Lessons from the development and delivery of a rural suicide prevention program.

AIMS: Suicide prevention remains a priority in rural and remote Australia, where suicide rates continue to be higher than those in urban communities. This commentary describes the Good SPACE suicide prevention program, and the lessons learned from delivering this program over a 14-year period. CONTEXT: The Good SPACE program has been operating in rural New South Wales since 2007. The program focuses on educating rural community members to recognise the signs of suicide vulnerability, and how to take appropriate action if they encounter someone considering suicide. APPROACH: Communities are selected to receive Good SPACE training in consultation with key stakeholder organisations, or by request from communities. Across the life of the program, key challenges in its administration have included short-term funding arrangements and staff turnover. Strengths have included the ability to adapt content to meet the needs of rural communities (eg from an initial focus on helping farmers during periods of drought, to a broader focus on all rural residents and a wider range of adversities). As the program moves forward, emphasis will be placed on harder-to-reach populations, including males and those with lower mental health literacy.
CONCLUSION: The Good SPACE program has ongoing funding to adapt its content and continue administration through the Rural Adversity Mental Health Program (https://www.ramhp.com.au/). The lessons learned throughout the life of the program might be of use to other organisations aiming to provide community-based education programs in rural and remote communities.

BACKGROUND TO GOOD SPACE

Suicide is a major public health concern in Australia, particularly in rural areas where suicide rates are up to double those observed in major cities. It has long been recognised that the community contribution is essential in rural suicide prevention strategies, for many reasons. The importance of social and community bonds in rural areas is well documented as an essential component of emotional well‐being. , In addition, community support may compensate for the lack of professional support services in these areas. For these reasons, various programs have been developed in recent years to build community awareness and recognition of mental health and suicide vulnerability, to improve rural mental health literacy and community response to those at risk of mental illness or suicide. Examples include the adaptation of Mental Health First Aid for rural communities, the Rural Adversity Mental Health Program (RAMHP) and South Australia's Suicide Prevention Networks.

One such program is Good SPACE (originally named Farm‐Link), developed in 2007 by the University of Newcastle. Good SPACE is a suicide prevention program designed to prevent suicide through community and clinical education, and delivered throughout the Hunter New England region of New South Wales by staff from the University of Newcastle. The program recognised that community members often link individuals to care. It aimed to improve community literacy regarding suicide prevention and health care options so that attendees could identify those who might be vulnerable to suicide and assist them to get help in the local community. Previous research has shown that this program is acceptable to rural communities and effective at reducing stigma and improving literacy around suicide at an individual level. However, as rural communities continue to change and new adversities arise, our response should evolve accordingly. This has necessitated changes to the Good SPACE program over its lifespan. This paper describes the evolution of Good SPACE, the challenges faced and factors critical to the sustainability of community‐focused rural suicide prevention programs. A summary of the program's key strengths, challenges and solutions is shown in Figure 1. The program content and formal evaluation are described in full elsewhere.

FIGURE 1

Summary of the Good SPACE program's key strengths, challenges and response to challenges

GEOGRAPHICAL AND POLITICAL CONTEXT OF GOOD SPACE

The Good SPACE project was initially named Farm‐Link and was developed in 2007 in the Hunter New England area, in response to the high rates of suicide observed among rural farmers and agricultural workers. In the intervening years, several observations led to the decision to change the program name. First, it became apparent that the name Farm‐Link, while engaging for farmers, did not encourage the broader rural population to attend the training. Second, the funding body for the program changed from the National Suicide Prevention Strategy (Australian Government's Department of Health and Ageing) to the Hunter New England Central Coast Primary Health Network, with the inception of primary health networks (PHNs) in 2015. The PHNs had a broader remit for regional suicide prevention than previous sponsor. It was agreed that encouraging a wider range of participants would be beneficial. In early 2017, a decision was made to update and redesign the Farm‐Link program as Good SPACE. The updated program commenced in July 2017 under a new funding contract. It was anticipated that the name change and revised content would engage a broader range of attendees making it clear that the training was relevant for all rural individuals and communities. The location of training was determined in consultation with stakeholders such as health and community agency staff, and in response to invitations and request by particular groups, within the parameters of the funding organisation (most recently the Hunter New England Central Coast Primary Health Network).

DIFFERENT FORMATS OF GOOD SPACE

Over the years that Good SPACE was delivered, the team were approached to develop tailored training courses for groups with specific needs. These were delivered as a variation of the core Good SPACE program and included additional content appropriate for the particular audience.

The We‐Yarn variation was developed with Aboriginal partners to provide culturally safe suicide prevention skills training for Aboriginal people and for those who work with Aboriginal communities and persons in rural NSW. One version was presented on country with no electronic aids. The evaluation considered the potential of We‐Yarn, a suicide prevention gatekeeper training workshop, to contribute to Aboriginal suicide prevention in rural New South Wales and showed that We‐Yarn was considered culturally appropriate and participants responded positively to facilitators’ lived experiences and reported significant improvements in understanding the links between cultural strengths, social and emotional well‐being, and suicide prevention.

The program also made use of existing training packages for other identified needs, ASIST training (Living Works) was delivered when advanced skills for suicide prevention were requested in the community. A recognition of a gap in local clinical skills to support people seeking help for suicidal ideation led to a collaborative model with the Black Dog Institute to deliver the ‘Advanced training in suicide prevention’ program (paper in preparation). Good SPACE engaged local rural clinicians and organised the half‐day workshops, and the Black Dog Institute general practitioner (GP) trainer delivered the workshop to rural clinicians (health and allied health professionals) were gathered, facilitating rural reach for this program. The evaluation showed significant improvements in knowledge and confidence that were sustained over time.

FUNDING CHALLENGES

The Good SPACE program was funded by the Australian Government's Department of Health from its inception in 2007, first directly through its National Suicide Prevention Strategy (3 sets of 2‐year contracts, then a one‐year extension) and then indirectly through the Hunter New England Central Coast Primary Health Network (yearly funding agreements), with the inception of the PHNs and the devolved responsibility of suicide prevention to these networks. Initially funded to support and prevent suicide in farmers, the program's target audience also included those who interacted with farmers and farm workers. Over time, it became apparent that there was a need and appetite for suicide prevention training in the broader rural community.

With the inception of regional planning for suicide prevention and funding through the PHN, the program was developed to suit a broader rural audience. The Farm‐link brand had become a limiting factor for broader rural community engagement. With support from the PHN, a substantial branding change of the program to Good SPACE enabled a visible reflection of the expansion of the remit and target population. The short‐term funding also created difficulties in long‐term planning for the program, particularly its relational continuity and its development, with uncertainty impeding plans across funding periods, and concerns regarding shifting priorities and requirements of the next work plan. More importantly, this contributed to challenges with staff retention, as the short‐term contracts became unappealing to experienced and skilled staff who were looking for greater stability. Staff retention, especially in health‐related fields, is a common challenge in rural areas, and was therefore not unique to the Good SPACE program. However, Good SPACE staff were open in identifying short‐term contracts and job instability as barriers to their continuation with the program.

SUSTAINABILITY OF OUTCOMES FOR RURAL SUICIDE PREVENTION

Assessing the long‐term effects of community suicide prevention programs is difficult, as deaths by suicide are rare events in small rural communities. Workshop attendees therefore might have few opportunities to use the knowledge and skills that they obtain in a one‐off workshop. Several interviewees mentioned the difficulties in recalling workshop content when they had not had cause to use it in their daily lives (see ref. 12 for examples). It also suggests that for rare but important life‐saving interventions (like cardiopulmonary resuscitation), there is a need to reinforce the skills acquired through repetition to enable people to remain able and confident to support others to get help.

This concern was not echoed by respondents who were employed in mental health services, or who encountered distressed people more regularly. In these cases, respondents reported unanimously that the skills they learned at the workshop were used frequently.

Another challenge reported by interview respondents was related to implementing the general skills they had learned within the specific context of their community. For example, a key workshop focus was teaching attendees how to recognise someone at risk of suicide and refer them to an appropriate mental health service. However, some attendees spoke about the difficulty of referring people to services in communities where mental health resources are severely limited.

However, a previous evaluation of the program found that Farm‐Link training was effective at reducing stigma related to suicide, as well as increasing suicide literacy. These changes were maintained 3 months after the training. Therefore, it is possible that these benefits to general suicide awareness and attitudes are more sustainable and applicable than the specific skills related to assisting an individual who is actively considering suicide.

Several respondents suggested that the training should be localised to each community and address the specific services that each community has available. While this would no doubt be advantageous, it is made difficult by the instability of many rural mental health services. Many such services are affected by high staff turnover, short‐term funding, poor coordination with other local services and various other issues, which contribute to real difficulties in creating an accurate ‘database’ of available local services within smaller rural communities. For example, a 2016 report detailing and mapping available mental health services in the Far‐West Local Health District of NSW did not include services with less than 3 years of funding, as it was felt that this would jeopardise the report's utility for informed planning. There are a number of efforts to address this with a number of directories of services available (notably Health Direct, funded by the Australian government); however, there is a significant challenge to keep these up to date, to reflect all options and local availability and wait times. There are some localised efforts where state and federally funded services are listed together coherently. A good example of this is as the MapMyRecovery (https://mapmyrecovery.org.au/) online interactive map of mental health and drug and alcohol services available across the Murrumbidgee region developed through a sophisticated co‐design and collaborative process. Such directories are of considerable value, but their best use probably lies with those who support others to find help more frequently such as GPs and those with specialist service navigation/linkage support roles.

CHALLENGES OF ENGAGING TRAINING PARTICIPANTS

Throughout the history of the Good SPACE program, it was often found that attendees were already well informed about mental health problems. As Davies et al describe, although attendees reported increased confidence in recognising and assisting people at risk of suicide after the workshop, many participants already reported confidence in these areas before attending. For example, prior to the workshop, over 80% of attendees felt comfortable talking to someone about seeking help for a mental health problem, and two‐thirds felt confident that they could both identify someone with symptoms of a mental health problem and link them with appropriate services. This is in contrast to previous research in general rural communities, suggesting that the recognition of symptoms of mental illness is often poor. A previous program evaluation showed that while participants reported significant improvements in mental health literacy and decreased stigma related to suicide after completing the program, baseline levels of these factors were already high and low, respectively, and might have contributed to small effect sizes as there was little room for improvement.

It was also a consistent finding that approximately 80% of workshop participants were females. This was disappointing as suicide fatalities occur predominantly in males. The challenges of attracting more males to such programs was noted by several interviewees with one noting (from ref. 12):

The thing is, if you turn up with a barbecue and a few beers, the boys will come and sit down and listen, but to go into town to do a thing like that, not many people will go and do it. – Morris

In general, these findings imply that community programs such as Good SPACE might be ‘preaching to the converted’ as those who attend might already have an interest in mental health. Other programs, such as the University of Newcastle RAMHP, are working to overcome these challenges by creating programs for harder‐to‐reach groups, such as males and those who might have poorer mental health literacy. For example, RAMHP has partnered with the NSW Baggy Blues Cricket Team (comprising retired state cricketers—male and female from NSW) to incorporate mental health training in their Rural and Regional Cricket Tour events in 2019‐2020. Of 133 attendees at the mental health training to date, 87% were males, suggesting that incorporating mental health education into an existing event with a high level of male attendees was a better strategy to encourage their involvement.

KEY LEARNINGS

After 15 years of delivering the Farm‐Link/Good SPACE program, several key learnings have been observed that might guide others who aim to deliver similar programs in rural and remote regions. First, we found that general promotional approaches tended to recruit training participants that are already reasonably well informed about mental health, and also predominantly female. To engage other groups such as males and people with lower mental health literacy is more challenging, resource‐intensive and time‐consuming, and might require deliberate targeted approaches. Strategies might include partnering with organisations that are already engaged with these groups or advertising using localised Facebook invitations.

Farm‐Link/Good SPACE has been operating since 2007, and the training content of all iterations (Farm‐Link, Good SPACE and We‐yarn) has been informed by research and evaluated in practice. However, the ongoing short‐term funding and evaluation requirements (largely process and activity‐driven) have led to a large body of data, which shows that people like the program, and that it decreases stigma and improves suicide‐related literacy and confidence, but that does not address the bigger issues of how to improve target audience reach, local engagement and connection to services.

Finally, stability of service provision is particularly important in enabling collaborative activities such as partnering for better target population reach. It is particularly important that commissioning priorities and processes recognise these issues. Engagement and collaboration take time, trust and effort that are often underappreciated and not included in contracts. Moreover, the inability to carry work from one contract to another leads to loss of trust, and this is difficult at the best of times and might be regarded as disrespectful when working with Aboriginal communities and services, as we learned with the We‐Yarn‐based contracts.

FUTURE DIRECTIONS

In 2021, the University of Newcastle was awarded an Innovation Grant by the Suicide Prevention Australia Suicide Prevention Research Fund and the Australian Government to adapt the content of the Good SPACE program in line with the latest evidence via a co‐design process for delivery by the University of Newcastle RAMHP (https://www.ramhp.com.au/). This includes evidence from an in‐depth analysis in the National Coronial Information System Rural Suicide Study. Moving forward, developing strategies to target whole groups or communities together might improve the sustainability of the training outcomes and encourage a wider range of participants. Funders and policymakers who are investing in suicide prevention and gatekeeper programs might want to consider how such investments might contribute to stable and sustainable rural mental health services in a range of rural and remote communities so that these lessons might be learnt and community capacity to contribute to suicide prevention increased.

CONTRIBUTORS AND SOURCES

All authors are current or past members of staff of the Centre for Rural and Remote Mental Health, University of Newcastle, which has administered the Farm‐Link/Good SPACE program since its inception. The authors have contributed to securing program funding, developing content and program evaluation. This article was inspired by the challenges encountered and lessons learned while successfully administering a community‐focused rural mental health education program for 14 years.

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

AUTHOR CONTRIBUTIONS

TEH: conceptualization; formal analysis; writing‐original draft; writing‐review & editing. KD: formal analysis; writing‐review & editing. AB: formal analysis; writing‐review & editing. HED: conceptualization; writing‐review & editing. DP: funding acquisition; writing‐review & editing.