Self-Stigma and Depression Help-Seeking in Rural Ireland

Background and Study Justification

Depression is one of the major causes of disability and disease burden in the world with more than 280 million individuals being affected (1). The latest national statistics in Ireland have shown that there are more cases of untreated depressive symptoms among rural populations than city dwellers and that this is highly a result of cultural practices, lack of access to care, and stigma about mental illness (3). Although there have been national awareness campaigns on mental health, the self- stigma on the behaviour to seek help still has a serious negative impact on those with depression (13).

Self-stigma is the internalisation of negative stereotypes, which lead to shame, low self-esteem, and unwillingness to receive treatment (9). The fact is evidenced by empirical studies in which the group of people who define mental illness as their personal weakness are less prone to disclosed symptoms and using mental health services (7,8). The situation is further exacerbated in the rural County Kerry, where there is a high emphasis on social cohesion and self-reliance that makes these internalised attitudes through delaying care delivery and worse clinical outcomes (14).

This is especially timely in the agricultural population of Ireland where the practice of seeking help is considered an indicator of your failure as an individual (4). According to a 2023 survey of Irish people, almost a half of those with mental health issues tried not to seek professional assistance because of fear of the judgment or embarrassment (11). In addition, qualitative results obtained in rural County Kerry suggest that people often turn to self-care and denial instead of professional help (10). The continuation of these behaviours leads to chronic under-treatment, suicide risk, and poor quality of life (16).

Though a few quantitative studies have investigated the prevalence of self-stigmatization, the available qualitative research does not investigate the lived experiences of depressed people in County Kerry Irish contexts. The qualitative inquiry gives an opportunity to learn more about the ways internalised stigma and help-seeking choices are formed by cultural beliefs, gender roles, and the social norms relevant in these areas (6,21).

This paper thus fills an important gap with the objective of exploring the role of self-stigma on the help-seeking behaviour of the depressed adult population in one rural county Kerry of Ireland. The findings obtained in this study can be used to develop specific mental health services and community stigma reduction initiatives to enhance the use of services and psychological comfort in rural communities.

Research Aim and Objectives

Aim

The aim is to investigate self-stigma and the effects it has on health-seeking behaviours among depressed people in County Kerry within Ireland.

Objectives

• To analyse individual perception toward and internalised beliefs on depression among adults in rural County Kerry.
• To know the outcomes of self-stigma on the choice to accept or reject professional mental health help.
• To determine socio cultural and environmental factors that support or minimize self-stigma within the rural communities.
• To produce recommendations on the stigma-reduction interventions and better access of mental health services in rural environments.

The purpose of the study is to help the public health know about the barriers that hinder timely intervention and to influence the mental health promotion policy that falls in line with the Ireland vision of Sharing the Vision. Through lived experiences, the study will provide a more subtle understanding of the functioning of stigma on both personal and community levels, which will help implement more efficient measures based on local needs.

Theoretical Background and Literature Review

The research is based upon the modified version of the Labelling Theory (MLT) suggested by Link and his colleagues according to which the stereotypes of mental illness propagated in society are internalised, and they influence self-concept and behaviour (9). In this context, people with own expectations of being discriminated against will either inaccessible themselves socially or refuse to use professional assistance to defend their identity. The process has been extensively underpinned in depression and self-stigma research work (7,25).

As it has been confirmed in recent studies, internalised stigma is associated with a lack of self-esteem, decreased empowerment, and reduced compliance with treatment (12,17). As Lasalvia et al. (16) discovered, self-stigma moderates the relationship between depressive symptoms and empowerment in a variety of cultural influences indicating that it has widespread activity. On the same note, Zhang et al. (10) found out that the self-stigma in combination with structural factors increases the unwillingness to access formal health care in rural populations. These results emphasize the role of stigma on the psyche and social sphere, particularly where there is a lack of access to mental health assistance.

It is also in Irish research which highlights the cultural aspect of stigma. Researches on farmers show that masculinity standards, privacy issues, and fear of social exclusion are among the reasons why they avoid psychological services (3,4). Similar patterns were experienced among the youth in the rural areas, whereby, the perceived expectations of the community prevent them from being open with respect to mental challenges (2). According to the Irish Times (13), there is continued stigma in the society, which further perpetuates internalised stigma to the affected individuals.

On a higher level, the Theory of Planned Behaviour (TPB) provides a complementary perspective regarding the way that help seeking intentions are predicted by attitudes, perceived norms, and self-efficacy (7,8). The integration of MLT and TPB can be used to develop a multi-dimensional perspective: MLT would be used to clarify the mechanism by which stigma can be internalised and TPB would help elucidate how internalised beliefs become behavioural avoidance.

There is scanty but not insignificant qualitative evidence on self-stigma of depressed rural Irish adults, in spite of vast international literature. Self-reliance and social norms have been highlighted in the past as significant obstacles in the case of qualitative studies in rural Australia and North America (14). Nevertheless, the peculiarities of culture that can be found in Ireland, namely, tightly-knit villages and the traditional distribution of sex roles deserve particular attention (3,19).

Overall, existing studies prove that self-stigma is a critical barrier to help-seeking even in people with depression in all settings (10,16). Nevertheless, the protest of rural Irish citizens, particularly those in County Kerry, are not represented well. The proposed study, therefore, will be able to fill this empirical and cultural gap in order to offer insights that can inform community-level mental health education and destigmatisation strategies.

Methodology

Study Design

This qualitative exploratory research paper is going to adopt semi-structured interview as a method of conducting research on the subject by exploring the effects of self-stigma on the health seeking behaviours of people with depression in the County Kerry in Ireland. The qualitative approach would be selected due to the possibility of a thorough investigation of lived experiences, beliefs, and meanings (22,23).

Past studies of similar backgrounds have been able to employ the qualitative methods of understanding mental health perceptions in rural populations (5,6). It is a research design that supports deep narrative data, which allows elucidating how personal and sociocultural variables intersect to influence stigma and facilitate help-seeking behaviours (3,14). The research will be conducted in line with the COREQ guidelines in presenting qualitative research.

Sampling

The adult population (defined as those of 18 years and above) that are clinically diagnosed with depression (and which live in a rural County Kerry) will be recruited via purposive sampling. The respondents will be identified by the local mental health support organisations, general practitioners and community centres. The purposive sampling will guarantee that the sample includes people that have varied experiences and backgrounds that address the research question (23,25).

The number of recruited participants will be about 15-20 participants in line with the principles of qualitative data saturation (20). The study will involve people who have undergone or currently experience depressive symptoms and are interested in sharing their views on the subject of stigma and seeking help. Participation will be done through informed consent. County Kerry was chosen due to its predominantly rural population and strong agricultural culture, which makes it suitable for examining stigma in close-knit communities.

Data Collection

Individual semi-structured interviews that take about 45-60 minutes will be the method of data collection. The interviews will be carried out either face-to-face, confidentially in a community setting, or through secure online communities at the choice of the participants and their availability. Research on the existing literature concerning the self-stigma and help-seeking will be used to create an interview guide (Appendix A).

Participants will be asked questions related to their own knowledge regarding depression and perceived stigma levels, coping, and views on mental health services. The interviews will be recorded with permission of the subject using audio-recording and transcribed word-to-text. Non-verbal information and the background information will be documented using field notes (20). This will foster free discussion in addition to permitting parties to facilitate discussions on sensitive issues (6,12,14). Rest of the information will be kept safely and anonymised to maintain the confidentiality.

Data Analysis

The data analyses will be conducted using thematic analysis based on the six steps of analysis of Braun and Clarke. The codes that will be used to code the transcripts will be inductive to bring out patterns and themes that are pertinent to self-stigma and help-seeking (20,23). The coding will be done manually with validation of a second researcher to increase credibility. Themes will be then viewed within the framework of the Modified Labelling Theory and Theory of Planned Behaviour (8,16). NVivo software could be applied to arrange the data and manage it systematically. Thematic analysis is appropriate in the study of intricate psychosocial life experiences, and it has been extensively applied in mental health stigma studies (5,10,14).

Ethical Considerations

The consent of the ethics committee of the concerned university and the Health Service Executive (HSE) will also be sought concerning ethics approvals. Participants will be given all information sheets and informed consent will be given in written form. All privacy and anonymity will be ensured and voluntary B. Referral to psychological support will be included in case of distress (15,23).

Strengths and Limitations

This study has a significant strength in the fact that it serves a rural County Kerry, Irish population and it deals with an under-researched field of public health (3,4). Semi-structured interviews will enable the participant to give more elaborate accounts of their experiences, with qualitative data being rich (20,23). The combination of theoretical frameworks leads to the enhancement of an analytical depth (9,18). Nonetheless, it can be assumed that any qualitative findings cannot be generalised because of small sample size and contextual specificity. Self-selection of the participants may result in bias since only the people who are less uncomfortable talking about mental health may become volunteers. Nevertheless, considering these shortcomings, the study by its exploratory nature offers a good insight into culturally sensitive interventions that will decrease stigma and enhance access to mental health care.

Timeline and Budget

The estimated duration of the project is more than six months:

Month 1-2: Ethics endorsement and recruitment.

Month 3-4: Collection of data (interviews)

Month 5: Transcription and thematic analysis.

Month 6: Reporting and dissemination.

Budgetary requirements are low, and include recording devices, transcription software and travel reimbursements of the participants (estimated EURO 500).

Implications to Policy and Practice

The implications resulting out of this study to mental health policy and practice in Ireland will be of significance. The knowledge of how self-stigma influences the process of health-seeking behaviours would be useful to the HSE in ensuring that communication of their community mental health policy is tailored around underserved rural areas such as County Kerry. The results might justify the incorporation of anti-stigma messages in the population health programs, school educational programs, and the GP training programs.

The study can inform policymakers to develop interventions that help create a culture of normalising psychological and structural barriers that may occur to seeking help, and enhance access to care early-on (4, 11, 13). Furthermore, involvement of the voices of lived experience might play a role in the national strategy frameworks such as the Connecting for Life and the Healthy Ireland strategy because the rural people should not be marginalized.

In practice, it can help mental health professionals be more empathetic, more stigma sensitive in their communication with the patients using the results. These evidence-based changes can lead to the decrease in the untreated depression rates and support the infrastructure of the mental assistance in Ireland in the long term.

References

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Appendix

Appendix A: List of Abbreviations

Abbreviation	Full Term
HSE	Health Service Executive
WHO	World Health Organization
GP	General Practitioner
NVivo	Qualitative Data Analysis Software
COREQ	Consolidated Criteria for Reporting Qualitative Research

Appendix B: Interview Topic Guide

I would like to thank you that you have accepted to participate in this interview. I am currently carrying out a research on the selected topic of self-stigma and health-seeking behaviour in people with depression in rural Ireland. This is supposed to see what you have gone through and what you think, no correct and wrong; It is just a way of knowing. All the information provided by you will be confidential and anonymous. You may discontinue the interview or forego any question. The interview will last approximately between 45-60 minutes and it will be audio-recorded, with your consent.

Main Interview Questions

No.	Question	Purpose
1	Can you tell me a bit about your experience living with depression?	To explore participants’ understanding and lived experience of depression.
2	How would you describe the attitudes towards depression in your community?	To identify perceived community stigma and social norms.
3	What comes to mind when you hear the term “self-stigma”?	To elicit personal definitions and awareness of self-stigma.
4	Have you ever felt judged or ashamed because of your mental health condition? If so, can you describe an example?	To explore internalised stigma experiences.
5	How do such feelings influence your willingness to talk about or seek help for depression?	To link stigma with help-seeking behaviours.
6	What kind of support systems (family, friends, community) have you found helpful or unhelpful?	To identify protective and risk factors.
7	Have you accessed mental health services before? What influenced your decision to do so or not?	To understand decision-making in help-seeking.
8	What barriers make it difficult for people in rural areas to seek help for depression?	To explore structural and cultural barriers.
9	What changes do you think would make it easier for people like you to seek help?	To collect participant-driven recommendations.
10	Is there anything else you’d like to share about your experiences or thoughts on mental health stigma?	To allow additional insights or closing remarks.

I am very grateful that you have been able to share your experiences today. Your input is highly useful and will contribute to the enhancement of the knowledge about the impact of stigma on the help-seeking among rural populations. Should the discussion raise any troubling emotions, then please talk to your GP, your local mental health support service or to any of the following helplines mentioned on your information sheet.

Appendix C: Participant Information Sheet

Study Title: Exploring the Influence of Self-Stigma on Health-Seeking Behaviours in Individuals Suffering from Depression in a Rural County Kerry, Ireland: A Qualitative Research Study

Researcher: [Your Name], MSc Public Health Student, [University Name].

Email: [Your email]

Purpose of the Study:

This research aims at investigating the role of self-stigmatization in influencing the choice of seeking depression help in rural County Kerry, Ireland. Knowledge of such experiences can be used to develop improved mental health interventions and community assistance measures.

Why You Have Been Invited:

The reason behind your invitation is that you experience personal depression and live in a rural community in County Kerry, Ireland. Your opinions and experiences can be helpful to this research.

What Participation Means:

One interview will be organized, lasting approximately 45-60 minutes and conducted either face-to-face or with the use of the Internet. The interview will be audio-recorded with your consent, of course. You have a right to refuse to give the answer to any question and be able to leave at any point without presenting the reason.

Confidentiality:

The information have will be held in confidence. The personal information and name will be changed with a code. The researcher will be the only person who will access the recordings and transcripts.

Potential Risks and Support:

The talk about mental health can be emotional. In case of distress, you may halt or put a break in the interview. You are also going to be equipped with contacts of the support services like:

Samaritans Ireland: 116 123

Aware: 1800 80 48 48

Pieta House: 1800 247 247

Benefits: Miscellaneous There are no immediate benefits but your involvement could help in furthering mental health awareness and assistance in rural settings.

Voluntary Participation: Your involvement is at your own discretion. You may drop out of the study until the analysis of data is done.

Data Protection: The data will be saved securely in the password-protected systems and will be destroyed within 5 years according to the data management policies within the university.

Appendix D: Participant Consent Form

Study Title: Exploring the Influence of Self-Stigma on Health-Seeking Behaviours in Individuals Suffering from Depression in a Rural County in Ireland: A Qualitative Research Study

Researcher:

Please read each statement carefully and tick the box if you agree.

Statement	Tick (✓)
I have read and understood the Participant Information Sheet.	☐
I have had the opportunity to ask questions and received satisfactory answers.	☐
I understand that my participation is voluntary and I can withdraw at any time without consequence.	☐
I consent to the interview being audio-recorded.	☐
I understand that my information will be anonymised and kept confidential.	☐
I agree to participate in this study.	☐

This sample is written by Sophia Patel, PhD in Nursing from King’s College London, specialises in providing guidance and support on public health related issues.

This nursing sample is a model academic paper developed with the objective of supporting students with their study, research and for reference purposes only. The information included does not constitute any kind of medical advice or recommendation, and scenarios (if any) utilised are hypothetical and should be used for educational analysis in accordance with university academic integrity policy.