Farming, including the wider agricultural industry, has one of the highest rates of mortality of any industry [1], accounting for 1.5% of the British economy but 24% of all workplace deaths [2]. As well as work-related accidents, depression in farmers is increasing and suicide rates are the highest in any occupational group [3, 4]. In 2019-20 133 people involved in UK agriculture took their own lives (ONS). Farming has higher rates of suicide than the national average and other rural males [1], with the risk of suicide in specific agricultural roles such as crop harvesting and rearing animals almost twice the national average. Farmers are also more likely to report thinking that life is not worth living [3, 4]. The problem of poor mental health in farming is not unique to UK, with reports of health issues, burnout, anxiety and depression etc. in Nigeria, Finland, Norway, Canada, and Australia [5]. Two useful reviews have also been undertaken, focusing on north America [6, 7]. Four out of five farmers in Scotland under the age of 40 consider mental health to be the biggest problem facing the agricultural community [8].
Farmers have been found to have lower rates of health seeking behaviour for mental illness than the general population, and suicide in farmers may be more likely to be impulsive [3]. Although, despite the conclusion that nearly all farmers who took their own life showed clear intent, suicide in male farmers has also been found to be an end point to a series of difficulties that have built up over time rather than a reaction to an immediate crisis [1].
Higher rates of suicide may therefore be due to easier access to lethal means and a more pragmatic view of death [1]. Farmers are more likely to have access to firearms, although changes to the law for gun ownership in England and Wales in 1989 means hanging has now taken over as the principle method of suicide [1].
Mental health pressures on the agricultural community
Farming has a unique mix of intertwined circumstances that are potentially hazardous to mental health, such as social isolation, long hours, variable income due to circumstances out with one’s control such as the weather, [1, 9]. Stress is linked to depression and high level of stress have been observed in farmers [10]. Compared to the general population, Norwegian farmers were more likely to report that life was not worth living [9].
Isolation and loneliness and rurality
Farmers and agricultural workers both live and work almost exclusively in rural areas, which is almost unique amongst occupational groups [1, 3]. Social and geographical isolation has been found to impact on mental wellbeing in farming communities, with many farmers experiencing isolation and loneliness [3, 11]. Rural areas in general suffer from geographical isolation, lower levels of educational attainment, worker shortages, young people moving away, and difficulty accessing appropriate healthcare [5, 12]. Social support, including emotional and practical support, is a protective factor in countering stress [9]. Not having social support or anyone to confide in was a large factor in farmer suicide [3, 13].
Agricultural incomes and housing
Farm income in several countries has been dropping since 2013/14 with many farmers experiencing high stress levels due to financial challenges [3, 5, 10]. The average income from a 500 hectare farm in the UK fell from £80 000 in 1995/1996 to £2500 in 2000/2001 and less than 50% of farmers currently make a living from farming [1, 11]. Financial stress is exacerbated by the reliance on unpredictable factors such as the weather and crop/animal disease [3]. Housing is a big concern to agricultural workers and tenant farmers as housing is often tied to insecure jobs and social housing is more scarce in rural areas [3].
Farmers in the UK with farms of < 300 acres are more likely to take their own lives, suggesting that those with smaller farms suffer more stress and have less support [3]. The biggest cause of distress was unemployment, independent of financial status [13]. A discrepancy between actual income and financial aspirations was strongly related to wellbeing [9].
Family, community and social cohesion
Most farms continue to be business owned and operated within one family, meaning work, home, and family roles are often blurred [1]. Tensions can exist between different family members working on the farm, which can be exacerbated by a lack of clear succession planning [1, 11]. The farm is often also the family home and may be shared between different members of the family, making it difficult for people to extract themselves from the business. Farmers also face societal pressure to maintain a farm that has been handed down for many generations and that they in turn hope to hand to their children [9]. Farmers cite passing the farm onto their children as a reason for investing in improvements or expensive automation [9]. In summary, although the farming community can be tight-knit there is also ongoing competition from neighbouring farmers [5].
Physical demands and working hours
Farming is physically demanding work and farmers work long hours in a variety of weather conditions [1, 3, 5]. The drop in farm income is making it more difficult for farmers to employ additional labour, adding both to isolation and farmers having to manage physical work alone [9]. The larger the herd the lower the job satisfaction [9]. Farmers often find it difficult to take holidays [3]. Farmers also suffer long-term exposure to pesticides and other chemicals, which may be linked to health conditions including problems with the central nervous system [1, 3]. One third of farmers in the UK report physical health problems that are serious enough to interfere with work and experiencing long-term back pain was a predictor of suicide [3]. Increased alcohol use also increases the likelihood of mental distress [3, 13].
Unpredictable environmental factors
Whilst farmers experience a complex relationship with the uncontrollable nature of the weather and working outdoors there are also benefits from the resilience that farming brings and the benefits of farm work keeping them active [14]. Exposure to natural landscapes can be seen as a source of relaxation and prevention of mental health issues but this also brings with it the unpredictability of weather and distance from services [5, 12], and may be less preventative in an occupational setting [15].
Regulation and bureaucracy
New technology, regulation, administration, and digitalisation bring challenges for mental health [5, 11, 14]. Coping with paperwork was ranked as one of the highest stressors for farmers, who perceive a lack of support dealing with bureaucracy [3, 14]. ’Technostress’ has been used to describe the problem of having to adapt to new information and communication technology (ICT) [9]. Whilst older farmers may experience more stress of new ICT and automation, they are also more likely to have more expertise in traditional methods [9].
Gender and age
Depression in farmers increases with age and is more associated with males [16]. Males in farming could be influenced by traditional expectations of male roles within the family and wider community, as well as men being less likely to socialise with close friends outside their family [1]. Men are more likely to link their wellbeing to financial success, whereas women focus more on relationships and work-life balance [9].
Older male farmers are much less likely to access help for their mental health than women or younger farmers, and rural clinicians found wives and children were more likely to encourage older male farmers to access help [5]. As with older farmers, in a wide ranging review, mental health consultation rates for rural young women have been found to be double those for rural young men, and rural young men are less likely to seek mental health help from their GP compared to urban young men [16].
Despite reporting lower levels of depression, rural men are much more likely to take their own lives than women, which has been described as a ‘silent crisis’ [4]. Men are more likely to be concerned about stigma around mental health and farmers are more likely to enact more traditional views of masculinity such as stoicism and self-efficacy.
Women in farming have different stressors. They have reported that they sometimes have to take on more work outside the farm to bring in additional income as farming incomes drop, and take on both the stress of the farm and additional stress of managing the wellbeing of family members [1]. Women are also likely to take on the bulk of the domestic work, despite also working outside the home and on the farm [1, 9].
Mental health disorders are more prevalent in youth than at any other time in life [13]. Children and young people living in farming communities face similar pressures to other rural young people, with additional stress that is unique to farming [1, 9]. Rural young people face greater challenges than those in urban areas in accessing appropriate services and doing so confidentially and without stigma [13].
The gap in current mental health provision
Living in rural areas may make it difficult to access help for mental health needs due to a variety of factors, including lack of awareness of services available, cost of travel, lack of privacy, no local mental health services, long travel times, lack of choice of health providers, increase reliance on local GPs [1, 3, 5, 16]. Clinicians often lack training around farming as a sub-culture, for example that farmers cannot take extended periods of time off work or the difficulty of separating work and home life [3]. Farmers are often reluctant to seek help so clinicians must be aware that conversations might occur indirectly whilst they are consulting a doctor for another reason [9]. Seasonal farm workers often lead a transient lifestyle that makes it difficult to access continuity of care [1, 5].
Whilst the independence exhibited by farmers can be a positive factor in mental wellbeing, it can also be a barrier to seeking help [1, 5]. Stigma can also play a negative role in farmers accessing mental health help, with depression being seen as a ‘weakness of character’ [1, 16]. As farming communities are small, this increases the visibility and makes it more difficult for people to access help without the fear of stigma, compared to those in more urban areas [1, 3, 10].
Farmers reported believing that professional mental health help would be inadequate with long waiting times [16]. Instead, social and community connections are particularly important in rural communities and farmers are much more likely to turn to their own community for help [5, 12, 13, 17]. Farmers are more likely to talk to others in the farming community and respected individuals such as vets [18]. This could be a useful tool in educating farmers to recognise, and provide support for, mental health problems within their own community [5].
Although farming is an occupation that may contribute to high stress and poor mental health there are also positives to be taken from farming communities, such as high resilience, time spent outside, close relations, shared identities, and community cohesion [5, 9].
The UK Department for Environment, Food, and Rural Affairs (Defra) define wellbeing as ‘a positive physical, social and mental state; it is not just the absence of pain, discomfort and incapacity’, but wellbeing can be different for different individuals [9]. A recent report on farming and mental health in Wales identified a three-pronged approach of preventing uncertainty, protecting farmer’s mental health against the impact of ongoing challenges, and promoting mental health and well-being amongst farming communities [11]. The Welsh report also recognized four areas for targeting mental health: (i) raising awareness about mental well-being and support targeted to the farming sector, (ii) increasing mental health literacy amongst support agencies, (iii) partnership working in order to integrate mental health and well-being across farm facing services, and (iv) outreach programmes. However, none have been identified that evaluated to understand the acceptability and efficacy [11].
As farmers are more likely to turn to each other for support, using the existing farming network could be a key target for mental health support [13]. Farmers report the most benefit from chatting to others who understand the farming life [9, 10]. Other farming specific approaches identified have included promotion in farming media, educating younger people in the farming community, and targeting mental health advice, support, and counselling to rural areas, along with other existing networks such as sports clubs, training providers, religious groups [3, 13]. Farmers are more likely to seek help from their own communities or from members within their communities (such as vets) or to use anonymous support such as the internet or self-help booklets [18].
Cognitive behavioural therapy (CBT) is a psychological therapy with the best established evidence for the management of common mental health problems [19]. CBT has advantages in that it can be completed in a relatively short period of time compared with other talking therapies; its structured nature means it can be provided in different formats (including remote and self-directed formats); and it teaches practical strategies that can be used in everyday life. Interactive computerised CBT has been found to be acceptable in U.S. rural communities in relation to privacy, accessibility, user-friendliness and cultural appropriateness [20].
There is also growing evidence from other areas that self-help interventions can be a low-cost and wide-reaching method of delivering behaviour change information, whilst reducing travel time and stigma (Emma paper). Interventions delivered by SMS text messages have been used to target hard to reach groups, such as those from deprived areas, heavy drinkers, or illicit drug users. Behavioural targets have included smoking cessation, binge drinking, weight loss, physical activity, and medication adherence [21,22,23]. However, there is no current knowledge concerning preferences and acceptability or up-take of remote interventions by farmers in the UK.
This study was undertaken in Scotland. The south of the country generally contains more fertile, larger farms than in the north of the country. Many farmers and agricultural workers live on small holdings, and have diversified to obtain more than one source of income, for example, by having a part time job, which supplements their farming income.
Aim and research questions
The focus of this qualitative study was to inform a pilot RCT of two mental health interventions: a Cognitive Behavioral Therapy package “Living Life to the Full for Farmers” (LLTTFF) and secondly a social and emotional support service that includes a telephone helpline, which is staffed by mental health first aid trained staff and volunteers from the Royal Scottish Agricultural Benevolent Institution, delivered separately or in combination as a psycho-social intervention. Living Life to the Full is based on a long standing program of research, which has subsequently been tailored for different audiences [24]. The helpline grew out of the farming community and was experientially developed over time, based on the experience of staff.
The two study aims were to:
The aims linked to two broad sets of research questions:
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1.
What are the preferences of farmers regarding remote/anonymous support for their mental health? What do interventions designed for farmers look like and how should they be delivered?
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2.
What are the barriers and facilitators for reaching people from the farming community to engage them in an intervention to improve mental health?