Four mental health services were identified as conducting community development and community support projects. The community development and support approach is not common in mental health services. These four community development projects represent only 2.7% of all the 149 projects taking place in mental health service settings. Two of the four projects are using genuine participatory strategies involving young people.

The Southern CAMHS in South Australia is running a program called Community Health Adolescent Murraylands Peer Support (CHAMPS). CHAMPS has set up a youth forum which provides young people with the opportunity to voice their concerns about mental health issues. A Youth Access and Resource Network (YARN) which provides a Youth to Youth telephone support network will be established on a four month trial basis. The program also incorporates a series of task orientated working groups made up of young people within the local community. The task groups organise camps, media liaison, conferences, Youth Access and Research Network (YARN), Youth Weeks and other activities.

A program based at the Women’s and Children’s Hospital Division of Mental Health in Adelaide is entitled ‘Partnerships with Young People: Working with Young People to improve mental health’. The overall goal is to increase the capacity of the community to promote the mental health of young people. The program aims to work in partnership with young people, communities and schools to increase knowledge among young people, parents, teachers and the wider community of protective factors that contribute to positive mental health, increase access to mental health information and services, enhance social skills of young people. One of the strategies used to increase community and youth participation in mental health promotion programs is the provision of small grants to community organisations for projects that are consistent with the program goals.

The youth suicide prevention literature has also raised concerns about the effectiveness and safety of suicide education programs. Most research has focused on school-based education programs however the findings are generalisable to other community education. Reviews of this literature conclude that changes in knowledge and attitudes in desired directions are modest at best and that young people in the higher risk groups sometimes show changes in negative directions (Hazell in Hazell & King 1996; Shaffer, Garland, Vieland, Underwood & Busner 1991). Even proponents of suicide education argue that such activities must be soundly integrated into comprehensive whole-of-school, primary prevention or early intervention programs (King in Hazell & King 1996; Kalafat & Elias 1995).

• build healthy public policy;

• create supportive environments;

• strengthen community action;

• develop personal skills;

• re-orient services.

The WHO community development approach to health promotion and primary health care is based on the recognition that the determinants of health and wellbeing include structural and social factors such as

"peace, shelter, education, social security, food, income, empowerment of women, a stable eco-system, sustainable resource use, social justice, respect for human rights and equity" (WHO 1997).

WHO recommends community development as particularly important when working to improve the health of people from socioeconomically disadvantaged and marginalised communities. Interventions that address the structural and social determinants of health are seen as essential for improving health outcomes and reducing health inequalities affecting such populations, especially rural, remote and indigenous communities. The input of people from these communities is seen as critical to the development of services and programs that are sensitive and appropriate to their needs. Community action is endorsed as the key strategy for achieving these conditions when they are lacking. Local community action may generate the physical resources, infrastructure or social conditions by itself or it may seek to obtain these by influencing public policy.

Voth & Jackson (1981; cited in Bracht 1990) have identified that citizen groups must be able to create, sustain and control an effective organisation, that their authority must be clearly defined and that resources must be available. Other important factors identified by Bracht (1990) include clearly stated roles and time commitments for community participants and the building of planned reinforcement (recognition) of citizen participants into program development and design. A recent Australian study of consumer and community involvement in mental health service development identified the importance of providing support and resources for at least a period of time. A diversity of support structures and other mechanisms are required to allow consumers and community members with different skills, abilities, interests, life circumstances as well people from different cultural backgrounds to be involved (Sozomenou, Mitchell, Fitzgerald, Malak & Silove 1999).

In Australia, involving local people as partners in all stages of program development and service provision is increasingly recognised as essential to program development in rural areas, primarily as a means of ensuring sensitivity to the diversity of rural communities (Wyn, Stokes & Stafford 1997). Empowerment of local people to carry on the work of programs after funding ceases is also essential for sustainability in rural areas.

A community development approach is also widely acknowledged as particularly appropriate for ensuring cultural sensitivity to the needs of indigenous people because of its emphasis on a holistic conception of health and the central importance of self-determination for indigenous communities. Aboriginal conceptions of health stress not just the physical and emotional wellbeing of the individual but also the social, cultural, and emotional wellbeing of the whole community (Anderson 1997). The importance of self-determination for indigenous communities is also widely recognised as critical for their health and wellbeing (eg Swan & Raphael 1995).

Similarly the Ottawa Charter states that "to reach a state of complete physical, mental and social wellbeing, an individual or group must be able to identify and realise the aspirations to satisfy needs and to change or cope with the environment" (WHO 1986). By emphasising the importance of interventions that target structural and social determinants of community wellbeing, and by seeking to involve all sectors of the community in the development of solutions the community development model also provides a practical framework for supporting a strategic response that matches holistic conceptions of health.

• Inadequate attention to structural and social determinants of community wellbeing; and

• Inadequate involvement of young people.

Community development in the WHO model is essentially about securing the basic physical and social conditions necessary for community wellbeing. Numerous writers have emphasised the importance of structural changes and social factors in understanding the increase in youth suicide rates in industrialised countries. Most well documented in Australia are the significantly reduced employment opportunities for young people that have occurred over the past 30 years, especially in the 1990s, and increased inequalities of opportunity due to economic restructuring (Morrell, Taylor & Kerr 1998; Probert 1995).

Reduced employment opportunities for young people have been argued as contributing to a lengthening of the period of dependency and increased strain on the family (Maas 1990; Polk & Tait 1990) as well as a reduction in access to experiences which form the basis of worth and status in our society (Polk & Tait 1990). Other strong themes in the sociological literature on young people include the continued exclusion of young people from decision-making processes (Cronin 1997; van der Veen 1994; Vick 1993) and the increasing exclusion of young people from public spaces due to the expansion of private interests (Malone & Hasluck 1998; White 1996).

Structural problems are central to an understanding of the situation facing young people living in rural and remote areas of Australia and indigenous communities. Researchers who have demonstrated more rapid increases in youth suicide rates in some rural areas have hypothesised that structural and social changes are the key factors underlying this trend (Cantor & Slater 1997; Dudley, Kelk, Florio, Howard & Waters 1998).

Ample research, and young people themselves, indicate that problems such as high unemployment and lack of access to appropriate ongoing education and training opportunities are contributing to ongoing emigration of young people from rural towns and increased demoralisation among those who remain (Wyn, Stokes & Stafford 1997). These factors as well as increased population movements following availability of employment (often seasonal) and housing is contributing to increased social inequality and decreased social cohesion in many rural areas (Wyn et al 1997). Young people living in many rural areas also face lack of access to appropriate health services, transport, and accommodation.

Wyn et al (1997) argue that the effects of class inequalities, gender/sexuality factors, and Aboriginality in rural areas serve to preclude a real sense of belonging for many.

It is also notable that only 8 community development and community support projects were found to target indigenous populations while 5 target the risk factor of generalised/socioeconomic disadvantage. Only one project was found to be addressing the problem of unemployment. This further suggests that insufficient attention is being paid to structural factors such as social inequality.

Writers concerned with the structural problems affecting young people’s wellbeing recognise that solutions lie well beyond the reach of staff within health and welfare service organisations or individual members of communities. It has been argued that these problems require a commitment from the whole of government and the whole of community to rebuild declining social infrastructure whose development has not matched population increases and community needs (Morrell, Taylor & Kerr 1998).

In the absence of broad social programs that are capable of modifying the structural determinants of socioeconomic inequalities, localised community development programs that provide people with opportunities to identify and address certain local concerns may provide a starting point in counteracting the impacts of structural factors. In this regard, recent research has identified a sense of ‘control of destiny’ as an important mediator of social disadvantage in the determination of a range of health outcomes (Marmot, Bosna, Hemingway, Brunner & Stansfield 1997; Syme 1998; Syme & Swan 1998). There is also evidence that such programs can develop psychological characteristics such as self efficacy and optimism essential to ongoing motivation for positive social action and mental health, even in highly disadvantaged and marginalised groups of young people (Paster 1986). Community development is also a strategy that addresses itself to a definition of resilience that encompasses the characteristics of mentally healthy communities, not just mentally healthy individuals.

Community development also provides a vehicle through which communities can challenge some of the moral and ethical values such as individualism and materialism that have been hypothesised as underlying high youth suicide rates in modern Western cultures such as Australia (Eckersley 1993, 1995).

Community development implies involvement of the people who are the primary recipients of programs. Young people are the primary recipients of most suicide prevention programs. Very few community development projects in the Stocktake appear to have successfully involved young people. The projects that were most highly consistent with the general principles of community development tended to target the general population and while community involvement was inclusive of people from a wide variety of backgrounds, young people rarely featured as key participants.

A small number of projects indicated that they involved young people in consultations during program development or involved young people in the implementation of activities. Only two projects appear to be controlled by young people: Northcliffe Youth Voice, and the NYSPS Projects based at Kyogle Youth Action.

Community development is about creating opportunities for individuals, particularly marginalised individuals to contribute to the community in a meaningful way. It is noteworthy that this idea of meaningful involvement with community has been identified as centrally important in sociological theories of suicide, dating back to 1897 with Emile Durkheim (Giddens 1978). Key concepts in Durkheim's thesis are those of anomie and opportunity structures. Opportunity structures include social and cultural norms, values and institutions that provide opportunities for people to engage with and be involved in the activities of the community. Anomie is a property of social systems, a disintegration of social cohesion and connectedness that results when social structures fail to provide these opportunities for engagement and involvement.

Community development is about ensuring that communities provide these opportunity structures. Paid employment is the opportunity that young people desire most. Recreational activities are a poor substitute. Involvement in the planning, implementation and evaluation of community development programs is one of the only opportunities that many young people in rural and remote communities have to make a recognised contribution. The potential of this strategy in meeting this need is yet to be fully realised.

The Communities That Care Program developed by Hawkins and Catalano and colleagues from Seattle in the United States (Hawkins & Catalano 1992) is a community development program that shows considerable promise in developing protective factors and reducing risk factors in both communities and individual young people. The program is based on the social development model (Catalano & Hawkins 1996; Catalano, Kosterman, Hawkins, Newcomb, Abbott 1996; Hawkins, Catalano, Morrison et al 1992) which posits that bonding or connectedness to a pro-social group (family, peers, school, community) is the core protective factor against outcomes such as antisocial behaviour and substance misuse. Bonding is determined by three factors: opportunities (for meaningful involvement), skills and recognition or reinforcement. The Communities That Care process involves mobilisation of whole communities to develop and implement local community action plans. Action plans are informed by the collection of baseline data about the prevalence of a wide range of risk and protective factors affecting young people in specific communities. These baseline data provide a mechanism for rigorous evaluation of the impacts and outcomes of the program over time.

A trial of this program has recently been initiated by the NSW Centre for the Advancement of Adolescent Health in the Western Sydney Area Health Service. The Centre for Adolescent Health in Victoria is currently conducting a large scale survey of school students in a number of rural and urban areas of Victoria using a version of the Communities That Care survey, modified to be suitable for Victorian schools. It is hoped that the information generated by the survey will stimulate up take of the Communities That Care program by school communities.

Evaluation of the four community development projects funded under the National Youth Suicide Prevention Strategy will also provide some valuable data, particularly regarding the impacts of community-service networks in rural communities.

Only 4.2 percent of the programs in the First Stocktake could be confidently classified as embodying the core principles of the community development approach. There would appear to be considerable room for expansion of this approach to youth suicide prevention.

Community development is a strategy that is widely used throughout the world to develop and support health services and health promotion programs. It is recommended by the World Health Organisation as critically important when working to improve the health of disadvantaged communities and is widely recognised as essential when working with indigenous peoples. As such community development is a strategy that is ideally suited to the prevention of youth suicide in the Australian context, particularly in rural areas and with communities that have been identified as at higher than average risk for youth suicide.

More generally community development is a strategy that lends itself better than any other to addressing one of the most important understandings to emerge from recent literature on youth suicide prevention, the concept of connectedness. Connectedness to community is essentially about feeling that one has a place and a meaningful role to play in ones social environment.

It is important to bear in mind that being based in a community organisation does not necessarily make a program or activity consistent with the principles of community development. The data considered in the current analysis suggests that most of the programs and activities based in community organisations are community support and community education projects rather than community development projects. While many community organisations have emerged from a community base they do not necessarily continue to function in a manner consistent with ongoing community empowerment. While they may involve volunteers in the conduct of their work, this work is not necessarily oriented towards involving the recipients of programs and services. It must be acknowledged however that the First Stocktake may not have captured adequate information about such involvement.

Of the 39 projects in the First Stocktake that have been identified as utilising a community development approach, only a few appear to have included young people among the participants or partners in program development and implementation. It is unlikely that such involvement has been underreported by respondents as its critical importance would be recognised by all those attempting this challenge. This suggests a serious gap in practice that requires urgent attention through applied evaluation research.

Even so, the Second National Stocktake of Youth Suicide Prevention Activities has sought to improve the reliability of data about projects’ involvement of young people. Focused investigation and dissemination of results concerning successful strategies for enhancing young people’s involvement will be a priority in the analysis of data from the Second Stocktake.

References

Anderson I (1997) Mental health and Aborigines. Health Promotion Matters, Issue 5, 4-7.

Bracht N (1990) Citizen participation in community health: principles for effective partnerships. In B Badura & I Kickbusch (eds) Health promotion research: Towards a new social epidemiology. WHO Regional Publications, European Series No 37, 477-496.

Cantor CH & Slater PJ (1997) A regional profile of suicide in Queensland. Australian and New Zealand Journal of Public Health, 21(2), 181-186.

Catalano RF, Arthur MW, Hawkins DJ, Berglund L & Olson JJ (1998) Comprehensive community and school based interventions to prevent antisocial behaviour. In R Loeber, DP Farrington et al (eds) Serious and violent juvenile offenders: Risk factors and successful intervention. 248-283, xxv, p,507.

Catalano RF & Hawkins JD (1996) The Social Development Model: A theory of antisocial behavior. In JD Hawkins (ed) Delinquency and Crime: Current Theories. Cambridge University Press, New York.

Catalano RF, Kosterman R, Hawkins JD, Newcomb MD, Abbott RD (1996) Modeling the etiology of adolescent substance use: a test of the social development model. Journal of Drug Issues, 26(2), 429-455.

CDHFS (1997) Youth Suicide in Australia: the national youth suicide prevention strategy. Australian Government Publishing Service, Canberra.

CDHFS (1998) The Second National Mental Health Plan. Australian Government Publishing Service, Canberra.

Dudley MJ, Kelk NJ, Florio TM, Howard JP & Waters BGH (1998) Suicide among young Australians, 1964-1993: an interstate comparison of metropolitan and rural trends. Medical Journal of Australia, 169, 77-80.

Eckersley R (1993) Failing a generation: The impact of culture on the health and well-being of youth. Journal of Paediatrics and Child Health, 29, Suppl. 1, S16-S19.

Eckersley R (1995) Values and visions: Youth and the failure of modern Western culture. Youth Studies Australia, 14(1) Autumn, 13-21.

Fawcett SB, Lewis RK, Paine-Andrews A et al (1997) Evaluating community coalitions for prevention of substance abuse: A case of Project Freedom. Health Education & Behavior, 24(6), 812-828.

Harachi TW, Ayers CD, Hawkins JD, Catalano RF (1996) Empowering communities to prevent adolescent substance abuse: Process evaluation results from a risk and protection focused community mobilization effort. Journal of Primary Prevention, 16(3), 233-254.

Hawkins JD, Catalano RF and Associates (1992) Communities that Care: Action for drug abuse prevention. Jossey-Bass Publishers, San Francisco.

Hawkins JD, Catalano RF, Morrison DM, O’Donnell J, Abbott RD & Day LE (1992) The Seattle Social Development Project: Effects of the first four years on protective factors and problem behaviors. In J McCord & RE Tremblay et al (Eds) Preventing antisocial behaviour: Interventions from birth through adolescence. Guilford Press, New York, NY, p 139-161.

Hazell P & King R (1996) Arguments for and against teaching suicide prevention in schools. Australian and New Zealand Journal of Psychiatry, 30, 633-642.

Giddens A (1978) Durkheim. The Harvester Press, Sussex.

Kalafat J & Elias MJ (1995) Suicide prevention in an educational context: Broad and narrow foci. In MM Silverman & RW Maris (Eds) Suicide Prevention: Toward the Year 2000. The Guilford Press, New York.

Maas F (1990) The effects of prolonged dependence on young people becoming adult. Youth Studies, February, 24-29.

Malone K & Hasluck L (1998) Geographies of exclusion: Young people’s perceptions and use of public space. Family Matters, 49, 20-26.

Marmot MG, Bosna H, Hemingway H, Brunner E & Stansfield S (1997)

Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet, 350(9073), 235-239.

Mitchell P (1998) The National Youth Suicide Prevention Strategy. Youth Suicide Prevention Bulletin No 1, 3-6.

Mitchell P (1999) First National Stocktake of Youth Suicide Prevention Activities: A content analysis. Youth Suicide Prevention Bulletin No 2, 2-7.

Morrell S, Taylor R & Kerr C (1998) Unemployment and young people’s health. Medical Journal of Australia, 168, 236-240.

Nutbeam D & Harris E (1998) Theory in a Nutshell: A practitioner’s guide to commonly used theories and models in health promotion. National Centre for Health Promotion, University of Sydney.

Paster VS (1986) A social action model of intervention for difficult to reach populations. American Journal of Orthopsychiatry, 56(4), 625-629.

Polk K & Tait D (1990) Changing youth labour markets and youth lifestyles. Youth Studies, 9(1), February, 17-23.

Probert B (1995) The transformation of work: social, cultural and political contexts. In J Spierings, I Voorendt & J Spoehr. Jobs for young Australians: Selected Papers of an International Conference, Adelaide, August 1995.

Shaffer D, Garland A, Vieland V, Underwood M and Busner C (1991). The impact of curriculum-based prevention programs for teenagers. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 588-596.

Sozomenou A, Mitchell P, Fitzgerald M, Malak A & Silove D (1999) Partnerships with consumers, carers, and communities from culturally diverse backgrounds in the development of mental health services. Australian Transcultural Mental Health Network.

Swan P & Raphael B (1995) "Ways Forward" National Consultancy Report on Aboriginal and Torres Strait Islander Mental Health. Australian Government Publishing Service, Canberra.

Syme SL (1998) Social and economic disparities in health: thoughts about intervention. Millbank Q, 76(3), 493-505.

Syme SL & Swan N (1998) Mastering the Control Factor. Radio National: The Health Report. 9/11/1998.

Van der Veen EW (1994) Young people and the environment. Youth Studies Australia, 13(4), Summer, 24-29.

Vick M (1993) On the margins of their own education: Constructing the relations between youth and schooling. Youth Studies Australia, 12(4), Summer, 30-34.

White R (1996) No-Go in the fortress city: Young people, inequality and space. Urban Policy and Research, 14(1), 37-50.

WHO (1978) Alma Ata Declaration. WHO, Geneva.

WHO (1986) The Ottawa Charter for Health Promotion. WHO, Ottawa.

WHO (1997) The Jakarta Declaration on Health Promotion into the 21^st Century, WHO, Jakarta.

Wyn J, Stokes S & Stafford J (1997) Challenges and resilience factors for young people living in rural Australia in the 1990s. Proceedings of the National Rural Public Health Forum, 12-15 October, Canberra.