Background
Australia's first National Mental Health and Wellbeing Survey, carried out in 1997, found that mental illnesses were common, associated with a high level of disability, but often not treated [
1]. There are many possible reasons for the low rate of health service use. These include practical barriers such as financial cost, waiting lists and regional isolation. There are also other barriers such as an inability to recognise mental illness, or harbouring attitudes that are unfavourable to mental health care or to mental health professionals. In fact, lack of recognition and negative attitudes to treatment pose a significant barrier to service use, as research has shown that only one in three Australians are able to correctly label symptoms of a mental illness, and a majority do not consider interventions endorsed by health professionals, to be 'helpful' [
2].
In 2001 the Mental Health First Aid program (MHFA) was established in response to the need for public education about mental illness and its treatment. MHFA offers a 12-hour course that applies a first aid action-plan model to mental illness [
3]. Mental health first aid is defined as the help provided to a person developing a mental health problem or in a mental health crisis. First aid is given until appropriate professional treatment is received or the crisis resolves [
4]. Through public education about helpful interventions for mental illness, this course aims to increase the public's mental health literacy and encourage the uptake of evidence-based treatment. Evaluations of the program have found that it is effective in increasing mental health literacy, changing beliefs about treatment to be more like those of health professionals, decreasing social distance from people with mental illness, increasing confidence in providing help to someone with a mental illness, increasing the amount of help provided to others and improving the mental health of participants [
5]. The MHFA program has now been independently adapted by organisations in Aotearoa/New Zealand, Canada, England, Finland, Hong Kong, Japan, Northern Ireland, Scotland, Singapore, Thailand, USA and Wales [
4,
6].
In order to improve the quality of the mental health first aid techniques being taught to the public, research has been carried out to develop guidelines on what constitutes best practice first aid. This involved using the Delphi method to develop expert consensus. Expert consensus studies have been used as a practical alternative to randomised or controlled trials, which are not considered feasible or ethical for evaluating specific first aid techniques [
7]. To date, guidelines have been developed for providing first aid in a range of mental health related crises, such as suicidal thoughts and behaviours [
8], deliberate non-suicidal self-injury [
9], and following traumatic events (Kelly, Jorm & Kitchener,
in submission); as well as for a range of developing mental illnesses, such as psychosis [
10], depression [
11], eating disorders [
12] and problem drinking (Kingston, Jorm, Lubman, Hart, Hides, Kelly, Kitchener & Morgan,
in submission)
The importance of culture
Research investigating the impact of culture on mental health has found that it is profound, multidimensional and complex [
13]. Investigations of mental health care use have shown that ethnic minority groups are under-represented in psychiatric services, both within Australia and across other nations with developed health systems [
14,
15]. This trend occurs despite the prevalence of mental disorders in minority groups being either equal to, or greater than, those of the majority group. Research has also shown that the under-representation of minority groups in mental health care is not simply explained by inequalities in socioeconomic status across groups [
15]. In fact, for cultural minorities other barriers, such as poor mental health literacy and culturally insensitive health services, play a much greater role in impeding use of services [
16,
17]. In recent years, many countries including the USA, Australia and Aotearoa/New Zealand have recognised the important role that culture plays in the identification, treatment and prevention of mental illness, and in response, have implemented standards of cultural competency in service delivery and specialised cultural adaptations of health education programs [
18,
19].
Indigenous Australians
In Australia, the diverse groups of Aboriginal and Torres Strait Islander peoples, who constitute 2.3% of the population [
20] exemplify the trend of poor mental health service use in the context of mental illness prevalence that is either equal to, or greater than, that of non-Indigenous Australians. Although prevalence estimates for mental illnesses in the Indigenous population are not well researched or documented (the two National Health and Wellbeing Surveys both elected not to collect specific information on the prevalence of mental disorders within the Australian Indigenous population [
1,
21]) there are some indirect measures which suggest that the mental health of Indigenous Australians is poor, recognition of mental illness within Aboriginal communities is low, and the prevalence of common mental illnesses such as depression and anxiety is high [
22‐
30]. A recent health survey of Indigenous Australians reported that Aboriginal and Torres Strait Islander peoples are twice as likely as non-Indigenous Australians to report high or very high levels of psychological distress [
31]. Furthermore, rates of suicide for the Indigenous population in Australia are estimated to be up to six times higher than rates for the non-Indigenous population [
32].
While many programs aimed at improving mental health and reducing suicide in Indigenous Australians have been implemented in Aboriginal communities (e.g. Advanced Suicide Intervention Skills Training [
33]), none have used an integrated approach to mental illnesses and associated crisis situations in a way that encourages early intervention and increased mental health literacy. The success of the MHFA course in increasing help-seeking behaviours, and the desperate need to provide Indigenous Australians with culturally appropriate training and education for improving mental health [
34], led the Office of Aboriginal and Torres Strait Islander Health, a branch of the Australian Federal Government's Department of Health and Ageing, to fund the development of a cultural adaptation of the MHFA training program, specifically for Aboriginal and Torres Strait Islander Australians [
35]. In 2007, an Aboriginal and Torres Strait Islander Mental Health First Aid training program (AMHFA) began teaching Australian Indigenous people a culturally adapted 14-hour course within Indigenous communities. The AMHFA course differs from the general MHFA course in recognising the historical, cultural and political forces that have affected Aboriginal mental health [
35]. For instance, the course discusses how Australian Aboriginal people have endured centuries of racism, dispossession, violence, trauma and loss. The forced removal of communities from their land, the systematic denial of culture and language, the suppression of political and human rights, and the forced removal of children, have all contributed to an environment of poor mental health compounded by ongoing social and economic disadvantage [
34]. In addition, the program acknowledges that Aboriginal people understand mental health within a unique cultural framework that is not necessarily complementary to the biopsychosocial model of western medicine [
28,
34]. Furthermore, it recognises that this cultural divergence can at times complicate the use of mental health services because Aboriginal people are either unable to find services that provide culturally sensitive treatment approaches, or fear accessing mental health services because historically these services have failed to provide care which incorporates and respects an individual's cultural world-view [
28].
The need for culturally specific mental health first aid guidelines
Although the existing Aboriginal Mental Health First Aid training program was developed through extensive consultation with Aboriginal people, it became apparent that the content of training would be improved by the development of best practice guidelines. In parallel to those developed for English-speaking [
8‐
11] and Asian [
6] countries, this research aimed to develop culturally appropriate guidelines for providing first aid to an Australian Aboriginal or Torres Strait Islander person who is experiencing a mental health crisis or developing a mental illness. By engaging Indigenous experts who work in the field of mental health, the research focused on the importance of culture and Indigenous experiences of mental illness.
Results
Expert panel members
31 panel members were recruited and a total of 28 participants (15 female, 13 male, age range = 31 to 61 years) completed at least three questionnaires. Table
1 outlines how many panel members responded to each round of each topic. There was a high retention rate both across rounds of questionnaires and across topics. The majority of panel members responded to more than 9 rounds; 18 participants (64.3%) completed 10-18 questionnaires.
Table 1
Number of respondents for each round of each questionnaire topic
Round 1 | 20 | 20 | 24 | 24 | 24 | 24 |
Round 2 | 18 | 18 | 20 | 20 | 20 | 21 |
Round 3 | 17 | 17 | 19 | 19 | 19 | 21 |
Participants were recruited from across Australia including: the Australian Capital Territory (n = 2), New South Wales (n = 11), the Northern Territory (n = 1), Queensland (n = 7), South Australia (n = 1), Victoria (n = 4) and Western Australia (n = 2). Tasmania was the only state without representation on the panel. Having a geographical spread of panel members was thought to be important for the representation of different experiences and attitudes of Aboriginal communities across Australia. It is therefore important to note that no participants identified as Torres Strait Islander. According to the 2006 Australian Census, 90% of the Australians who identified as Indigenous were of Aboriginal origin only, 6% were of Torres Strait Islander origin only and 4% were of both Aboriginal and Torres Strait Islander origin [
20]. Given that Torres Strait Islander people constitute such a small percentage of the Indigenous population, it is not surprising we found it difficult to recruit a representative from this community.
Participants were employed in a range of different services across the mental health field, including: private psychology clinics, Aboriginal medical services, government health services, universities, cultural resource and counseling services, prisons, social services, and drug and alcohol services.
The panel was very experienced, with more than half having between 6-10 years experience in the mental health field (5 years or less = 12.5%, 6-10 years = 62.5%, 11-15 years = 12.5%, 16-20 years = 12.5%). In addition, approximately one quarter of panel members had obtained a post-graduate degree (Certificate level = 11.6%, Diploma = 11.76%, Bachelor Degree = 47.06%, Bachelor degree with honours = 5.88% Graduate Diploma = 5.88%, Masters degree 17.65%, PhD = 0.00%).
Endorsed statements
Of the 1,016 statements that were presented to panel members across the 6 Delphi studies, 536 were endorsed as either
Essential or
Important to the development of guidelines on providing mental health first aid to an Aboriginal person. A list of all endorsed statements can be found in Additional File
2, Tables S1 - S6. The number of statements presented in each first round questionnaire differed markedly across topics and was largely determined by the amount of accessible literature on the area. There is, for instance, a large and culturally relevant literature on the issue of suicidal thoughts and behaviours, however, there is a notable dearth of culturally relevant information on issues such as depression and deliberate self-injury. The largest questionnaires were those on trauma and loss, and psychosis. Table
2 lists the number of statements presented in each Delphi study.
Table 2
Number of statements presented, endorsed and rejected in each Delphi study
Round | New statements | 155 | 143 | 42 | 125 | 76 | 211 |
1 | Statements being re-rated | 0 | 0 | 0 | 0 | 0 | 0 |
| Total number of statements | 155 | 143 | 42 | 125 | 76 | 211 |
| Statements Endorsed | 72 | 125 | 24 | 30 | 16 | 125 |
Round | New statements | 13 | 10 | 27 | 20 | 22 | 18 |
2 | Statements being re-rated | 26 | 32 | 8 | 17 | 12 | 32 |
| Total number of statements | 39 | 42 | 35 | 37 | 34 | 50 |
| Statements Endorsed | 21 | 24 | 25 | 22 | 13 | 27 |
Round | New statements | 0 | 0 | 0 | 0 | 0 | 0 |
3 | Statements being re-rated | 3 | 2 | 5 | 4 | 4 | 9 |
| Total number of statements | 3 | 2 | 5 | 4 | 4 | 9 |
| Statements Endorsed | 1 | 2 | 3 | 1 | 2 | 3 |
Total number of statements | | 197 | 187 | 82 | 166 | 114 | 270 |
Total number of endorsed statements
| |
94
|
151
|
52
|
53
|
31
|
155
|
Total number of rejected statements | | 103 | 36 | 30 | 113 | 83 | 115 |
Rejected statements
Some statements were strongly rejected by the panel, with a majority of participants rating a statement as either
Unimportant or
Should not be included (see Additional File
2, Table S7, for a list of strongly rejected statements). Across the 6 Delphi studies 36 items were rejected with strong consensus (50% or more of panel members rated an item as either
Unimportant or
Should not be included). The majority of strongly rejected items came from the suicide and deliberate self-injury surveys, while the psychosis, cultural considerations and trauma and loss surveys received no strong rejections.
Other statements were rejected because there was disagreement within the panel. For instance, some statements failed to be endorsed because, even after a second rating, the statement just failed to achieve 90% consensus.
Panel member feedback
Eighteen of a possible 24 participants responded to the feedback survey. The percentage of panel members responding in each category are shown in Table
3. Of particular interest were the responses to statements that were designed to assess the cultural appropriateness, the utility and perceived quality of the guidelines produced. For instance, in response to the statement
I would recommend the guidelines to other people, all participants responded with either
Strongly Agree or
Agree. In addition, 88.9% of the panel responded with either
Strongly Agree or
Agree in response to both statements
I thought the guidelines were culturally appropriate and
I believe the guidelines will benefit Aboriginal people. While these results are promising, they are not unexpected, given that the panel members were involved in the development of the guidelines. The results would be well supported by further evaluation of the utility of the guidelines in Indigenous communities.
Table 3
Selected statements from the panel member feedback survey
I thought the Guidelines were easy to follow. | 44.4 | 44.4 | 5.6 | 0.0 | 0.0 |
I thought the Guidelines were too long. | 0.0 | 5.6 | 22.2 | 61.1 | 11.1 |
I thought the guidelines used appropriate language. | 22.2 | 55.6 | 22.2 | 0.0 | 0.0 |
I thought the language used in the guidelines was too clinical. | 0.0 | 5.6 | 27.8 | 55.6 | 11.1 |
I thought the guidelines covered the appropriate issues. | 33.3 | 61.1 | 5.6 | 0.0 | 0.0 |
I thought the guidelines were culturally appropriate. | 27.8 | 61.1 | 11.1 | 0.0 | 0.0 |
I believe the guidelines will benefit Aboriginal people. | 55.6 | 33.3 | 5.6 | 0.0 | 0.0 |
I would recommend the guidelines to other people. | 55.6 | 44.4 | 0.0 | 0.0 | 0.0 |
I thought the time commitment was appropriate. | 16.7 | 66.7 | 0.0 | 16.7 | 0.0 |
I thought the remuneration was appropriate. | 27.8 | 61.1 | 11.1 | 0.0 | 0.0 |
I thought participating in this research was worthwhile. | 83.3 | 16.7 | 0.0 | 0.0 | 0.0 |
I enjoyed participating in the Delphi research. | 61.1 | 33.3 | 5.6 | 0.0 | 0.0 |
I believe the Delphi process can be of benefit to Aboriginal people. | 44.4 | 38.9 | 11.1 | 5.6 | 0.0 |
I would recommend the Delphi method for other research projects for Aboriginal people. | 44.4 | 38.9 | 11.1 | 5.6 | 0.0 |
Statements regarding the appropriateness of the Delphi research method also received a high level of agreement, with 83.3% of participants responding with either Strongly Agree or Agree to the statements I believe the Delphi process can be of benefit to Aboriginal people and I would recommend the Delphi method for other research projects for Aboriginal people.
Discussion
By engaging Aboriginal people who are experts in the field of mental health, this research aimed to develop culturally appropriate guidelines for providing mental health first aid to an Australian Aboriginal or Torres Strait Islander person. Despite diverse backgrounds, the expert panel was able to reach consensus on a range of first aid techniques, from offering a cup of tea or coffee to a person who has experienced trauma, through to talking about the sensitive issue of suicide.
Across the different Delphi topics, statements were rejected and endorsed at different rates. For instance, the psychosis study proposed a total of 187 first aider action statements, of which 81% were endorsed and 19% were rejected. In contrast, the deliberate self-injury study proposed a total of 114 statements, of which 27% were endorsed and 73% were rejected. While it might be expected that the Delphi studies containing the most cultural information may have had the highest rates of endorsement (e.g. trauma and loss or cultural considerations), in fact the pattern of endorsement mirrored that of other international Delphi studies, which have found differences in the strength of established expert consensus [
8‐
11]. That is, because of wide-ranging and effective research into first episode psychosis, there is a strong consensus on how emerging psychosis should be managed. Conversely, due to a dearth in controlled trials and treatment studies, there is little expert consensus on how deliberate self-injury should be treated in a clinical context, let alone managed in the community.
Although each Delphi study addressed a different mental health issue, there were two themes that appeared in each survey and subsequent guidelines. The first theme was about how the person providing first aid needed to understand and assess symptoms of mental illness within the cultural context of the person they were helping. The second was the essential role that family and community play in promoting and protecting the health and wellbeing of individuals with mental health problems.
Understanding symptoms of mental illness within a cultural context
A particular concern of culturally appropriate mental health first aid is to check, or to understand, the cultural norms of the community, before assuming that an Indigenous person is displaying symptoms of mental illness. All of the Delphi study surveys included statements about symptom recognition in the context of culture. For instance, the depression study included the statement - The first aider should take into consideration the spiritual and/or cultural context of the person's behaviours. The psychosis study included the statement - The first aider should be aware of what constitutes culturally appropriate behaviours so that they don't misinterpret such behaviours as symptoms of psychosis (e.g. in some communities, limited eye contact is expected behaviour). The suicidal thoughts and behaviours study included the statement - The first aider should learn about the behaviours that are considered warning signs for suicide in the person's community. And the deliberate self-injury study included the statement - The first aider should be aware that pathological self-injury, such as cutting and burning, is fundamentally different to ritualistic, culturally accepted Aboriginal ceremonial or grieving practice.
Each of these statements were endorsed by panel members and incorporated into the guideline documents. That each of the developed guidelines contain information about the need for the person providing first aid to be mindful of cultural norms, before assuming that someone is experiencing a mental health problem, suggests that this is a cornerstone of culturally appropriate first aid. Importantly, from the feedback provided by panel members during the Delphi studies, this principle was not only seen as important for non-Indigenous people providing first aid to Indigenous people, it was also seen as crucial for any Indigenous person who was assisting outside their own community.
While panel members endorsed this idea of culturally appropriate first aid, they did so with a caveat. Panel members comments suggested that individuals providing first aid need not get so immersed in the need for cultural awareness that they lose sight of the physical and emotional needs of the person they are assisting; as one panel member's comments suggest: "Whilst having attested to the importance of these cultural awareness items, they sum to a maxim that it's crucial to take time to become familiar with local beliefs and norms, [yet] it is actually counter-productive to think one has to be an anthropologist - across the minutiae of all Australian Indigenous cultures...". This idea was also especially apparent in the study on trauma and loss. In the Round 1 and 2 surveys, panel members were presented statements about seeking culturally appropriate professional help. Allowing an Aboriginal person to seek out a professional who is trained or experienced in treating Aboriginal people and their experiences of trauma, was seen as particularly important in facilitating recovery. As the Delphi progressed, however, it became apparent that any rigid statements about the need for culturally appropriate professional help were not going to be endorsed, because they alone precluded the right of the person receiving care to seek help that is close to their home and community, and which suits their individual needs. The Trauma and Loss guidelines therefore not only include the statement Suggest that the person see a professional who is trained or has experience in working with Aboriginal people and their experiences of trauma and loss, it also contains the additional caveats: It is important to note that counselling suitable for Aboriginal people may be quite difficult to find or gain access to, as there is a shortage of appropriately trained Aboriginal psychologists and counsellors. If this is the case, you can engage other options; and Most importantly, encourage the person to find someone who will help them tell their story and who the person can trust and feel comfortable talking to. So while this research supports the importance of providing culturally appropriate first aid, it also asserts that when assisting an Indigenous person with a mental health problem, it is equally important to meet their individual needs, regardless of their cultural identity.
The role of family and community
The statements endorsed by the panel and the feedback comments submitted in the first round of each study revealed that, to provide culturally appropriate first aid, the person assisting should facilitate additional support for the person in their care, by encouraging positive relationships with family and community members, while upholding the person's right to confidentiality. For example, the Psychosis guideline contains the statement - Encourage the person to take a support person, such as a family member, to their appointment. If you wish to help the person contact their family, be aware that you must ask the person if its okay for you to talk to family. The Cultural Considerations guideline contains the statement - Try to get the person's family involved in supporting them until they get better, but in doing so, you must uphold the person's right to confidentiality. The Trauma and Loss guideline contains the statement - Whether or not the person seeks professional help, you should encourage them to identify sources of support. These may include community members, support groups and men's or women's groups.
While facilitating support for a person experiencing a mental health problem is recommended as a first aid action in the guidelines produced by previous Delphi studies for English-speaking countries (for instance see
Depression: First Aid Guidelines) [
31], the focus of previous guidelines has been on developing a supportive relationship between the person providing the first aid and the person receiving care. The Delphi studies conducted in this research, reveal that it is important to establish an additional support person, who can act as a mentor or carer.
This additional first aid strategy appears to have arisen for a number of important reasons. For example, many Aboriginal people live in regional or remote communities with limited access to mental health care. Establishing a positive and trusting relationship with another person is a way to establish additional psychological support that may otherwise be unavailable. This is demonstrated by the Cultural Considerations guidelines, which state: Establishing a network of support for an Aboriginal person is a very important step in helping them resolve their mental health crisis, especially if access to professional support or mental health services is limited. Another reason for including the facilitation of additional support is to protect against further psychological distress by enhancing the person's social and emotional wellbeing. This is exemplified in the statement: Discuss with the person what their interests and activities are and encourage participation in any group activities that will help them to develop feelings of purpose, belonging and achievement, which also appears in the Cultural Considerations guidelines.
Acceptance of research outcomes and plans for dissemination
The feedback from panel members demonstrated that support for the Delphi method and the guidelines it produced was very strong (see Additional File
2 Table S4). However, for the developed guidelines to be successful, they need to have a direct impact on the Indigenous communities within Australia. The culturally specific 14-hour course developed by the Aboriginal Mental Health First Aid program is one avenue to achieve this impact.
Since its inception in 2007, the AMHFA course has been presented to over 1,936 Australians. When the teaching materials are revised to reflect the consensus on first aid techniques developed by these Delphi studies, the information in these guidelines will reach a significant number of Indigenous Australians. Furthermore, the detailed material presented in the guidelines will be organised under the MHFA ALGEE action plan [
40] and will have associated teaching activities such as role plays and DVD clips. A pictorial flip-chart is also planned. The dissemination of the guideline information in this way reduces the need for English literacy and thus makes the first aid information more accessible to Indigenous people who may only use English as a second (third or fourth) language.
In addition to the AMHFA course, the beyondblue: the national depression initiative has developed a national dissemination program whereby copies of the guidelines will be sent free of charge to health, education and community resource centres across Australia, who engage Indigenous clients. Furthermore, the guidelines will be made available to order free from beyondblue. Given that a number of important stake-holders in Aboriginal mental health were involved in the guideline research as expert panel members, and that the feedback survey demonstrated these stake-holders approve of the research outcome and are willing to recommend the guidelines to others, the authors believe the national dissemination project will be successful in presenting the guidelines to a large number of people who care for Indigenous Australians with mental health problems.
One limitation of the current research is the lack of pertinent information for members of the community who wish to provide mental health first aid to young Indigenous Australians. Given that, in 2001, 39% of Indigenous people were under 15 years of age, compared with 20% of non-Indigenous people, providing first aid resources for young Aboriginal and Torres Strait Islander Australians is an important task for AMHFA. It was however, a considered decision of the research team to develop guidelines focused on adults. Now that the validity and acceptability of the research method and outcomes have been established, it is hoped that future Delphi studies will be able to develop best practice guidelines for providing assistance to young Indigenous people developing a mental illness or experiencing a mental health crisis.
Despite provisional support from the experts involved in the guideline production, and a highly structured dissemination plan, only further evaluation of first aid outcome will elucidate whether or not the information developed by this research is effective in decreasing the barriers to mental health care faced by many ethnic minority groups in Australia, such as poor mental health literacy, and ultimately increasing the use of health services by Indigenous people.
Conclusion
Aboriginal mental health experts were able to reach consensus about what are appropriate first aid actions for a range of mental illnesses and mental health crisis situations. The Delphi research method was able to develop a resource, which describes for the first time, what constitutes culturally appropriate best practice first aid for Aboriginal and Torres Strait islander people with mental health problems. Through a range of dissemination programs, the information in the guidelines will be made available to Indigenous and non-Indigenous people throughout Australia.
According to the outcomes of this research, to provide culturally appropriate first aid to an Australian Aboriginal or Torres Strait Islander person, individuals must be aware of relevant cultural factors in mental illness, such as cultural behaviours that may mimic symptoms of mental illness, the important role of family and community, and the need to facilitate supporting relationships. These findings are consistent with the broader literature on culturally appropriate care [
17,
18].
This research also demonstrates that the Delphi consensus method is a framework that can be used to guide the improvement of mental health services for Indigenous people, as it allows participants to engage in a culturally appropriate way, and produces resources that can of benefit to their community.
Acknowledgements
The authors would like to thank the following people who contributed to this research Amy Morgan, Anna Kingston, Betty Kitchener, Joanna Parker, Carol (Kara) Eddington, Kathryn Junor and Tom Brideson. The authors would also like the panel members whose dedication to this research has been outstanding. We hope this research has done justice to your passion and commitment to the Aboriginal and Torres Strait Islander people of Australia.
The research was funded by the beyondblue Victorian Centre of Excellence in Depression and Related Disorders (bbVCoE). This funding body was not involved in the study design, data collection, analysis or interpretation. bbVCoE also funded the publication of the guideline documents.
Competing interests
LK is the Deputy Director of the Australian Mental Health First Aid Training and Research program, and Manager of the Aboriginal Mental Health First Aid (AMHFA) training program. AFJ is the scientific director of the Australian Mental Health First Aid training and research program. CMK is the Manager of the Youth Mental Health First Aid training program. The publication of this manuscript may benefit the AMHFA training program by advertising the concept of mental health first aid for Aboriginal Australians.
Authors' contributions
LMH carried out the systematic literature search, was involved in panel member recruitment, drafted the surveys, carried out the data collection and analysis, chaired the working group which discussed and modified the survey and guideline drafts, drafted the guidelines, and drafted the manuscript. AFJ participated in the conception and design of the Delphi research protocol, was co-ordinator of the research, participated in the working group and helped with the drafting of the manuscript. LGK was involved in design and co-ordination of the study, participated in panel member recruitment and participated in the working group. CMK was involved in design and co-ordination of the study, participated in panel member recruitment and participated in the working group. RLL participated in the systematic literature search, panel member recruitment, drafting the surveys, and data collection and analysis. All authors read and approved the final manuscript.