Rural Contexts: Digital Interventions and Strategies for First Responders' Mental Health
Funding: This research is funded by a Medical Research Futures Fund (MRFF) grant MRF2031244.
ABSTRACT
This perspective presents a discussion on digital interventions and strategies to support the mental health of first responders working in regional, rural and remote areas. First responders are often required to respond to traumatic, violent and challenging situations. Accumulative exposure to these situations can impact first responders' mental health, and symptoms of depression, anxiety, psychological distress, and post-traumatic stress disorder (PTSD) are common. Rural first responders have similar prevalence rates of trauma to their metropolitan counterparts. However, rural first responders are likely to experience psychological difficulties exacerbated by limited access to mental health interventions due to geographical isolation and limited availability of services. Geographical location and availability of services are barriers often preventing first responders working in rural areas from accessing interventions to help them manage their mental health. Digital adaptations of mental health interventions may help to fill this gap in rural health care. Despite the popularity of first responder research developing and evaluating industry-specific mental health interventions and strategies, there is limited research focussing specifically on the effectiveness of these for Australian rural first responders, and how other mental health interventions can be digitally adapted.
1 Background
For first responders, attending to life and death situations is a daily reality (White 2019), and exposure to traumatic events (Varker et al. 2018) is considered a significant part of their role. Many different occupational groups can be considered first responders, such as police officers, paramedics/ambulance personnel [including emergency medical technicians (EMTs), medics], firefighters and fire rescue personnel, and other emergency services personnel [such as State Emergency Services (SES) and Volunteer Rescue Association (VRA)] (Jones, Jackson, Ranse, et al. 2024; Varker et al. 2018). Although trauma exposure in these occupations may be direct (e.g., attending dangerous situations), indirect exposure to traumatic events is common (e.g., vicariously witnessing others' trauma) and can equally lead to post-traumatic acute or chronic stress reactions (Krupnik and Ferreira 2019). Events that can cause trauma in these occupations may include attending incidents involving sexual assault and domestic violence, complex violent and unpredictable situations, accidents involving death, intentional injury or death of children and disasters (Jones, Jackson, Ranse, et al. 2024).
Importantly, exposure to an event alone is not sufficient to cause a trauma response. For an incident to cause trauma, an intense emotional response is required, such as anger, guilt, dissociation, horror, intense fear or terror, that is difficult for the person to process psychologically (Griffin 2020; Reeves 2015). Hence, trauma is largely subjective, and events can impact people differently. For example, one event may have little to no impact on one person, yet may instigate transient distress in another or lead to PTSD for someone else. However, repeated exposure to traumatic events increases the likelihood of developing psychological disorders or symptoms of mental illness (McKeon et al. 2023).
Reported prevalence rates of mental health issues in first responders in Australia vary significantly across studies. A scoping review reported the following estimates of mental health issues across first responders: PTSD between 3% and 91%, psychological distress between 10% and 62%, suicidal ideation between 5% and 7%, depression between 11% and 47%, anxiety between 12% and 43%, emotional trauma between 72% and 90% and fatigue between 10% and 56% (Jones, Jackson, Ranse, et al. 2024). Table 1 summarises the mental health issues for individual cohorts of first responders (Jones, Jackson, Ranse, et al. 2024).
| Police (%) | Paramedic/Ambulance (%) | Firefighter (%) | State emergency service (%) | |
|---|---|---|---|---|
| Depression | 16–47 | 16–26 | 11–14 | |
| Anxiety | 16–43 | 21–31 | 12 | |
| Emotional trauma | 72–90 | |||
| Psychological distress | 14–61 | 29–61 | 9.8–58 | |
| Suicidal ideation | 3.9–4.7 | 6.8–7.2 | 5.5–7.2 | |
| Post-traumatic stress disorder (PTSD) | 11–80 | 8–15 | 9–91 | |
| Fatigue | 56 | 6.4 |
Although prevalence estimates vary, there is sufficient evidence that the rates of mental illness are typically higher for first responders than the general population (Berger et al. 2012). Additionally, research indicates that a high percentage of first responders needing help for a mental illness neither sought nor received it (Rikkers and Lawrence 2022). Digital interventions and strategies involving delivery assisted by technologies, such as the internet or smartphones are one way of addressing current issues around accessing services and circumventing barriers to help-seeking such as stigma, discrimination and confidentiality issues (Philippi et al. 2021). Digital interventions and strategies also offer a cost-effective way to deliver health care interventions for rural first responders (Murray et al. 2016). For regional, rural and remote first responders, geographical isolation can have an impact on available resources, access to appropriate services and support, first responder safety, workloads and violent and traumatic experiences, leading to higher rates of fatigue, emotional trauma and psychological distress (Jones, Jackson, and Usher 2024). As such, digital interventions may be able to help overcome geographical barriers if tailored correctly to address specific needs.
2 Discussion
2.1 First Responder Help-Seeking and Rural Service Delivery
Previous research indicates that first responders did not seek help for mental health issues (Rikkers and Lawrence 2022). Barriers to help-seeking for first responders are varied. For example, they include the existing organisational culture of emphasising toughness and self-reliance, and a lack of individual awareness and education around mental health issues (such as recognising signs and symptoms of mental illness, when to seek help and available resources and services) (Jones et al. 2020; Rikkers and Lawrence 2022). Additional barriers include the stigma associated with mental illness, confidentiality concerns, perceived impact on their career and their position within the wider team, lack of access to services, negative experience with previous help-seeking and ineffective treatment, protecting families and the burden to families related to their mental health issues (Jones et al. 2020; Rikkers and Lawrence 2022). Further to this, first responders working in rural and remote areas of Australia are likely to experience more barriers or amplified impacts (Kavanagh et al. 2022; Roberts et al. 2020), such as lack of services, limited appointments available, poor mental health literacy, more expensive, concerns with confidentiality (Kavanagh et al. 2022) and more difficulties with mental health related to geographical isolation (Jones, Jackson, Ranse, et al. 2024).
There are unique challenges that influence trauma exposure and first responders' mental health in rural and remote areas, and these may impact the content and delivery of mental health services for first responders. For example, having personal connections with their patient/clinician, high community expectations of the first responders and their roles, and distances impacting response time and available services (Jones, Jackson, Ranse, et al. 2024). Additionally, rural and remote areas have unique differences compared to metropolitan areas, not only in terms of geographical location, but also in the associated amplified risk of mental health issues, poor life expectancy for people with a mental illness, and difficulty accessing services (Roberts et al. 2020). As such, ensuring access to interventions and strategies for this population is essential to improve their mental health, and digital interventions may overcome some help-seeking barriers for rural first responders (Farrell et al. 2023).
2.2 Mental Health Digital Interventions and Strategies for First Responders
There is a noticeable gap in available evidence for rural first responders in Australia seeking help for mental health issues related to their roles (Jones, Jackson, Ranse, et al. 2024), which highlights the need to assess the effectiveness of interventions and digital adaptations specifically for this population. Previous research has looked at some interventions for mental health and trauma in first responders; however, there is limited research focussing on their application and effectiveness for first responders working in regional, rural and remote areas of Australia. Mental health and trauma interventions for first responders include cognitive behavioural therapy (CBT) (Beahm et al. 2021; Bryant et al. 2021), resilience and mindfulness training (Joyce et al. 2019), eye movement desensitisation and reprocessing (EMDR) (Farrell et al. 2023), and others (such as physical activity, screening, social support and emotional regulation).
Some of these mental health interventions have been delivered digitally, including smartphone mental health apps (Deady et al. 2022), online screening (Marshall et al. 2021), physical activity programmes through social media and mobile phone apps (McKeon et al. 2023), EMDR via video conferencing (Farrell et al. 2023), internet-delivered CBT (Beahm et al. 2021) and mindfulness and resilience programmes via online medium (Joyce et al. 2019). There is some evidence to suggest these interventions have demonstrated improvements in mental health such as resilience and mindfulness (Deady et al. 2022; Joyce et al. 2019), depression (Deady et al. 2022), PTSD (Farrell et al. 2023; McKeon et al. 2023), and psychological distress (McKeon et al. 2023), although there were no changes reported for suicidal ideation or sleep quality (McKeon et al. 2023), nor for moral injury (Farrell et al. 2023). In addition, one study reports a potential improvement in stigma associated with mental illness using internet-based CBT; however, some participants felt it was less effective as a treatment intervention (Beahm et al. 2021). These preliminary results suggest that some digital interventions may potentially be valuable for rural first responders and offer a promising treatment modality to reduce barriers to help-seeking and service delivery in rural and remote areas, such as accessibility, lack of services and trained personnel, stigma and culture and confidentiality.
Digitalised interventions such as CBT, EMDR, resilience and mindfulness may be effective for delivery in rural areas given the broad applicability/adaptability of these approaches. Other interventions for first responders that could be digitally adapted include psychological debriefing or psychological first aid, and peer-support programmes; however, there is limited research in a rural Australian context to determine the acceptability and effectiveness of these interventions for first responders' mental health. It is also important to note that for the digital interventions that have demonstrated some effectiveness (discussed above), some common issues with methodology have impacted the reliability of the results. These often included small sample sizes, no long-term follow-up, high loss to follow-up, no diagnostic interviews undertaken at baseline, no comparison between interventions to determine which was more effective, and none of these interventions reported effectiveness for regional, rural or remote participants. Hence, it is difficult to determine if any of these interventions are acceptable and effective for regional, rural and remote first responders.
There are also recognised barriers to digital delivery, such as poor engagement and adherence to intervention, minimal impact of one-off training sessions, poor internet, lack of face-to-face connection (Joyce et al. 2019), poor usability of the platforms (McKeon et al. 2023) and perceived lack of confidentiality due to organisational involvement (Marshall et al. 2021). Reported enablers of digital adaptability of interventions were flexible delivery and increased users' control over the intervention (Joyce et al. 2019). Research is needed to identify specific techniques to overcome these digitalisation barriers and maximise intervention effectiveness for Australian first responders working in rural areas.
2.3 Digital Interventions for First Responders Moving Forward
Digital interventions show great promise as a mental health prevention and intervention strategy. However, implementation trials that evaluate the effectiveness of digital interventions and engagement in real-world settings are needed. Therefore, although digital interventions could help to increase the availability and choice of services and supports in rural and remote areas, there is limited strong evidence and restricted options at present. It is also important to consider the unique needs of first responders working in rural and remote areas, to assess the effectiveness, acceptability and utility of digital interventions specifically within their unique context. In this regard, what is needed moving forward is to focus research on the key mental health issues for rural and remote first responders, to identify first responder needs and mental health concerns, and to identify which interventions are most promising in terms of acceptability and effectiveness. This would ensure future research is targeted to rural first responders' needs, and research is developing and evaluating digital solutions that can help to circumvent help-seeking barriers for this population.
While there is great value in research reporting on the effectiveness of interventions for this group, research that reports interventions that were not found to be effective is also highly valuable for informing treatment and prevention strategies for first responders. Knowing what is unsuited to this population is also critical in understanding how to best allocate resources and to prevent implementing strategies that may not be acceptable or effective. For example, first responder pre-employment screening or psychoeducation implemented in isolation have shown a relatively poor evidence base despite their use in other emergency services (Wild et al. 2020). Similarly, while screening for elevations in psychological symptoms during employment may assist with early detection and referral for intervention and could be amenable to digital delivery, research is needed to assess the effective implementation of such strategies.
2.4 Clinical Implications
There are clinical implications relating to the discursive presented in this paper for mental health practitioners working in regional, rural and remote areas. First, mental health practitioners need to be aware of the barriers to help-seeking that impact first responders accessing mental health support. Designing and delivering services that circumvent these barriers is essential to delivering effective mental health care and support to first responders working in rural areas. Second, repetitive exposure to traumatic incidents is an occupational hazard for first responders; hence, standard primary health care services should include the delivery of effective strategies and supports for first responders to prevent psychological impacts from this inherent component of their role. Third, mental health practitioners and researchers need to be aware of the gaps in evidence related to digital interventions for rural first responders. Research needs to focus on ensuring digital interventions are effective and accessible for all rural populations.
3 Conclusion
Repetitive exposure to traumatic incidents is an occupational hazard for first responders, and effective strategies and support need to be provided to prevent psychological impacts from this inherent component of their role. This perspective has discussed various mental health interventions and digital adaptations for first responders and highlighted the notable gap in evidence for first responders in rural areas. Geographical location and availability of services are barriers often preventing first responders working in rural areas from accessing interventions to help them manage their mental health. Although current evidence is limited, several digital mental health interventions have shown promise in improving mental health for first responders. Attempts should be made to integrate evidence-based digital solutions into the suite of interventions and strategies offered to rural first responders.
4 Relevance to Clinical Practice
- Digital intervention shows great promise as a mental health prevention and intervention strategy. However, implementation trials that evaluate the effectiveness of digital interventions and engagement in real-world settings are needed.
- What is needed moving forward is to focus research on the key mental health issues for rural and remote first responders, to identify first responders' unique needs and mental health concerns, and to identify what interventions are most promising in terms of acceptability and effectiveness.
- Repetitive exposure to traumatic incidents is an occupational hazard for first responders, and effective strategies and supports need to be provided to prevent psychological impacts from this inherent component of their role.
Author Contributions
We acknowledge that all authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and that all authors are in agreement with the manuscript.
Acknowledgements
The authors have nothing to report. Open access publishing facilitated by University of New England, as part of the Wiley - University of New England agreement via the Council of Australian University Librarians.
Conflicts of Interest
The authors declare no conflicts of interest.
Open Research
Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analyzed in this study.
