Mental Health First Aid training: lessons learned from the global spread of a community education program
Authors: Anthony F. Jorm, Betty A. Kitchener, Nicola J. Reavley
Journal: World Psychiatry (2019)

Many health education interventions achieve limited dissemination, even when there is supporting evidence for their efficacy1. We think there are lessons to be learned for those aiming to disseminate such interventions from those rare examples where the dissemination has been successful. Here we describe the factors that appear to underlie the success of one such program: Mental Health First Aid (MHFA) training. The MHFA training program conducts courses which teach members of the public how to provide mental health first aid, which has been defined as "the help offered to a person developing a mental health problem, experiencing a worsening of an existing mental health problem or in a mental health crisis; the first aid is given until appropriate professional help is received or until the crisis resolves"2. Participants are trained to: approach, assess and assist with any crisis; listen and communicate non-judgmentally; give support and information; encourage appropriate professional help; encourage other supports. MHFA training began in Australia in 2000 as a collaboration between one volunteer with lived experience of mental illness (BAK) and a researcher (AFJ)3. From this small beginning, it spread rapidly in Australia and to other countries. By mid 2018, over 700,000 Australians had been trained and the program had spread to 25 other countries, with over 2.7 million people trained globally4. We believe that six factors underlie this successful dissemination. The first is that MHFA training builds on the familiar First Aid model. Members of the public are familiar with the idea that they can help in a physical health emergency if professional help is not available, and many people have done a First Aid course. It is a natural extension to expand this concept to include mental health problems. The second factor is that MHFA training fulfills a public need. Because the prevalence of mental disorders is so high, members of the public will frequently have contact with people who are affected5. Many people lack knowledge and confidence in how to help, which may motivate them to seek training. The third factor is that the course has been tailored to meet different needs. In addition to the standard MHFA course for adults to assist other adults, courses in Australia have been tailored for specific age groups (e.g., adults helping youth, adults helping older people, teenagers helping their peers), professional roles (e.g., medical and nursing students, legal professionals) and cultural groups (e.g., indigenous people, people from non-English speaking background)6. When MHFA training is disseminated in other (mainly high-income) countries, there is tailoring to local languages, health systems and cultures, including for minority groups. The fourth factor is that there is a strong partnership with research. The content of MHFA training has been based on expert consensus guidelines developed using Delphi studies7. The experts in these studies have been mental health professionals and people with lived experience. The guidelines have covered how to assist with a wide range of developing mental health problems and crises. The Delphi method has also been used to draw on cultural expertise in assisting people from special groups (e.g., indigenous Australians; refugees and immigrants; lesbian, gay, bisexual and transgender people). The other area in which research has been important is evaluation of outcomes. From the very first MHFA courses taught, evaluation data were gathered and published8. These data have now expanded considerably, with 18 controlled trials in a range of countries. A systematic review and meta-analysis of these trials showed improvements in mental health first aid knowledge, recognition of mental disorders, beliefs about treatments, confidence in helping, intentions to help and amount of help actually provided9. MHFA training also leads to a reduction in stigma9. The fifth factor is that dissemination is devolved rather than centralized. In Australia, MHFA training is run by Mental Health First Aid International. This organization trains instructors but does not employ them. Rather, the instructors are employed by non-governmental organizations (NGOs), government agencies or private businesses. This devolution has allowed well-targeted local marketing by instructors. When MHFA training is disseminated in other countries, there is a partnership with a local organization, generally a mental health NGO or a government agency. Again, the decentralized dissemination facilitates roll-out by drawing on local knowledge in a way that a centralized model would not. The sixth factor is that there is a sustainable funding model. In Australia, government and philanthropic grants have been used for development, initial dissemination and evaluation of new training products, but such grants are time limited and not a sustainable basis for ongoing funding. However, like First Aid, MHFA training is potentially sustainable by offering courses on a fee-for-service basis. A longer-term aim is for MHFA training to become accepted as a necessary qualification for certain human services roles, as is the case for physical First Aid training, which will facilitate sustainability. In recent years, MHFA International has received many enquiries about local training from low- and middle-income countries. However, major health system and cultural differences between these countries and Australia, where the program originated, mean that the appropriateness of course content and implementation models in these settings is unknown. In general, evidence in low- and middle-income countries on how best to translate, adapt and scale-up population mental health interventions that have shown benefit in high-income countries is limited. In 2017, in collaboration with investigators from China and Sri Lanka, we were awarded a Global Alliance for Chronic Diseases grant to develop and trial MHFA training for these countries. This project represents the first effort to formally adapt MHFA training to lower-resource countries. We have recently started a similar program of work in collaboration with researchers in Brazil, Chile and Argentina. These projects offer opportunities to identify and evaluate the most appropriate models for cultural adaptation and implementation of community-based education programs that aim to improve population health.