Monday, February 29, 2016

Writing women’s reproductive health: A Uganda study

By Rosanne Anholt and the Health Journalist Network in Uganda (HEJNU)

Research shows that the decisions people make with regards to their health may be in part drawn from various mass media resources. As such, the media not only mirrors how health is understood within the society – it also shapes that society’s health behaviours. The effect of any particular media message however, depends on the way the information is framed.

The idea of media frames is easy to grasp: if we read or hear about family planning methods that emphasise the dangers of the procedure or the possible negative consequences, we may hesitate to use them.

On the other hand, if articles about family planning methods focus on our right as women to decide whether, when, and how many children to have – we may very well consider using a method of family planning. Simply put, a media frame is a point of view on a given issue. Certain aspects of reality are highlighted or excluded, such as either the dangers of family planning methods, or the right to use them – which then causes people to interpret these issues differently.

How an issue is framed, depends on many factors. Research, such as by Darrin Hodgetts in New Zealand, shows that the journalist (i.e. the writer) has a significant effect on the way an issue is framed. Professional factors specific to journalism may impact how an issue is presented, as well as the organisational milieu in which the media message was created. 

Sources, whether particular persons, documents, or other, may also impact the point of view on any given issue, depending on the standpoint taken by the source. Finally, any environmental issue – economic, or political – may also have an effect on the way in which an issue is presented in a media message. We can describe frame-building as the process in which media frames are created. 

Together with the Health Journalist Network in Uganda (HEJNU) and under supervision of the Athena Institute at the Vrije Universiteit Amsterdam in the Netherlands, a study was carried out in order to analyse how women’s reproductive health is framed in Ugandan media, and what factors influence the way in which Ugandan journalists construct these frames.

To answer the first question; how women’s reproductive health is framed, an analysis of print media content was made, considering relative ease of analysing written content. Even though most Ugandans receive their news through the radio, local radio stations often review newspapers. Indeed, some community radio stations with no budgets to support reporters in the field read the stories from the newspapers as news items. This makes print media, despite its relatively low coverage, an important communication channel fit for analysis.

A total of 204 articles on women’s reproductive health were collected from four national newspapers published between 1 May 2015 and 31 May 2015.

To answer the second question; what factors influence journalists’ frame-building, 19 in-depth semi-structured interviews were done with journalist in and around Kampala. The sample consisted of eight men (42%) and 11 women (58%), from both print and broadcast media (both television and radio), with an average of 7.5 years of experience.

On July 22 2015, HEJNU organised a research dissemination seminar which was attended by 20 people. Six attendees had already participated in the interviews, whereas eight had not. The latter consisted of three men and five women, who were in either in print or broadcast media. Other attendees included a medical doctor who gave a presentation on the social determinants of health and human rights, the HEJNU president, two HEJNU interns, a media researcher, and the writer.

Firstly, the content analysis showed that half of all articles on women’s reproductive health addressed maternal health topics, such as pregnancy, childbirth, and the midwifery profession. Pregnancy was primarily understood as a dangerous ‘condition’ from which ‘vulnerable’ women ‘suffer’ or die. 

The International Day of the Midwife on May 5 and the events that surrounded this day noticeably influenced articles, highlighting Uganda’s lack of midwives and the dangers associated with (unassisted) childbirth. 

The main treatment recommendation for the country’s lack of midwives was recruitment schemes and ‘re-branding’ of the profession – in other words, giving the profession a new, positive image that will draw students to choosing midwifery as a career. Other maternal healthcare services were understood in terms of missteps made by individual healthcare workers, or successes gained by government or NGO projects.

Twenty-five percent of the articles was about sexual violence, understood primarily as arrests or case proceedings from (gang) rape and defilement cases, although harmful traditional practices such as female genital mutilation/cutting (FGM/C) were also addressed. 

The national high profile defilement case of police athletics coach Peter Wemali in particular received much media attention. In general, sexual violence was very much approached from a criminal justice perspective, placing the individual perpetrator at the centre – sometimes literally, with their full names exposed. This perpetrator-focused point of view was similarly evident in punishment being advocated as the primary solution to sexual violence.

Thirteen percent of articles addressed various health conditions, including reproductive tract infections (RTIs), sexually transmitted infections (STIs), HIV/AIDS, HPV and cervical cancer, and obstetric fistula. What was especially noteworthy about these articles was that conditions of RTIs, STIs, HIV/AIDS and HPV and cervical cancer were predominantly blamed on women’s own behaviour. 

For example, HPV infection was attributed to girls’ early onset of sexual activity, and subsequent cervical cancer was attributed to women not going for regular health check-ups. Obstetric fistula on the other hand, was primarily attributed to medical causes. Also notable, solutions for obstetric fistula cases focused on what NGO projects can achieve, rather than seeking treatment or behaviour change.

Other topics (12%) included family planning, menstruation, and abortion. Family planning was understood primarily in terms of the possible adverse consequences of family planning methods, and in the light of women not using family planning – attributed to men’s resistance to family planning. 

When women experience any issues that may relate to their use of family planning, they are encouraged to ‘visit their doctor and get treatment’ – without any consideration of their ability to actually carry out that advice. 

Menstruation was addressed in the light of Menstrual Hygiene Day on May 28 and advocacy around national programmes targeting the improvement of menstrual hygiene practices in schools, in order to combat girls’ high dropout rates. Abortion, although hardly covered, was primarily understood as a dangerous procedure with debilitating consequences – moreover, it is against the law and religion. The primary ‘solution’ for abortion focused on the individual: instead of aborting one should rather focus on pregnancy prevention.

Similar to previous studies on how women in Ugandan media are portrayed, this study shows that in articles on women’s reproductive health, women themselves were portrayed predominantly as victims: vulnerable to suffering and dying.

Also, but considerably less, women were described as passive recipients of healthcare services: expectant mothers receiving mama kits free of charge from national telecommunications provider Airtel Uganda, or mothers saved from death by skilled birth assistants. Women were also portrayed as being responsible for their adverse health outcomes: their own behaviour caused health conditions such as STIs and cervical cancer – leaving social determinants of health, such as poverty, unchallenged.

The fourth and final way in which women were portrayed in stories about women’s reproductive health was what we may call a ‘passive agent’. In this type of portrayal women were given advice of what to do in cases of health conditions: when you experience constant vaginal bleeding, you have to visit your doctor and get treatment. 

At first glance, it seems that this advice enables women to exercise their power over their own health. After all, these stories give them the information on what to do – sometimes even providing a step-by-step approach. At the same time however, it is not only assumed that women do not know they have to visit a doctor when they experience health problems, also, the woman’s personal, cultural, or economic barriers in accessing that care, are dismissed. If they cannot even afford the transport fee to the hospital, is ‘advice’ that tells them to visit a doctor even useful to them?

Secondly, the interviews with Ugandan journalists showed that various factors on the personal, professional, organisational, source-related, and environmental level influence the way these media frames are constructed. 

On a personal level, having an in-depth understanding of women’s reproductive health has a significant effect on how issues are presented in the media. For example, if a journalist understands women’s right to health, she or he may be more likely to take a human rights-based approach to the topic they are writing about. 

On the other hand, if a media professional fails to grasp the social, cultural, and economic causes of certain reproductive health outcomes, she or he may blame the individual for her illness – as we have seen in the identified frames. In this study, interviewees emphasised that you have to understand an issue first, before you can explain it to others.

Training media professionals on (women’s) reproductive health could advance their understanding, results however, showed that training is primarily a personal initiative. This means that attending a training depends greatly on the individual journalist’s ability to access information about potential training opportunities – resulting in unequal opportunities. 

Likewise, it depends on journalists’ media houses. Some media houses may be neglected by trainees because their impact on the community is considered insignificant – thereby significantly crippling talent development. Although this was not directly examined, training opportunities may depend on the type of media; print media journalists may be far more likely to go for training than radio or TV journalists.

On a professional level, journalists understood their work in terms of disseminating information, acting as a link between the public and policymakers, and as playing the role of watchdog, critically interrogating government policies. In the articles, the role of ‘educator’ or ‘provider of information’ was much more evident than advocacy and accountability. 

One way in which this showed was journalists’ self-expressed need for quoting official sources in their stories, such as government officials or medical professionals. Interviewees shared that this is not only ‘good journalism’, it also ensures the information you have is correct.

On an organisational level, an important finding was the challenging work environment: media houses’ lack of resources simply bars journalists from pursuing stories if it means they have to make costs, such as travel expenses. In addition, low pay causes many journalists to be unsatisfied with their job, using journalism as a ‘stepping stone’ to other jobs, such as with an NGO. This also means a high turnover of staff in journalism in general. 

In addition, results showed that editors have a crucial role in whether and how a story eventually appears in the newspaper, highlighting the need to involve editors in any training initiative that addresses the importance of covering women’s reproductive health.

On the source-related level, the low pay and lack of facilitation invites sources such as (international) NGOs to step in and provide travel reimbursements, accommodation, food, and sometimes even a per diem. Interviewees expressed their concern that this practice may bias journalists’ objectivity. Some articles used clear NGO language, summing up the strides made by a particular organisation as the necessary steps towards addressing Uganda’s reproductive health issues.

Finally, on an environmental level, the politics of the season and media houses’ commercialism influenced if and how health stories in general made it to the newspapers. In the light of the upcoming presidential elections of 2016, the space for health-related news is increasingly less, in order to make room for political stories, since these are the ‘stories that sell’. One interviewee recommended that health journalists have to learn how to navigate these challenges cleverly, by for example reporting on presidential candidates’ health policies – yet none such articles appeared during the study period.

So what do these results mean? For women in Uganda, it means that they are currently not supported through an empowering media discourse. This is in line with previous studies on the way women are portrayed in Ugandan media. The results point out that there are many opportunities for journalists and other stakeholders to improve the practice of health reporting in a way that will allow the media to more clearly play the advocacy and watchdog role. This may also require Ugandan journalists to proactively communicate their needs. Strong journalists’ associations may be able to leverage their power to demand better working conditions.

For NGOs, the results of this study highlight that (international) organisations must be aware of their influence on the media through practices such as providing facilitation where journalists’ own media houses cannot. This calls for the inclusion of ethical media practices based on respect and integrity into existing policies – or the development of comprehensive media collaboration policies.

The results reinforce previous studies’ recommendations that media development initiatives should be needs-driven instead of driven by the wishes of international donors, emphasising the importance of local ownership. Training should be independent from (inter)national NGOs’ agendas, which highlights the importance of grassroots media organisations, such as HEJNU and other national journalists’ associations. Media development should be led by Ugandan journalists and Ugandan researchers from Ugandan institutions, who have in-depth knowledge of not only the needs, but also the local context.

For government, the results of this study point to the severe lack of resources that Ugandan media houses suffer from. In order to use media as a vehicle for women’s (health) empowerment and social justice, the government should support the media rather than restrict them, not only financially but also through a conducive legal environment.

In conclusion, media is shaped by society and has a significant effect on the shaping of that society. In Uganda, this study shows that there are ample opportunities for media, civil society organisations, local experts, and government to work together to improve the current practice of health reporting for a more empowered, more socially just society.

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