The prevalence of HIV/AIDS frames in Kenya Newspapers: A summative content analysis of the Daily Nation

Abstract Kenya has one of highest numbers of people living with HIV/AIDS in Africa (UNAIDS, 2018). The Kenyan media and most notably the Daily Nation play an important role in the social construction of HIV/AIDS nationally. This article uses the theory of media framing to understand the manner in which Kenyan newspapers make sense of the HIV/AIDS issue between the years 2011 and 2015. Specifically, this analysis focuses on multiple frames used by stakeholders with respect to the following topical categories (a) valence (positive/negative), (b) the action frame, (c) victim frame, (d) severity of HIV/AIDS in Kenya, (e) causes and solutions, and (f) beliefs about who is at risk. The findings show the action and victim frames to be most dominant. The group “other” was considered most at risk of contracting HIV, while positive valence was noted in most sampled articles.


Background
According to UNAIDS (2018), there were about 1.5 million people living with HIV/AIDS in Kenya in 2017. Of these, about 1.4 million were adults aged 15 years and above. Moreover, according to AVERT (2018) James Kiwanuka-Tondo is an Associate Professor in the Department of Communication at North Carolina State University. His main area of research is health communication campaigns with particular emphasis on HIV/AIDS. His major contribution has been the development of the first ever quantitative model of relationships between organizational factors, campaign planning, and campaign execution variables.

PUBLIC INTEREST STATEMENT
Kenya has one of highest numbers of people living with HIV/AIDS in Africa. The Daily Nation newspaper was selected as one of the oldest newspapers in the region with control of a large share of the newspaper readership in Kenya. Considering that media play an important role in interpreting epidemics and shaping public opinion, we argue that the framing of news on health issues by campaign designers influences how different audiences perceive these issues. The purpose of this study is to analyse the framing of HIV by the Daily Nation newspapers. By doing so, the study makes a significant contribution of identifying the frames most commonly used by the print media in the country which in turn helps to understand the media's construction of HIV. Furthermore, the study educates policy makers how the media frame health issues in order for them to better understand media's influence on their work. highest number of people living with HIV/AIDS in the world. The report further indicates about 53,000 people were newly infected with HIV in the year 2017. On the other hand, the media play an important role in interpreting epidemics and shaping public opinion. In fact, some scholars argue that the media play a conduit between complex scientific information and its understanding by the general public (Nelkin, 1991).
In the case of Kenya, the Daily Nation is one of the most important daily newspapers which control a large share of the readership in the country. Hence, if HIV/AIDS is framed negatively in this newspaper's articles, then the 1.5 million people living with HIV/AIDS in the country are more likely to be stigmatized. On the other hand, if the articles in this newspaper frame HIV using a positive valence frame, the Kenyan society is more likely to be more accommodative of those living with HIV/AIDS. We argue that the framing of news on health issues by campaign designers influences how different audiences perceive these issues. For example, policy makers may be guided by information in the media to formulate health policies.
The purpose of this study is to analyse the framing of HIV by the Daily Nation newspapers. By doing so, the study makes a significant contribution of identifying the frames most commonly used by the print media in the country which in turn helps to understand the media's construction of HIV. Furthermore, the study educates policy makers how the media frame health issues in order for them to better understand media's influence on their work. The study also aligns itself with Global Plans and initiatives such as the Global Plan to eliminate new HIV infections among women and keeping their mothers alive (UNAIDS, 2011), in which Kenya participated as a priority country.

Framing theory
For this article we utilise the framing theory, which was first propagated by Erving Goffman (1974). The basis of framing theory is that the media focuses attention on certain events and then places them within a field of meaning. Framing theory suggests that how something is presented to the audience, "the frame," influences the choices people make about how to process that information. The most common use of frames is in terms of the frame the news or media place on the information they convey. They are thought to influence the perception of the news by the audience which could be construed as a form of second level agenda-setting where they not only tell the audience what to think about (agenda-setting theory), but also how to think about that issue (second level agenda setting, framing theory).
When the nation newspaper publishes stories on HIV/AIDS, its readers are likely to start thinking about this topic. However the readership of this media is also likely to form opinions of the epidemic, and people living with HIV (PLWHIV) as a result of how HIV is framed within the daily newspaper. This research aims to further the framing theory in relation to media representation of people living with HIV in Kenya.
Scheufele (2004) classifies framing research into three branches: First, the communicator approach concentrates on media coverage, which is the focus of this paper. Secondly, the public discourse or social movement approach examines political actors and their influence of frames in the media. Here media are seen as carriers of the frames for others. Media content serves as an indicator for the examination of discourse. Finally, the media effects approach which goes beyond cognition to examine the influence of media framing on schemata, attitudes, emotions and decisions of media users. This article focuses on the communicator approach of the framing.
Although framing has been used for a number of years, it has its fair share of criticism: Druckman (2001), for example cites a lack a consensus on what a framing effect is as well as an understanding of how and when framing effects occur. The researcher though downplays these inconsistencies as isolated cases. Zaller (1992) argued that through competition the public gets divided over an issue and this limits framing effects. For example, when media frame HIV negatively, yet public figures frame HIV positively, the public are torn on where to form their own opinions. This shows that other factors also exist that influence the publics attitudes and opinions of HIV in Kenya.
This research develops the framing analysis of health issues notably HIV, specifically with respect to the following frames: (a) valence (positive or negative frames), (b) the action frame, (c) victim frame, (d) severity of HIV/AIDS in Kenya, (e) causes and solutions, and (f) beliefs about who is at risk.

Framing of health issues in the media
Jaworski (2009) explores the problematic ways in which the popular media frame issues related to reproductive justice. In her research, Jaworski finds that in both popular music and television series, reproduction is framed in ways that limit reproductive justice for women. Women who actively choose to use birth control are portrayed negatively, misinformation about condoms and access to reproductive healthcare is perpetuated, and stereotypes about women and reproduction are reinforced. In the same way, this paper proposes if the media frame people living with HIV in Kenya negatively, the public is likely to also form negative opinions about them. As a result stigma against people living with HIV is also likely to rise.
De Souza (2007) highlights the importance of studying media frames in a health context because of the implications it has for individual behaviour and institutional policy. Media frames can serve to close the sense-making gap, or the gap between what one group views as real and what another group experiences. The incomplete coverage of certain health topics, misrepresentation when reporting the prevalence of health threats, and juxtaposition of competing health messages can have negative implications for health beliefs and behaviours. She further argues that the media define the playing field upon which political struggles of the world are waged as the policy decisions depend on the ability of advocates to define a particular proposal as beneficial to a large group of people. Thus the manner in which HIV/AIDS is defined within certain cultural contexts-especially with regard to its causes, consequences, and solutions-has important implications for policy making. Therefore, if the Daily Nation frame people living with HIV subjectively, it could have far reaching consequences on the understanding of the disease to policy makers.

Framing of HIV/AIDS in the media
Kiwanuka-Tondo, Albada, and Payton (2012)  Concerning HIV-related topics, the private newspaper included more features, printed lengthier articles, incorporated a greater variety of news frames, and published more articles by foreign journalists than the government-owned newspaper. The private newspaper employed the "HIVprevention," "action," and "victims" frames more often than the government-owned newspaper.
Journalists at the government-owned newspaper adopted a "solutions" frame more often than their private-press counterparts. Though foreign journalists were more likely than local journalists to employ the HIV-prevention frame, additional tests revealed that the news organisation for which the journalists worked contributed to issue framing to a greater extent than did either a local or foreign reporting origin. Local (Ugandan) journalists working for the two news organisations differed in their tendencies to apply the HIV-prevention, action, victims, and tragedy frames in news stories on HIV and AIDS, with journalists at the private newspaper using these frames more often than did journalists at the government-owned newspaper. As Kenya is Uganda's immediate neighbour, this paper would be a great comparison to the findings of Kiwanuka-Tondo et al. (2012) on how journalists frame people living with HIV/AIDS. Pickle, Quinn, and Brown (2010) in their study on HIV/AIDS Coverage in Black Newspapers, 1991-1996, found that the disease was most prominent in the New York, Oakland, and Washington, D.C., African American newspapers. Although most of the 201 articles analysed framed the story primarily as a health issue, a large proportion also exhibited a critical attitude toward the government and the "AIDS establishment" about their commitment to saving the lives of minorities. Articles often conveyed the message that fighting HIV/AIDS first requires substantial action regarding the larger contextual issues-economic, political, and social-that cause health inequities.
Although this study by Pickle et al. (2010) is not primarily focused on women living with HIV, it does reflect the negative frames created by the media concerning HIV and people living with the disease. The warped frames also contribute in building on already existing phenomena and negative stereotypes.
In his study on Framing AIDS in China, Wu (2007)  The study purposed to uncover how the social reality of HIV/AIDS in China is constructed by the two leading news organizations. The study findings suggested an anti-government frame, which was evident in AP while Xinhua's coverage supported a pro-government frame.
While China may have a different system of government than Kenya, and therefore frames identified by Wu (2007), will be different from those identified in Kenya, our findings support the notion of the link between society and the news. In addition, scholars, such as Ndeti (2013), also note the complexity of interpersonal and sexual relations, and further states the need to create HIV/AIDS messages in the African context with consideration to African cultural values and practices.
D'angelo, Pollock, Kiernicki, and Shaw (2013) undertake an analysis of the topics and frames in coverage of AIDS in Anglophone African newspapers. They specifically focus on the topics by which AIDS is covered, the frames journalists use in covering these topics, and the role of political factors such as media systems and structural factors in framing. The authors argue that media frames must also be analysed in light of political and structural factors, in order to get a fuller perspective of empirical patterns and a more suitable basis from which to make normative judgments about press coverage of AIDS. Furthermore, the researchers relate higher levels of AIDS prevalence to higher proportions of articles emphasizing a decline frame compared to countries with lower levels of AIDS prevalence and vice versa.
As the study above suggests, it is likely that because Kenya's HIV prevalence rate is not as high as South Africa, Kenya would have less articles on HIV/AIDS than South Africa. Therefore, the 982 articles found on HIV/AIDS between the years 2011 and 2015 in the Daily Nation newspaper may be doubled or tripled in newspapers within countries with higher HIV prevalence rates.
Even further, Brodie, Hamek, Kates, Altman, and Drew (2004), note a growing discussion about the scope and focus of news coverage of HIV/AIDS by the U.S. news media, even questioning if there is AIDS fatigue by media organizations. The authors further suggest that Journalists report great difficulty in persuading their news organizations to run HIV/AIDS stories. This is also supported by the few fundamentally new scientific developments in the HIV epidemic in recent years.

The Daily Nation
The Daily Nation newspaper was selected as one of the oldest newspapers in the region with control of a large share of the newspaper readership in Kenya. Elliott (2015) found the Nation newspaper as the top newspaper by audience size and share, beating the competition by a large margin. In fact, the poll showed, Daily Nation had an average readership of approximately 4,379,400 per day, while its competitor the Standard had an average of 2,223,500 per day. Therefore, nationwide, Daily Nation has a 40% share of newspaper readership.
The study covers the period between the years 2011 and 2015. Which represents a timeframe for National and Global HIV plans such as the Global Plan to eliminate new HIV infections among children and keeping their mothers alive (UNAIDS, 2011). This research period also represents the end of the Millennium Development Goals (MDGs) and the start of the Sustainable Development Goals.

Research questions
The following research questions have guided this study: (1) What was the most prevalent frame in the coverage of HIV/AIDS by the Daily Nation newspaper in years 2011-2015?
(2) Who was believed to be most at risk of contracting HIV among adolescents, drug users, prostitutes, women and others in the Daily Nation newspaper articles between the years 2011 and 2015?
(3) Who was the most prominent source (agency, correspondent, own reporter, other) of the articles on HIV/AIDS in the Daily Nation newspaper between the years 2011 and 2015?

Research methods
A quantitative content analysis was conducted to study the coverage of HIV/AIDS by the of the Daily Nation newspaper during the period of 2011-2015. Krippendorff (2013) describes content analysis as a research technique which enables replicable and valid inferences from texts. Berelson (1952) describes quantitative content analysis as a research technique for the objective, systematic and quantitative description of the manifest content of communication. It can also be described as a research method based on measuring the amount of something (e.g. violence, negative portrayal of women) found in a representative sample of a mass mediated popular art form. We conducted an online search of articles covering HIV/AIDS in the Daily Nation newspaper which yielded 982 articles. According to Qualtrics (2018) calculator the suggested sample size for a population of 982 at 95% confidence level and a margin of error of 5% is 277. We oversampled and selected a sample of 295 articles using systematic sampling of every 3rd article. Key words "HIV/AIDS" were used to search for news links on the online site of the Daily Nation newspaper. An initial search yielded 982 articles.
Two coders were trained for the data collection process. The coders undertook a pilot coding exercise of 10% of the 295 articles. The inter-rater coding activity yielded a percentage agreement of 52%. The unit of analysis was the entire story, as sometimes headlines can be deceptive. The coders coded every 3rd story of the entire population until 295 articles were coded. If the 3rd story in the population was not HIV/AIDS-related, coders were asked to pick the next article. The coding sheet included aspects such as the date the article was published, the by line, length of the story in paragraphs as well as the presence of the frames in the article.
For this study, six categories of news frames adopted from various studies (Bekker & Hosek, 2015;De Souza, 2007Kiwanuka-Tondo et al., 2012;Krishnamurthy, Carter, & Blair, 2001;UNAIDS, 2016). These frames were classified as follows: (1) Valence: A positive or negative tone in reference to HIV. Positive tone is where the writer depicts an aspect in HIV positively. For example, focusing more on initiatives or progress of persons living with HIV. A negative tone is where words are used to focus on the challenging aspects of HIV. For example, number of HIV deaths, increase in the numbers of persons living with HIV.
(2) Action Frame: Includes action taken against the spread of HIV such as distribution of condoms, provision of antiretrovirals etc.
(3) Victim Frame: Includes stories where persons living with HIV are considered victims and often times in need of assistance.
(4) Severity of HIV/AIDS in Kenya: Includes stories that highlight statistics of HIV in Kenya.
(5) Causes and Solutions: Articles which highlight the means of contracting HIV, prevention and management methods.
(6) Beliefs about who is at risk: Articles describing those at risk of contracting HIV, such as adolescents, drug users, prostitutes and women among others.
Regarding ethical considerations for this research, all articles were accessed freely from the Daily Nation website. Furthermore no identifying information of the article authors or names of individuals or companies mentioned in the articles were recorded.

Findings
Research question 1 examined the most prevalent HIV frame within the following frames: valence, the action frame, victim frame, severity of HIV/AIDS in Kenya, and causes and solutions and beliefs about who is at risk, in the Nation Newspaper between the years 2011 and 2015. Findings show that the action frame and victim frame were the most prevalent both appearing in 61% of articles. Most of the articles sampled showed positive valence making up 52.5% of the articles. The severity of HIV and the causes and solutions frame appeared in 36.3% of the articles.
Research question 2 examined groups that are considered most at risk of contracting HIV in Kenya as shown in Chart 1 below.
The group other are believed to be most at risk. This group could include clusters such as infants and children, men, persons in the gay/lesbian community and any others not considered adolescents, drug users, prostitutes or women.
Research question 3 examined the source of the articles on HIV/AIDS in the Nation Newspapers between the years 2011 and 2015. Findings reveal that most articles (69.8%) were sourced by the media houses' own reporters, followed by agencies (12.5%), followed by correspondents (4.4%). Thirteen percent of the articles examined did not have a by-line.

Discussion
In a country with one of highest numbers of people living with HIV/AIDS in Africa, (an estimated 1.5 million people living with the disease, UNAIDS, 2018), the Kenyan government and partners have been working together to curb the disease. These government initiatives could have contributed to the prevalence of the action frame (61%). A finding that can be compared to Pickle et al. (2010) as well as D'angelo et al. (2013) where HIV/AIDS articles, fit in the larger related aspects of the economic, policy and social agenda.
However results also reveal 61% of the articles highlighted the victim frame, where persons living with HIV were considered victims and in need of assistance. This reveals further actions need to be taken to do more in combating the spread of HIV in Kenya and supporting those living with HIV, in order to reduce the perception of people living with HIV as victims.
It is interesting that the statistics between the victim frame and action frame do not defer. This may be because as journalists report actions to curb HIV, the issues and challenges of living with HIV are also reported within the same story. Thus for every action, the explanation as to why the action was required, resulted in a victim frame.
Currently, the government of Kenya have a number of HIV-prevention initiatives focused on adolescents whose HIV infection rates are considered to be rising. However, in the period of the study (2011)(2012)(2013)(2014)(2015), vulnerable groups such as adolescents, prostitutes, women and drug users (Bekker & Hosek, 2015;UNAIDS, 2016) were not considered high on the agenda during the study period (8.5%, 3.4%, 15.2% and 1.4% respectfully). It is plausible, therefore, that the group others which could consist of infants and children among other groups was rated high on the agenda during the time period. This is supported by a number of initiatives such as the Global Plan to eliminate new HIV infections among children and keeping their mothers alive (UNAIDS, 2011), as well as the First Lady's framework on maternal and neonatal health (Office of the First Lady, 2012) which were launched during the this period. These initiatives had a major focus on infants and children.
This finding is in line with De Souza (2007) who noted the role of media frames in closing gaps between what one group views as real and another group experiences. In this study adolescents, drug users, prostitutes and women were viewed to have been the most vulnerable groups (Bekker & Hosek, 2015;UNAIDS, 2016), however findings from the newspaper articles showed otherwise.
Considering that the Daily Nation is a Kenyan newspaper, one would expect that their focus on news would be on local content, and therefore their articles on HIV/AIDS would be centred within the country. It is, therefore, no wonder that 69.8% of the articles examined were authored by their own reporters as opposed to agencies (12.5%) or correspondents (4.4%). These figures also signal good news as the Nation Newspapers still makes efforts to ensure their own resources are put to use on covering HIV/AIDS stories.

Conclusion
This article used the Framing theory to analyse the frames used in newspaper articles (Nation Newspapers, Kenya) about HIV/AIDS. Specifically, the analysis focused on multiple frames, specifically, (a) valence (positive or negative), (b) the action frame, (c) victim frame, (d) severity of HIV/ AIDS in Kenya, (e) causes and solutions, and (f) beliefs about who is at risk. During the period of this study, a number of HIV/AIDS initiatives were launched by the government of Kenya and its partners which reflected on the framing of the articles. This reflection is seen in the prevalence of the action frame, the group other considered most at risk and the positive valence in most sampled articles. In addition, the victim frame was also dominant in the articles revealing the need to better support people living with HIV. Most of the stories being local were written by the media houses' own reporters.
To gauge whether the results from this study are generalizable, future research should strive to incorporate more daily newspaper outlets from Kenya such as the Standard Newspaper articles as a different perspective from Nation Newspaper articles. Similarly, future research can also examine media coverage of the HIV/AIDS during the same time period in other HIV prevalent countries such as the Democratic Republic of Congo, Burundi and Tanzania. Furthermore, a composite week sampling method could also yield a more representative sample.

Funding
The authors received no direct funding for this research.