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----------------------- 页面 1----------------------- Health Transition Review 6, 1996, 169-178 Searching for solutions: health concerns expressed in letters to an East African newspaper column a b b Rose Asera , Henry Bagarukayo , Dean Shuey b and Thomas Barton a Dana Center, University of Texas at Austin b AMREF, Kampala Questions people ask reveal not only the gaps of knowledge, but also reveal their existing attitudes and ideas and personal problems (Arya and Bennett 1973). Abstract This study examined health care questions from an unusual data set: 1252 unsolicited letters written over a three–year period to an advice column in an East African newspaper. Analysis of the letters was a non-intrusive method of ascertaining prevalent health questions and opinions. People wrote seeking information, advice, solutions, and reassurance about health problems. Emotions expressed in the letters ranged from hope to fear and frustration. The written format allowed questions which are generally too embarrassing or stigmatized to present in other public or interpersonal settings. More than half the total letters raised questions about sexual behaviour, sexually transmitted diseases, and HIV/AIDS. The letters present not only personal health concerns, but also expectations of health-care quality and reflections on the medical options presently available in Uganda. As a whole, the letters express dissatisfaction not only with the outcomes of health encounters, but with the process. Of the letter writers with specific physical complaints, more than one-third had already sought medical care and were dissatisfied with the results. The letters were seeking solutions, especially for alleviation of symptoms and discomfort. Almost equally prevalent was a plea for accurate and relevant health information; people not only want to feel better, but they also want to understand their own health. Health education campaigns are designed and directed in response to policy makers’ perceptions of major health problems. Health education is less often able to elicit and respond directly to prevalent personal health concerns which may or may not coincide with programmatic health priorities. This study examined questions from an unusual but revealing data set: the unsolicited letters written over a three-year period to a health advice column in an East African newspaper. These letters present concerns, comments and complaints about writers’ own health and about the health-care options available to them. The written format, with its inherent distance and lack of direct personal contact, allowed questions which might be too embarrassing or stigmatized to present in other public or interpersonal settings. Only a few other studies and authors have sought to ‘read between the lines’, analysing questions presented in African newspapers, letters and other media. Jahoda (1959) examined the transformation of attitudes and norms in social relationships as presented by letter writers. He found the letters described conflicting forces promoting and opposing social change in the realm of male-female relationships. Kisekka (1973) analysed letters written to a sexologist, seeking advice about sexual behaviour. The letters contained information about how individuals interpreted and internalized cultural values related to sexual behaviour. Arya and ----------------------- 页面 2-----------------------170 Rose Asera, Henry Bagarukayo, Dean Shuey and Thomas Barton Bennett (1973 uncovered misinformation embedded in the questions Ugandan university students asked about syphilis and gonorrhoea. Background to the study The New Vision, a daily English-language newspaper published in Kampala, Uganda, runs a weekly health section, which includes a question and answer column written by the African 1 Medical Research Foundation (AMREF) . The column answers between one and three letters each week, but a much larger volume of letters is regularly received. The letters examined in this study were written between 1991 and 1994, in the context of a particular cultural and socio-political setting and time. The early 1990s in Uganda have been a national period of post-conflict development, a period of increasing political stability and economic growth. While the national economy and social services have been improving since the NRM government took over in 1986, the infrastructure is still not able to provide levels of service and care in health (or other social services) that were available in 1970. Uganda in the 1960s had a strong and well established social infrastructure, including a well- stocked and well-used health care system. Both the system and its subsequent breakdown during more than a decade and a half of civil unrest from the early 1970s to the mid-1980s have been well documented (Dodge and Wiebe 1985; Whyte 1990; Macrae, Zwi and Birungi 1993). During the years following Amin’s takeover in 1971, the national economic and social infrastructure crumbled, and government services including health care weakened. The letters present not only personal health concerns, but also expectations of health care, beliefs about quality of care, and reflections on the medical options at present available in Uganda. In addition the early 1990s overlap the period of national and international recognition of the seriousness of the AIDS pandemic. Since 1986, the Government of Uganda, numerous non-governmental organizations and international health organizations have contributed to massive health education campaigns to control and prevent the further spread of HIV/AIDS. A large number of letters present queries about HIV which reflect the effects of the epidemic or of the health education effort. In this study, we examined the full data set of published and unpublished letters, and all letters were read by at least two researchers. The letters were coded for demographic characteristics of the writers, nature of any physical complaints, and for less clinical issues such as expressions of stigma, personal anxiety, misinformation, perceptions of the health care system, and reasons for writing to an advice column. These categories arose from the content of the letters themselves. When these categories were clustered, patterns of the letter writers’ health concerns emerged.2 Limitations There are a number of limitations inherent in undertaking a content analysis of letters to a newspaper. First, the letters are anecdotal and personal. Information contained in the letters was variable in quality and quantity. Writers usually provided some descriptive information about themselves and their problems, but it was not possible to obtain any additional details, clarification, or follow-up. Secondly, because the medium was an advice column, the letters 1Related articles are in progress from the same data set documenting questions from letters specifically about HIV and STDS. 2Content analysis of other newspaper columns using letter formats, for example, social advice, or legal matters, could be used as an unobtrusive method to gauge popular concerns, and extract questions which are too sensitive to emerge in other settings. Health Transition Review ----------------------- 页面 3----------------------- Health concerns in letters to an East African newspaper 171 focused on difficulties and problems, which does not provide a balanced picture including successful treatment events. Thirdly, the letter writers are self-selected, and thus not a statistically representative sample either for the population as a whole or for young people from the mid-teens to the late twenties. In addition, the writers are not geographically distributed. Uganda is one of the least urbanized African countries (89% of the population lives in rural settings); urban inhabitants were overrepresented among the letter writers. Not all letters carried any indication of location, but New Vision is printed and principally distributed in urban areas like Kampala. Lastly, the writers are all literate in English, which indicates some formal post-primary education. The national adult (above 15 years) literacy rate in any language is slightly above 50 per cent; 63 per cent for males and 44 per cent for females (Ghana Ministry of Education 1994). Although the letter writers are a self-selected group, we believe that the questions and problems presented in the letters are not unique to this group nor directly related to the qualities which make them non-representative. The presence of these problems in this urban, literate subset of the population is only ‘the nose of the hippopotamus’. The questions and problems extend beyond the small visible portion above the surface. The letters Letters came on domestic aerogrammes, on unlined scraps of paper, or on folded sheets of lined paper, some of it pulled from school notebooks. Some letters, in fact, resembled school themes, with a title in capital letters underlined across the top of the page. Other requests were written on reused paper with writing on the other side; paper itself was scarce. The letters often began with a flowery salutation: ‘I take this golden opportunity to greet you and to thank you for all of your good work towards promoting health and helping the people of this country’. After such greetings, the letters continued on a more personal note. Each weekly printed column included questions and responses for one to three written queries. Letters selected and published in the newspaper were edited and shortened for reasons of space and confidentiality. The editor has used the column as a public forum for a wide range of health education topics. Published responses to letters have been informational, providing background about the condition and general guidelines for seeking treatment, but not giving personal recommendations for treatment. Yet despite this constraint, letters from concerned individuals were often long, involved, and almost confessional in tone. Often, towards the end of the letter, the writers included a request that if the letter were to be published in the newspaper, only their initials be used. Despite the potential motivation to see one’s letter in print, as noted by Jahoda (1959), most often the Ugandan writers said that they did not want their friends and relatives to recognize them. Some writers requested a personal reply through the mail because they could not afford to buy a newspaper regularly. A few sent stamps or envelopes with a request for a private reply. Letters finished with pleas for advice, sometimes requesting advice ‘before it is too late’. The most common closings at the end of the letters were ‘confused’, ‘worried’, and ‘desperate’, followed by a name, initials, or signifier such as ‘student’ or ‘citizen’. One woman signed her letter ‘your obedient, miserable housewife’. Health Transition Review ----------------------- 页面 4-----------------------172 Rose Asera, Henry Bagarukayo, Dean Shuey and Thomas Barton The writers There were a total of 1252 individual letter writers. Of the total letters, 189 letters were 3 published, and 1063 were unpublished. Among those who identified themselves by sex, there were far greater numbers of male letter writers (588) than female writers (343). Jahoda (1959) in a review of letters to a West African newspaper advice column, noted an even greater majority (90%) of male writers and attributed this to greater male enrolment in school. The majority of writers in this study were people in their late teens (16 and above) to late twenties. The youngest writer was nine years old, and the oldest was 50, both males. In this present Ugandan study, there were 321 writers who gave no indication of sex by self-identification, physical description or distinctive name. Of these writers of indeterminate sex, 270 also gave no indication of age. Table 1 Total writers by sex and age Male Female Indeterminate sex 9-19 69 81 13 20-30 184 102 29 30 + 45 18 9 Interdeterminate age 286 142 270 Total 588 343 321 Students were the largest self-designated subcategory of letter writers. Of 246 self-identified students, 137 were secondary school students; a small number, 28, were post-secondary, either at university or in vocational, business or teacher training colleges. Many simply introduced themselves or signed their letter as ‘a student’. One hundred and fifty of the students were male, 64 female, and 32 of indeterminate sex. One hundred and seven correspondents (59 males, 42 females, and 6 indeterminate) identified themselves as married. Marital status, whether married or single, was mentioned most often when it was relevant to the presenting problem, for example, a possible sexually- transmitted disease or a question about fertility. Males as old as mid- to late-twenties referred to themselves as ‘boys’ or ‘youths’ if they were not married. A few people wrote letters as concerned parents, spouses or friends, but most wrote with a personal problem which had confused or frustrated them. Excerpts from letters have been extracted and edited slightly, for reasons of readability and confidentiality, but they maintain the essence of the writers’ words and meanings. Health concerns and underlying questions An emotional range of concern, denial, hope, fear and frustration lay beneath the surface of the letters. People wrote seeking information, advice, solutions, and reassurance about health problems. Physical problems described in the letters ranged from headaches to sore feet, from visible rashes noted as embarrassing to equally embarrassing but less visible symptoms in their ‘private parts’. People wrote about acute symptoms, recurrent problems and long- standing debilitating conditions. Any attempt to count or categorize the health concerns expressed in the letters quickly became problematical. Many letters contained more than one question. Others included 3In total, this study reviewed both unpublished and published letters: unpublished materials from 1991 to December 1993, published letters from March 1992 to January 1994. Health Transition Review ----------------------- 页面 5----------------------- Health concerns in letters to an East African newspaper 173 multiple symptoms which from the writer’s perspective were linked, but may or may not be so medically. Some symptoms appeared in different guises. For example, there were 47 letters with an itch or skin rash as the major presenting concern, but dozens more letters included a skin rash as a possible symptom of a sexually transmitted disease or of AIDS. Thus there is no clear way to quantitatively measure the importance of a single question or topic. If, however, these numbers are taken qualitatively, they can give some indication of the magnitude of writers’ concerns, although there is no satisfactory way to generalize to the national population. Noticeably absent from the letters were questions about some of the major recognized public health concerns such as infant diarrhoeal diseases, immunization, and acute respiratory infections. This may be, however, because of the age group and marital status of the writers. HIV/AIDS, also a major public health concern, was one of the most queried topics. Some of the writers’ symptoms were clinical conditions: physical problems which were uncomfortable or interfered with normal functioning and for which it could be appropriate to seek medical care. In fact, of the letter writers with presenting complaints such as stomach pain, rashes, headaches, joint pain, malaria, and sexually-transmitted diseases, more than one- third had already sought medical care and were generally dissatisfied with the results. Their letters requested an alternative, or perhaps more accurately, a definitive diagnosis and treatment advice. For the writers with clinical conditions who had not yet sought medical attention, their letters were substitutes for a visit to the doctor; they too sought diagnosis and treatment advice. These letter writers did not seem to view it as unusual or unrealistic to seek diagnosis or treatment advice at a distance, without physical contact or personal interaction. Sexual health, sensitive topics and stigma 此文章不全，如果合适的请给我发邮件，并附上PDF格式的文件

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1.Washington (Agencies via Xinhua)---US and Latin American officials are close to agreement on a communique for next week’s drug summit pledging US help to revamp the drug-dependent economies of Peru, Bolivia and Columbia, sources say.华盛顿(新华社报道)-消息人士称,美国和拉美的官员在一份公报上达成共识,在下周的药物峰会上保证美国帮助秘鲁,玻利维亚,哥伦比亚改善吸毒者经济.2.The Clinton administration proposed today to reduce the government’s role as traffic cop for the internet, a medium born as a research tool that has grown into a freewheeling means of mass communication.柯林顿政府今天计划减少政府网络警察的作用,媒体的诞生是作为一种研究工具,其逐渐成长为公众交流一种随心所欲的手段.3.Turkey acted yesterday to repair ties with Washington after its parliament blocked any US attack on Iraq through Turkey territory. 昨天土耳其采取行动来缓解由于议会阻止美国通过其领土进攻伊拉克而与华盛顿的紧张关系.