Lack of anonymity.

Participants referred to a lack of anonymity resulting from small region dynamics that seemed to increase residents’ reluctance to engage with mental health services. For example, participants discussed the greater possibility for dual relationships with residents, which can impede help seeking. Indeed, participants mentioned that HCPs who also played other roles for rural residents (e.g., neighbour) could be a barrier to sharing mental health symptoms or distress, which may preclude help seeking and, thus, contribute to suicide risk. This was reflected in the following interview excerpt:

…thinking about the clinics in rural areas, you know, maybe some people don’t want to go because the person working there is their neighbour, or, you know, is their sister-in-law, or whoever it is, you know. Maybe they don’t want someone close to them knowing their deep dark troubles. You know, there’s no anonymity. (Participant 2)

Another individual similarly shared:

I might be your doctor. But our kids might also be in hockey together. And I’m gonna see you in the supermarket, and I’m gonna see you at the gym, or I’m gonna see you when I’m out for a walk with the dogs. And we’re gonna say ‘hi’ at the post office, because we’re both members of this teeny, tiny community. (Participant 1)

Others talked about the notion that community members are often aware of each other’s personal lives, as the following participant noted: “But it can be really difficult because everybody knows your business all the time. And that is a really stressful thing for people” (Participant 10). Having residents, including community HCPs, more involved or aware of the details of each other’s lives indicates how lack of anonymity may be an important obstacle in help seeking.

Stigma toward mental health difficulties.

In line with a lack of anonymity, more stigma in rural areas compared to non-rural counterparts was also noted by HCPs as an impediment to help seeking for residents. Whereas a lack of anonymity focuses more on the dual relationships experienced in rural settings or the increased awareness between community members, this subtheme more pertains to the unique attitudes towards help seeking in rural regions. In line with this, one participant reflected on the views of mental health and suicide in rural areas, indicating that:

I get it, mental health stigma is a universal issue right now. But it seems to be worse in rural Newfoundland. People just don’t seem to get just how mental health and suicide are real issues. And then they look down on other people who might, you know, need to get help for those issues. It’s very sad. (Participant 3)

Another participant discussed ‘toxic masculinity’ and how it often interferes with an individual’s help seeking, and how rural NL seems to be particularly at risk: “…the way we socialize men. It’s fucked up. Newfoundland and Labrador has a lot of, I hate to have to say this, but I’m gonna say it, toxic masculinity. Like culturally, Newfoundland and Labrador, we’re 20 years behind everybody else” (Participant 4). This led to discussions on how to reduce suicide risk, which focused on reducing stigma and toxic masculinity:

We should be talking about it at an early age and de-stigmatizing it [mental health]. And talking about the different types of supports that aren’t just therapy. Because if again, if I if my mind is correct, it’s mostly men killing themselves or dying by suicide. Oh, no, we don’t say that [sarcastically]. Then it’s about attitudes about therapy, support, talking about your feelings, the way men communicate. Those openings… I think that’s tangible, right, like, you know, talking about violence, talking about feelings. From a young age in the school system. The way we socialize men has to change. (Participant 4)

Clearly, participants reflected on how stigma toward help seeking was an area of concern when considering suicide risk in rural areas.

Normalised risky substance use.

Many participants discussed the normalisation of substance use in rural areas as playing a role in heightened suicide risk. Substances included alcohol, marijuana, and illicit drugs. For example, one participant discussed that alcohol is being used at a younger age by rural residents when compared to previous generations, “I think everywhere rural has a huge alcohol issue. And it’s recognized and kind of accepted. But now the alcohol is in the younger crowd. And it’s… it’s scary to see the differences…see the changes over time”. (Participant 6)

Others reflected on higher incidences of alcohol misuse, “It’s like, all these small communities, you know, and I wouldn’t just say it’s in smaller communities, but there’s a lot of drug abuse and alcoholism” (Participant 7). Another participant reflected on their suicide prevention efforts that focused on reducing alcohol consumption, “So what we have focused on predominantly in our main safety pillar, is the correlation between alcohol consumption and these means of suicide. Because our research has also shown us that too… And that’s what we focused on was alcohol use, but again, there’s such a culture of, you know, drinking and drinking excessively, as opposed to social drinking, like you see in some other places” (Participant 5).

Others mentioned drug use, such as one participant who discussed an increased suicide risk in rural areas because of drug use:

And there’s so many different sides, every story, but a few of the kids are college-aged kids that left our site went home and committed suicide, there was drugs and alcohol involved. And obviously, they’re from rural [removed] and [removed]. …you’ll get people coming in that just needs to talk or vent and they’re like, ‘oh, a lot goes home and a lot of us drink and do drugs’. And that’s a big thing.” (Participant 10)

One participant commented how seasonal workers, which many rural residents in NL are, may have extended periods without work, which is related to increased substance use. For example, when discussing the winter months, during which Newfoundlanders and Labradorians who work in the fish industry are not working: “And then that tends to be when there’s more alcohol consumption, more drug use, and then more issues that would lead them to formal [mental health] service” (Participant 11). Another noted about some rotational workers at risk for suicide by feeling isolated from family, and using alcohol to cope:

Almost all the time that they’re home, they’re off time. And so they’re in the shed, and they’re partying, and they’re drinking, and they’re doing other things as opposed to being home, or doing things you would normally do with your family. So the family life is kind of turned upside down. And I think that does have something to do with their own anxiety, depression, maybe a feeling isolated, not connected… those kinds of things to their families”. (Participant 5)

It seems, therefore, that participants consider risky drug use, particularly alcohol, as one factor that is related to later suicide risk.

Individual-rural identity misalignment.

Participants also discussed how rural residents can sometimes perceive that rural culture does not align with their identity. For example, given there is less cultural variability within a rural area, a potential misalignment between someone’s identity and rural culture may be more likely than in non-rural areas and can be a factor in mental health difficulties and suicide risk. Rural culture was often described as marked by outdoor activities and that issues may arise if a person does not enjoy these activities. As one participant noted, “not everyone is outdoorsy” (Participant 2).

Another participant reflected on the potential struggles of growing up and not enjoying outdoor and related activities: “Some kids don’t enjoy the typical rural activities like hunting, fishing… even if their parents are very invested in those activities. And you can imagine how hard it is for those kids. Like, there’s five kids in the community and they’re the odd one out.” (Participant 3). Others spoke of the impact of having fewer individuals to connect with who may be like-minded; “So if you’re from a rural area, you’ve got, like, this select amount of people that you can know, or like, you have a similar culture” (Participant 8). This individual continued to explain that, “If you’re an outlier in the culture, or the community… you don’t have a lot of options to feel supported”. In sum, participants perceived the potential difficulty in connecting to others in the community and the broader rural culture as a potential risk for some rural residents.

Unique economic and vocational challenges.

Participants often spoke of the changing economic and vocational landscape in NL. They commented on the faltering of typically relied-upon industries, such as the cod fishery, that has affected individuals’ identity and livelihood. For example, one participant noted that:

A sense of purpose, a strong sense… healthy sense of identity, I think is really difficult in Newfoundland, because of how much it’s changed, and the lack of jobs and the way that the landscape of opportunity industry has changed so much over the last 30 years since the [cod] moratorium. (Participant 4)

Another participant added how job loss interacted with other factors to increase suicide risk, “And so things happen, you know, loss of jobs, and you’re coming home. And when you get drugs in the mix, and things like that it can be it can be hard when your entire mix there knows every everything about what’s happening” (Participant 10). Others expressed that loss of employment impacts individuals’ sense of purpose and identity, “There’s a lot of unemployment in rural areas and remote areas …and unemployment doesn’t necessarily inspire people to live” (Participant 8). Similarly, another participant expressed:

So you go through periods where there’s high rates of employment, a project comes in to the shipyard or something like that, and there’s, you know, a whole bunch of people employed and things are well, you know, it doesn’t seem like people’s mental wellness is affected as much because they’re financially stable. And then we go through very long periods of very high unemployment rates, and people out of work … So, we see a lot of men with like trades backgrounds, having to go away for work. And then, you know, that kind of a lifestyle has its own challenges, of course, but even for individuals who stay around and are employed, like in the local companies, when they get a layoff, I mean, their employment has been such a big, you know, indicator of who they are that when they’re laid off, they lose that sense of who am I as an individual because I’m no longer an employee. (Participant 5)

As can be seen above, participants noted that the unique economic and vocational challenges of rural NL lead to numerous negative outcomes, all of which may increase the risk of suicide.

Discrepancy between supply and demand.

Some participants reflected on the lack of professionals available to serve the mental health needs of rural residents. Participants discussed a lack of physicians, psychologists, nurses, and other professionals who play a role in suicide prevention and intervention. For example, one participant noted:

Take it from the top doctors on down, there’s a lack of doctors, when you’re waiting seven months for referral. And that’s going on here. They get referred to a counsellor and it’s a seven month wait to see him… or you see a suicide risk come in. They’re referred to a counsellor, but sorry, the counsellor is unavailable for two weeks. I’m like, this can’t wait two weeks, and you send them home with a parent that may or may not have to work or whatever… there’s a lack of actual warm bodies. (Participant 6)

Others talked about a lack of mental health professionals in their region such as psychologists. Participants often mentioned a lack of public mental health services, which limit who can access the already limited number of psychologists in the province.

We need the government, not just the Newfoundland government, but the federal government to fund psychologists… if I had to avail of a psychologist, I’m okay. I got medical and dental insurance. So my insurance will pay up to maybe, I don’t know, seven or eight hundred dollars, you know, you might get four or five sessions. Most people don’t have that. (Participant 7)

The desire to have more appropriately trained professionals serving within or near rural communities was also shared by participants. For example, one participant stated, “They need the professionals there in the communities. So I think they need access to these professionals, mental health professionals, there within, you know, an hour drive, maybe” (Participant 2).

Others discussed the reduced appeal of working in rural mental health care, which contributes to a mismatch in supply and demand. This was illustrated by the following individual: “But if those positions aren’t filled, because nobody wants to work in rural health care, and in some communities, it just… the service doesn’t exist” (Participant 1).

From the perspectives of the participants, there is a lack of services available to residents of rural NL. Participants noted this was the case for all health care professionals. This lack of health services may be due to lower service allotment and the difficulty in recruitment and retention of health care professionals in rural regions.

Practical barriers to care.

Participants also discussed the barriers experienced by HCPs in providing, and rural residents accessing, mental health and suicide-related services. For example, participants indicated that rural Newfoundland and Labrador has barriers to service provision, such as reduced technology and connectivity, poor weather conditions, and lengthy drives to provide or receive services. As one participant noted, “Even just having to drive two hours to a home visit in the middle of March. Like you don’t have cell phone coverage. The weather’s really bad. There’s a lot of wear and tear in your car” (Participant 1). This individual continued to explain that transportation is an ongoing barrier, “Yeah, there can be a Doorways [mental health walk-in service] clinician in your community. There can be a walk-in clinic, there can be a physician. But if you can’t get to them, you don’t get service.”

Several participants referred to the technological challenges associated with mental health and suicide-related care in rural NL. In line with this, they noted that, while beneficial for some, telehealth was not a feasible method of receiving services for a large proportion of rural Newfoundlanders and Labradorians. For example, one individual noted:

And we’re really limited in what we can do to, to reach out because we’ve got all this wonderful technology that COVID brought us, you know, all the Facetimes and meetings like this, which is amazing… but it’s absolutely useless if you don’t have an internet connection, or a phone or a laptop… which a lot of our clients don’t have access to. (Participant 10)

Others reflected on their time living in rural areas to describe technology barriers, “Yes, I’ve lived in a couple of different areas where the internet is not super. And this was probably 10 years ago. So I don’t know… things have changed. But I’ve worked in areas that you know, there’s no cell reception” (Participant 2). Another individual noted, “I lived in one area that had dial-up internet. And this was in… 2013, so not long ago. I couldn’t load the news, let alone sign onto a video chat. So how could you expect a patient to do it, especially if they’re in crisis?” (Participant 3).

Another participant noted that technological barriers are quite pervasive and in potentially unexpected areas, such as close to larger urban regions in NL, “I mean, we have patients, even in the St. John’s region, they don’t have phones” (Participant 1). It appears that numerous barriers exist that impede the availability and provision of health services to rural Newfoundlanders and Labradorians.

Lack of suicide-specific training.

The third aspect of service provision difficulties involved a lack of background, training, and opportunities for suicide-specific care. Participants often noted the limited training received through their formal education or by their current employers. Specifically, while some felt comfortable identifying suicide warning signs, there was little training regarding follow-up to suicide risk. As a result, individuals were often referred to emergency services, including hospitalization, which could create additional challenges in consistent, long-term suicide-related care. As clearly noted by one participant, “So there’s no training. We need training. People aren’t even talking about it” (Participant 12).

Individuals spoke about the lack of time or incentive to seek formal training: “There is no incentive to go and do training, specialised training ‘cause you have to pay for it yourself” (Participant 4). This same individual spoke about how underqualified they are at their position, yet were expected to provide evidence-based treatment without training:

People should not be doing this job with a Bachelor of Social Work, put that in your paper. I should not be doing this job. The only reason I’m good at my job is because of my personality and the amount of reading I’ve done in my life, my own personal experience… I still don’t think I should be doing the job. (Participant 4)

The fact that there was no mandatory training for suicide intervention was common across participants. Another participant noted “…it’s unreal, that I can’t believe that [suicide intervention training] hasn’t become a mandatory” (Participant 6). Participants also spoke to the larger issue that the professionals with extensive training are simply not available to rural regions, “A big problem with it is that the people who I think really are trained are just not available, always in rural areas” (Participant 2).

Some participants indicated that they completed Applied Suicide Intervention Skills Training (ASIST). However, ASIST is a short-term crisis identification intervention that seeks to then connect the individual in crisis to longer-term care, which is a critical component of suicide management. For example, one participant noted that ASIST is a community approach and by providing this as the main intervention received by HCPs, they are no different than general community members:

…the only training that we’ve really had, or that we’re offered is ASIST. …which I did when I was a student in my undergrad, and maybe at the time, it was a fitting type of training for the place that I was at. And for where I was in terms of like being a student, and also a community member, just having an awareness of like reacting suicide and things like that. But it’s still considered by [health authority] as like the training for professionals mental health clinic, which I would disagree with. You know, it’s not really preparatory, or comprehensive enough, as somebody who should know more than a community member… if it’s being offered to anybody who wants to have it, you then it’s saying like, you know, as much as anybody who is in the community. Right? Which we’re supposed to be specialists, more so than somebody just off the street, right? (Participant 8)

Ultimately, participants expressed a lack of suitable and specialized care related to suicide. Despite this, participants noted their willingness and desire to complete training, which was sometimes impeded by little incentive or support.

Lack of policy/support.

Participants often described that there was insufficient or conflicting policy regarding suicide prevention. For example, one participant reflected on their time working in various health authorities in NL. At the first authority, there was substantial policy and guidance around suicide assessment. However, when they moved to another health authority, they perceived that there was inadequate and desultory guidance for working with at-risk individuals. While discussing the current practice in their workplace, they noted, “Like, how do we react? Because I’ve worked here for four years, where’s my package of assessments? It’s literally, I’ve worked here for four years, someone [manager] told you literally say to the person [patient], ‘do you have a plan?’” (Participant 4). Another individual spoke about wanting a more comprehensive assessment strategy but being denied financing to purchase these assessments: “They [manager] will say like, ‘oh, well, you don’t need to do this test… you can tell if they’re okay or not, or base all just kind of on subjective information’” (Participant 8). Another participant expressed similar concerns over a lack of formal suicide assessment policy:

Coming here, I was shocked and all that there is no formal paperwork for that kind of stuff. There’s not even a rating, one that we fill out on a policy level. So I was kind of shocked by that. Because I think there is quite a high rate of new suicidal… suicide or suicide attempts in Newfoundland and Labrador. (Participant 3)

Another discussed their surprise when they learned that there was a lack of suicide-related policy in one specific health authority. For example:

When I came to [health authority] and to work for [location]. I was like, oh, so what’s the suicide policy? Because the very first day I worked here, I had a suicidal teenager. So they were like, oh, no, they’re not really is one [policy] you just like, you know, ask them if they have a plan to kill themselves. And like if you think they need to go to the hospital, tell them to go to the hospital. And I was like, don’t we? So like, I think [health authority] is underprepared, or under-policied, or under-structured when it comes to suicide. (Participant 4)

Others reflected on how management may not understand the unique challenges of rural practice because they themselves are not located in rural regions. As a result, they may not be able to relate to HCPs’ experiences or provide relevant support:

I mean, your manager might be in another part of the region, but you never physically see them ever. And you might have to wait a week to get a call back to consult on something. And if you’re sitting in somebody’s house, and they are saying, ‘I don’t want to live anymore’, you have a week. And I mean, that’s certainly not every manager, but there are some that are just inaccessible… and why are they inaccessible? (Participant 1)

Another HCP discussed how smaller mental health teams in NL are typically comprised of and managed by social workers, who may have a different approach to suicide assessment and intervention when compared to other health care professionals. This participant, a non-social worker, indicated that this can create challenges when seeking support, consultation, or guidance from managers. For example, a participant expressed, “my manager is a social worker who isn’t trained like me… they don’t approach assessments or treatment like I would. I hate to say it, but sometimes it feels like what’s the point of consultation when we view the major issues as different” (Participant 3).

Another participant noted the lack of consultation structure or integration between units that hinders supporting rural individuals. For example, this participant recounted being in a counselling session with a patient who indicated that they were planning suicide. After some discussion, the patient quickly and unexpectedly exited the telephone session. The participant reflected that, “And so for me, because I am not part of the mental health team, I was like, frig, like, what do I do? So luckily, I walked down the hall. And it’s like, ‘Hi, I need to consult, I need to consult’. And that should really be a formalized structure, instead of me hoping that somebody is at their desk” (Participant 1).

Indeed, as illustrated above, participants highlighted several difficulties that can arise from less cohesive relationships with managers and a lack of structure or policy regarding suicide prevention.

Onus on provider.

The last aspect of service provision difficulties focused on the provider bearing responsibility to acquire suitable suicide intervention training. Participants commented on the lack of formal and required trainings on suicide assessment and interventions. For example, one individual remarked that “We had one small… we call them learn modules, which is like a, you know, we go into our learning interface. And we do… it’s like probably a 20-minute video on suicide. And that’s not compulsory. That is if you choose to do it” (Participant 7). Others discussed how learning and professional development are not feasible in the rural public sector because of an increased workload:

Like, unless you’ve built the skill yourself, unless you’ve done the research, which from a public services kind of perspective, we don’t have the time to do it. Like there is no time built into my day or week to research things… I have a waitlist, there are people who are desperate for service. So it’s like, do I take two hours to… to read something? Or do I see two individuals who are desperate for service? (Participant 1)

Similarly, one participant explained that even if training were available, “…it wasn’t compulsory. And you know, for someone working Monday to Friday, eight to four, you can’t commit to that stuff, right? Because they aren’t going to give you the time to do it” (Participant 3). Ultimately, some participants perceive that getting suitable suicide-related training conflicts with the numerous other demands of their work and, inevitably, is given less priority over these other demands.