The partial or incomplete presentation and assessment of information from news articles regardless of its pertinence or accuracy, can negatively affect people’s understandings, opinions, and decisions related to the topic [37
]. The results of this analysis demonstrate that, in the Daily Nation newspaper, the limitations of VMCC, its possible negative consequences and importance of condom use is not being communicated regularly or explicitly in individual published news stories.
The few times that the limitations and potential consequences of VMMC were explicitly communicated, newspaper articles seemed to present information about the limitations of VMMC by camouflaging limitations by portraying them as benefits to identify potential drawbacks of VMMC. The limitations of VMMC as an HIV prevention method were camouflaged in positive language, which highlighted risk reduction and not the fact that VMMC does not afford full protection. Even if a procedure reduces the risk of infection, it does not mean that the risk of becoming infected with HIV is eliminated. Previous research has indicated that for health promotion messaging, “gain” framed messages, where the benefits of a procedure or action are emphasized make individuals more receptive to undertake the procedure or behaviour than approaches that emphasize a loss frame [38
]. While this suggests it is logical to present VMMC in a “gain frame” in order to encourage people to receive the procedure [38
], it should not necessarily eliminate the need for further communication about individuals’ continued susceptibility to HIV. Other articles blamed the general population for not understanding the limitations of VMMC, using statements such as “it should be understood that” and “residents have been warned”.
The use of percentages to communicate both the benefits and limitations of VMMC may be problematic and potentially misleading, as most lay people are not numerically literate and may misinterpret the meaning [39
]. Health numeracy is an important ability that helps people understand relative risks and benefits from medical procedures [14
]. Research has consistently shown that vulnerable groups, including those who live in poverty, often have low numeracy [41
], with those with lower numeracy tending to be “less sensitive to numerical differences in probability” [42
]. One reader’s comment directly addressed this, writing that even he, a “technology suffy [savvy] reader” has difficulty understanding its meaning. There is also evidence that the context of the presentation of results is just as important as the numerical format in which results are presented [40
None of the messages communicated that while VMMC may help reduce the numbers of HIV infection in a total population, a 60% reduction is not a highly effective method of protecting oneself from HIV infection, given the availability of other highly effective prevention methods. The absence of specific information reporting, in this case not using the words “limit” or “limitation” is an important finding, as it seems to contradict the recommendations put forth by the WHO and other experts to continually identify not only the benefits but also the limitations of VMMC in their risk communication strategies.
The majority of the 25 news articles did not emphasize the need for additional protective measures against HIV. Previous research has shown that the media can be very effective in communicating about HIV prevention methods. One study found that people were less able to identify abstinence as an HIV prevention method because it was the least likely method reported in the media [21
]. This may suggest that if VMMC and condom promotion are not communicated regularly in the same articles, people may not associate VMMC with the need for continued condom use even if condom use is still promoted in other news articles.
In one study investigating global newspaper reporting of VMMC trials, of the 219 articles found 82 articles reported that individuals should use condoms [25
], though there is no information on how this information was reported. The results from the current study, however, indicate, the Daily Nation, does not follow the same worldwide pattern in promoting condom use. This suggests that the individuals in Kenya are not receiving critical information about the limitations of VMMC as often as they could and should be.
While the news articles did not include the limitations of VMMC or promote sustained condom use, the Op/Ed articles often emphasized these points. While news articles are based on facts gathered by reporters, Op/Ed articles are the opinions of an individual. Thus, Op/Ed articles may be more likely to express views different than the newspaper editors. Op/Ed articles included evidence about the limitations of VMMC and the importance of condom use, and expressed concern over their perceived lack of prominence in the VMMC programme. Few articles expressed a strong sentiment against VMMC. Rather the focus was on the need for more public education, or what some of the articles referred to as “enlightenment”. Even though these critical messages are present in Op/Ed articles, it is unclear how many people read this type of article, and if individuals assign to them the same importance as news articles.
Another important finding was the placement of important messaging within the news stories. The lack of statements located at the beginning of the articles, other than the 60% phrase, communicating the limitations of male circumcision is telling. Little emphasis was placed on communicating limitations in these news stories. The relatively few statements encouraging other methods to prevent HIV transmission, such as abstinence and condom use, were not emphasized. Their placement, almost always within the body or middle of the news story, may indicate that few people read these important messages.
Though the strength of this research lies in the interpretation of the messages provided by the newspaper articles, readers’ comments provide some insight into understanding and concerns regarding VMMC. Similarly to the Op/Ed articles, many individuals wrote comments referring to the benefits and limitations of VMMC, the need for sustained condom promotion, and expressed concern that the media and government should provide better and more comprehensive risk communication.
This research demonstrates that one Kenyan newspaper, the Daily Nation, is not effectively or comprehensively communicating the limitations of VMMC. Thus, several recommendations are being proposed to improve risk communication. First, the government could provide regular news releases or information sessions to the media, which communicate the procedures’ partial protection. This information should be presented in a clear and concise manner, without the use of probabilities. This may be challenging, as the VMMC campaign may no longer be considered newsworthy of reporting. Second, continued monitoring is needed to ensure media messaging concerning VMMC includes discussion of limitations and encourages condom use following circumcision. If this emphasis does decline, this should signal the need for a repeated media campaign on the part of public health professionals to raise public awareness. Third, further research should be conducted to investigate whether the general public understands that VMMC does not completely protect them from HIV infection and the importance of sustained condom use whether or not they are circumcised. This research could involve surveys of people’s attitudes or employ more qualitative methods of focus group discussions and interviews.
This study has several limitations. The Daily Nation online newspaper was selected due to its ease of access and wide readership across Kenya, however no other newspapers were selected. It is possible that many Kenyans prefer other news outlets to receive information, and that other newspapers may communicate the limits of VMMC and encourage sustained condom promotion in a more pronounced way. The Daily Nation is also an English language newspaper. Even though many Kenyans speak English, it is possible that non-English newspapers may represent VMMC in a different way. This small sample size is therefore only a small portion of a larger news media landscape. As Daily Nation is not indexed by any news database system, it is possible that additional articles may have been missed. Moreover, newspapers are only one source of mass media that shapes public understandings of risk information. NGO and Government pamphlets and community outreach programs may communicate slightly different messages than that from newspapers because newspapers are independent bodies that present information in ways designed to attract increased readership. In addition no inter-coder reliability score was produced as only one individual coded and analyzed the data, though a group reflexive process and audit trail were employed. The single coder developed conceptual categories, including operationalized definitions, collaboratively with a senior-member of the research team, who also served as auditor of the interpretive coding. While double coding was not undertaken, emerging interpretations were challenged to ensure against premature closure of ideas. Lastly, in September 2011, Kenya was cited as the leading country in the uptake of VMMC in Africa, thus a limitation is the time period in which this analysis was conducted (2008–2010) because it does not include the 2011 calendar year [43