse in the farming community.

BACKGROUND: Farm men and women in Australia have higher levels of problematic alcohol use than their urban counterparts and experience elevated health risks associated with excessive alcohol consumption. The Sustainable Farm Families (SFF) program has worked successfully with farm men and women to address health, well- being and safety and has identified that further research and training is required to understand and address alcohol misuse behaviours. This project will add an innovative component to the program by training health professionals working with farm men and women to discuss and respond to alcohol-related physical and mental health problems. METHODS/DESIGN: A mixed method design with multi-level evaluation will be implemented following the development and delivery of a training program (The Alcohol Intervention Training Program {AITP}) for Sustainable Farm Families health professionals. Pre-, post- and follow-up surveys will be used to assess both the impact of the training on the knowledge, confidence and skills of the health professionals to work with alcohol misuse and associated problems, and the impact of the training on the attitudes, behaviour and mental health of farm men and women who participate in the SFF project. Evaluations will take a range of forms including self-rated outcome measures and interviews. DISCUSSION: The success of this project will enhance the health and well-being of a critical population, the farm men and women of Australia, by producing an evidence-based strategy to assist them to adopt more positive alcohol-related behaviours that will lead to better physical and mental health.