The adaptation and implementation of guidelines for responsible media reporting on suicide in Slovenia.

INTRODUCTION: The existing literature provides evidence of the link between media reporting and suicide in terms of either preventive or provocative effects. Hence, working with media representatives on responsible reporting on suicide is of great importance. Until recently in Slovenia, there has been an obvious lack of communication between media representatives and suicidologists. The aims of the present study were twofold; firstly, to introduce the adaptation and dissemination of intervention on responsible media reporting, and secondly, to evaluate the effectiveness of the implemented intervention on suicide reporting.
METHODS: We used a pre-post research design. Newspaper articles were retrieved over two 12-month periods: the baseline period and the follow-up period. In between, we had a year of implementation of our intervention program (launching and disseminating the Guidelines via workshops). Each retrieved article was rated qualitatively with respect to its adherence to the Guidelines.
RESULTS: The comparison of baseline and follow-up periods revealed some significant differences. Reporting in the follow-up period was less sensationalistic, there was less reporting about specific cases of suicides and more about causes of suicide and pathways out of mental distress. Furthermore, in the follow-up period, there was a significant improvement related to headlines of media articles. Contact information about where to seek help was more often included in the articles.
CONCLUSION: The findings are promising, but working with the media needs to be continuous and ongoing if sustainable results are to be achieved.

Introduction

Four decades ago, Phillips (1) reported that suicide rates significantly increased after suicide reports were published on the front page of the New York Times. It was then that he first introduced the term ‘Werther effect’, which has since become synonymous with the suicide-inducing impact of media reporting. Since the groundbreaking research of Phillips, the Werther effect – also referred to as the ‘copycat effect’ due to specific media portrayals of suicidal behaviour- was well replicated in other studies. It was found that the imitation risk partially depends on the characteristics of the reader (2), as well as on the topic and style of the media (3).Factors most commonly mentioned to influence imitation include media coverage (4), an explicit description of suicidal methods and place (5, 2), sensationalism and glorification of suicide (6).

As a counterpart to the Werther effect, Niederkorthenthaler and colleagues (7) coined the term ‘Papageno effect’ to shift the attention to suicide-protective impact of media reporting, which the term refers to. Reports can have a preventive effect if the focus is on the treatment of mental illness and suicidal behaviour (8), encouraging those at risk to seek help and refuting myths about suicide (9), focusing on individuals who have overcome their suicidal crisis by adopting functional coping strategies (7). Even though the media can have a protective effect, according to Sisask and Varnik (10), there is a reporting bias, since more research is available on the Werther, rather than Papageno effect.

Based on the findings that media reports about suicide can cause imitation, as long ago as in 1996, the World Health Organization listed responsible reporting on suicide, in particular toning down reports, among the most important cornerstones of suicide prevention (3, 11). Media guidelines for responsible reporting on suicide were since developed and adopted in many countries (11, 12). The evidence from literature shows that the implementation of the guidelines has had an effect on the quality of suicide reporting (13-16); however, journalists’ awareness, use and opinion about guidelines appears to be low (13). In their study, Michel and colleagues (15) found that reporting about suicide has changed after the intervention (was more in compliance with the guidelines), but that in the follow-up period, more stories on suicides were published. That reporting was more in compliance with the guidelines after the intervention was also found by Pirkis and colleagues (17).

In the most optimistic scenario, the implementation of the guidelines has had an impact on the number of suicidal acts. One of the first documented cases is Austria, where the introduction of media guidelines in 1987 resulted in the reduction of suicides in the Viennese subway (14). Furthermore, Niederkrothenthaler and Sonneck (18) proved that implementing guidelines in Austria did not only have a positive impact on the Viennese subway suicides, but also on the reduction of suicides nationwide. The nationwide effect is thought to be the result of a continuous and nationwide collaboration with media representatives. Nevertheless, as noted by Niederkrothenthaler and Sonneck (18), other factors may have been important, and possibly contributed to the decrease in suicides in Austria (i.e., changes in the labour market, an increase in the sale of antidepressants). Indeed, in their review of the most effective suicide prevention interventions, van der Feltz and colleagues (19), next to working with media representatives, list also a cooperation with general practitioners, public awareness campaigns, training sessions for gatekeepers and community facilitators, self-help activities for high risk groups, improvement of access to care and restriction of access to means. Similar targets of suicide prevention interventions were also identified by Mann and colleagues (20), who, on the basis of their review results, emphasized that more studies would need to focus on the evaluation of the impact of media guidelines.

Maloney and colleagues (12) found that the existing media recommendations (in different countries) vary with regard to included preventive factors and the attention dedicated to new media development. Hence, the need for the optimization of responsible media reporting is in place.

Summing up, work with media representatives is of great importance when combating suicide at the public health level, especially in high-risk countries. Slovenia is regarded a high suicide-risk country. Its average suicide rate in the years 1990–2000 was 30.0/100 000. In the last fifteen years, however, the suicide rate significantly decreased in both genders and in the majority of age groups (21), with average suicide rate between the years 2000-2014 dropping to 23.8/100 000 (22). Even though many initiatives were undertaken to tackle this public health problem, the collaboration with the media was a malnourished field. Until recently, there has been an obvious lack of communication between suicidologists and media representatives with regard to their role in suicide prevention. One of the main reasons that the collaboration was hindered was the non-existence of media guidelines in the Slovenian language. Thus, in 2010, media guidelines were developed in Slovenia, and implemented nationwide. The aim of the present paper is, firstly, to describe the process of adaptation and implementation of the guidelines in Slovenia, and secondly, to evaluate whether the intervention has had any effects on the quality of reporting about suicide. To our knowledge, the present study is the first of this kind conducted on a Slovenian sample.

Methods

Procedure

The Adaptation of the Media Guidelines

The adaptation of media guidelines to the Slovenian language was a joint action of four institutions, which, among others, work on suicide prevention in Slovenia, namely: the National Institute of Public Health, UP Institute Andrej Marusic (Slovene Centre for Suicide Research), National Organization for Quality of Life OZARA, and Slovene Association for Suicide Prevention. The adaptation procedure can be divided into four basic steps, as shown in Figure 1.

Figure 1

Four steps applied in the adaptation of the Media guidelines.

Firstly, we translated the original version of the WHO document ‘Preventing suicide: a resource for media professionals’ (11) into the Slovenian language (Step 1). We then circulated the translated version to seven editors and journalists (radio n=1; printed media n=3; television n=3), with whom the authors of the paper closely collaborated in the past, and asked them for critical feedback on the guidelines (Step 2). In particular, the media representatives were asked to review the guidelines in terms of their usefulness, clarity, what they would want to add and what might be missing. A meeting was held with journalists a month after the initial request was sent out to them (Step 3). We gathered their comments and observations and adapted the original version of the WHO guidelines according to their feedback. We added: (i) ethical considerations, (ii) examples of reporting where the copycat effect is minimized/maximized (23), (iii) a table with examples of appropriate vs. less appropriate terms/expressions, (iv) a table with examples of appropriate vs. less appropriate titles, (v) a table with examples of appropriate vs. less appropriate photographic material, (vi) telephone numbers of help lines and other sources of help, (vii) vignettes of appropriate reporting (on a suicide attempt of a youngster, suicide of a celebrity person, suicide during recession), (viii) guidelines on how to deal with a suicidal individual on a live show (24), and (ix) a text in which most common myths about suicide are debunked.

The final version of the Slovenian media guidelines (25) was publicly released on September 10, 2010 (World Suicide Prevention Day 2010), when we held a launch event, with the president of Journalists’ Honour Court being one of the main speakers (Step 4).

As described in the section Research design, steps 2–4 are already considered to be a part of the intervention phase, since the communication and collaboration with media representatives was very intense in this period, and we had no control over the wider spread of information (e.g., by the ‘snowball effect’).

The Implementation (Dissemination) of the Guideliness

The overall implementation process was coordinated by the National Institute of Public Health (NIPH), relying on the network of nine regional units, one in each of the nine health regions in Slovenia. Representatives of the regional units were asked to facilitate the implementation of the guidelines in their domestic region by sending out invitations to local media representatives and by being advocates of the guidelines. We believed that if the invitations were sent and signed by someone known to local media representatives, the intervention would receive greater attention and response.

Within the period Sept 10, 2010 - April 30, 2011, we held one 90-minute workshop in each of the nine health regions, with the local media representatives. At the workshop, each attendee received a free copy of the media guidelines, and the content of the booklet was introduced and thoroughly discussed. An emphasis was placed on exchanging opinions between representatives of suicidology and journalism on what is known about the Werther and Papageno effects, etc., rather than on teaching and being patronizing.

After we concluded with workshops in all nine health regions, we sent a PDF-copy of the guidelines to the Journalists Honour Court and The Chamber of Slovenian Journalists, and asked them to disseminate the booklet to their members.

Research Design

A pre-post research design was used to evaluate the effectiveness of the intervention. The main research question was whether the intervention has had any effect on the quality of reporting about suicide. Articles from printed media matching the keyword suicid* (in Slovenian samomor*) were retrieved via Kliping – Company for Media Analysis and Follow Up. The papers were retrieved for two 12-month periods: the baseline period (May 1, 2009 – April 30, 2010) and follow-up period (May 1, 2011 – April 30, 2012). In between, we had a year of intervention, which we divided into two parts: part 1 (May 1, 2010 – Sept 9, 2010), which included communication with media representatives, adaptation and finalization of guidelines, and part 2 (Sept 10, 2010 – April 30, 2011), which included dissemination workshops. A detailed process diagram is given in Figure 2.

Figure 2

A process diagram for selecting articles eligible for the analysis.

The Sample and Analysis

Altogether, 2,255 papers from printed media were retrieved from Kliping for the baseline and follow-up period. Articles addressing suicide in relation to acts of terrorism or on a phrasal/metaphorical level (e. g., political suicide), and articles not directly addressing suicide were excluded from further analysis. After applying the exclusion criteria, 342 papers were eligible for analysis (Figure 2).

In each eligible paper, we were assessing the presence of the following qualitative elements (guidelines) referring to the content of the paper: (i) the headline of the article (the usage of the word ‘suicide’), (ii) an inappropriate photographic material, (iii) detailed descriptions of a suicide method, (iv) detailed descriptions of a suicide location, (v) informing the public about the reasons for suicide, (vi) a non-sensationalistic writing style, (vii) careful reporting about VIP suicides (celebrities), (viii) displays of empathy towards the grieving/bereaved, (ix) stating suicide-prevention resources (e. g., emergency line phone numbers), (x) general information about suicide-prevention resources and where to seek help, and (xi) real-life stories of those who overcame their hardships. Not all guidelines were applicable to all papers.

For the purposes of assessment, two categories were formed, namely: provocative aspects of media reporting and preventive aspects of media reporting. A similar method was also used by Sisask, Varnik, and Wasserman (26). The respective guidelines were classified into one or the other of the two categories (see Table 1). Eligible papers were rated according to whether they referred to each of the listed provocative and preventive aspects of reporting (yes/no). All articles were analysed by one researcher (SR), since there is a high level of objectivity of the guidelines and the evaluations are assumed to be reliable. Since the researcher analysing the articles was not blind to the status of the articles (i.e., whether the articles were from the pre- or post-intervention sample), we checked for the reliability of the analysis. A sample of 10% randomly selected articles (eligible for analysis) was analysed by a second researcher (ATG), who was blind to the status of the articles. We calculated the percentage of match between the two raters. The match was observed in 87.51% of ratings across all guidelines on selected cases, upon which we conclude that the evaluations made by the SR on the whole sample are sufficiently reliable. For each aspect of reporting, the number of articles showing a provocative or preventive aspect in the baseline and follow-up periods was compared. Hypotheses about the efficacy of intervention leading to the change towards more responsible reporting were tested with one-sided Fischer’s exact tests, at the 5% alpha error rate.

Table 1

The number (and percentage in parentheses) of articles in which guideline criteria were present both at the baseline and the follow-up period.

	Baseline(N=201)	Follow up(N=141)	P
Guidelines – The provocative aspect
Headlines	117 / 200 (59)	61 / 141 (43)	.004
Inappropriate photographic material	34 / 133 (26)	37 / 85 (44)	--a
Detailed descriptions of a suicide method	106 / 133 (80)	56 / 71 (79)	.513
Detailed descriptions of a suicide location	84 / 118 (71)	45 / 69 (65)	.245
Guidelines – The preventive aspect
Informing the public about the reasons for suicide	35 / 200 (18)	54 / 132 (41)	< .001
Non-sensationalistic writing style	65 / 200 (33)	77 / 140 (55)	< .001
Careful writing about VIP suicides	3 / 11 (27)	2 / 5 (40)	.516
Displays of empathy towards the grieving	19 / 60 (32)	17 / 71 (24)	.215
Stating suicide-prevention resources (e. g., emergency line phone numbers)	6 / 201 (3)	12 / 137 (9)	.020
General information about suicide-prevention resources	21 / 201 (10)	32 / 139 (23)	.002
Real-life stories of those who overcame their hardships	2 / 200 (1)	7 / 133 (5)	.023

No test was applied here, as the change was contrary to the one expected, if this individual guideline for responsible reporting had been effectively implemented.

Results

The overall number of suicide-related papers has decreased in the follow-up period (N=141), in comparison to the baseline (N=201). In the baseline period, 70 articles (35%) reported on specific cases of suicide, whereas this number decreased to 29 (21%) in the follow-up period. The decrease in the percentage of articles covering specific cases of suicides was statistically significant, p=.003. The ratio between the annual number of published papers reporting on specific cases of suicide and the annual absolute number of suicide cases revealed that, in the baseline period, 16.1 papers were published per 100 suicides, whereas in the follow-up period, only 6.8 papers were published per 100 suicides.

As can be seen in Table 1, in 6 out of 11 guidelines, statistically significant changes in the expected direction were observed in the year after the intervention. After the intervention, the usage of the word ‘suicide’ in the headlines of the articles was reduced by more than 15%, and journalists were significantly more inclined to offer suicide prevention materials alongside the articles, reporting emergency phone numbers and giving details of other sources of help. Statistically significant differences between the baseline and follow-up period were also found in terms of informing the public about causes and pathways to suicidality, and describing the reasons behind the act. Additionally, in the follow up period, the reporting of experiences of suicidal people who successfully overcame their crisis slightly increased. However, after the intervention, we also observed that the usage of an inappropriate photographic material has increased. This change was unexpected.

Discussion

The aim of the present paper was to introduce the process of adaptation and implementation of media guidelines in Slovenia, and to evaluate whether the intervention has had any effects on the quality of reporting about suicide.

Even though, in the last decade, many initiatives were undertaken in Slovenia (for details see ref. (21)) to tackle the problem of suicide, the work with media representatives did not receive enough attention. Based on anecdotal reports, we know that a few attempts were made in the past to establish a thorough collaboration between suicidologists and media representatives, but did not turn out to be as fruitful as hoped. The results described in this paper are an outcome of the collaboration between suicidologists and media representatives in Slovenia, which was, in many ways, different from the preceding ones.

From the very beginning, the target group – media representatives – was included in the formation of the guidelines. This probably led to their greater identification with the guidelines and increased media representatives’ motivation to participate, rather than them being just passive recipients of information. Furthermore, by inviting them to participate in the phase of guideline formation and development, we might have increased their feeling of being an important partner in suicide prevention. A similar approach was adopted in Australia, where media guidelines were developed in collaboration between media representatives, health professionals and suicidologists (27). A significant figure advocating the intervention and media guidelines was the President of the Journalists’ Honour Court, who supported the action throughout the whole process. In line with studies which have similarly included a patron of the intervention (28) or a renowned member of a target group, we also believe that her involvement has played a significant role in the success of the intervention. In their review, Pirkis and colleagues (27) noted that in most cases the guidelines were not being implemented optimally, since the most typical method of dissemination was mail-out procedure. In this sense, our intervention was a positive exception. In other words, similarly as with the development, in the implementation process, we adopted a similar method as was adopted in Australia (27), conducting face-to face workshops and handing out copies of the guidelines. The network of the NIPH and its regional units has made the nationwide intervention in such a form possible and much easier to implement.

As a consequence of our proactive approach towards media representatives, they themselves got organised and optimised the existing Journalists’ Ethical Code in 2010. Until that time, this code of conduct did not refer to suicide reporting at all. The amendments made to the code by journalists’ own initiative now include a paragraph referring to circumstances when a journalist is prohibited to report about suicide. Our observations regarding the development and implementation process are hence consistent with those of other authors in that approaches need to be directed towards collaboration (13, 18) and that the optimal results are achieved if the reference group is included (27). Another factor contributing to positive outcomes of our intervention may be the fact that, in the first year of implementation, we have responded to articles (an e-mail sent to the editor of the newspaper and, if known, also to the journalist of the article) that were either complying with the guidelines or not. If a paper did not comply with the guidelines, we pointed out major drawbacks of the article and encouraged the authors and the editor to comply with the guidelines in the future (guidelines were attached to the e-mail). If an article did comply with the guidelines, we expressed our gratitude and satisfaction. Last but not least, our experiences support that of Michel and colleagues (15), who found that the best intervention method proved to be a personal contact with the editor – the personal approach we took was much appreciated by media representatives. Our finding that fewer papers were published on the topic of suicide in the follow-up period are not consistent with those of Michel and colleagues (15), who found quite the opposite. At the workshops with media professionals, we did not advise against suicide reporting (except under certain circumstances as given in the guidelines), but rather to report it ethically and responsibly. The decrease in suicide reports after the intervention can thus perhaps be explained by a more selective and responsible work of media professionals, rather than by them reporting on any suicide story. After the intervention, we have also observed a significant reduction in papers focused on specific cases of suicide. This can be similarly explained by the fact that journalists were cautious and thoughtful when it came to reporting about suicide, and that a judgement was made as to what is newsworthy and what is not. However, no significant differences were observed between the pre-and post-intervention periods in terms of revealing the suicide method and the location of suicide. This implies that even though the overall number of articles focusing on specific cases of suicide has decreased, the quality of reporting (taking into account these two guidelines – the description of a suicide method and location) has not improved. Nevertheless, a decrease in the number of published papers on specific suicide cases per 100 suicides, from the baseline to the follow-up period, seems to be a positive outcome of the intervention. Regarding the relationship quantity/quality of reporting and the copycat effect, literature provides mixed information. Michel and colleagues (15) argue that it is not the quantity of articles, but rather the quality that is important; on the other hand, Pirkis and colleagues (27) found evidence of the links between the imitation of a type and quantity of news coverage.

After the implementation of the guidelines, the usage of the word ‘suicide’ in newspaper headlines decreased, which is in line with findings of other researchers (e. g., 14, 15). Furthermore, we observed that the language used in articles published after the intervention was less sensationalistic, which, too, is in accordance with findings of others (15). In contrast to Pirkis and colleagues (17), who found that articles published on suicide after the intervention in Australia did not contain enough referral and preventive information, we found that the number of articles stating suicide-prevention resources (e. g., helplines) and general information on how and where to seek help increased after the intervention. Surprisingly, we noticed an increase in the use of inappropriate photographic material after the intervention. This observation is not in line with findings of other researchers (15), who reported that, after the implementation of the guidelines, the pictures were less sensational. We explain this finding by anecdotal reports from the journalists themselves, who said that even if they had chosen a more sensitive photo, the editor would have prevented it from being published (i. e., editors are looking for a sensationalistic photo). Another possible explanation is that since the journalists have complied with the majority of guidelines after the intervention, it is the photographic material where they want to keep their ‘artistic freedom’. Nevertheless, no other negative effects of the intervention were observed. In the period after the implementation, we have noticed a significant increase in the number of articles focusing on stories of persons who have overcome their suicidal crisis. By complying with this guideline, the journalists have contributed enormously to the suicide protective impact of media reporting, which according to Niederkrotenthaler and colleagues (7), increases if the report focuses on individuals who overcame their suicidal crisis by adopting functional coping strategies. Furthermore, the overall compliance with the guidelines in the post-intervention period was good, since a statistically significant change in the desired direction was observed in 54% (6 out of 11) of guidelines. Hence, we may speculate that in the postintervention period, there was a tendency towards the Papageno effect.

However, despite the promising results, our study has some limitations worth mentioning. The workshops that took place were a common event for both editors and journalists. According to other authors (7), it is better to conduct separate workshops for these two target groups due to their different needs and work demands. It may be that the requirements of some guidelines (e. g., about photographic material) have reached journalists, but not editors. Also in the future, it would be worthwhile to hold separate meetings for photographers and editors to emphasize the importance of a responsible selection of photographic material. Furthermore, we had briefings with ‘serious’ and ‘tabloid’ press representatives at the same time. This, too, does not seem to be a good practice, since the tabloid press is knowingly more sensationalistic, and needs more attention with regard to such reporting and a more directed approach. Another limitation of our study is the fact that we do not know the exact number of journalists who were acquainted with the guidelines, since the guidelines were not only introduced at the workshops, but also disseminated via the journalist association. As a consequence, it is difficult to estimate how many journalists were needed to achieve the introduced positive results.

Nevertheless, this is to our knowledge the first study of this kind conducted on Slovenian data. Not only do the results of our study show that collaboration with media representatives adds to suicide prevention activities in Slovenia, but they also add to the state-of-the-art literature about media and suicide prevention. Future work should definitely focus on the optimization of guidelines according to findings of Maloney and colleagues (12), in order to include new media (e.g., social media). The attention and systematic follow-up of suicide-related publications should be extended from printed to all other forms of media – internet, television, etc. Furthermore, a program of nationwide workshops that would be more regular and systematic (e. g., carried out separately for editors vs. journalist, or for serious vs. tabloid press) would be necessary. New, young journalists should be included. Booster sessions for those who have already had contact with the media guidelines should be ensured. A systematic education on responsible reporting about suicide (with a detailed introduction of media guidelines) should be included in university curricula. Finally, the work with Slovenian media representatives, as also stated by Niederkrothenthaler and Sonneck (18), must be continuous and nationwide.

Conclusion

The existing literature provides good evidence that media reporting can be linked to either a suicide provocative or a suicide preventive effect. The existing study describes Slovenian efforts to adapt media guidelines in collaboration with media representatives, and disseminate them nationwide. An evaluation of the intervention revealed that the overall compliance with the guidelines was good, but that there are nevertheless areas which deserve further attention. Some aspects of the quality of reporting have yet to be improved. There is a need for the continuous work with the media and for the optimization of the guidelines.