Approaches to Print Media Advocacy for the Control of HIV/AIDS: Case of Cameroon Tribune and the POST Newspapers

The media is not only the mirror and the window but also the watchdog of society [3]. The media sets the agenda. It may not be successful much of the time in telling people what to think, but it is stunningly successful in telling its readers what to think about [4]. As Malcolm X put it, the media is the most powerful entity on earth. They have the power to make the innocent guilty and the guilty innocent, because they controls the minds of the masses. It therefore goes without saying that the media is an essential if not indispensable advocacy tool for health promotion.


Introduction Background and justification
The media is not only the mirror and the window but also the watchdog of society [3]. The media sets the agenda. It may not be successful much of the time in telling people what to think, but it is stunningly successful in telling its readers what to think about [4]. As Malcolm X put it, the media is the most powerful entity on earth. They have the power to make the innocent guilty and the guilty innocent, because they controls the minds of the masses. It therefore goes without saying that the media is an essential if not indispensable advocacy tool for health promotion.
Defined as the strategic use of the print and audiovisual media to promote an issue in order to influence policy-makers and encourage social change [5], media advocacy has played a tremendous role in the improvement of Knowledge Attitude Behavior and Practice (KABP) for the control of HIV/AIDS. In South Africa, for example, it required the muscle of multi-sector media advocacy campaigns through the Soul City project to convince many an incredulous one that HIV causes AIDS [6]. Similarly, it required the 'SIDA dans la Cité' program to boost the use of condoms in Ivory Coast and the Holidays Without AIDS media campaign to encourage youths to go in for the AIDS screening test in Cameroon.
Studies which have demonstrated the transformative power of media advocacy abound. Yet, while expounding on the importance of media advocacy in the control of disease like HIV/AIDS, researchers have treated the subject from a general perspective. A huge gap which should distinguish print media advocacy from audio visual media advocacy for health promotion remains to be filled. Even still, although significant studies have been made on why and how general advocacy should be done; there is very little comprehensive data on how media advocacy should be done, especially through the print media.
Moreover, no popular research work accentuates the demarcation line between external media advocacy (done by non-media actors) and internal media advocacy-done by Journalism practitioners) in terms of health communication. As observed from Table 1, most stakeholders end at reporting and do not go further to advocate for the control of HIV/AIDS. This paper explains the approaches though which print media advocacy has been done by external and internal media actors in Cameroon through a state owned and private newspaper. The end result would serve as a guide to actors who intend to use the print media to advocate for health.

Media advocacy vs. reporting
The power demonstrated by media advocacy in changing lives makes it imperative for stakeholders to go beyond simply informing and advocate if they hope to achieve good health and wellbeing (United Nations Sustainable Development Goal 3). Media advocacy strikes a difference between using the media to address an 'information gap' and using the media to challenge a 'power gap. During reporting "… the mass media is being used as an educational strategy primarily to provide individuals with more information to make better health choices". In media advocacy, however, mass media is "…used as a political tool to target and pressure policymakers for social change and to mobilize widespread support to apply the pressure" [7].
Lippman as cited in Wallack [8], identified three main functions of media advocacy in health promotion namely; Agenda setting: Media advocacy uses the media to place attention on an issue by bringing it to light. Substantial evidence suggests that the media agenda determines the public agenda: what is on people's minds reflects what is in the media.
Framing: Media advocacy holds the spotlight on the issue and focuses on "upstream" causes. This is the process of framing. Recent research from the political science field suggests that the way that social issues are framed in the news media is associated with who or what is seen as primarily responsible for addressing the problem.
Advancing policy: Media advocacy seeks to advance social or public initiatives as a primary approach to the problem. Changes in the social environment through the development of healthy public policies are viewed as the means for improving public health.
Reporting on the other hand has as main function to inform the public. While reports are done mainly by media actors (in mates of a media house like journalists and editors) media advocacy can be done both by media actors and non-media actors. Thus, reporting in the It is the best way to reach the primary and secondary targets of health advocacy: While the radio is mostly followed by the rural population and the television is mostly followed by the urban population, the print media is mostly read by decision makers in Cameroon. Decision makers remain the primary targets of every advocacy plan. Civil Society Organizations generally make up the secondary targets while the public constitutes the tertiary targets [11]. In Cameroon, newspapers and magazines are used and consumed mostly by those who make policy (primary targets) and those who pressure for advancements in policy (secondary targets). The print media is equally popular amongst donors, investors, tourists and partners (Annexure).
The print media therefore plays a great role in influencing health authorities for large scale funding of policies. It can make available information to assist in making complex choices such as selecting health plans, care providers and treatment. Print media plays a mediator role between the people of the nation and government. It is highlighting the people's problem in front of government and partners and taking feedback from the government back to the people upon social and safety issues.
It provides detailed information: Print media has the advantage of making a longer impact on the minds of the reader, with more in-depth reporting and analysis. Details such as etymology, history and evolution of a disease are better explained in the print media. It provides more space to explain certain difficult, technical and scientific terms than the audio visual media. In print media readers have the choice to go back and recheck unlike with electronic media. Print media provides more scope for in-depth analysis of events.
It is a key tool for monitoring and harmonizing works between partners: With the plurality of actors, the media serves as a key enabler of coordination as it eases collaboration and permits all the actors to know about recent developments. This goes a long way to avoid unnecessary repetitions or contradictions which may hinder effective  advocacy efforts. This explains why most institutions which do media advocacy for health promotion do press clippings of the newspapers which bear items in their domain of interest.

Methodology
Given that the study is basically an investigation into the content of written material, the content analysis method was used. This method was complemented with in-depth interviews.

Content analysis
Content analysis, according to Kerlinger [12] is a method of studying and analyzing communication in a systematic, objective and quantitative manner for the purpose of measuring variables. Following a pre-study to select the most popular government owned and private newspapers used for advocacy, Cameroon Tribune representing the government owned media and the POST Newspaper, representing the private owned media were selected for this study. As evident from Table 1 below, a total of 4572 Newspapers, (3408 Cameroon Tribune and 1164 the Post Newspapers) ranging from the period 2000 to 2012 were analyzed. This study focuses on advocacy-oriented items or articles covered by the newspapers under study. Wallack L, Dorfman L & Woodruff K., 2005 note that media advocacy articles have the following characteristics. It emphasizes on the social dimensions of the problem.
It attributes primary responsibility away from the affected individuals to those whose decisions affect these conditions.
The journalist or official in the article goes beyond simply informing and proposes alternative solutions.
The official or journalists advocating suggests that policy options have practical appeal.

In-depth interviews
To further explain the analyzed content, in-depth interviews were conducted. The purposive sampling technique was used to select the interviewees. This was based on their relevance in providing adequate information on the topic. A semi-directive approach was employed to collect data. By this approach, the researcher has a list of questions or fairly specific topics to be covered, often referred to as an interview guide, but the interviewee has a great deal of leeway in how to reply. Questions may not follow on exactly in the way outlined on the schedule and some questions may arise in the course of the interview [13]. Given that media advocacy could be either external or internal, we interviewed 30 non-media actors (health program managers, health communicators, researchers, public health workers, medical practitioners and statisticians) and 16 journalism practitioners (editors and health journalists). All actors interviewed had been involved in media advocacy for health for at least 5 years.

General observations
Out of 1283 items of coverage on HIV/AIDS in Cameroon Tribune, 297 items were oriented towards advocacy, 942 towards information, 28 towards publicity, 13 towards opinion sampling (Vox pops) and 3 towards entertainment. In the Post newspaper, out of the 327 items of coverage on HIV/AIDS, 179 were oriented towards advocacy while 124 were oriented towards information, 20 towards publicity and 4 towards opinion sampling ( Table 1).
Out of the 297 items oriented towards advocacy in Cameroon Tribune, 286 of the advocating items originate from non-media actors (external media advocacy) while 65 come from journalists and editors (internal media advocacy).
Out of the 176 items oriented towards advocacy in the Post newspaper, 100 items come from non-media actors while 76 items come from journalists and editors of the newspaper.
The following table shows the different topics of advocacy in both newspapers ( Table 2).
Analysis which combined variables from both the state owned, Cameroon Tribune and the privately owned the Post newspaper revealed that non-media actors and journalism practitioners used the same approaches to advocate in both newspapers.

Approaches to external and internal print media advocacy
External media advocacy refers to the strategic use of mass media to  pressure for social change by non-media actors or non-practitioners of Journalism. Similar to Advocacy Journalism, internal media advocacy refers to advocacy done by Journalism practitioners or inmates of a media organ such as Journalists and editors.
Approaches to external print media advocacy: External media advocacy originated from a variety of sources. 25% originated from government ministries, 13.63% from international organizations, 12.17% from researchers, 4.62% from Non-Governmental Organizations (NGOs), 4.14% from religious authorities, 4.14% from victims, 4.38% from medical doctors, 4.38% from celebrities(actors and musicians), 3.90% from traditional medics, 2.68% from local chiefs and 20.96% from other actors like Common Initiative Groups, bilateral partners, political parties and victims. Six approaches were used by non-media actors to advocate namely; inserts, media events/news articles, interviews, op-eds, speeches and letters. Table 3 shows that inserts were predominantly used for external media advocacy, covering a total of 59%. Inserts here refer to short phrases or sentences used for advertisement in a medium UNAIDS and Cameroon's Ministry of health published inserts advocating for the control of HIV? AIDS such as for the love of my family, I must protect myself against AIDS, In the face of AIDS, lets change our behavior and protect ourselves, If you love me, protect yourself against HIV/ AIDS in both Cameroon Tribune and The Post newspapers. Inserts are important in print media advocacy in that they convey meaning in a short, simple and captivating way.

Media events/News articles:
Media events reported in the form of news articles were the second most popular approach used by non-media actors (25%). News coverage reinforces information that people receive about a disease from other sources, such as their friends, health careworkers, and billboards. It is common for institutions fighting against HIV/AIDS to organize media events such as seminars, workshops, press briefings, press conferences or press dinners in order to have their voices heard. For instance The POST Newspaper reported on a seminar organized by German Technical Cooperation (GIZ) in which its health official Nzeuzeu Flavien advocates thus: The media should improve its communication strategy on HIV/AIDS by contextualizing its messages to suit its respective targets (Njofor, 2001). Media events constitute an important way through which advocacy messages can feature as hard or breaking news (Akamba, 2013). It is worth noting that news remains an essential component of the mass media. An event communicated on the news is accorded much importance by decision makers, donors, civil society organizations and even the public. Hardly would a serious person afford to miss the news.
Interviews: Interviews constitute 5% of approaches used by nonmedia actors to advocate. An interview here refers to a recorded conversation between the journalist and the interviewee (often an expert) where questions are asked and answers are given, respectively. Whether the question asked was intended for the interviewee to propose a solution or not, the latter can always take advantage to advocate. For instance, when asked if the HIV/AIDS vaccine has been discovered, Dr.Nnomzo'o rather proposes that stakeholders should lay more emphasis on prevention campaigns as this is the best way to stamp out HIV/AIDS.

Op-eds:
Another way of advocating through the media is by writing an opinion piece to be run on a newspaper's opinion-editorial page. In this study, op-eds make up 4% of ways used to advocate. Writing an opinion article offers an opportunity to present an extended argument. Unlike editorials, op-eds are written by non-media actors instead of journalism practitioners. But like editorials, an op-ed often carries more weight than a letter to the editor. It presents a point of view with much greater detail and persuasion than a short letter allows. Advocating for more funds to be invested in health, Pr. Monekosso explains in an op-ed that: "health contributes in socio-economic development in the following ways: reduction of absenteeism, increase in work hours, increase in quality productivity of manpower, eradication of diseases, change in knowledge, attitude, behavior and practice(KABP) and thus promotion, innovation and spirit of enterprise as well as increase in mental development He then advocates for the Cameroon government to auto-finance its health projects and especially those for deadly pandemics like HIV/AIDS and malaria [14].
Speeches: These make up 4% of all the approaches used by nonmedia actors. It is common for print media organs to publish the speeches of top officials on key issues, especially during important events. One of such is the speech made by Cameroon's former Prime Minister Musonge titled: "Cameroon advocates for a significant drop in the prices of anti-retroviral drugs," presented during the extraordinary session of the UN on AIDS in New York, USA. In it, he explains that despite the enormous technical and financial support of the United Nations System and a loan of 50 million US dollars from the International Development Agency (IDA) under the multi-country AIDS Program (MAP), the HIV/AIDS pandemic can only be stemmed if the prices of ARV are reduced. Unlike in an interview in which a person can only advocate when asked a question, speeches are broader as they give the speaker the opportunity to speak fluently as they deem necessary without interruptions.

Letters:
Be it letters to the editor or letters from an official to a targeted audience, letters represent a simple way to communicate an opinion as it is addressed directly to the targets concerned [15]. They make up 3% of approaches used as revealed by this study. In the frequent letters published in Cameroon Tribune titled a letter from an elder brother by former Minister of Health, Olanguena Awono in the years 2002 and 2003, he advocates for more enrichment of knowledge, attitude behavior and practice for students in primary and secondary schools, in order to curb the spread of HIV/AIDS. These letters which were published prior to the beginning of each academic year during the said Minister's reign bore an informal and brotherly tone and could have a greater effect on the targeted audience who were students.

Approaches to internal media advocacy
Four approaches were used by journalism practitioners to advocate namely; commentaries, feature stories, editorials and edutainment (Table 4).
Commentaries: Commentaries (45%) mostly describe or comment on an event or situation. Like editorials, they carry a tone of soft news and are generally used by journalists to highlight an issue, giving it more importance. For instance commenting on the 18 th World AIDS conference in July in Vienna, Australia, Boudhi [16] of the POST newspaper reveals that Cameroon spends 0.06% of its domestic revenue

Speeches 4%
Letters 3% Source: Author on HIV/AIDS programs which is almost insignificant considering that only 30% of adults who need HIV treatment are getting any. He therefore calls on the government to allocate more funds to meet the needs of the dying population.
Feature stories (35%): These are special human interest stories or articles which focus on particular people, places, and happenings and do not closely tie up with recent news events. They could equally be defined as journalistic, researched, descriptive, colorful, thoughtful, reflective, thorough writing about original ideas. Feature stories cover topics in depth, going further than mere hard news coverage by amplifying and explaining the most interesting and important elements of a situation or occurrence [17]. A feature story reveals the journalist's desire to investigate on an issue. For example, in a feature story published in Cameroon Tribune titled: ARV: A Burden In Rural Settings, Nkematabong recounts the story of two women who died of HIV/AIDS in their villages owing to the lack of Anti-Retroviral drugs (ARV).He reveals that only 1958 out of 5150 infected persons in the rural areas in the Northwest are on drugs. In this story, Nkematabong compares the situation in a rural area like Belo in the Northwest region to Douala, an urban area and further reveals the following.
"Illicit drug vendors in Douala purchase a packet for 2000 frs and sell for 5000 frs.Cameroon currently faces high rates of ARV 1 st and 2 nd line resistance due to irregular drug supply and lack of effective drug distribution programs at routine care settings, especially in the countryside where the needy are permanently deprived of HIV/AIDS treatment declared free by the state in May,2007 after receiving huge financial backing from Global Fund and The Clinton It is necessary for Government to put in place a committee that would guarantee the effective implementation of the free-ARV drug policy." Editorials: An editorial is an opinion piece written by the senior editorial staff or publisher of a newspaper, magazine, or any other written document (Silk, 2009). Advocating for a multi-stakeholder involvement in the fight against HIV/AIDS, Cameroon Tribune editor, Kometa [18]. Another problem that has made the treatment of HIV/ AIDS a problem has been the absence of a vaccine. Whatever the arguments, coordinated action appears imperative in handling HIV/ AIDS given that efforts within a state that excludes other skate holders would obviously be limited in time and scope." Edutainment: Edutainment also referred to as educational entertainment is any entertainment content that is designed to educate as well as to entertain [19]. To be effective, messaging about HIV/AIDS must be both educational and entertaining. These two goals should not be mutually exclusive. Through radio and television, edutainment mostly comes in the form of movies, songs and micro-programs. But in the newspapers under study, advocacy through edutainment was done through poems and cartoons. For example, in a poem titled; Nimbolithic HIV, Boudah [16] advocates for the fight against stigmatization and calls for a greater respect of human rights.

Discussion
This study examined the approaches used for external media advocacy and internal media advocacy for the control of HIV/ AIDS through the Cameroon print media. A content analysis of the state owned, Cameroon Tribune and the privately owned, the POST newspapers revealed that non-media actors used the following approaches for external media advocacy; inserts, media events, interviews, op-eds, speeches and letters. On the other hand, media actors used approaches like commentaries, feature stories, editorials and edutainment for internal media advocacy. It is worth noting that, approaches used for external media advocacy can also be used for internal media advocacy. For instance, a journalism practitioner can decide to publish a letter to the public or an insert. Equally, a nonmedia actor can send a poem (edutainment approach) and have it published by a newspaper.
The media, heath communicators and educators are the gatekeepers of today's health information. They determine for the most part, what consumers hear, read and believe about health. The mass media "provides the forum through which the relationship between science and the public is constructed and pursued, and it is the forum through which the public make moral judgments about science" [20]. The media helps health workers expand their audience reach which is crucial. This is so because face-to-face channels of information often require huge resources and reach relatively a small number of people in large, underserved rural areas. The mass media are an effective way to persuade target audiences to adopt new behaviors or to remind them of critical information.
Media advocacy can be a significant force in influencing public debate and putting pressure on policy makers by increasing the volume of the public health voice as well as the visibility of values, issues and people behind the voice. Media advocacy is about making sure that the story is told from a public health perspective.
Thus, by virtue of the power it has demonstrated in resource mobilization for health promotion and control of diseases like HIV/ AIDS, media advocacy (be it external or internal) has to be well planned and executed. To ensure proper delivery and outcome, media advocacy requires an appropriate strategy. Fundamental to media advocacy is knowing what policy goals one wishes to accomplish. Thus, the first step is to establish what the policy goal and expectations. The second step is to decide the target of the advocacy. Consider whether the target in question has the power to make the change advocated for. The third step is to frame the issue and construct messages. The fourth step is to construct an overall media advocacy plan for delivering the message and creating pressure for change [8].
Stakeholders who chose the print media for health promotion or disease control should carefully chose the newspapers and magazines through which they intend to advocate. Some print media are general while others are specialized in health. Others have a wider readership while some have a narrow audience.
After determining the goals, targets, messages and channel, stakeholders should choose the most appropriate approaches. As explained in the results, each approach (be it external or internal) is important depending on the objectives the advocate aims to achieve.
Finally, it is important for advocates to evaluate how well they have done what they set out to do.

Conclusion
In a nutshell, this study examined and explained the approaches through which advocacy was done in the Cameroon print media,

Feature stories 35%
Editorials 15% Edutainment 5% Source: Author more specifically, Cameroon tribune and the POST newspapers. It distinguished external media advocacy from internal media advocacy. This piece equally led us to understand that even with the pre-eminence of the audiovisual media, the print media is of remains relevant to health promotion in general and the control of HIV/AIDS in particular. The print media is the best way to reach the primary advocacy targets of every advocacy plan in Cameroon. It provides details and helps in monitoring of activities between partners. The study revealed that six external print media approaches were used to promote the control of HIV/AIDS namely; inserts, media events, interviews, op-eds, letters and speeches. Approaches to internal print media advocacy included; commentaries, feature stories, editorials and edutainment (poems and cartoons). Further research in the same line should consider analyzing approaches to audio visual media advocacy.