Systematic search of the literature

Development of the questionnaire

A total of 73 peer reviewed and grey literature informed the development of the Round 1 questionnaire (N = 42 and N = 31 from the peer-reviewed and grey literature, respectively). Statements were extracted from the relevant literature and reviewed by a working group that comprised four members (NH, PT, JR, and NR) who were experienced researchers in suicide prevention or the Delphi expert consensus method. The working group omitted statements that contained duplicate information, and when required, systematically reworded statements for consistency across multiple online communication platforms. For example, the statement “When choosing imagery for your blog post, avoid selecting clichéd, emotional images or graphic depictions of violence or self-harm” was reworded as “If posting or sharing an image or video avoid images of people looking dishevelled or threatening, or clutching their head.” The final questionnaire consisted of 284 items and was organised into nine topic areas, summarised in Table 1. Two paid youth advisors (ZT and RB) from Orygen were appointed to provide ongoing feedback on all materials developed throughout the duration of the project. All items included in the questionnaire are available in the S1 Table.

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Table 1. Sections included in the Delphi questionnaire and example items.

https://doi.org/10.1371/journal.pone.0206584.t001

Expert panel formation

Two panels, one consisting of international suicide prevention researchers and media and communications specialists and one consisting of Australian youth advocates (referred to hereafter as the professional panel and youth panel, respectively) were recruited for participation in the study. All panel members were at least 18 years of age and fluent in English. Recruitment and eligibility of panel members are described below.

Delphi consensus ratings

Panel members were asked to complete two rounds of questionnaires distributed online using the web-based survey software ‘Qualtrics’. Panel members were advised that their participation in the Delphi study would lead to the development of a set of guidelines for young people involving safe communication about suicide online. During both the Round 1 and Round 2 questionnaires panel members were instructed to rate each item according to its importance for inclusion in the guidelines using a five-point Likert scale that included the following options: essential, important, unsure/depends, unimportant, should not be included.

Development of the #chatsafe guidelines

The authors from the working group combined all items (i.e. those that received >80% consensus for inclusion in the guidelines) that contained similar content, and combined them into prose, and wrote them into the actual guidelines. The working group and two project youth advisors (ZT and RB) reviewed the guidelines and ensured that the content and language was youth and social media friendly, and where relevant, provided some practical examples to be incorporated into the guidelines. Careful consideration was given to ensuring that the final guidelines were true to the original wording of the questionnaire items whilst still being coherent and easy to read. The draft guidelines were then provided to panel members for final feedback and endorsement. No changes to the content of the guidelines were made at this stage. A copy of the #chatsafe guidelines are available in the S1 File.

How the #chatsafe guidelines compare to traditional media guidelines

As noted above, guidelines to assist professionals report safely about suicide have existed for many years and form a key component of several suicide prevention strategies around the world [28–30]. The guidelines developed in the current study have some similarities to extant guidelines, but they also include advice relating to some of the issues specific to the amorphous and interactive nature of social media. For example, Section One ‘Before you post anything online about suicide’ details the type of content and language that is generally considered to be unhelpful when communicating about suicide, such as graphic descriptions or images of suicide methods or locations. It also includes examples of types of language that should be avoided, such as terms like ‘committed suicide’ which portrays suicide as a criminal act and as such may be stigmatising for some, or terms like ‘successful suicide attempt’, which may hold a positive connotation. There has been significant debate in recent times about appropriate language to use when communicating about suicide [31, 32]. To date, inconsistencies in the nomenclature of suicidal behaviours, has not only limited comparison between studies, but also, at times, may be perceived as pejorative towards individuals who have experienced suicidal behaviours, and their friends and relatives [33, 34]. In the current study the two panels rated a number of language-related items and endorsed the term ‘died by suicide’. They also endorsed items advising that the complexity of suicide, and messages of hope and recovery be conveyed in posts about suicide. This reflects research that has shown stories that portray an individual gaining a sense of mastery over their problems may have a preventative effect [11]. For example, in a study of media reports of suicide in Austria, Niederkrotenthaler and colleagues (2010) demonstrated that newspaper reports that included stories of suicide ideation, not accompanied by a suicide attempt or suicide death was associated with a decrease in suicide rates, and thus may have a protective effect. However until now this has only been included in media guidelines targeting journalists and has not been used to help educate or inform young people.

The current guidelines also provide young people with advice on how to respond to someone who has indicated suicide risk. Previous studies have shown that young people are more likely to engage in social media content that depicts suicidal behaviour [35] and endorse taking action to assist those who share suicidal content online [36]. Nevertheless, concerns have previously been expressed about the safety of talking about suicide on social media for the reasons cited above. However, rather than advising young people against communicating in this way, the guidelines include specific tips on how to have these conversations safely and provide some examples of language to use if they are worried about someone who is suicidal (e.g., ‘Are you thinking of suicide?’ or ‘Do you feel suicidal?’) They then give young people a series of options on how to respond. Importantly, the #chatsafe guidelines inform young people that it is ok not to respond to someone who may be suicidal. The notion of self-care and personal wellbeing are emphasised throughout the guidelines, and include additional strategies such as taking a break from social media, taking control of content which may cause distress, and reflecting on one’s emotional state and ability to respond to suicide-related content. These recommendations are particularly important given the maturation of complex cognitive, and socio-emotional processes that influence decision making and affective regulation in young people are in a state of ongoing development [37].

Unlike other guidelines, the #chatsafe guidelines also advise on issues specific to the online environment. For example, Section 1 includes a number of items that remind young people about issues relating to privacy, to the permanency of content posted online, to the speed at which content can spread, and the lack of control one might have over content once it is posted [38, 39]. Additionally, the final section of the guidelines focuses on how to operate closed groups and memorial pages safely. These groups and pages are often established following a suicide death by those who wish to memorialise their friend or loved one; they can also be supportive environments that provide a sense of community [40]. However, concerns have been expressed about how to operate these pages safely, and regarding their possible impact on suicide contagion and clusters [41, 42], hence reiterating the need for evidence-informed guidance in this area.

Involving young people in the study

The involvement of young people was central to this study. To the best of our knowledge only very few Delphi expert consensus studies that focus on mental-health related topics have included young people as panellists [26, 43]. This may be explained by the reluctance to involve young people in certain types of research, and in particular suicide-related research, for fear of iatrogenic effects [44]. However, there is an emerging body of evidence to suggest that it is indeed safe and acceptable to include young people in suicide prevention research, including online research [45], and given that the #chatsafe guidelines are designed for young people, their active participation was crucial.

Of interest are some of the items that did not achieve consensus due to the differing views of young people and professionals. One example is the item ‘If you see a post and are worried that someone may be suicidal always reach out to them directly’. This item was endorsed by the youth panel as important to include but not by the professional panel and was therefore excluded from the guidelines. This lack of consensus may reflect the different ways in which the younger and older generations engage with social media [46]. Young peoples’ on- and off-line worlds are far more integrated than those of the older generations [47], with the youth panel making comments such as ‘of course we would reach out directly to someone we were worried about’. By contrast, the professionals raised concerns about issues such as the complexity of responding to someone at risk of suicide and young people assuming too much responsibility.

Implementing the guidelines

Critical to uptake of guidelines is the way in which they are implemented, and in this case the #chatsafe guidelines will be implemented via a large-scale social media campaign. The delivery of population-wide media campaigns has gained attention recently as a potentially effective suicide prevention strategy, with the evidence suggesting that they have the capacity to increase knowledge and awareness of suicide, and improve attitudes towards help-seeking [48]. To date, however, there is limited evidence regarding the impact of such campaigns on young people, and few, if any, actively involve young people in their design and implementation. We recently conducted a small pilot study with secondary school students that examined the feasibility and safety of co-developing suicide prevention campaign materials for delivery via social media. Young people responded positively to the project, reporting it to be enjoyable and educational and no adverse events were reported [49]. Thus, building on the findings from the previous pilot, the #chatsafe guidelines developed in the current study will now be brought to life via the development of a co-designed social media campaign developed by and for young people.