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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
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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
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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
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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.
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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
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