Mental health first aid has been defined as "the help provided to a person developing a mental health problem or in a mental health crisis. The first aid is given until appropriate professional treatment is received or until the crisis resolves" . In order to increase the mental health first aid skills of the public, Kitchener and Jorm [2, 3] developed a MHFA training course in Australia. This course has been found to improve knowledge, attitudes and helping behaviour in two randomized controlled trials with the Australian public . The course is now widely disseminated in Australia and has spread to many other countries .
In developing this course, it was recognized that there is a significant cultural element to mental health first aid. Culturally-sensitive training of the public needs to take account of such factors as: the cultural group's dominant understanding of mental disorders, particular risk and protection factors operating in that group, cultural rules that may affect what are considered appropriate first aid actions, and the availability of culturally-appropriate professional help to which a person may be referred. For this reason, it has been necessary to carry out cultural adaptation of the course as it has spread to other countries and to accommodate the needs of cultural minorities within a country .
One cultural group within Australian society with particular mental health needs are Aboriginal and Torres Strait Islander peoples, who comprise 2.4% of the Australian population. Although this percentage is small, it comprises around 500,000 people, many of whom have high levels of physical illness, lower life expectancy, and high levels of psychological distress. Many live in socially disadvantaged environments, with limited access to transport, poor housing and low incomes [6–8].
Historically, Aboriginal people have suffered significant losses since Australia was colonised in the 1700s. These include loss of land, loss of traditional hunting grounds, loss of traditional language, forced relocation onto missions and reserves, loss of cultural and legal traditions, and the forced removal of children. These significant losses and social upheavals have impacted negatively on Aboriginal people, and have left many individuals, families and communities significantly traumatised and grief stricken. This has resulted in large numbers of people being at high risk for developing a range of mental health problems and mental illness. Current data indicates high levels of self-reported psychological distress, with symptoms of anxiety and depression twice as common in Aboriginal people compared to non-Aboriginal people , higher rates of hospitalisation for intentional self harm, and higher suicide rates compared to non-Aboriginal Australians [7, 8]. Although mental illnesses are prevalent, and suicide rates unacceptably high, most Aboriginal communities receive little education on how to manage mental health problems or to deal with mental health crises.
The 'Ways Forward' National Consultancy Report on Aboriginal and Torres Strait Islander Mental Health  advocated the use of strategies that provide general community education programs concerning the recognition, responses and prevention of suicidal behaviours and mental health problems. Similar recommendations were identified by the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and Emotional Wellbeing 2004 – 2008  and the National Mental Health Plan 2003–2008 . All of these documents called for increases in the levels of mental health awareness and increased levels of mental health literacy in the community, including Aboriginal communities. The adaptation of the MHFA program for Aboriginal and Torres Strait Islander peoples was seen as one means of fulfilling some of the recommendations made in these documents.
Process of cultural adaptation
Consultations with Aboriginal and Torres Strait Islander individuals and groups between 2004 and 2006 indicated the need to modify the MHFA course developed by Kitchener and Jorm  to better suit the needs of Aboriginal and Torres Strait Islander peoples. To guide this adaptation, an AMHFA Working Group was established in 2006, comprising a small body of Aboriginal people with professional experience in the Aboriginal mental health field and Len Kanowski who is one of the MHFA Trainers of Instructors. An AMHFA Manual was finalised by MHFA staff in conjunction with the AMHFA Working Group by working through the existing Australian manual and course materials and commenting on where specific adaptations were needed. The changes were then made by Len Kanowski in conjunction with other MHFA staff. Materials that were culturally adapted for the AMHFA program included a manual , teaching notes, resource folder, PowerPoint slides, and DVDs featuring Aboriginal people talking about mental health problems or demonstrating mental health first aid skills. A workbook was also developed . The final version of the materials was approved by the AMHFA Working Group. Culturally appropriate Aboriginal social and emotional well-being and mental health materials were also sourced and included in the instructor training kit. All these materials were deemed by the Working Group to be culturally appropriate and relevant to community needs before being included in the program. The Working Group was disbanded at the end of December 2006 once the materials were finalised to their satisfaction.
An important result of the cultural adaptation process was that the materials were empowering for Aboriginal people and acknowledged their resilience in surviving historical traumas and losses. Aboriginal artwork was used throughout the teaching materials and manual to illustrate important messages and Aboriginal concepts of mental health and well-being, and to give a clear identification of these materials as belonging to Aboriginal and Torres Strait Islander people.
The final adapted AMHFA package involved a 14-hour course for Aboriginal and Torres Strait Islander community members and a 5-day Instructor Training Course. It was anticipated at the beginning of the project that further adaptations would need to take place to meet the needs of Aboriginal communities with lower levels of written literacy, and that further adaptations of the course and materials would be informed by feedback from the AMHFA Instructors and the outcomes of the initial evaluation.
The need for AMHFA Instructors
An important feature of the MHFA program in general has been its devolved organization. The MHFA Training and Research Program at Orygen Youth Health Research Centre does not employ Instructors. Rather, it works in partnership with other organizations working at the local level, who employ Instructors and sponsor courses. This means that Instructors are based in the community where they are working and that any skills they acquire through attending AMHFA Instructor training are more likely to stay in that community. This principle of local partnership is particularly important when working with and within Aboriginal and Torres Strait Islander communities.
During the process of adapting the course, staff at MHFA and the Office of Aboriginal and Torres Strait Islander Health (OATSIH) identified a need to increase the number of Aboriginal and Torres Strait Islander Instructors to conduct the culturally adapted AMHFA course in Aboriginal and Torres Strait Islander communities. At the time the cultural adaptation was carried out, there were only three Instructors who identified as Aboriginal. To increase the existing number of accredited AMHFA Instructors who would then conduct the 14-hour AMHFA course nationally, OATSIH provided scholarships to allow the training of additional Instructors in 2007–2008. Successful applicants were required to meet the following criteria prior to undertaking the 5-day AMHFA Instructor Training Course:
Aboriginal and/or Torres Strait Islander person;
Good knowledge of mental disorders and their treatment;
Personal or professional experience with people with mental health problems;
Good teaching and communication skills;
Good background knowledge of mental health and community services;
Good organisational support (as shown by a letter of support from the applicant's supervisor) to ensure AMHFA sustainability
Two Trainers of Instructors (Len Kanowski and Kara Eddington) conducted a series of 5-day Instructor Training Courses across Australia. Once Instructors had the initial training, the Trainers of Instructors continued to provide them with on-going support (face-to-face, telephone and e-mail) as they began to offer 14-hour AMHFA courses in their own communities.
Approach to evaluation
This paper reports an initial evaluation of the AMHFA program. The evaluation can be usefully considered using the framework of Campbell et al. [14
] for the design and evaluation of complex interventions to improve health. These authors propose that evaluation of complex interventions proceeds through four phases:
Modelling (identifying the components of the intervention which are likely to work);
Definitive randomized controlled trial; and
The present evaluation corresponds to Phase 1 of this framework. It provides a basis for improving and refining the intervention before a formal trial is carried out. After these improvements have been carried out, the AMHFA program will be ready for a Phase 2 exploratory trial.