Introduction

Mental health of children

Mental well-being in young people is associated with better physical health, social relationships, and academic achievement (Goodman et al., 2015; O’Connor et al., 2019). A large systematic review of global prevalence data found that 6.7% of young people have a diagnosed mental illness, with depression, anxiety, and conduct disorders most frequently reported (Erskine et al., 2017). An Australian survey of young people with mental illness reported double the global prevalence (13.9%), with ADHD the most common, and anxiety, major depression, and conduct disorder also reported (Lawrence et al., 2015). In rural areas, Goldfeld and Hayes (2012) found rural Victorian children are two times more likely than metropolitan children to experience mental illness. Given that most children attend school from an early age, schools provide an important universal site for the promotion of children’s mental health and well-being, especially rural schools where children have unique mental health needs.

Child mental health in regional and rural areas

Children in regional and rural areas face unique challenges related to mental health. Children in regional and rural areas may be confronted by natural disasters, such as bushfires, floods, and drought (Cook et al., 2008), resulting in significant loss, displacement, and interruptions to children’s education and social activities (Kousky, 2016). Children living in these communities typically report reduced educational attainment and are at greater risk of substance misuse, self-harm, and suicidality (Fitzpatrick et al., 2021). Simultaneously, many regional and rural communities have less access to psychological and medical services, including school-based mental health interventions (Meadows et al., 2015). Access is problematic due to cost, availability of professionals, and/or geographical distance (Aisbett et al., 2007; Fuller et al., 2000). Other barriers to accessing mental health support include prevailing stigmatisation about mental illness in rural and regional areas, reluctance to acknowledge mental illness, and a lack of anonymity (Aisbett et al., 2007; Fuller et al., 2000; Jensen et al., 2020). Due to these barriers, schools can be ideal settings to provide mental health support to children.

School programs addressing child mental health

Many school well-being programs have been developed (Berger et al., 2022) some with a focus on promoting social and emotional learning (SEL) (Clarke et al., 2015), and others targeting depression, anxiety, self-harm, and/or suicide (Berger et al., 2022). Berger et al. (2022) found the common features of efficacious programs included cognitive behavioural strategies, and the promotion of mental health literacy, help-seeking, social skills, and emotional regulation. Previous reviews have found that young people who participate in school-based well-being programs have improved social and emotional adjustment, academic achievement, and reduced symptoms associated with mental illness (Barry et al., 2013; Clarke et al., 2015; Corcoran et al., 2018; Goldberg et al., 2019). However, Zaheer et al. (2011) found that universal school-based well-being programs are typically designed for urban contexts, risking disengagement by regional and rural schools that do not feel the programs are relevant to them. Literature suggests that school well-being programs are most effective when they target individual community needs (Catalano et al., 2012; Zaheer et al., 2011), rather than generalised programs that do not meet the unique contextual needs of schools. However, there are limited school well-being programs targeting regional and rural young people (Berger et al., 2022). Goldberg et al. (2019) recommended consultation with school communities to enhance the acceptability and effectiveness of school well-being programs.

Study aim and research questions

The aim of this study is to ascertain, from the perspective of a range of community stakeholders, what content might be included, and what pedagogies may be employed when delivering well-being programs for children living in rural and regional areas of Australia. Collaboration with regional and rural children, families, and school staff might inform the development of school-based well-being programs specific to this context. The terms rural, regional, and rural and regional are used to denote experiences of children, families, and schools located outside of metropolitan areas.

Method

Participants

Nine focus groups were held with 29 participants, comprising primary (or elementary) students, parents/guardians, school leaders, teachers, and school well-being staff. Participant demographics for each focus group are shown in Table 1.

Table 1 Focus Group Participants by State and Location
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The largest participant group was parents (31.0%), followed by teachers (27.6%), school leaders (10.3%), well-being staff (17.2%), and students (13.8%). Fifteen participants lived and worked in a regional area, and 13 lived and worked in rural areas. One worked in a regional area and lived in an urban area.

Students Four students (3 males, 1 female) attended two focus groups. Students’ ages ranged from 10 to 15 years (mean = 12), mostly attending primary (or elementary) school.

Parents Two focus groups were held for nine parents/caregivers (1 male, 8 females). Parents/caregivers identified as Australian (n = 6), African (n = 1), New Zealander (n = 1), and North American (n = 1). Regarding employment, parents/caregivers reported the following roles: farmer (n = 3), scientist (n = 1), mental health worker (n = 1), events manager (n = 1), investment officer (n = 1), self-employed (n = 1), and not listed (n = 1).

School leaders A total of three school leaders (1 male, 2 females) attended a focus group. Two attended a focus group for school leaders, while the other attended a focus group for well-being staff. School leaders were those identified as working within leadership positions in schools, namely principals, assistant principals, or year-level coordinators. Participants taught in primary (elementary) schools (n = 1), high (secondary) schools (n = 1), and combined primary and high schools (n = 1) and identified as principals both current (n = 1) and retired (n = 1), and as year level coordinators (n = 1). All three participants identified as Australian.

Teachers A total of eight teachers (8 females) attended two focus groups. Teachers identified as Australian (n = 6), New Zealander (n = 1), and Asian (n = 1). Participants taught in primary (elementary) schools (n = 5), high (secondary) schools (n = 1), combined primary and high schools (n = 1), and specialist schools (i.e., for students with disabilities or additional learning, social, emotional, or behavioural needs; n = 1).

Well-being staff Two focus groups for well-being staff were held. A total of five participants (5 females) attended. All participants identified as Australian (n = 5) and worked in primary schools (n = 2) or combined primary and high schools (n = 3).

Materials

Semi-structured interview schedules were developed for the focus groups. The semi-structured nature of the focus groups meant that questions may have been asked slightly differently or in a different order depending on topics raised by participants. Due to COVID-19 travel restrictions and geographical distance, focus groups were held via the video-conferencing platform, Zoom, and were facilitated by a member of the research team (EB).

Each interview schedule included a preamble outlining the aim of the project, participation, and how confidentiality would be maintained. Questions explored the topics and considerations for school-based well-being programs for these children. Participants were encouraged to reflect on their experience of rural and regional living and the strengths and resources of rural and regional children. Example questions included: “What comes to mind when you think about mental health and well-being of students living in regional and rural areas?” “What topics should be addressed in a school wellbeing program to address the well-being of regional and rural children?” and “How can parents/caregivers and teachers/staff work together during delivery of a well-being program for students in regional and rural areas?”

Procedure

A stakeholder reference group of 15 (including the five researchers, three colleagues from Rural Aid, and the remaining mental health, education, and academic experts) was established before recruitment, comprising members with experience living or working in regional and rural areas, and/or with schools and school mental health. The stakeholder group acted as a consultative body for each stage of the research and data analysis. The stakeholder group reviewed the procedure, focus group interview questions, results, and conclusions of this study. Ethical approval was obtained from the Monash University Human Research Ethics Committee prior to conducting the focus groups. Focus group participants were recruited using social media (Facebook, Instagram, LinkedIn), direct communication with teachers and schools, and word of mouth from stakeholder reference group members and research team members. Advertisements were circulated which included a link for participants to read about the project and register their interest. Interested participants clicked on the advertisement link, reviewed an information sheet about the study, and provided their consent and contact details to participate in a focus group. Parents were asked to provide consent and their own contact details for student participation. Verbal assent was obtained from each student participant prior to the start of the student focus groups.

Initially, 45 school staff (teachers, well-being staff, and school leaders), 40 parents, and 31 parents of children expressed interest in the study by completing the initial consent form. Of these, 23 school staff, 17 parents, and 12 parents of children completed an online demographic form and indicated their (or their child’s) availability for a focus group. Finally, 16 school staff, nine parents, and four students attended one of nine focus groups, conducted throughout November 2021. Prior to focus groups, verbal consent from each participant was obtained to audio-record each focus group. To confirm participants’ status as rural or regional, they completed a demographic form prior to participating in the focus group indicating the state and town or suburb where they lived. The town or suburb was checked via Google and eligibility was determined according to the Australian Rural, Remote and Metropolitan Area (RRMA) classification (Department of Health and Aged Care, n.d.). One student was living in Sydney (the capital city of New South Wales) and was therefore removed from the analysis. This meant that four rather than five students were included in the final sample.

Focus group length ranged from 1 h, 2 min to 1 h, 23 min, with an average length of 1 h, 13 min. All focus groups were audio recorded and later transcribed by a professional transcription company.

Data analysis

Data were analysed using the six-step process of thematic analysis (Braun & Clarke, 2013). First, a member of the research team (AM) familiarised herself with the data by reading and re-reading the transcripts and noting initial ideas and potential themes. This researcher then collated data into tentative themes. Next, the two team members who conducted the focus groups (EB) and analysed the data (AM) collaborated on the tentative themes to develop the final set of themes and subthemes. The following themes were identified, (1) the curriculum (content) of well-being programs, (2) the pedagogical considerations of well-being programs, and (3) implementation issues and possible solutions. The final themes and subthemes were defined in consultation with all research team members.

Results

The themes and subthemes identified in the thematic analysis are described below. Both differences and similarities in responses across participant groups are reported. Illustrative excerpts are provided under each subtheme and tagged with the relevant participant type. The term ‘adult participant’ refers collectively to adults, and may include a combination of parents/guardians, teachers, well-being staff, and/or school leaders. The thematic structure is shown in Table 2.

Table 2 Thematic Structure
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Curriculum of well-being programs

Participants identified a range of content they considered important to include in well-being programs for rural and remote students.

Stigma and understanding mental health

Adult participants identified stigma around mental illness in regional and rural areas as impacting children’s well-being. For example, “I think stigmatisation is still a big problem [in regional/rural areas] … like, toughen up, you know – got to do stuff in the country, we’ve gotta get through it” (Wellbeing staff). Ways to mitigate stigma were also discussed, for example:

I just think it’s about normalising it, if we started talking about mental health, mental illness, wellbeing, all those concepts right from a very early age. Talking about going to talk to a counsellor the same way as we talk about going to a physio [physiotherapist] with a netball injury or something (Parent).

Adult-participants also reported that children in regional and rural areas do not necessarily understand mental health. For example, one parent said: “They [children] have a lot of … myths and misunderstandings of what mental illness is. But when we talk about the more positive side of wellbeing, it’s not something that they consciously think about.”

While several wellbeing staff and teachers had a clear sense of what well-being meant to them, some parents and students struggled to define it or explain factors that contributed to well-being. Two students referred to well-being as relating to how one feels or thinks, as well as having opportunities to express how one feels and thinks. There was a sense amongst students that when they were feeling emotionally healthy, they were less likely to feel overwhelmed, “…because you feel calm, you can think about things, and you don’t feel overwhelmed. So, when you feel [stressed, your brain] just goes ‘I don’t know what to do, I don’t know what to do’” (Student). The idea to present mental health concepts to children at an early age was shared among adult participants. Adult-participants were consistent in their view that education about well-being was an important first step in helping children cope with challenges and manage their mental health.

Shared language around mental health

All participant groups reported that promoting a shared language amongst staff, students, and parents for mental health and well-being was important. One parent noted the disparity between rural parents and children in how they discussed mental health terminology:

I think the schools do a good job these days of [talking about] resilience and growth mindset and all these beautifully worded concepts, but parents don’t often use the same words. [This] generation has a risk-taking/growth mindset and we [parents] use words like “failure” and “dealing with it” (Parent).

Help-seeking/giving behaviours

Participants emphasized the importance of promoting help-seeking behaviours. To illustrate, adult participants described the importance of overcoming a ‘toughen up’ and ‘solider on’ mindset common to rural areas. One parent said: “There is that tendency as a generalisation in country areas … to be ‘resilient’ - whatever that means. And to be strong and to be stoic and just soldier on”. Another said:

… letting them [children] know that you don’t always have to be strong. And you don’t always have to be resilient, and you don’t always have to fall down and bounce straight back up … It’s okay to admit sometimes when you need help and to reach out for that. So, I like the idea of introducing that to them right from the beginning (Parent).

Students identified specific adults, mainly parents and extended family members (e.g., aunties, uncles, grandparents) who could provide support when needed. Students wanted reassurance that their parents would be available: “I think your parents … they just need to tell the kids that they know… that they’re there if they want to talk to you or you need to talk to them” (Student).

Relatedly, students described wanting to help their friends who were going through a hard time but found it difficult to know how to help. To illustrate, “You just try and help them [friends] out, talk to them. I don’t know, I just don’t talk easily… I don’t know”. Another student stated that a well-being program could: “teach you [students] about how to help out other friends and things like that”.

Increased anxiety in children

Several parents held the belief that mental health is “declining” in rural and regional children and that “they seem to have a lot more worries than they should” (Parent). Such concerns are represented by a parent’s reflection:

I see anxiety very increased, more of anxiety going on in children and behaviour associated with it. Again, I don’t know … probably on the rise everywhere. So, I think that’s something that kids really are struggling with (Parent).

Regarding the source of the anxiety, one student said that some children worry about their parents and “what they’re doing, how they’re going, if everything’s okay”, as well as “friends or their schoolwork”. Adult-participants identified separation anxiety as a contributor to school refusal in younger children. Well-being and teaching staff identified that both students and parents could benefit from support with school refusal, also stating that the COVID-19 pandemic played a significant role in exacerbating this issue.

…school refusal never happens on its own, so when the parents are uncertain, when there’s those younger parents as well, who aren’t as confident in their parenting decisions, we’re seeing them where they’re like, ‘Oh no, we’ll just keep them home.’” (Well-being staff).

Social-emotional skills

Students identified several aspects they believed should be included in a school-based well-being program, including discussions about emotions, coping strategies, and resilience. For example:

To know how to get through things. I don’t know, just talk about the different types of emotions and feelings, things like that I suppose… they could teach them just because it seems like the end of the world there’s always a way to get through things, even though it seems like the end of the world (Student).

For students, managing conflict with peers and making friends was difficult in rural schools with small student numbers; for example:

If you don’t get along with one [boy], then you’ve only got one other… you’ve kind of got only one other friend in your year and then they could also be friends with [a child I don’t get along with] and stuff (Student).

Furthermore, if friendship difficulties do arise, “you don’t kind of have as many friends. You have to play with younger kids sometimes” (Student). Within this context, one student commented on the importance of good social skills: “you can’t force other people to be friends all the time, but I think you could try to help them just to try and get through it”.

Use of responsible social media

Several adult-participants described how children’s peer relationships were complicated by social media and the internet more generally:

… and then [peer challenges] get backed up with social media, with them I think in a negative way when they’re on TikTok and Snapchat and hearing conversations that are not positive and they go and try it, they explore it. So that doesn’t help in moving in a positive way (Teacher).

Both well-being and teaching staff suggested that a well-being program would benefit from teaching children about healthy and responsible use of social media, for example, “… so, giving kids options …which ways to think [about social media], does that thinking serve you in a good way or does that thinking serve you in a bad way?” (Teacher).

Promoting inclusion

Adult participants described regional and rural communities as holding traditional values regarding mental health, religion, race, disability, gender, and sexuality.

I found the community to be more conservative, and I would say that that is the case for the attitudes towards mental health and neurodiversity, and also diversity in general… I think, for a lot of the kids that are neurodiverse or gender-diverse, finding their community has been very difficult (Well-being staff).

Accordingly, adult participants indicated that well-being programs should include open discussions with students about diversity and inclusion to increase a sense of belonging and acceptance in the local community, which could, in turn, support children’s well-being.

Students also discussed the importance of acceptance and belonging, inferring that a well-being program should promote both. For example: “We’ve actually done up a bench for people to actually sit down and relax…some people need that calm down time…People could get hurt because they’re just so overwhelmed that they don’t know how to control it” (Student).

Grief and loss

Adult participants agreed that including grief and loss in a well-being program for regional and rural children would be important and useful. Participants identified many losses associated with regional and rural life, including loss of farm animals due to old age, accident, or drought; loss of family members and friends due to moving away, moving to the city, or suicide; loss of community or family assets such as farmland and/or water; and loss of natural habitats due to climate change, drought, floods, and/or bushfire.

If you go on a farm, you certainly see a lot of death, so the kids see that too… I mean, a few years ago we had lightning strikes and it killed five sheep, so it’s never clear cut, can’t really do much about it… but city kids are not going to see that (Parent).

Challenges of isolation

All participant groups reported a sense of isolation due to the remoteness of regional and rural living. As one student said, “walking down my front gate you’d only get halfway doing 10 minutes” and “out here you kind of have to drive to school…”. Reduced access to resources and services due to isolation was pointed out by one student: “Well, some things are harder like in small towns you don’t always have everything you need so you have to drive into the bigger cities or bigger towns to get what you need.”

Students also appeared aware of the challenges facing their parents due to isolated living, particularly the need to travel further for shopping or employment: “Some things that wouldn’t be as good for adults are like there’s not a town, so you have to drive until you get to bigger cities and stuff to get jobs because there’s more jobs there.”

Utilising strengths

Teachers and parents noted particular strengths in rural and regional communities that could be applied in well-being programs, such as comradery, mateship, resilience, mental toughness, and good humour. To illustrate:

Quite often you would have another parent come to school and say this family might need a bit of extra help, a bit of love and so on, and the community spirit in itself in a rural community is just amazing and that’s just a wealth of support right there (Teacher).

Talking more generally, one teacher explained: “[every]body has their strengths, their natural strengths, once they find out about them and explore those…that’s your calling…and allow that to happen for children”. Resourcefulness was also described as a strength of rural people, as this parent explained:

… resourceful, we don’t potentially have all those things to keep us busy on the weekend. So, it is about building a cubby house out of sticks or setting up a bike jump out of random stuff in the garage. So, there’s lots of strengths there in terms of them keeping themselves busy with not much material stuff around them.

Sport was identified by many participants as a major strength in regional and rural communities, particularly football and cricket. Some students said that sport gave them a positive opportunity for connection, for example: “when I missed out on a bit of football season, not as much training, [I miss] seeing my footy friends” (Student).

Pedagogical considerations

Participants identified various pedagogical considerations when delivering well-being programs to rural and regional students as outlined below.

Importance of context

Many adult participants recommended that well-being programs should avoid being “metrocentric” (Parent):

[It] would be great if the case studies were specific…to regional areas because people can identify with that…Making it a kid that our kids can relate to and the sorts of issues that they’re dealing with, it makes it much more believable and relatable (Parent).

When asked for examples of this, students described their roles within their families, such as, “feeding chooks, pigs, dogs, dishwasher, clothes” (Student). One parent highlighted that many farming families encourage a strong work ethic: “[children] see Mum and Dad working hard every day and not [saying] ‘I don’t feel like doing it today’, right. So yeah, there can be a lot of work ethic”.

Similarly, according to adult participants, well-being program facilitators needed to be aware of and sensitive to the particular social context within the community. Specifically, many parents and teachers described family violence, drug use, and poverty as common in regional and rural communities. Adult participants expressed that children are often exposed to details of adversity and dysfunctional coping by adults in their communities. For example:

What we probably see a lot at our school is the well-being and mental health impacts that family violence is having…you get a case history of these kids that have come along with so much trauma from their background and…having had no intervention to support them with this at all (Well-being staff).

Adult participants commented on how adult topics, such as substance use or welfare issues, were often discussed when children were present. Teachers and well-being staff suggested that addressing complex family dynamics, emphasising boundaries between adult and child hardships, and empowering teachers to understand and respond to behaviours associated with adversity would be helpful in a well-being program for regional and rural children.

The importance of nature

Several participants suggested that integrating nature into program delivery (e.g., outdoor activities or natural materials) may enhance students’ engagement as it would feel less like a typical classroom. One student said, “…for me, living in the country helps me to bond more with nature compared to the city”. Related to the natural environment and context of rural life, students were aware of how hard their parents had to work to maintain the family farm following natural disasters, and their financial vulnerability due to environmental factors. For example, “Sometimes my father’s got to stay up late nights spraying, harvesting crops, insurance with hail. Just before we got hit by hail on our canola” (Student).

Reduced mental health support

Adult participants considered it important that well-being program facilitators be aware of the local context and avoid referring children to unavailable or inaccessible services for support beyond the program. Participants also reported that urban-based services were not always sensitive to the experience of people living in rural and regional areas. A well-being staff member reported:

In metro, we’ve been able to refer kids to get more support, and here we can’t really refer them anywhere. And so, we try and put in proactive well-being supports, but it always ends up being reactive and short-term, whereas Melbourne [metropolitan city] it seems to be a bit different (Well-being staff).

Adult-participants expressed concern about the lack of specialist services for young people. Participants reported that children often had to travel to metropolitan areas for targeted assessment and treatment.

I would say a big difference between the country and the city is, beside service and specialised services, so it’s more general services down here, even the GPs are very general, like you’re not going to get a GP who has an interest in autism as much down here (Well-being staff).

Clear and accessible resources

Teachers expressed a desire for clear and accessible information that could be easily incorporated into the curriculum:

I think if you have that program … then it would be embedded – you would be able to embed it throughout the other PE [physical education] and health and all that, the art programs and stuff because the teachers would all be using that same language (Teacher).

Similarly, parents explained that being time-poor meant they would need simple information: “Maybe little videos … that you can just take two or three minutes at a time … and not big chunks or piles of paper you go ‘Oh’ and just put aside; yeah, more digestible bits and pieces” (Parent). Parents reported a preference for “one-on-one conversations” about the program and their child’s participation, rather than group sessions. One parent said they would feel best prepared to support their child if they were given information in advance, “I think the curriculum or outline or … what’s going on should be given to the parents in advance and we can know what’s happening week to week” (Parent).

Hands-on activities

Parents agreed that well-being sessions should feel different to classroom learning:

Get away from the desk and the chair whether it’s inside or out, if the kid wants to lay down/sit up, however they feel comfortable… rather than having to sit, feet on the ground, staring ahead, hands on the desk, you know (Parent).

Parents and students highlighted a preference for hands-on group activities, suggesting role-plays, making movies or movie trailers, posters, writing a play, skit or story. For example: “acting it out through plays or … maybe writing … a short snippet of a story about an emotion going through someone” (Student) and “perhaps part of it could be in a sport situation … teamwork and they’re a bit more comfortable and it’s a bit more fun I guess” (Parent).

Program and session length

Preferences for program and session length varied. Several students stated that weekly or fortnightly would be helpful, with session times varying from “half an hour” to “two hours”. Several parents and teachers reported that well-being programs would be most effective if they were delivered over time to facilitate capacity building in staff and children:

I think for it to have any impact it needs to be frequent and long-term, like weekly or fortnightly at the latest for the whole year or three terms or two terms… if you really want kids to share and get involved, they need to be in that trusting comfortable situation, so it takes a while to develop that (Parent).

Adult participants largely agreed that children would learn better if program content was emphasised consistently throughout the year. Some suggested that a short-term program could be delivered, along with tools and resources that could be used ongoing.

Implementation factors

Participants identified various implementation considerations when delivering a well-being program in rural and regional schools.

Parent’s role

Many adult participants stated that parents’ support was critical to the success of a school-based well-being program; both for program implementation and generalisation: “Like in most interventions for kids in a primary age group, like you can’t not include the parents… when the parents are involved, then we can really sort of build up their skills” (Well-being staff). Teachers highlighted the importance of parent ‘buy-in’: “[Parents] need to be respected. And they need to be involved and the more they can be educated the better off their kids are going to be” (Teacher). Likewise, a parent said:

The important thing is that we want to be involved so we can discuss further or maybe if we don’t agree with everything, we can share our values [with our child] … without contradicting it but saying ‘Well we actually believe this and going that’s more why’.

Respectful relationships between facilitators and parents were perceived as important for program delivery. Parents reported that strained relationships between program facilitators and families (if they are known to one another, as may be likely in rural/regional areas) may impact their willingness to allow their child to participate (and their child’s willingness to participate). For example: “Well the challenges are if a parent doesn’t agree with it, I guess or because they obviously know [the facilitator], maybe they don’t like them, who knows” (Parent). Parents and teachers also indicated that children may be reluctant to share their personal challenges due to concerns about the community knowing their business. Parents also said that they would need to have a strong understanding of the program, the benefits of the program, and who would be facilitating the program to feel confident with their child participating.

Part of supporting parental involvement and enhancing trust between the school and parents included emphasising family and community strengths and reminding parents that they do not need to do things perfectly.

One of my favourite things is reminding them that you’ve only got to get it right 30–40% of the time, like you’re actually doing a great job, and it’s okay if you don’t do it perfectly all the time, but that’s probably one of my favourite things to share with them because I can see the relief (Well-being staff).

Time and the crowded curriculum

Many teachers pointed out that an already large workload and busy curriculum would be a barrier to them facilitating the program. Teachers voiced concerns about having to rush through material (academic or well-being-related):

I just find that sometimes these kids are just hit with so much…and as a teacher too - our plates are full. Like please don’t say you need to teach this one hour a week, because I’m sorry as sad as it is, unfortunately sometimes you need to cut stuff away and you do tend to skim over things (Teacher).

Although teachers consistently reported workload as a challenge, one teacher highlighted that because teachers are trusted, their involvement in a school-based well-being program could be beneficial:

I know you guys are saying that you don’t want another thing to do or another thing to teach, but I think the kids really benefit from having those discussions with you in those small groups as well, like being able to talk to us about things like that.

Facilitator role

Many teachers suggested that having well-being staff or an external facilitator run the program would be helpful, with resources for teachers to use in class to promote engagement over time:

I think one thing that has worked at our school is that we have had a well-being lady who comes in once a week, and we try and reinforce some of the stuff that she does. She has such a positive interaction with the kids, and we always sort of refer back to her little session, it’s only half an hour and that has helped (Teacher).

Discussion

This study aimed to elicit program topics to cover and identify the pedagogical and implementation considerations for school well-being programs intended for delivery in regional and rural schools. Much of what was identified is similar to other school-based well-being programs, but some elements appear to be specific to rural and regional schools. Pedagogical considerations related to the need to draw on local context, program intensity, and the importance of applied activities, and succinct and accessible resources were identified.

Similar to other school-based well-being programs (e.g., Berger et al., 2022), stakeholders recommended the promotion of social skills. Perhaps different from their urban counterparts, social skills for regional and rural children should focus on resolving disputes and ways to get along with a small cohort of peers. Promoting help-seeking is commonly featured in school-based well-being programs (Berger et al., 2022), and was also identified by participants to be important for rural and regional schools. Helping-seeking was important because of what one staff member referred to as the “toughen-up mentality” in rural and regional communities, which according to Kaukiainen and Kõlves (2020), can prevent children (and others) from seeking help. Another recommendation was to promote a shared language around mental health and well-being, within the whole community and not only in schools. Sometimes referred to as mental health literacy, promoting a shared language around mental health has been shown to reduce stigma and encourage help-seeking, both of which facilitate better mental health outcomes (Morgan et al., 2019). This recommendation is consistent with literature showing the importance of ‘whole-of-community’ approaches to young people’s mental health and well-being (Goldberg et al., 2019). The responsible use of social media was another identified topic, reflective of other school-based programs in this field (Department of Education, 2022). This is important for rural and regional students who may use technology to reduce their sense of isolation and access information about mental health.

Another recommendation was for well-being programs to promote inclusion, which appears to be important given the conservative values in many rural and regional communities (Robards et al., 2019). This involves creating an environment where all children and young people feel welcome and respected (Goldberg et al., 2019). Research has found rural communities include racially and ethnically diverse populations. In part, this is due to federal government policy which encouraged new immigrants to settle in regional and rural areas (Forrest & Dunn, 2013). Further, whilst the majority of Indigenous Australians reside in cities and regional areas (81% in 2016), one in five Indigenous Australians reside in remote areas (Australian Institute of Health and Welfare [AIHW], 2023). Thus, promoting the culture of Aboriginal and Torres Strait Islander people and culturally and linguistically diverse groups would appear to be especially important for well-being programs in rural and remote areas of Australia. In Australia, cultural diversity within different rural communities can vary significantly. Therefore, while some schools may require catered well-being solutions for children of different cultural groups (e.g., Aboriginal students, refugee students), others may not. This is an important consideration when designing well-being programs that are suitable and sustainable in different regional and rural communities.

Participants indicated that children in rural and regional areas needed to be able to manage grief and loss due to their connection with the natural environment and exposure to natural disasters, which reflects their increased exposure to natural disasters (Cook et al., 2008). Experiences of natural disasters can be unique to different regional and rural communities, as well as the impact and availability of services to aid community recovery following a disaster event. It is important to replicate this study with different communities to understand their unique needs following exposure to and recovery from different disasters. For example, research by Berger and colleagues (2018) found that a trauma-informed program delivered in a rural Victorian school was difficult for teachers to implement following a disaster event. This finding further highlights the importance of understanding the unique circumstances, culture, and context of regional and rural school communities when designing and delivering well-being programs for students.

Drawing on the community’s willingness to help each other and their resourcefulness, key features of many rural communities (Buikstra et al., 2010), was another consideration for school well-being programs. It is important to note that strengths-based approaches to mental health have been shown to enhance outcomes (e.g., Slade, 2010), and regional children can be resilient to the effects of natural disasters provided they are well supported by parents and at school (Berger et al., 2020). Helping students to become more aware of the strengths that exist in their community can also increase their basic sense of safety, which is foundational to mental health (Peters et al., 2019). Moreover, helping students become more aware of their strengths can enhance their sense of self-worth and increase their resilience (Mizuho et al., 2012).

Regarding the pedagogy of well-being programs in rural and regional schools, participants recommended that program materials should reflect rural life to promote children’s engagement. This finding resonates with Zaheer et al. (2011) who found that families and children from rural and regional areas tend to disengage when program content feels irrelevant to their circumstances. Appreciating the local context was considered important for facilitators, including an understanding of the impact of natural disasters and the circumstances of students and families involved with the program. Relatedly, program facilitators should also be aware of referral services (if available) within or surrounding the community when delivering school well-being programs. Participants stressed the need for clear and accessible program materials, such as videos and individualised information, materials and case studies that reflect rural life, and summarising information of key learnings and/or listing ideas to practice skills between sessions. Moreover, materials could be designed to be placed visibly in the home (e.g., fridge, noticeboard) to assist with reinforcing students’ learning outside the program and help create a shared language between parents and children - another important consideration from the current study.

Another consideration was for parent involvement, particularly for primary-aged children; likewise, parents in this study reported a desire to be involved in school-based well-being programs. Parents viewed their role as assisting children to practice skills and reinforcing learning outside sessions. This recommendation is consistent with literature showing that parent involvement is important for the success of school-based programs (Shucksmith et al., 2010). There was some discussion about who was best placed to facilitate well-being programs in rural and regional schools . Some teachers expressed concerns about their workload and parents expressed concerns about unknown facilitators running a well-being program with their children. The challenge of who facilitates well-being programs in regional and rural schools remains, with participants suggesting that people with local knowledge should run such programs in schools. However, the isolation and lack of resources in some rural communities may prevent this from occurring. Further, practical considerations, such as travel time and distance to rural schools, may mean that sessions delivered over time are not possible, as suggested by participants, particularly with an external facilitator. Access to external facilitators is likely to differ across regional and rural schools based on the geographical remoteness of schools, and should be a consideration when developing and implementing school well-being programs.

Limitations

This study is one of the first to present stakeholder recommendations for school-based well-being programs for regional and rural children in Australia, and we suspect one of few internationally. Limitations include the small number of participants in some focus groups and the low cultural diversity in both focus group participants and the stakeholder reference group, where Aboriginal and Torres Strait Islander people were not included. Future studies could build on the present findings by targeting different types of rural, regional, or remote communities to identify how program requirements might vary. Including remote and Aboriginal and Torres Strait Islander people is particularly important given the high level of risk for young people in those communities. Similarly, there was lower representation of young people in the study compared to the adult participant groups. While the inclusion of young people could be considered a strength of this study, it is important that future research focus on evaluating the needs and perceptions of children related to school well-being programs. Research has found that parents and teachers tend to have a different view of child mental health compared to children themselves (Maybery et al., 2005). Future research using interviews with each of the different participant groups (i.e., parents, teachers, students) may extend on the findings of this study. Nonetheless, the recommendations generated from this study could be used to inform well-being programs for schools in regional and rural areas, with future studies assessing their effectiveness and efficiency.

Conclusion

Young people who live in rural and regional areas are at greater risk of mental health issues than those living in metropolitan areas and schools are an opportune setting for targeted programs to support the mental health and well-being of young people. Participants provided a number of suggestions for tailored delivery of school well-being programs to improve the mental health and wellbeing of students in regional and rural schools. This included consideration of cultural and geographical differences between regional and rural schools, including unique community experiences of grief and disaster exposure. The challenges of regional and rural school schools, such as available time of teachers to deliver programs, access to external mental health services, and mental health stigma of regional and rural communities are other important considerations when tailoring well-being programs to regional and rural school communities.