Panel 1.

Exploring the framing of diseases in Pakistani media

Health policies must account for how societies perceive and understand a given disease’s origins and causes, and media sources play an important role in framing health issues (Nelkin, 1991; Entman, 1993). Document analysis was employed to understand the frames used in print media (newspapers) in Pakistan when discussing Human Immunodeficiency Virus (HIV) and viral hepatitis, two diseases that are spread using similar modes of transmission but have varying levels of stigma in the country. Alongside document analysis, key informant interviews were used for triangulation and to flesh out what stigma for HIV meant in the country.  A sample of newspaper articles was drawn from the electronic database LexisNexis (January 2006-September 2016) based on readership, electronic availability in LexisNexis and geographic diversity, to capture cultural differences across provinces over time (Strömbäck and Dimitrova, 2011). Broad search terms were used for HIV and viral hepatitis, resulting in 3415 articles for hepatitis and1580 articles for HIV. A random sample comprising 10% of the total HIV articles (n = 156) and 5% of the total hepatitis articles (n = 176) was selected and coded using a fixed coding guide. The coding guide was developed using an inductive approach (Krippendorff, 2004; Mayring, 2004), which involved reading a sample of articles line by line to identify media frames for HIV and viral hepatitis (Abdelmutti and Hoffman-Goetz, 2009; Claassen et al., 2012). Two rounds of pre-testing were carried out before the final sample of articles was coded. However, the use of LexisNexis as the primary data source excluded newspapers published in the local language (opening up the possibility of omitting some media frames). Therefore, interviews were important for triangulation of findings.  Data from document analysis were collated in an Excel sheet and analysed in STATA 14. The findings of the document analysis highlighted that while both diseases were transmitted predominantly through injecting drug use in the country, hepatitis was only discussed using frames such as ‘medical’ (discussing transmission, prevention, and treatment methods), ‘resources’ (resources available to fight the disease), ‘magnitude’ (gives the scope of the problem or disease prevalence) and ‘need for awareness’–there was no ‘stigma and discrimination’ frame attached to the disease [Figure, HIV and viral hepatitis articles by main frames (%)]. In contrast, the ‘stigma and discrimination’ frame and the ‘social causes of disease’ frame (discussing non-medical causes for the spread of disease) were used exclusively in articles on HIV, notably including suggestions that acquiring the disease was linked to socially immoral and un-Islamic behaviour. Key informant interviews helped to probe further the traits associated with someone who had HIV. Taken together, document analysis and key informant interviews helped build a richer narrative of HIV stigma in the country.  Given the difference in how these diseases were understood, these findings suggested that there was a need for explicit policy to reframe HIV as a disease. Countries such as Iran, Indonesia and Malaysia have successfully garnered government and policy attention to HIV and reduced stigma by reframing it as a disease spread through injecting drug use (Kamarulzaman, 2013).