How do South African newspapers frame schizophrenia and other psychotic disorders?

doi:10.21203/rs.3.rs-1600232/v1

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Research Article

How do South African newspapers frame schizophrenia and other psychotic disorders?

https://doi.org/10.21203/rs.3.rs-1600232/v1

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Background: The way schizophrenia is portrayed in the media contributes to the dissemination of misinformation about the symptoms, causes, and treatment of the mental disorder. The framing of news stories has the potential to perpetuate or mitigate the stigmatization of schizophrenia. While research on the news media’s role in exacerbating or mitigating the stigmatization of schizophrenia has been conducted widely in other contexts, our search did not yield any study on media framing of schizophrenia in South Africa. Therefore, this study uses the framing theory to investigate the media framing of schizophrenia in the South African context.

Methods: We examined 216 news stories that covered the schizophrenia spectrum and other psychotic disorders from 20 South African newspapers retrieved from the SABINET – SA Media online archive over a 10-year period (2004–2014). Thematic analysis was used to analyse the news stories.

Results: The findings show that most of the news stories had problems as their main frame. These were followed by stories framed to diagnose the causes of schizophrenia and other psychotic disorders; and stories that made moral judgements about issues around the schizophrenia spectrum and other psychotic disorders. Stories that were classified as suggesting remedies were relatively less frequent. Problems and causes were the dominant frames each year for the 11year period. Suggested remedies were shown to be the least reported each year. Nonetheless we observed fluctuations across the years of analysis.

Conclusions: The study underscores the potential role of media analyses in framing schizophrenia and other psychotic disorders. We found that using the framing perspective as a way of identifying the primary themes or ideas presented in print media was very useful. Our findings highlight the need for collaboration between researchers and the media to enhance opportunities for improved and more nuanced reporting of mental health issues.

Non-communicable diseases

Media framing

Mental health care

Schizophrenia

Newspaper

South Africa

Schizophrenia affects approximately 24 million people worldwide [1] and it is one of the top 20 leading contributors to years lost to disability globally [2]. In both men and women, schizophrenia is equally prevalent. However, its onset is earlier in men than in women [3]. In the new DSM-5, schizophrenia is classified under the Schizophrenia Spectrum and Other Psychotic Disorders category. By definition, psychotic individuals are subject to profound changes in personality, hallucinations, delusions, and formal thought disorder; and have lost touch with reality [4]. Schizophrenia is a mental illness that is chronic, severe and disabling, and is characterized by positive symptoms (i.e., delusions and hallucinations), disorganization (i.e., thought disorder, behaviours that are unusual, or incoherent speech) and negative symptoms (i.e., avolition and restricted emotional expression) [5, 6]. The negative and positive symptoms of schizophrenia are associated with functional outcomes that are poor, which include difficulties in social functioning and reports of lower quality of life [5].

Schizophrenia is treatable and currently a mix of psychosocial interventions and medications are used for the treatment of schizophrenia [5]. Current treatments (antipsychotic medications) assist in alleviating some of the positive and disorganization symptoms experienced by individuals with schizophrenia. However, people living with schizophrenia often continue to experience residual symptoms and in some medicated patients, residual hallucinations and delusions do not completely resolve [5, 7]. Psychosocial treatments are also used for the treatment of schizophrenia, and they offer additional promise as an effective treatment for those positive symptoms that are persistent or medication resistant [5].

With adequate treatment and support most individuals with schizophrenia are able to live a meaningful and satisfying life, in the presence or absence of symptoms. However, structural and psychosocial factors may compromise treatment outcomes for individuals diagnosed with schizophrenia. People with schizophrenia are less likely to seek care than the general population owing to ignorance and stigma surrounding the condition [8, 9]. Although there have been significant advances in treatment, in past decades, the stigmatization and discrimination of people with mental illness has persisted [10].

Ninety per cent of people with untreated schizophrenia live in low- and middle- income countries [11] where lack of access to mental health services prevails. Prevalence data on mental disorders including schizophrenia in South Africa is limited [12]. The Global Burden of Disease study estimated that the 12-month prevalence for any mental, neurological and substance use disorders in South Africa in 2016 was 15.9%, with schizophrenia contributing 0.2% [13]. One study in South Africa indicated that mental health stigma perpetuated by family members, peers, community members and health care providers was rife often leading to delays in help-seeking among patients [14]. An online study, using Twitter to investigate stigmatising and trivialising attitudes across a range of mental and physical health conditions found that mental health stigma is common on social media with schizophrenia being the most stigmatised condition [15].

Theoretical framework

Entman’s [16] framing theory provides a useful lens for exploring media representations of schizophrenia, as well as how the media shapes public perceptions and policies around schizophrenia. Entman [16] defines framing as the process of assembling a narrative that highlights the connections among a few elements of perceived reality (that have been culled) to promote a particular interpretation. According to Weaver [17], media frames are the central organizing idea for news content. He further argues that frames suggest what the issue is by using emphasis, selection, elaboration, and exclusion. Frames also supply a context. The inferences that people make about the message are shaped by media frames, which are properties of a message [18].

Over the years, the framing theory has become increasingly popular in media analysis. Framing essentially involves selection and salience. Entman [16] proposes four main purposes of frame analysis which encompass the core business of strategic framing: (1) to define problems, (2) to diagnose cause, (3) to make moral judgments, and (4) to suggest remedies. Framing basically means choosing certain aspects of a perceived reality and making them more salient in a communicating text, in such a manner that it promotes a definition of a particular problem, interpretation of the causes, moral evaluation, and/or suggestions of the treatment of/for the described item [16]. In problem definition, frames determine the costs and benefits of what a causal agent is doing, and common cultural values are often used as a measure of this [16]. In diagnosing the causes, identification of the forces creating the problem is achieved [16]. Causal agents and their effects are evaluated by frames that make moral judgements; and treatments for the problems and predictions of their likely effects are offered and justified by the frames that suggest remedies [16].

Perhaps most concerning of all, the media often creates a negative imagery of mental illness that emphasise dangerousness, criminality and unpredictability [19]. The media can also trivialize mental illness, either by promoting mental illness as not being severe or being less severe than it really is [20]. More often than not, in movies, characters with schizophrenia are presented as “homicidal maniacs” or “psycho killers” [21]. A media analysis conducted in the Czech Republic and Slovakia found that a vast majority of the analysed articles presented mentally ill individuals as perpetrators of aggressive behaviour [22]. The way schizophrenia is framed in the media could contribute to the dissemination of misinformation about the symptoms, causes, and treatment of schizophrenia as well as other forms of severe mental illness. Previous research conducted in Europe has focused on the news media’s role in exacerbating or mitigating the stigmatization of schizophrenia [23] but our search did not yield any study on media framing of schizophrenia in South Africa. Therefore, this study uses the framing theory to explore how the South African print media frames schizophrenia. The findings of the study could help inform mental health policies and enhance our understanding of how to engage the media in South Africa.

We used SA Media – located on the SABINET search engine to search for news stories relating to schizophrenia spectrum and other psychotic disorders. SA Media is a database that provides full-text electronic records (from 1978 onwards) of South African print media. SA Media contains functions for identifying news stories with various terms/key words. The searches were conducted between May and June 2015.

Newspaper search and selection strategy

We retrieved newspapers available in SA Media using a search strategy that the research team jointly developed. We developed a set of inclusion criteria through an iterative process to assist in retrieving newspapers from SA Media. The criteria for inclusion were that newspapers had to: 1) be classified as a newspaper published in South Africa; 2) be published in English; 3) be published for a fairly broad readership (e.g., newspapers that were printed solely for the police forum or financial mail were excluded as we felt they were not widely read by the general public); 4) the news story had a term related to schizophrenia and other psychotic disorders in the heading or the full text of the news story. Twenty newspapers met the inclusion criteria (see Table 1). The inclusion criteria was set to include newspapers published for a 11-year period (from 1 January 2004 to 31 December 2014).

Table 1

Newspaper characteristics covered in analysis
Geographical circulation of newspapers	Newspapers	Frequency	Publisher	Circulation
National Newspapers
	Citizen City Press Mail & Guardian New Age (The) Star (The) Sowetan Sunday Independent (The) Sunday Times Sunday Tribune Times (The)	Mon-Fri Sunday Weekly Daily Mon-Sat Daily Weekly Weekly Weekly Weekly	CTP/Caxton Media24 M & G Media Ltd. Johannesburg TNA Media Independent Newspapers, Johannesburg Avusa Media Ltd., Johannesburg Independent Newspapers, Johannesburg Avusa Media Ltd., Johannesburg Independent Newspapers, Johannesburg Avusa Media Ltd., Johannesburg	54689 94290 30286 Not registered with ABC 85567 92453 Not registered with ABC 338532 61035 109484
Provincial Newspapers
Eastern Cape	Daily Dispatch Herald (The) Weekend Post	Mon-Sat Mon-Fri Weekly	Avusa Media Ltd, Johannesburg Avusa Media Ltd, Johannesburg Avusa Media Ltd, Johannesburg	23585 21285 18441
Gauteng	Pretoria News	Mon-Sat	Independent Newspapers, Johannesburg	14401
KwaZulu-Natal	Business Day Daily News Independent on Saturday The Witness	Daily Daily Saturday Daily	BDFM Publishers (Avusa Media Ltd) Independent Newspapers, Johannesburg Independent Newspapers, Johannesburg Media 24	25753 25091 39061 14879
Western Cape	Cape Argus/Argus Weekend Cape Times	Mon-Sun Daily	Independent Newspapers, Johannesburg Independent Newspapers, Johannesburg	31197 54689

Selection Strategy

Using the described inclusion criteria, the first author (NM) searched for news stories from the twenty newspapers on the online database, SA Media, using specific search terms. All the terms that are related to schizophrenia, generally used in the literature as well as the DSM-5, were used as search terms instead of restricting the search to only the terms “the schizophrenia spectrum and psychotic disorders”. This was to ensure that as many news stories as possible were retrieved. These search terms are “schizophrenia”; “psychosis” (and its variant spellings); “psychotic disorders”; “schizotypal”; “schizoaffective”; “schizophreniform”; and “catatonia”. We conducted the search of these terms in the titles as well as the full texts of the news stories. Therefore, if the title or the full text of the news story had the at least one of the exact search terms, those news stories were retrieved from SA Media.

Selection of news stories

A total of 1033 news stories were retrieved from the selected 20 South African newspapers (see Fig. 1). A set of explicit exclusion criteria was developed to enable us to remove those news stories that were deemed irrelevant to the purpose of the study. First, we removed all the duplicate news stories. The same news story retrieved by the same search term was defined as a duplicate. Secondly, if different search terms yielded the same news story, it was regarded as an overlap. We found and removed 72 news stories that were overlaps. Thirdly, we removed 173 news stories that had a very narrow readership or were written in a language other than English. Fourthly, we removed 376 news stories without a main focus on schizophrenia/psychotic disorders and were left with 227 news stories. A further 11 news stories were removed based on a more thorough assessment of the full texts of news stories, and the remaining 216 constituted the sample and were included in subsequent analyses.

Analysis of news stories

We conducted a qualitative analysis on the 216 news stories that made up the sample. The first (NM) and second (PN) authors worked collaboratively for analysis of these news stories to validate the data and regularly consulted with the third author (OA). Various themes were developed regarding the way in which South African print media frames the schizophrenia spectrum and other psychotic disorders. We used a hybrid approach of qualitative methods of thematic analysis which incorporated both the deductive approach and the data-driven inductive approach [24]. This approach complemented the research questions and theoretical approach by allowing the tenets of framing theory to be integral to the process of deductive thematic analysis while allowing for themes to emerge direct from the data using inductive coding. An inductive approach meant that the identified themes were strongly linked to the data themselves [25].

We conducted inductive thematic analysis following the six steps outlined by Braun and Clarke [25]. Once the sample news stories had been selected, NM, in the first step, familiarised herself with these news stories by reading and re-reading the stories whilst making notes before coding began. NM was fully cognisant of Entman’s [16] description of frames which would later (in the second step) form the basis for organising the data into broad meaningful concepts. These concepts are: i) problems, ii) causes, iii) moral judgement, and iv) suggested remedies. In the second step, NM organised the data under these four concepts by generating an initial list of codes relating to dominant frames of these four concepts in each news story. The initial coding was then reviewed and modified by OA. Thirdly, the codes were organised into potential themes under each of the four concepts and the data relevant to each theme was collated. In the fourth step, in order to determine if the themes were relevant in relation to the whole data, PN conducted a general review of the themes, and the themes were reworked where they proved problematic, for instance, if there was not enough data. Fifth, themes were defined and named, following revision. In the last and final step, we present a report on the final analysis of the news stories. All the authors revised, finalized and agreed upon the themes.

Characteristics of data set

The 20 newspapers that met the inclusion criteria for analysis are shown in Table 2. The circulation figures ranged from 14 401 to 338 532. The national newspapers had higher circulation figures (except the Mail and Guardian whose circulation figure is significantly lower than the other national newspapers) than the provincial newspapers. We could not find circulation figures for the Sunday Independent as well as the New Age (two national newspapers), because they are not registered with the ABC.

Table 2

Newspaper characteristics covered in analysis
Geographical circulation of newspapers	Newspapers	Frequency	Publisher	Circulation
National Newspapers
	Citizen City Press Mail & Guardian New Age (The) Star (The) Sowetan Sunday Independent (The) Sunday Times Sunday Tribune Times (The)	Mon-Fri Sunday Weekly Daily Mon-Sat Daily Weekly Weekly Weekly Weekly	CTP/Caxton Media24 M & G Media Ltd. Johannesburg TNA Media Independent Newspapers, Johannesburg Avusa Media Ltd., Johannesburg Independent Newspapers, Johannesburg Avusa Media Ltd., Johannesburg Independent Newspapers, Johannesburg Avusa Media Ltd., Johannesburg	54 689 94 290 30 286 Not registered with ABC 85 567 92 453 Not registered with ABC 338 532 61 035 109 484
Provincial Newspapers
Eastern Cape	Daily Dispatch Herald (The) Weekend Post	Mon-Sat Mon-Fri Weekly	Avusa Media Ltd, Johannesburg Avusa Media Ltd, Johannesburg Avusa Media Ltd, Johannesburg	23 585 21 285 18 441
Gauteng	Pretoria News	Mon-Sat	Independent Newspapers, Johannesburg	14 401
KwaZulu-Natal	Business Day Daily News Independent on Saturday The Witness	Daily Daily Saturday Daily	BDFM Publishers (Avusa Media Ltd) Independent Newspapers, Johannesburg Independent Newspapers, Johannesburg Media 24	25 753 25 091 39 061 14 879
Western Cape	Cape Argus/Argus Weekend Cape Times	Mon-Sun Daily	Independent Newspapers, Johannesburg Independent Newspapers, Johannesburg	31 197 54 689

The characteristics of the 216 news stories that constituted our sample are shown in Table 3. Only two media organizations published the majority (80.6%) of the news stories of which most of these stories (128, 59.3%) were published by Independent Newspapers. The majority of the news stories (119, 55.1%) were published in provincial newspapers; while the remaining news stories (97, 44.9%) were published in national newspapers. Of the 216 news stories (from both provincial and national newspapers) that constituted the sample for the first phase of analysis, the largest grouping (49, 22.7%) were published in the Western Cape’s newspapers, followed by the KwaZulu Natal (40, 18.5%) and Eastern Cape (17, 7.9%). Most of the news stories in the sample (32, 14.8%) were published in 2013.

Table 3

Characteristics of news stories with main focus on the schizophrenia spectrum and other psychotic disorders (N = 216)
Variable	Sub-variable	Total	%
Newspaper source
National newspapers		97	44.9
	Citizen City Press Mail & Guardian New Age (The) Star (The) Sowetan Sunday Times Sunday Tribune Sunday Independent (The) Times (The)	10 06 12 01 39 08 05 05 05 06	4.6 2.8 5.6 0.5 18.1 3.7 2.3 2.3 2.3 2.8
Provincial newspapers		119	55.1
	Eastern Cape newspaper news stories Daily Dispatch Herald (The) Weekend Post	17 09 03 05	7.9 4.2 1.4 2.3
	Gauteng newspaper news stories Pretoria News	13 13	6.0 6.0
	KwaZulu-Natal newspaper news stories Business Day Daily News Independent on Saturday (The) Witness (The)	40 10 18 02 10	18.5 4.6 8.3 0.9 4.6
	Western Cape newspaper news stories Cape Argus/Argus Weekend Cape Times	49 32 17	22.7 14.8 7.9
Year of publication	2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014	21 17 19 24 18 10 20 15 25 32 16	9.7 7.9 8.8 11.1 8.3 4.6 2.3 6.9 11.6 14.8 7.4
Publisher	Avusa Media Ltd. CTP/Caxton Media24 M&G Media Ltd. Independent Newspapers TNA Media	46 10 16 12 128 01	21.3 4.6 7.4 5.6 59.3 0.6

Framing

The dominant frames which are the most salient aspects of each news story were identified. Following Entman’s [16] conceptualization of framing, four dominant frames were drawn which are: “problems”, causes”, “moral judgements”, and “suggested remedies”. Table 4 presents the themes that were identified within each of the dominant frame.

Table 4

Print media frames of the schizophrenia spectrum and other psychotic disorders
Problems	Causes	Make moral judgements	Suggest remedies
Included stories discussed: (a) public perceptions/stigma/general misconceptions about illness (b) incidence/prevalence (c) social implications of illness on the mentally ill (d) shortage of mental health professionals (e) adherence to medication and beliefs about illness/treatment (f) lack of funding for mental health initiatives (g) NGOs and communities taking action	Included stories discussed: (a) effects of drugs/substances on mental health (b) new, on-going, or proposed research on causes (c) evidence of cause or cure	Included stories discussed: (a) call for action (b) opposition of particular solution	Included stories discussed: (a) proposed solution (b) implemented solutions

Figure 2 indicates that there were 171 (79.0%) news stories that had problems related to schizophrenia as their dominant frame, and 93 (43.1%) news stories had the causes of schizophrenia and other psychotic disorders as their dominant frame. Twenty-one (9.9%) news stories had suggestion of remedies as their dominant frames, and 38 (17.7%) news stories had moral judgements about issues and actions relating to the schizophrenia spectrum and other psychotic disorders as their dominant frames.

The dominant frames with the highest frequency each year were problems as shown in Fig. 3, while suggested remedies were the least reported each year. Results of the dominant frames in each year of analysis shows that 2008 had the highest number of news stories (16 of 17, 94.1%) reporting on problems, followed by 2004 with 16 of the 18 news stories (88.8%). Among the news stories that discussed causes as a dominant frame, 2007 had the highest number of news stories with 16 out of 20 news stories (80.0%), followed by 2004 with 12 out of 18 news stories (66.6%). The year 2004 had the highest frequency of news stories (8 of the 18, 44.4%) making moral judgements, while 2009 had no news stories making moral judgements. Frames on suggested remedies were the news stories with the lowest frequency for most years. None of the news stories suggested remedies in 2007, 2009 and 2014.

Problems

This theme encompasses the main issues regarding the schizophrenia spectrum and other psychotic disorders that frequently appear in news stories and the context in which they are framed that suggests problem definition.

(a) Public perceptions/stigma/general misconceptions about illness

News stories illustrated actions taken by the families of the mentally ill driven by their perceptions, misconceptions and stigma. In some cases, schizophrenia was perceived as a spiritual problem that required spiritual intervention.

“Mduduzi suffers from a mental illness; his parents brought him to St John Apostolic Church in Etwatwa, East Rand seven months ago. They hope church rituals such as induced vomiting by swallowing "holy water" will rid him of his demons…Prayers and rituals cure patients better than modern medicine, says St John's minister Lucas Kunene.” (The Star, 15 July 2004)

Other news stories reported on how culture played a role in influencing the perceptions of people regarding mental illness. Although the presence of mental illness was acknowledged in some cultures, derogatory terms were used to describe people with mental health problems:

“…naturally this does not mean that there are no people with mental illness in Zulu speaking communities. There are. We just don’t say a person is autistic, schizophrenic or suffering from manic depression. We say umuntu uyahlanya: a person is mad. We say umuntu usangene: a person is insane or, if we are feeling particularly colourful, that ngathi azithathi kahle ekhanda: a person has a brain malfunction.” (The Business Day, 24 June 2010)

A common thread in the news stories was the misconceptions and the perceptions the public had about mental illness mainly emanating from media programmes. Such misconceptions reported by the news stories led to beliefs that people living with schizophrenia should be institutionalised:

“Despite what you have learnt from poorly researched movies and TV programmes, schizophrenia does not involve having multiple personalities...but if someone with the disorder commits a crime everyone assumes that the schizophrenia is to blame…sometimes this even renews calls for all "mental" patients to be locked up "for the good of the public".” (The Citizen, 12 June 2012)

(b) Incidence/prevalence

Most news reports of incidence/prevalence claimed that schizophrenia is very common in South Africa and that most people who suffer from it have never been properly diagnosed. The news stories also reported on the proportion of the population that is affected by schizophrenia.

“Schizophrenia affects about 1% of the population and usually manifests in males aged 15 to 25 and females 25 to 35, according to Dr Yusuf Moosa, senior psychiatric specialist with Gauteng Community Mental Health Department.” (The Star, 10 October 2005)

“According to Wikipedia between 0.6 % and 1% of the world's population suffers from schizophrenia. That translates to somewhere between 3000 and 5000 people in South Africa.” (The Herald, 16 April 2008)

(c) Social implications of illness on the mentally ill

Some news stories documented the personal experiences of people with schizophrenia, detailing how they suffer in silence. The news stories further documented the difficulties that patients encounter in their social spaces, particularly in families and in the workplace as they endeavour to keep their diagnosis a secret:

“Due to the stigma and misunderstanding surrounding the illness, my son will not tell his employer that he has it, so the same level of performance is expected as from any other person…his father does not accept that he has schizophrenia…” (The Independent on Saturday, 08 July 2006)

(d) Shortage of mental health professionals

A commonly reported problem in the news stories is the shortage of mental health care professionals. A news story described the current situation in the country thus:

“Taking the 2% of the population afflicted with the most severe of psychiatric illnesses means that 800000 South Africans are in need of psychiatric care which would mean each psychiatrist should have more than 2000 regular full-time patients, most have only a few dozen at the most, said Prof. Stein.” (The Citizen, 08 January 2004)

Indeed, these new stories placed a general emphasis on South Africa’s clinician to patient ratios: The issue of shortage in mental health professionals was portrayed as pervasive.

“…the public sector faces a severe shortage of psychiatrists and psychologists, he said. Only 14% of the 2692 clinical psychologists registered with the Health Professions Council SA are working in the public sector, just 0,32 psychologists per 100 000 of the population and 0,28 psychiatrists per 100 000.” (The Cape Argus, 31 March 2014)

The shortage of mental health professionals within the mental health care systems was framed as a symptom of even bigger problems that exist within the health care system such as the inadequate number of mental health care facilities, few professionals being trained per year, as well as few professionals that exist in the public sector.

(e) Adherence to medication and beliefs about illness/treatment

Poor adherence to treatment among patients with schizophrenia was generally reported as the root cause of relapses. News stories emphasised how patients failed to completely follow their medication due to several factors which included the beliefs the patients had about medication:

“If medicated, many may be stabilized. But often, patients have to be persuaded to take daily medication. Many think it will extinguish their creative spark, Katz says.” (The Star, 15 July 2004)

The news stories reported that patients were acting against medical ‘good practice’ and ‘irrationally’. Some news stories discussed how parents preferred to take their children to church for ‘faith’ healing rather than to mental health institutions:

“Actually, I don’t believe much in tablets….one resident said….This is a spiritual thing.” (The Sunday Independent, 15 august 2004)

Other news stories reported common threads of non-adherence to medication among the patients mostly due to alcohol or drug use. They also reported on the implications of patients’ poor adherence which ultimately causes relapses:

“Poor compliance is definitely the most important cause of relapses, and relapses are one of the biggest problems with the illness.” (The Cape Argus, 22 September 2005)

(f) Lack of funding for mental health initiatives

Several of the news stories illustrated the insufficient funding of mental health initiatives, whereby mental health providers had to supplement for shortfalls in their budget. One of the news stories reported the experience of a non-governmental organization providing mental health services:

“...mental health was the least funded and the least marketable…mental health is not sexy….here [in the NGO] we give them voice. There's no stigma," she said…but funding is a challenge. "…we receive 36 % of our funding from the DOH [Department of Health], but we have to fund raise for the remaining funds.” (The Cape Argus, 15 July 2013)

Some news stories also discussed how many organizations which were supporting the government by providing housing for discharged mentally ill patients had to deal with insufficient funding.

“The homes are in constant battle against closure, since donations and work contracts for residents fail to raise enough money. Signs of poor funding are everywhere at Gordonia… Government officials told staff that its funding covered about 75% of the home's cost, Haywood says. Figures indicate however that the contributions amount to less than 18% of the home's annual costs.” (The Star, 15 July 2004)

(g) NGOs and communities taking action

News stories recognized that NGOs, churches, as well as community members were taking matters into their own hands, albeit in an inhumane manner. This was driven mainly by the misconceptions surrounding mental illness, as well as the shortages in resources (insufficient MHC facilities and MH professionals).

“Mduduzi hasn’t seen his parents for several weeks, but hopes he will go home soon. He knows that if he becomes hyperactive or aggressive, he'll be handcuffed. But he says he feels fine and has stopped taking his medication he receives on his rare visits to a local clinic….Kekana sees the chaining of mentally disabled people, which happens at several St John's congregations, as a last resort. "Some of the priests chain them because they get so wild they can kill people," he says… Rensburg says NGOs - themselves badly funded - need to function as a "deadlock" in cases where parents and church maintain they're doing the right thing.” (The Star, 15 July 2004)

However, not all organisations treated mentally ill people inhumanely. Some news stories reported on other organizations taking action to criticize and condemn organizations that were committing human rights violations.

“The human rights commission, in a meeting in late July, described the chaining as a human rights violation. Still St John's leaders felt misunderstood.” (The Sunday Independent, 15 August 2004)

Other news stories reported on the active role played by certain organizations in bringing awareness in communities as they felt that government was not doing enough to address mental health-related issues:

“The organisation's work, she said, involved bringing awareness to communities of what mental health was and how victims and families of victims should approach problems.” (The Herald, 17 October 2007)

Causes

(a) Effects of drugs/substances on mental health

A major cause of problems reported in the sample was the use of substances and the effects it had on the mentally ill, or how it triggers mental illness, particularly psychosis. Cannabis was commonly framed in several articles as a growing concern. A number of these news stories reported on various studies that investigated the relationship between MH and cannabis. The findings of most of these studies were that cannabis almost always exacerbated symptoms of psychosis in people who already had mental illness, and that the use of cannabis is consistently associated with psychotic symptoms which include disabling psychotic disorders. The studies reported in the news stories also found that cannabis aggravates schizophrenia. The news stories further reported that people have limited knowledge about the link between psychoactive substances and mental illness.

“People should know about this; they know you have a risk of lung cancer with smoking but nobody knows about the risk of psychosis with cannabis.…Experts believe that about 10% of schizophrenia cases are triggered by cannabis.” (The Cape Argus, 02 December 2004)

(b) New, on-going, or proposed research on causes

Scientists and psychiatrists were mostly quoted as the ones discussing existing research on possible causes. One of the news stories discussed research that was conducted for a doctoral thesis on the causes of schizophrenia, the remaining news stories discussed research that was conducted in psychiatric institutions in various countries (South Africa, Scandinavia, Britain, France, US). Several news stories reported that most of the research focussed on Cannabis and its link to psychosis. The studies found that regular cannabis use could trigger schizophrenia in some people.

“A Dutch study found that heavy users, who smoked two or more cannabis joints a week were almost seven times more likely to have psychotic symptoms three years later. And research in France found smoking at that level can trigger psychosis in people with a family history of psychiatric illness - Daily mail.” (The Star, 13 July 2004)

Despite reporting on the link between drug use and schizophrenia, a number of news stories noted that the exact causes of schizophrenia and psychosis are not well understood even in the science field. Several news stories reported that Stellenbosch University's medical school was at the cutting edge of new research into injectable medications for patients with schizophrenia.

“What we won the right to test is a new-generation anti-psychotic in a longer-acting injectable form. We are the first to be conducting trials worldwide using it as a first line treatment for schizophrenia…Emsley said.” (The Cape Argus, 22 September 2005)

(c) Evidence of cause

There was a consensus amongst the news stories that schizophrenia is a chronic mental disorder characterised by recurrent episodes of psychosis in which the individual experiences hallucinations - usually auditory - as well as delusional ideas, disorganized behaviour and illogical thought processes. Cannabis use was again consistently framed as the major trigger for schizophrenia in these news stories which referenced evidence of various research findings.

“Peter Stoker, of National Drug Prevention Alliance, said: "This research gives the lie to apologists for cannabis who have consistently tried to find something other than cannabis to blame for mental illness. It makes it clear that everyone who smokes is vulnerable.” (Daily News, 12 July 2004)

Moral Judgements

This theme encompasses moral judgements that were reported about actions proposed and taken, opposition to particular solutions as well as support of particular solutions.

(a) Call for action

The news stories called on both the national and provincial governments to increase the numbers of practitioners and the mental health resources available. In addition, the news stories discussed some of the challenges undermining the implementation of mental health policies.

“It [strategy] exists in policy, but seldom in practice, due to staff shortages, siloed [isolated] sectoral planning, lack of training in mental health promotion, and particularly transport. At the same time, the basics are in place: clinics, medication, rehabilitation therapists in (some) district hospitals. R300 million over three years, invested in building up existing services in the province, would go some way towards alleviating the crisis.” (The Daily Dispatch, 21 June 2013)

The need for more beds in mental health facilities was made clear in numerous news stories. There was also a call in numerous news stories for an increase in community mental health services.

“…but Daniels said she would like to see an urgent audit of the availability of mental health beds countrywide, with the aim of providing more. We also need increased community psychosocial mental health services to assist and support people living with mental disability on their journey to recovery.” (The Saturday Argus, 27 July 2013)

One news story highlighted the benefits of early detection of mental illness and the need to prioritise issues related to mental illness.

“Making fun of people in institutions like Weskoppies and Sterkfontein [mental health institutions] and mocking those with mental illness must stop…if people are diagnosed early, many disastrous consequences can be prevented. Just like detecting cancer early can help people survive, so can people with mental illnesses who are diagnosed early enough be helped...there is a desperate need to treat the problem of mental illnesses more seriously.” (The Star, 19 May 2014)

(b) Opposition of particular solution

News stories frequently reported on the government’s policy that promotes deinstitutionalization after psychiatric treatment. This was in an effort to cut costs and reintegrate patients with psychiatric illnesses into communities. However, the policy has been reported in many cases to have backfired. Several issues were discussed by the news stories in relation to deinstitutionalization. 1) it was reported that the problem with this is that after leaving these institutions, people who suffer from schizophrenia are not automatically ready to continue with everyday life; 2) once de-institutionalised, people with schizophrenia still suffer from negative symptoms like lack of drive, low motivation and social withdrawal – which makes it difficult for them to interact with friends and family, more specifically people at work; 3) families struggle to cope and many patients end up being hospitalized partially due to the fact that they stop taking their medication; because South Africa has underfunded institutions which gives rise to amateur efforts to provide assistance.

“Particularly attractive is the notion that care of the mentally disabled should be de institutionalised and relocated within communities. In an ideal world, this would make good sense. But our world isn't ideal. The main effect of the policy, therefore, is underfunded institutions, a situation that gives rise to amateur efforts to provide assistance.” (The Star, 21 July 2004)

Another policy that the news stories were opposing was one in relation to the 72-hour process employed by secondary institutions before a patient is transferred to a tertiary institution or sent home. The problem with this appears to be the large numbers of patients who require long term care, that are released back into the community, which gives rise to numerous issues that were mostly discussed above.

“In another policy change aimed at keeping patients out of long-term care, hospitals are obliged to keep psychiatric patients in short-stay wards to see whether they can stabilize them rather than sending them to psychiatric hospitals.” (The Mail and Guardian, 07 September 2006)

Suggestion of Remedies

This theme encompasses proposed remedies/solutions which include policy options, solutions that have already been implemented, as well as the cancellation or removal of solutions.

(a) Proposed solution

Efforts to train and educate both mental health facility personnel and the public were reported. One of the news stories reported on promises made of increased funds and resources for mental health services:

“A [mental health] action plan is being finalised in consultation with stakeholders and…resources will be allocated to fund the priority activities, said Maja. The answer is more beds.” (The Mail and Guardian, 18 April 2013)

(b) Implemented solutions

The government’s "deinstitutionalisation" policy was reported in many news stories, and it was described as an effort of cutting costs and integrating patients in communities by discharging them back to their families. Another solution that has been implemented was the MHCA (17) of 2004.

“The mental health care act (17) of 2002 was promulgated in December 2004 to address the problems and protect the rights of mental health care users. The DOH has since embarked on extensive quality evaluation of healthcare facilities around South Africa.” (The Star, 04 July 2006)

“…unlike the previous health care system which followed a curative and hospital-based approach for mental health, the new system emphasises prevention and health promotion with mental health services integrated into the primary healthcare system.” (The Cape Argus, 11 December 2008)

There were also programmes that were reported with aims of creating awareness around mental illness with a huge focus on eradicating the stigma that is associated with it and to correct/clarify any misconceptions through educating communities as well as patients with mental illness.

“Mokgata said SAFMH had programmes to educate and empower communities about metal illness. He said one of the primary objectives was to remove the stigma associated with the condition of mental health.” (The Sowetan, 19 July 2006)

(c) Cancellation or removal of a solution

There were no reports in the news stories of any solutions to problems or policies being removed or cancelled.

Our study aimed to provide insight into how the South African print media frame issues relating to schizophrenia spectrum and other psychotic disorders. There were slightly more provincial newspapers than national newspapers in our sample. A possible explanation for this could be the fact that in South Africa, implementation of policies occurs at the provincial level. Issues relating to the implementation of mental health policies are more likely to be covered at the provincial level than at the national level. We note, however, that the provincial newspapers had about half the circulation figures of the national newspapers which mean that the national newspapers had about double the reach of the provincial newspapers.

Of all the provinces, KwaZulu-Natal had the highest combined circulation figures, but Western Cape was the province with the highest proportion of news stories in our sample (22.7%) followed closely by KwaZulu-Natal province which made up 18.5% of the total number of news stories. These two provinces (Western Cape and KwaZulu-Natal) combined to make up about half of the total number of news stories in our sample and almost the same proportion as the national newspapers. Most of the news stories from the Western Cape were about the relationship between substance abuse and psychosis, lack of funding of mental health issues or insufficient financial resources for dealing with people with mental health issues and issues relating to awareness of mental illnesses. The majority of the news stories were published in the Weekend/Cape Argus and were about deinstitutionalization, shortage of resources and lack of funding for mental health issues in the Western Cape province and nationally.

The majority of the news stories reported on the four dominant frames espoused by Entman [16]: problems, causes, moral judgements and suggestion of remedies. However, frames relating to problems were the most dominant, followed by those relating to causes, moral judgements and suggested remedies in that order. It was notable that the news stories did not report on moral judgements related to schizophrenia in one year (2019) while there were no news stories with dominant frames on remedies for three years (2007, 2009, 2014). It is not clear why this is the case as there does not seem to be a particular pattern to the reporting of these issues. The fact that there were frames of problems over the 11-year period and the lack of frames for suggested remedies in three years is concerning. Given the wide reach of these newspapers, this mean that the public gets to read about the problems and causes of schizophrenia as well as the moral judgements that people make about the illness but have little information in terms of possible solutions to the problems related to schizophrenia spectrum and psychotic disorder. This could distort the public views about this issue and it would tend to magnify the scale of the problem since there are fewer remedies that have been suggested to address the problems discussed.

A common thread in the news stories is the misperceptions about schizophrenia and other psychotic disorders. Most of the news stories had various frames about how members of the society perceive people living with schizophrenia. These frames show that people living with schizophrenia and other psychotic disorders are perceived by society as violent and dangerous and therefore highlight the need to institutionalise them. An online study by Owen [26] analysing 41 movies for depictions of schizophrenia found that the majority of characters in the movies displayed violent behaviour toward themselves or others. The framing of schizophrenia in the media may trigger and sustain the false stereotype that people with schizophrenia are prone to violence and unpredictable behaviour. Nonetheless, it was reassuring that some of the news stories in our sample had frames debunking this myth. In fact, some of these news stories indicated that people with schizophrenia are frequently victims of violence.

Some of the frames reflect the societal perceptions of the illness as a spiritual problem which requires treatment by spiritual people. A study among Xhosa people in South Africa found that schizophrenia may be attributed to the influence of ancestors or to bewitchment which requires a better understanding of the cultural frameworks in treating the illness [27]. Our study further shows how the print media frames the cultural interpretations of schizophrenia and other psychotic disorders. These portrayals tended to be derogatory and therefore stigmatising. Rydderch and colleagues [28] conducted a media analysis of mental illness in England and found that people had negative attitudes towards people with schizophrenia and other psychotic disorders. In addition, our media analysis shows that the media painted a picture that psychotic disorders and other mental illnesses are not being taken seriously by the policymakers.

Another common frame in the news stories was on the incidence and prevalence of psychotic disorders. According to the DSM-5, the prevalence of schizophrenia spectrum disorders is 0.3–0.7% of the population with variations across regions and countries [4]. Many of the new stories cited medical experts while others cited Wikipedia. One news story citing Wikipedia indicated a prevalence of 0.6–1% while another news story referencing a physician cited the prevalence as 1% of the population. Yet another news story cited a rate of 2%. Although the rates cited by the news stories seem to be slightly higher than that by the DSM-5, it is consistent with the documented evidence. In this case, the framing of the prevalence of schizophrenia does not appear to have exaggerated the true prevalence of the condition. Therefore, one could argue that the framing of the prevalence of schizophrenia in the news stories is close to accurate.

One of the problem frames in the news stories is the shortage of mental health professionals notably psychiatrists and psychologists. These stories focused on the clinician to patient ratios. The problem of shortage of health professionals was framed as pervasive and a symptom of larger problems within the health system namely few mental health professionals being trained every year, few mental health care facilities and the problem of trained health care professionals not working in the public health sector. This framing seems to be consistent with the literature that suggests that there is an artificial shortage of mental health professionals as many qualified and registered mental professionals choose to work in private practice, leaving the majority of the South African population without access to basic mental healthcare services [29].

Most news stories had frames that framed schizophrenia and other psychotic disorders as mainly caused using psychoactive drugs/substance. The most frequently mentioned psychoactive drug is Cannabis and some of the news stories cited various experts as indicating that drug use triggers psychotic disorders. Closely related to this is that several news stories reported on new and on-going research of causes of psychosis mainly focussing on studies that found a link between Cannabis and psychosis. Some reported on the people who had a family history are more likely to develop psychosis if they smoked Cannabis. This framing is consistent with the literature [30]. Still, it is interesting that most news stories noted that the exact causes of schizophrenia and psychosis are not well understood even in the science field, a position that is consistent with the literature [31]. However, it was notable that few news stories discussed therapies for schizophrenia. This is a cause for concern because this may tend to mislead the public into having a limited understanding of the potential therapies available for the treatment of schizophrenia. This might tend to discourage health seeking among people living with schizophrenia and their significant others.

The framing of moral judgements was evident in some of the news stories most of which were calls to action. These news stories called for an increase in the number of mental professionals and the provision of more psychosocial and mental health services, specifically an increase in the capacity of mental health institutions and community mental health services. This framing seems to be consistent with the literature that suggests that community mental health services are cost-effective in terms of improved population coverage [32]. Many of the news stories also called for the provision of services that will ensure early detection of mental health problems. A few of the news stories had frames relating to proposed and implemented interventions to address problems related to schizophrenia and psychosis. With regards to suggested remedies, de-institutionalisation was a dominant frame in the news stories. However, some news stories opposed this policy by framing it as being primarily aimed at saving cost. Some news stories also framed de-institutionalization as not properly implemented because people living with schizophrenia spectrum and other psychotic disorders eventually end up being re-institutionalised.

A number of limitations of the study must be noted. First, we limited our study to the print media whereas other types of media such as radio, television and social media reporting issues relating to schizophrenia and other psychotic disorders were excluded. Second, we included only print media available on the SA media database on SABINET whereas there might be print media not available on this database. Third, we included new stories published in English but did not include those published in local South African languages. Print media published in local South African languages may be important sources of information for a wide variety of people in South Africa.

This study found that using the framing perspective as a way of identifying the primary themes or ideas presented in print media was very useful. It is evident from the findings that the South African print media presents mental illness, with specific focus on schizophrenia and other psychotic disorders in a way that highlights the problems and causes more, rather than balancing this with reports on support of / proposed / implemented solutions that are congruent with the key policy developments. This is particularly concerning in the South African context as public opinion is largely shaped by the media. Our findings highlight the need for collaboration between researchers and the media in order to enhance opportunities for improved and more nuanced reporting of mental health issues.

Ethics approval and consent to participate

We only include information from published newspapers available in the public domain. We used SA Media which is a database that provides free access to full-text electronic records of South African print media. Thus, our research does not require ethics approval as we did not involve human participants.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analysed during the current study are available in the SA Media – located on the SABINET search engine

Competing interests

The authors declare that they have no competing interests

Funding

The authors have no funding to report

Authors' contributions

NM was the principal investigator and OA was the supervisor. NM and OA conceptualised and designed the study and NM collected the data. NM, OA and PN conducted the data analysis and interpretation. The manuscript was prepared by NM, OA and PN. All authors provided critical input to the paper. All authors have read and approved the final manuscript.

Acknowledgements

Not applicable

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No competing interests reported.

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How do South African newspapers frame schizophrenia and other psychotic disorders?

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