1. Introduction
After terrorist attacks, media will generally focus on these attacks in 24 h news cycles, bringing the latest news and rumors surrounding the attacks [
1]. Research indicates that watching such terrorist attacks and their aftermath through the media is associated with health issues. Most of the studies investigating this were based on the attacks in the United States on 11 September 2001 (hereafter 9/11). One such study showed that post-traumatic stress reactions could be linked with seeing images of the attacks on the Twin Towers, as well as seeing people jump out of the towers [
2]. Another study, in a representative sample in the U.S., showed that 22% of the population reported 9/11 to be their worst life event, even though they only viewed it through the media [
3]. A study conducted 1–3 weeks after 9/11 showed that watching more than four hours of 9/11-related television, combined with cumulative acute stress, predicted both mental and physical health issues, two to three years later [
4]. On the other hand, in a study of people directly exposed, media watching was not a good predictor of mental health issues [
5]. Such results are also seen in one of the few European studies: after the Paris attacks on 13 November 2015, media watching of terrorist attacks was associated with post-traumatic stress reactions. However, this was also not present in those directly exposed to the attacks [
6]. Other factors may explain the variability in the association. Higher age, lower socio-economic status, and female gender are associated with a higher chance of having mental health issues due to media watching [
6].
However, there are a few gaps in prior studies. First, many studies are performed long after the initial event. For example, some are performed one to two months later [
7], seven months later [
6] to even 35 months later [
8]. As these studies asked the respondent to recall months later how much media on a terrorist attack someone watched during the days after the attack, a recall bias is highly probable. For instance, someone with mental health problems following the attacks, might have a more vivid recollection of how much media they watched.
Second, while most studies of media watching and terrorism have concentrated on post-traumatic stress disorder, this has led to a gap in our knowledge of other mental health reactions. In fact, as of 2013, the new version of the DSM-V (diagnostic and statistical manual of mental disorders 5) removed media-exposure to violent events as a possible inclusion for post-traumatic stress disorder [
9]. Considering the enormous number of studies showing depression and anxiety being linked with terrorist attacks, it is surprising that not more studies have looked at media watching and these mental health issues [
10]. Especially when taking into account that general media studies showed that people with depression and anxiety disorder tend to use more media than healthy controls [
11].
Third, there is a reason to suspect that media watching can also be linked with somatic reactions (see [
4]). For example, some studies found that cardiovascular ailments might increase due to stress reactions upon seeing terrorist attacks [
12,
13]. Then again, other studies found no such reaction [
14]. Thus, the relation between seeing terrorist attacks through media and certain somatic reactions remains unclear.
Fourth, it remains unclear in what way proximity plays a role in relation to media watching. We know that being directly exposed is a better predictor than media watching [
5,
6], but working or living close to the area of the attack remains understudied when combined with media watching.
Finally, as most studies were conducted in the U.S., and even in relation to 9/11, it remains difficult to generalize the association between media watching and mental health issues [
6].
In the current study, we investigated media watching after the terrorist attacks in Belgium of 22 March 2016. On 22 March 2016 (hereafter 22 March 2016), two terrorist attacks occurred in Belgium. The first attack took place at the national airport, called Brussels Airport. Just before eight a.m., a suicide bomber near a coffee shop. Immediately after this, another suicide bomber struck near a check-in. A third man, who was supposed to do the same, fled the scene and was arrested weeks later. Approximately an hour after the airport attacks, a second attack took place while a metro was leaving the government area, involving a male suicide bomber. In total, 32 people were killed, in addition to the three suicide bombers, and hundreds were wounded [
15]. The national threat level, indicating the chance of attacks on the nation’s soil, was increased to the maximum level, though it was lowered again by one level a couple of days later. Across the nation, people felt threatened by these attacks and feared further attacks [
16]. Media outlets focused extensively on this terrorist attack, with many images of the massacre in the airport spreading, as well as videos of people escaping the metro station through the unlighted tunnels. Meanwhile, rumors spread around the internet of more threats, with bomb threats near the university in Brussels and even messages from gunmen on the roof of the airport.
Despite the extensive media coverage, there have been no studies on the association between media watching and health after the terrorist attacks in Belgium. It is important to have variation in studies on media watching, as media coverage might differ between countries. Furthermore, the current study is not hampered by possible recall bias, as it was conducted one week after the attacks in Belgium. Thus, in the present study, we investigated the relationship between media watching and health in Belgium, one to two weeks after the attacks.
We aimed to investigate:
The relation between media watching and mental health outcomes, namely anxiety and depressive symptoms.
The relation between media watching and physical health outcomes.
The role of proximity in relation to media watching in association with health outcomes.
4. Discussion
In the present study, we looked at the association between watching media coverage on terrorist attacks and proximity to the attacks 1–2 weeks after the terrorist attacks in Belgium of 22/03/2016. Our results suggest that, although proximity was associated in an important way with mental and somatic symptoms, media watching had a seemingly stronger association, especially when watching more than three hours of media about terrorist attacks. However, it should also be noted that all health reactions were on average higher in Brussels than outside of Brussels, indicating again the role of proximity. Furthermore, in addition to media watching and proximity, factors such as age, gender and education level were also important. In general, the severity of mental and somatic symptoms was quite low. For mental health, 34.5% had either moderate or severe symptoms, while for somatic health, this was 19.4%. On average, the group watching more than three hours of media had scores bordering on mild mental and somatic symptoms.
In general, the associations we found were similar to those identified in prior studies. For example, studies after the Boston Marathon bombing and the Paris-attacks showed that more time spent media watching was associated with higher stress scores [
6,
19]. When looking at media watching, it seemed that watching more than three hours was associated with worse mental and physical health. For example, 16.2% of those watching for more than three hours of media had severe acute mental health symptoms. However, an important nuance is that the percentages were also relatively high for mental health symptoms for those watching less than three hours of media: 10.2%. Furthermore, 35% of those who watched more than three hours reported no mental health reactions. It should thus be remembered that when stating that watching too much media is associated with health reactions, we are discussing a relatively small group in our study.
Yet, then again, media watching does seem to fit better in association with health symptoms than proximity. In fact, proximity did not even play a role in predicting somatic reactions compared to media watching for work proximity and somatic reactions. In general, there were less severe somatic symptoms than those of mental health. That might indicate that the “threshold” to get such symptoms is higher. It is also possible that those with higher levels of somatic symptoms were more likely to watch media.
Another aspect might be that people who work are generally healthier than people who do not work; we excluded unemployed and retired people for work proximity. Hence, we cannot ascertain whether the higher symptom levels among those with high media watching were actually due to the media exposure to the attacks. Furthermore, the working sample did not include those out of work. Therefore, it is possible that there were overall lower levels of somatic symptoms in this sample than when we also included those who were out of work in the analysis of home proximity. Keeping that in mind, having one’s work in Brussels might also feel less threatening than living in Brussels. Living in Brussels may mean taking public transport more often, and the metro line that was bombed was an important metro line, going to the central station and to a university. Furthermore, people who worked in an area close to the attacks probably did not go to work during the week of the attacks due to the threat. For students, many stayed home during that week because reaching the university was difficult.
Surprisingly, for somatic reactions, age was never a significant predictor. Why that might be is unclear, though we would point out that even for mental health reactions, age had a weak association, albeit a significant one. The very low B-values indicated that age, in general, does not play a role in such reactions. That is quite similar to the study on media watching and the Paris attacks [
6], while different from a study in the U.S. [
4].
The direction of the relationship between symptoms and media watching is unclear. For example, it might be that people with mental health issues seek out more media about terrorist attacks. After all, non-terrorist media studies have shown that people with depression and anxiety disorder tend to use more media than healthy controls [
11]. Explaining the direction is impossible with our cross-sectional design.
However, context is important to give insight into what might be more plausible. The attacks in Belgium were one in a series of attacks in Europe. Just months earlier, on 13/11/2015, France was attacked by terrorists whose base of operations was located in Belgium. In fact, just before the Belgium attacks, one of the lead terrorists of the France attacks had been arrested. Thus, it might be that there was already quite some distress among some people of the population, which led them to view more of the terrorist attacks in Belgium than the average person. That would support the findings in other studies, where media-watching and mental distress are in a sort of vicious cycle, each strengthening the other, and cumulatively building up [
20]. A study on the media watching of 9/11 by Oklahoma City bombing survivors showed that there is reason to suspect that cumulative exposure to media and stress can be important in explaining the association [
21].
However, would we not then expect the relationship between media watching and health reactions to be stronger? The Belgian attacks occurred after the media-covered attacks on Charlie Hebdo and the Paris attacks, in a climate of regular attacks. Yet, the relationship between media and health is quite mild, all things considered.
It might also be that people in Belgium had gotten used to the threat of terrorism. While there is hardly evidence of the public health impact of the Paris attacks, the number of suicides increased during the two-week lockdown period after the Paris attacks in Belgium, while there was no increase after the Belgian attacks [
22]. It is not unthinkable that people in Belgium were “expecting” an attack sooner or later. Thus, perhaps those affected by the long-term threat also viewed more media during the Brussels attacks.
Comparing our results to the studies from the U.S. is difficult, as such studies take place in a different media landscape, e.g., Belgium has no 24/24 h news channels. Thus, we would need more European research on terrorism and media watching. If media plays an important role, it is necessary to look at the role of different media cultures. While certainly there is also a difference in media in Europe itself, the point is that the focus at the moment of media watching of terrorist attacks is primarily an American study field.
As mentioned, we have no indication of the long-term problems that might be related to media watching in Belgium. A study conducted 2.5 years after the attacks in Belgium showed that a sample in Brussels did show slightly fewer mental health issues than in the current study, but most importantly, it showed a significant association between mental health, the perception of terrorist threat and types of avoiding behavior: people avoided certain places associated with the attacks [
23]. That cannot, however, not be linked to the media, as at that point, there was hardly any coverage of the attacks in Belgium. The attacks themselves probably left a mark on the people living in Brussels, affecting their behavior, and indicating the role of proximity after the media stopped reporting on an attack.
It may, however, be that this “mark” was created by the extensive media coverage at the moment of the attacks. Another interpretation in relation to the current study might be that people who feel distressed continue to fear future terrorist attacks, even after the media has stopped reporting on them. It might, therefore, be that these people are also the ones who will view a lot of media when a new terrorist attack occurs. In short, it remains unclear, though it might be reasonably expected that the association between media watching of terrorist attacks and health cannot be solely explained by one single attack [
20].
Our study showed that media watching could be associated with health reactions during the week after an attack. Whether these symptoms will last is unclear. However, there is no reason to recommend balancing sensationalistic aspects of media coverage [
20]. Considering the number of ways of accessing media (e.g., television, social media, the internet and newspapers), it seems more opportune to invest in public health promotion so that the general population is informed of the possible (short-term) adverse problems associated with high media consumption. Aside from such actions, we should trust the critical thinking of the general population to handle free and uncensored media [
24].
This study is limited in several ways. First, it was an online survey with convenience sampling, and it is unlikely that this is a representative sample of the population. Our sample differs from several indicators of the population of Belgium. In our sample, 4% were unemployed, while during this period this was 7.6% in Belgium overall. For gender, in the general population, the difference is more toward 51% female, while in our sample, 69.9% were female [
25]. Second, in measuring so soon after the attacks, we measured what were probably mainly normal reactions. It is unclear how many of these respondents developed long-term problems. Their reactions in this study should therefore not be medicalized. Third, it is impossible to make a causal connection: people with more emotional reactions might be more inclined to see more about the attacks. Fourth, we did not investigate what type of media people watched—it might be that social media is more harmful than regular news channels, for example.
The study has several strengths. The greatest strength is the lack of temporal lag in the data collection. While most media-watching studies in terrorism research take place a long time after the attack, potentially creating recall bias, this study sample completed the survey one to two weeks after the attacks, limiting the potential recall bias. Second, this study also took into account somatic reactions. This shows the diversity of symptoms associated with such attacks. Third, to our knowledge, this is the first study to look at the relationship between media watching and health after terrorist attacks in Belgium.