Farming is an occupation that involves numerous physical and psychological hazards. In recent years, Australian farmers have faced increased exposure to natural disasters, particularly prolonged droughts, fires and floods [1]. Farmers often both live and work on their farms, with family members across multiple generations being involved, consequently blurring the line between work, home, and family roles, which adds to their stress [2-5]. Financial pressure, loss of control, and uncertainty about the future are also associated with environmental stressors and are thought to significantly increase the risk of farmers experiencing mental health problems [3,6,7]. The inability to control these stressors and the sense of hopelessness and entrapment they can engender are thought to be potential risk factors for rural male suicide [8]. Indeed, studies have found a significantly higher incidence of suicide among rural and remote populations compared with metropolitan populations [9,10] and between agricultural workers compared with other employed rural people [11,12].

At the same time, farmers are known to face numerous barriers to help seeking from traditional physical and mental health services. These barriers are structural, such as the limited availability of medical and psychological professionals [13], and attitudinal [14,15]. For generations, Australian farmers have been characterized as being independent, stoic, and skilled at solving practical problems [2,16]. However, in the context of help seeking for the management of psychological distress, traits such as stoicism, independence, and a strong desire to keep personal matters private, may in fact be maladaptive [17]. Recent Australian research has found that farmers were half as likely to have sought help from a general practitioner (GP) or mental health professional in the previous 6 months compared with other employed rural people [13].

Fortunately, the National Broadband Network has now been rolled out in Australia, increasing rural access to internet sites and services [18]. A recent survey of 2000 businesses within the Australian agricultural sector found that up to 95% now have access to the internet [19], and the use of the internet to access health services is known to be increasing in the rural population [20,21].

The delivery of evidence-based interventions on the web offers opportunities to overcome some traditional barriers to help seeking faced by these populations. There is emerging evidence that computerized cognitive behaviour therapy (CCBT) interventions are acceptable in rural communities [22], and an unpublished example of a CCBT intervention designed to address anxiety, depression, and social functioning in Scottish farmers is Living Life to the Full (although it reported limited success) [23]. Given farmers’ numerous barriers to help seeking and the strong perception within the industry that outsiders (including health professionals [24]) fail to understand their needs and way of life, the development of such interventions needs to be done carefully. Consumer involvement in intervention design ensures that interventions are relevant, usable, and culturally appropriate for the target audience [25,26], which in turn can improve intervention success [27].

The purpose of this paper is to describe the co-design of content and functionality of a website that aims to help farmers adopt transferable coping strategies that are likely to help them effectively cope with stress. The second purpose of this research is to test the acceptability and feasibility of this website in a broader Australian farming population. The development of this website involved the sequential integration of research evidence, expert knowledge, and farmers’ preferences. Methodological guidance and examples such as the studies by O’Brien et al [28] and Short et al [29] and the work outlined in this paper, provide a transparent account of intervention co-design and development upon which other clinicians and researchers can build.

Ethics approval for this project was granted by the University of South Australia human research ethics committee (application ID 0000035637). A 9-stage co-design process that included the sequential validation and optimization of evidence and expert opinion with farmers’ wants and preferences was used in a process similar to that described by Easton et al [30]. Each stage resulted in outputs (described in the Results section) that were used to inform the next stage of development. Figure 1 summarizes these stages.

In total, four key methodological approaches informed these stages: (1) synthesis of evidence from prior research to understand the problem and possible solutions (stages 1 and 2); (2) intervention mapping techniques to chart the logic of the intervention (including key acceptance and commitment therapy [ACT] processes or performance objectives, determinants of change, relevant behavior change strategies, and persuasive system design elements; stage 3) [31-33]; (3) a person-based approach via the involvement of farmers as co-designers [34,35] (stages 2, 5, and 7); and (4) iterative updating based on user feedback that allows for ongoing improvements to be made to the website (stages 8 and 9), which is informed by adaptive trial design methodology [36].

All farmers who participated in the research were adults who owned or played an active role in the operation of a farming or pastoral enterprise in Australia (or the spouse of someone who did), were fluent in English, had access to the internet, and had access to a mobile phone with reliable connection or reception at least once per week. The following 9-stage iterative process was conducted over a 3-year period.

Key learnings from published works [6,14,37-40], our own unpublished work, and views from relevant experts across the agricultural, financial, and mental health fields were summarized by the research team. The research team was well-placed to prioritize learnings, given their extensive knowledge of agriculture (KMG, SB, JD, and AB), behavior change interventions (DT, CES, and KMG), web-based interventions (KG, CES, and SB), and rural health (KG, SB, JD, AB, and NH) and mental health (KMG and DT).

The logic of the intervention was systematically developed by KG to ensure that important intervention targets (identified in stage 1 and explained further in the Results section) were addressed and that the effectiveness of the targets could be systematically assessed later. This included mapping the module content to the core ACT processes (acceptance, cognitive defusion, being present, self as context, values, and committed action [43]). It also included ensuring that relevant behavior change techniques [31] (outlined in the Results section) were included throughout to help address each of the behavioral determinants (ie, knowledge, skills, emotion, action planning, beliefs about capabilities, beliefs about consequences, motivation and goals, and memory, attention, or decision-making processes) thought to influence whether a user would successfully adopt the core ACT processes. The selection of these behavior change techniques was based on what has been previously shown to effectively address relevant behavioral determinants [31]. Although some overlap with behavior change techniques and persuasive system design elements is acknowledged, persuasive system design elements (as defined by Kelders et al [33] and outlined in the Results section) were also built into the intervention logic to help maximize user engagement and limit dropout.

The text, video, and audio content contained within each website module were then drafted by KG by integrating the key design principles from stage 1, farmers’ preferences established in stage 2, and the intervention logic identified in stage 3. Her first-hand experience of using ACT in her role as a clinical psychologist, living on a farm in a farming family, developing self-help mental health materials for rural populations, and formal training in intervention mapping, assisted with this process. The general principles of adult learning [44] were also considered.

The purpose of this stage was to produce a working intervention prototype. The research team supplied the website content and design documents developed in earlier steps to a web developer and then worked in close collaboration with them to ensure that lessons from previous stages were integrated into the website and technical glitches were addressed. The prototype was made public in February 2018.

The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000506392) on April 3, 2017.

Following the acceptability assessment of the prototype outlined above, the website was adapted to improve user experience. This aligns with the adaptive trial design methodology [36] and the person-based approach to intervention design of Yardley [34] by continuing to incorporate user feedback after live testing of the intervention.

A summary of our evidence synthesis and the key overarching design principles identified from this are shown in Table 2. In brief, farmers face many barriers to accessing traditional face-to-face mental health services, including a lack of service availability, cost, time, and concerns about confidentiality. They also perceive that outsiders (including health professionals) often do not understand the issues they face. The types of challenges that cause farmers the most stress are those that are beyond their control, and these are the things they feel least equipped to cope effectively with. However, acceptance has been shown to be an adaptive coping strategy for farmers in this context [40]. Together, these factors suggest that a new web-based mental health and well-being resource could help overcome existing barriers to engagement by being an accessible, confidential source of farmer-focused, practical self-help strategies based on ACT [51] if co-designed with farmers.

As reported elsewhere [41], farmers said that they would like a web-based resource that is easy to navigate and compatible with multiple devices and internet connections, as well as their sporadic internet use around work schedules. They preferred a casual and friendly tone, minimal use of jargon, and the inclusion of humor, and they requested information on when and how to seek additional professional help. They also said that they wanted a resource that was authentic, that reflected their challenges and way of life, and that they could see the benefits from quickly. There was no evidence of themes that contradicted the key design principles identified in stage 1.

Mental health professionals provided guidance on the appropriateness and safety of the content and suggested minor changes. These included grammatical edits, alterations to simplify the language (eg, being clear about your values changed to knowing what matters to you), and adding a few more detailed explanations and metaphors to explain key concepts (eg, your mind as an ideas generator). Additional reflective questions were also suggested, for example, “what happened to the thought?” following an exercise to help let go of distressing thoughts. It was also recommended that additional text be added to help normalize the fact that one’s ability to focus and shift attention may vary from day to day.

Overall, participants felt that the module content was acceptable and relevant to farmers. Changes made to the content included repeating icons throughout the modules to guide the user, the inclusion of a summary of content at the beginning of each module, the inclusion of additional cartoons, and the removal of some references to stress, which farmers felt their peers would find off-putting (eg, under pressure rather than stressed). Additional methods for tailoring the content to farmers were also identified. For example, a co-designer suggested likening sorting out thoughts into different categories, to drafting sheep into different pens.

A web-based intervention prototype that could be tested by users was created, and wireframes to summarize the website’s structure were developed, as detailed in Figure 2. Internal testing by members of the research team resulted in comprehensive lists of hundreds of technical revisions that needed to be made by web developers to improve the user experience.

This stage resulted in several changes to the look and feel of the website, such as a change of font color to improve readability and the inclusion of additional banner photographs featuring machinery and images of younger farmers to ensure broad appeal. Suggestions for improvement also included some website usability issues, such as the ease of saving and returning to a module later. Guidance was also provided on when would be a suitable time of year to advertise and launch the website (ie, not in January when many Australian grain farmers are on holidays after busy harvests in the lead up to Christmas). The website was made public in February 2018.

In response to the findings detailed above, several changes were made to the website. To improve clarity and brevity, minor wording changes and reductions in the text were made in all modules. Audio recordings were professionally rerecorded to improve quality. Edits to the text were also made to acknowledge that accessing a GP can be difficult for those in rural areas, that module 1, in particular, was very long because of the pre-evaluation questionnaires (but that subsequent modules would involve less reading and more activities), and that questionnaires were standardized and only included for the purposes of website evaluation (not part of the intervention itself; eg, cognitive fusion). To improve usability, additional reminders were included about the inability to go back and the need to double tap responses if using an iPad or iPhone. A Things to remember when using this website page was added to emphasize these key messages. The save and continue button was also made more prominent. To improve relevance, additional images and rotating banners were included on the home page to reflect the broader range of demographics of users accessing the website. To improve adherence, additional SMS text messaging reminders were added 7 days after registration if module 1 was not completed and 28 days after the preceding module was completed if the next module was not started for modules 2 to 5 (Figure 2). Module 3 was shortened by removing 1 value clarification exercise that gave users feedback on values they may not be living consistently with (based on their answers to a questionnaire; Table 3). The revised module 3 retains an exercise asking users to select values that are very important to them, think about whether these values drive their behavior and decision-making, and how they might plan to live more consistently with these values in the future.

This paper outlines the process of integrating evidence from the literature and consumer and expert advice to create a resource that is informed by evidence and perceived as acceptable and relevant by its users. A strength of this intervention development process was the clear, iterative methodology that allowed the integration of different types of knowledge at each step. This involved the synthesis of evidence from prior research and intervention mapping to identify key determinants of behavior change, relevant behavior change and engagement strategies, and the involvement of farmers as co-designers throughout the process to ensure the acceptability of evidence-based strategies. In particular, the farmers’ feedback was used to inform the initial design of the website, amend the prototype before launch, inform the timing of the launch, and update the intervention following acceptability and usability testing of the prototype. At all stages, farmers’ feedback was prioritized and integrated with research evidence and expert opinions. These approaches enabled us to develop a resource that reflects the unique farming culture, is built on evidence-based approaches to mental health and well-being, demonstrates an understanding of the audience for which it was intended, and as detailed in this paper, was found to be acceptable.

More specifically, the acceptability and usability testing of the prototype that included both quantitative and qualitative components and farmers from a variety of Australian states and farm types, found that once people started a module, most completed that module. Approximately 83.6% (117/140) of users starting module 1 completed module 1, and all people who started modules 4 and 5 completed them. Importantly, acceptability with the previous module was not found to predict whether a user went on to complete the next module, which aligns with the qualitative feedback from people who did not complete every module that their main reason for not progressing was Too busy/not got to it yet. Overall, 37.1% (52/140) of people who started module 1 completed the entire 5 module intervention. Comparatively, recent studies have shown a wide variation in the rate of adherence and attrition to web-based interventions for mental health between 2% and 83% [72]. Other studies have reported that approximately 75% do not use mHealth apps more than once after installation [73]. Pleasingly, the present intervention was found to be most acceptable to those who needed it most (ie, those who were most highly distressed when they started module 1) rather than those who were most educated. These high levels of acceptability are significant, given the aforementioned reluctance of farmers to seek help [14], engage with resources targeting their mental health [37], and their general perception that existing services are not designed for them [24]. The intervention also aims to help farmers identify when and how to seek professional help and highlights the role of their local GP. In turn, this may prevent the development of severe mental health problems and facilitate access to treatment at an earlier stage, thereby minimizing the intensity of interventions required and reducing both social and treatment costs. Findings from the qualitative interviews with noncompleters (N=108) to find their reasoning for ceasing participation, also met calls for more research to aid the understanding of engagement in web-based interventions [74] and may be used to inform the inclusion of strategies for improvement in future interventions.

The only comparable farmer-focused well-being website is the aforementioned Scottish CCBT Living Life to the Full, which includes personalized support emails in addition to computerized modules [23]. That trial found that of those who logged on (N=35), only 5 (14%) completed the 5 core modules, which is much less than the 37.1% (52/140) reported in this study. Bowyer et al [23] noted that rates of attrition in their study with farmers (73.2%) were much higher than those experienced when they tested a very similar intervention with other population groups (26%-27% attrition) [75,76], reinforcing the notion that the farming population is particularly difficult to engage in health and well-being–focused interventions.

Although acceptability with the ifarmwell modules was generally high, along with the interview comments, they did highlight some areas for improvement. Following the acceptability testing reported in this paper, the website was adapted to address any concerns and improve the user experience. Changes included shortening a module, improving the quality of audio recordings, and incorporating additional SMS text message reminders, which demonstrates the value of adaptive design in building a resource that is responsive to user experiences. This aligns with the person-based approach by continuing to incorporate user feedback after live testing of the intervention [34], which is a strength of this work as it allows interventions to be responsive to the needs of the audience while remaining publicly available. The need to ensure that modules are as short as possible (or can be easily stopped and recommenced) is important for other farming-focused intervention developers to keep in mind. Our finding that farmers lack the time to engage in web-based interventions aligns with findings that more than half of the Australian farming population work ≥50 hours per week, compared with just 16% of the rest of the working population [77].

The sample was limited to those farmers who self-selected to take part in the website evaluation and may not be representative of the wider farming community [78]. Another limitation of this research is that it was not clear to many users that the questionnaires used for evaluation purposes were not part of the intervention itself, which may have contributed to the perception of module length and negatively affected user acceptability. A yellow background was used behind the evaluation components; however, in the future, this delineation should be made even clearer, possibly by having users access the questionnaires via a separate window.

We have demonstrated that a co-designed website is usable and acceptable to farmers, and many of the lessons from this research may be applied to the development of future farmer-focused interventions. However, further research is needed to systematically test the effectiveness of this intervention and examine the psychological mechanisms that facilitate changes (or otherwise) in outcomes. In the case of ifarmwell, analyses should specifically examine whether key ACT processes (Table 3) are influenced by the intervention and, if so, how they relate to any changes in distress and well-being outcomes. This would not only inform further refinements to the ifarmwell website but also help progress important gaps in knowledge about psychological mechanisms in the field of ACT [43,51].

This paper describes the first web-based intervention co-designed with farmers to help them adopt coping strategies to better manage their stress by accepting things beyond their control and living according to their values, regardless of the circumstances they face. Importantly, this paper outlines the value of a co-design approach in facilitating the development of interventions that are centered on evidence-based therapeutic approaches, that also appeal to audiences who are typically reluctant to seek help for mental health problems. It also details a comprehensive, successful website development and acceptability testing process, which may inform the development of future web-based interventions for difficult-to-reach populations.